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IN-DEPTH REVIEW |
Departments of Medicine1 and Physiology/Pharmacology,2 The University of Western Ontario, London, Ontario, Canada
Correspondence to: A.A. House, A10-107 London Health Sciences Centre, University Hospital, 339 Windermere Road, London, Ontario N6A 5A5 Canada. Andrew.House{at}lhsc.on.ca
Elevated plasma total homocysteine (tHcy) is a risk factor for
cardiovascular disease; however, in light of several recent randomized trials,
the issue of causality has been cast into doubt. Patients with end-stage renal
disease are particularly interesting as they consistently have elevated tHcy
and their leading causes of morbidity and mortality are related to
cardiovascular disease. In the present article, we review the early evidence
for the homocysteine theory of atherosclerosis, homocysteine metabolism,
mechanisms of toxicity, and pertinent available clinical investigations. Where
appropriate, the sparse evidence of homocysteine in peritoneal dialysis is
reviewed. We conclude by addressing the difficulties associated with lowering
plasma tHcy in patients with end-stage renal disease and suggest some novel
methods for lowering tHcy in this resistant population. Finally, to address
the issue of causality, we recommend that clinicians and scientists await the
results of the FAVORIT trial before abandoning homocysteine as a modifiable
risk factor for cardiovascular disease, as this study has recruited patients
from a population with consistently elevated plasma tHcy who are known to
respond to vitamin therapy.
KEY WORDS: Homocysteine; atherosclerosis; end-stage renal disease.
Received 15 May 2007; accepted 13 July 2007.
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