10-cebeci:cebeci 28-02-2012 11:46 Pagina 214

ACTA BIOMED 2011; 82: 214-222 © Mattioli 1885

O R I G I N A L A R T I C L E

Evaluation of oxidative stress, the activities of paraoxonase

and arylesterase in patients with subclinic hypothyroidism
Egemen Cebeci1, Fatma Alibaz Oner1, Murat Usta2, Selen Yurdakul3, Mecdi Erguney1
1
Istanbul Education and Research Hospital, Internal Medicine Department, Istanbul; 2 Education and Research Hospital,
Clinical Biochemistry Department, Istanbul; 3 Istanbul Florence Nightingale Hospital, Cardiology Division, Istanbul

Abstract. Introduction: In subclinical hypothyroidism (SH), serum lipid and lipoprotein concentrations are
frequently changed. Compared to the normal population, the levels of oxidized low-density lipoprotein
(LDL) cholesterol are higher and the levels of high density lipoprotein (HDL) cholesterol are lower. In SH
patients, the mechanism of atherosclerosis may be attributed to the lipid abnormalities. There is evidence
showing that, oxidation plays an important role during the process of atherosclerosis, preventing the lipid
peroxidation of paraoxonase 1 and thereby, acting against the atherosclerosis. In this study, we evaluated the
activity of paraoxonase and arylesterase in subclinical hypothyroidism and investigated its relation with ox-
idative stress. Method: The study enrolled 25 cases with SH and 20 healthy controls. The patient group and
the control group were compared in terms of the activity of paraoxonase and arylesterase and the oxidative
stress index. Results: Between two groups, no significant difference was found in terms of age, gender, total
cholesterol, low-molecular weighted lipoprotein, high-molecular weighted lipoprotein. In SH group, the ac-
tivity of paraoxonase was significantly lower than that observed in the control group (p=0.01). Also, the ac-
tivity of arylesterase was significantly lower in the group with subclinical hypothyroidism (p=0.03). Oxida-
tive stress index was found to be significantly higher in the group with subclinical hypothyroidism compared
to the healthy controls (p<0.01). Oxidative stress index showed a strong positive correlation with the levels
of TSH in all cases (r=0.60, p<0.01. Conclusion: Consequently, in SH, the activity of paraoxonase and
arylesterase were significantly low and oxidative stress was significantly high. Lower activities of paraoxonase
and arylesterase indicated increased oxidative damage in SH. This may be useful to elucidate the mecha-
nism of atherosclerosis in SH. In addition, these findings suggested that the activities of paraoxonase and
arylesterase may be used for the determination of therapeutical response and during the follow-up.
(www.actabiomedica.it)

Key words: subclinical hypothyroidism, paraoxonase, arylesterase, atherosclerosis, oxidative stress

Introduction ciency. The most marked complaints of the patients

are dry skin, weakening of memory and thinking,
Subclinical hypothyroidism (SH) is the most weakness of muscles, fatigue, muscular cramps,
commonly seen thyroid dysfunction and is defined as swollen eyes, cold intolerance, constipation and deep
the presence of high levels of thyroid stimulating hor- voice (1, 2). Definitive insights about the therapeutic
mone (TSH) when the values of free triiodothyronin modalities are still lacking.
(fT3) and free thyroxin (fT4) are within normal range. SH is accompanied by left and right ventricular
30% of the patients which are asymptomatic may systolic and diastolic dysfunction, increased athero-
show symptoms suggesting the thyroid hormone defi- sclerosis and myocardial infarction risk. In the patients
10-cebeci:cebeci 28-02-2012 11:46 Pagina 215

Oxidative stress in subclinica hypothyroidism 215

with SH, mechanism of atherosclerosis may be attrib- Material and method

uted to the lipid abnormalities (1, 3-5).
In thyroid disorders, serum lipid and lipoprotein This study was prospectively designed. The study
concentrations are commonly changed. Compared to protocol was approved by the local ethic board of our
the normal population, the levels of oxidized low hospital. Before performing any procedure, all the pa-
density lipoprotein cholesterol (LDL) are higher and tients were extensively informed about the study and
the levels of high density lipoprotein cholesterol signed “informed consent form”.
(HDL) are lower (1, 3-5). HDL prevents the oxida- From the patients between 18-65 years that ad-
tive changes in LDL. It is reported that, paraoxonase mitted to our hospital for various reasons, the patients
1 (PON 1), which is an antioxidant enzyme present with SH for whom medical history, physical examina-
in the structure of HDL, contributes to the protective tion and clinical and laboratory investigations were
effect of HDL, by preventing the LDL oxidation (6, performed; who were newly diagnosed and who had
7). PON 1 is associated with the apolipoprotein A-1 never received medical therapy until that time were
(apoA-1) and apolipoprotein J (apoJ) proteins of enrolled to the study. Our study group consisted of
HDL (8). ApoA-1 is the structural protein of HDL 25 cases with SH (37±11 years, 72% female) and 20
and stabilizes the linking of PON 1 to the HDL age and sex-matched healthy subjects (35±9 years,
phosphoriles by N-terminal ending. It was suggested 60% female) .
that, lower PON1 serum activity despite the normal The exclusion criteria were defined as follows:
levels of HDL would lead to a decreased protective age below 18 or above 65,morbid obesity (body mass
effect of HDL against the oxidation of LDL and index> 35 kg/m2), hyperlipidemia, hypertension, dia-
thereby, to an increased incidence of atherosclerosis. betes mellitus, malignancy, hepatic disease, acute or
PON 1 is an ester hydrolase that has both arylesterase chronic infections, renal failure, autoimmune disease,
(ARE) and PON activities (9). As PON, for whom cardiovascular disease, anemia and smoking.
the physiological substrates have not been defined According to the criteria of the biochemistry lab-
yet, catalyses the hydrolysis of the organophosphate oratory of the hospital, normal serum levels were con-
compounds frequently used for the production of in- sidered as follows: TSH: 0,27-4,20 mIU/mL, fT3:
secticide and sarin, it is especially important for the 1,80-4,60 pg/ml, fT4: 0,93-1,70 ng/dl. Cases with SH
toxicologic studies and for the in vivo xenobiotic me- were defined as having a TSH level above 4.20
tabolism studies. On the other hand, following the mIU/ml and fT4 level within the normal range. Blood
determination of the presence of PON in the struc- samples were collected from all patients after a 8-12
ture of HDL in the plasma, the studies investigating hours fasting period. For the blood samples for which
the physiological functions of PON are gradually the serum part would be separated, the tubes with gel
increasing. The importance of PON for the cardio- and red cap were used. To separate the serum and the
vascular physiology, the relation of PON with lipid plasma, the blood taken into biochemistry tubes were
and lipoprotein metabolism, its potential anti-athero- centrifuged at 3000 rpm during 10 minutes. Serum
genic effect and the antioxidant characteristics samples were aliquoted and then stored at -80°C.
against peroxidative damage are extensively investi- Systolic and diastolic arterial blood pressures of
gated . all the cases were measured using an aired manometer
Our aim is to evaluate the activities of PON and from right brachial artery following a resting period of
ARE in patients with SH and to investigate the status at least 5 minutes at lying position before the exami-
of serum total antioxidants and total oxidative status nation. Body weight was measured using a calibrated
to see whether there is a relation between PON/ARE balance at 0.1 kg sensitivity with light clothes and
activity and oxidative stress. Moreover, we aimed to without shoes. Height measurements were performed
determine whether PON/ARE activity and total an- in standing position without shoes with a sensitivity of
tioxidant status contribute to the development of ath- 0.01 m. BMI was calculated by dividing the body
erosclerosis in the patients with SH. weight to the square of the height in meter (kg/m2).
10-cebeci:cebeci 28-02-2012 11:46 Pagina 216

216 E. Cebeci, F. Alibaz Oner, M. Usta, S. Yurdakul, M. Erguney

HOMA-IR (homeostasis model assessment of Evaluation of Oxidative Stress Index (Oxidative

insulin resistance), was calculated using a formula de- Stress Index – OSI)
fined by Matthews.
HOMA-IR= (fasting insuline level (mi- OSI was used as an indicator of the oxidative
croU/ml)*Fasting glucose level (mmol/dl) / 22,5 stress grade in the patient and control groups. Calcu-
lation of OSI using the kits for TAC and TOS was
Measurement of total oxidant level (Total Oxidant Status performed according to the formula cited below:
– TOS) OSI (Arbitrary Unit) = [ TOS (µmol H2O2 equiv-
alent/L)/TAC (µmol Trolox equivalent/L)] x 100.
In the serum samples, TOS levels were investi-
gated using a full-automatized method developed by Measurement of PON1 Activity
Erel(10). According to this method, serum oxidants
oxidize the complex of ferrous ion-o-dianisidine to PON1 activity of the serum samples was exam-
ferric ion. Again, the existing molecules of glycerol ac- ined using full-automatized method developed by Rel
celerate the oxidation reaction. Ferric ions form a col- Assay Diagnostics® (Mega Tıp, Gaziantep, Turkey).
ored complex with xylenol orange in an acidic envi- According to this method, Paraoxonase activity is mea-
ronment. The intensity of the color, which is related to sured in medium without NaCl (basal paraoxonase ac-
the amount of the oxidants present in the serum sam- tivity) and with NaCl (salt-stimulated paraoxonase ac-
ple, is measured at 37°C and at a wave length of 530 tivity). Hydrolysis of the paraoxone (diethyl-p-nitro-
nm with spectrophotometry. As the calibration of the phenylphosphate) is monitorized with the follow-up of
measurement is done using hydrogen peroxide, the re- the increase of absorbance at 37C and 412 nm. The
sults of the measurement are expressed as micromolar amount of p-nitrophenol resulting from the hydrolysis
hydrogen peroxide equivalent in one liter ( mol H2O2 is calculated using the molar absorption coefficient
Equiv./L). 17,000 M-1cm-1 (at pH 8). Net value with enzymatic ac-
tivity is calculated by subtracting the basal activity val-
Measurement of Total Antioxidant Capacity (Total ue from salt-stimulated activity value. The results are
Antioxidant Capacity – TAC) expressed as Unit/Liter which is equal to the hydroly-
sis of 1 micromol substrate in one minute and one liter.
In the serum samples, TAC levels were investi-
gated using a full-automatized method developed by Measurement of PON 1 Arylesterase Activity
Erel (11). According to this method, as a strong bio-
logical radical, ABTS+ cathion radicals are formed. PON 1 arylesterase activity of the serum samples
ABTS [2,2’-azino-bis(3-ethylbenzthiazoline-6-sul- was measured using full-automatized method devel-
phonic acid)] enters to a reaction with peroxidase and oped by Rel Assay Diagnostics® (Mega Tıp,
H2O2 and is oxidized to blue-green ABTS+ cathion Gaziantep, Turkey. According to this method, pheny-
radicals. Antioxidants of the serum sample convert the lacetate is used as a substrate for the measurement of
blue-green ABTS+ cathion radicals to the uncolored arylesterase activity and, with the hydrolysis of pheny-
ABTS form and thereby, decrease the amount of en- lacetate, phenol and acetic acid are formed. The re-
vironmental ABTS+ cathion radicals. The change of sulting phenol joins to 4-aminoantipyrine and potas-
absorbance at 37°C and 660 nm will be associated sium ferricyanide and is measured with colorimetric
with the total antioxidant capacity of the serum sam- method. ARE enzyme activity is calculated from 4000
ple. As the calibration of the measurement was per- M-1cm-1, which is the molar absorption coefficient of
formed using stable antioxidant standard solution the resulting colored complex. The results are ex-
called Trolox Equivalent (an analogue of Vitamine E), pressed as Unit/Liter which is equal to the hydrolysis
the results of the measurement are expressed as µmol of 1 micromol phenylacetate in one minute and in one
Trolox Equiv./L. liter.
10-cebeci:cebeci 28-02-2012 11:46 Pagina 217

Oxidative stress in subclinica hypothyroidism 217

Statistical analysis

When evaluating the results obtained from the

study, statistical analysis was performed using SPSS
(Statistical Package for Social Sciences) for Windows
11.5 software. The variables were expressed as stan-
dard deviation and mean or median. The means were
compared using Student T Test and median values
were compared using Mann Whitney U Test. Data
were compared with each other using Spearman cor-
relation test. The incidences were compared using
Chi-square and Fisher’s Exact tests. In this analysis, Figure 1. The thyroid function tests of patients and controls
p<0.05 was considered as significant.

54) in the cases of subclinical hypothyroidism and

Results 35±9 (range, 21 and 51) in the control group. The sta-
tistical difference between two groups was not signif-
The study group included 25 cases diagnosed icant (p=0,56). Figure 1 shows the comparison of the
with subclinical hypothyroidism (SCH) and 20 cases thyroid function tests of the cases with subclinical hy-
with normal test results of thyroid function. The pothyroidism and healthy cases in our study.
groups formed had similar distribution in terms of age The two groups did not show any significant dif-
and gender. Of 25 cases of subclinical hypothy- ference in terms of age, gender, total cholesterol,
roidism, 18 were women and 7 were men. Of 20 LDL, HDL, urea, creatinine, HOMA-R, diastolic
healthy cases, 12 were women and 8 were men. The and systolic blood pressure and heart peak beat.
statistical difference between two groups was not sig- Paraoxonase activity was 135(82-195) in the
nificant (p=0,52). Mean age was 37±11 (range, 18 and group with subclinical hypothyroidism and 190 (124-

Table 1. Clinical-demographic characteristics of the patients and controls

Subclinical hypothyroidism Healthy control P value
(n=25) (n=20)
Age (years) 37 ± 11 35 ± 9 0,56 (not significant)
Total cholesterol (mg/dl) 184 ± 35 172 ± 27 0,47(not significant)
LDL (mg/dl) 112 ± 29 102 ± 22 0,32(not significant)
HDL (mg/dl) 50 ± 11 51 ± 10 0,78(not significant)
Triglyceride (mg/dl) 107 ± 37 85 ± 40 0,02(significant)
Paraoxonase (U/L) 135 (82-195)* 190 (124-355)* 0,01(significant)
Arylesterase (kU/L) 232 ± 33 255 ± 40 0,03(significant)
TAC (µmol Trolox equivalent/L) 2,5 ± 0,2 2,3 ± 0,2 < 0,01(significant)
TOS (µmol H2O2 equivalent/L) 5,9 (5,4-7,4)* 3,9 ± 0,8 < 0,01(significant)
OSI 239 (194-303)* 174 ± 41 < 0,01(significant)
Glucose (mg/dl) 85 ± 7 93 ± 4 0,01 (significant)
Urea (mg/dl) 23 ± 4 25 ± 5 0,15(not significant)
Creatinine (mg/dl) 0,7 ± 0,1 0,8 ± 0,07 0,67(not significant)
BMI (kg/m2) 26 ± 2 23 ± 3 < 0,01(significant)
HOMA-R 1,8 ± 0,8 1,5 ± 0,5 0,22(not significant)
Diastolic blood pressure (mmHg) 71 ± 8 71 ± 6 0,98(not significant)
Systolic blood pressure (mmHg) 111 ± 12 116 ± 9 0,13(not significant)
Heart’s peak beat (beats/min) 76 ± 8 77 ± 7 0,73(not significant)
* Median values between 25-75% confidence interval
10-cebeci:cebeci 28-02-2012 11:46 Pagina 218

218 E. Cebeci, F. Alibaz Oner, M. Usta, S. Yurdakul, M. Erguney

355) in the healthy control group. The difference of

paraoxonase levels observed in two groups was statis-
tically significant (p = 0,01). In the group with sub-
clinical hypothyroidism, paraoxonase showed a slight
correlation with total oxidant level (r = 0.40, p=0.04).
In the group with subclinical hypothyroidism, paraox-
onase did not show a correlation with HDL (r = 0.18,
p = 0.37).
Arylesterase activity was 232±33 in the group
with subclinical hypothyroidism and 255±40 in the
healthy control group. The difference of ARE activi-
ties observed in two groups was statistically significant
(p = 0,03). Arylesterase showed a moderate correlation Figure 2. Comparison of paraoxonase activity, arylesterase ac-
tivities, TAC, TOS, OSI values between the patients with sub-
with HDL levels in the healthy control group (r = clinical hypothyroidism and the healthy cases
0.49, p = 0.02). ARE showed a slight correlation with
triglyceride level in the patients with subclinical hy-
pothyroidism (r = 0.41, p = 0.03). ARE showed a 0.01). TAC showed a slight correlation with heart’s
moderate correlation with BMI in the patients with peak beat in the group with subclinical hypothy-
subclinical hypothyroidism (r = 0.58, p<0.01). ARE roidism (r = 0.41, p = 0.04). TAC showed a slight cor-
showed a slight correlation with glucose levels in all relation with TSH levels in all cases (r = 0.43, p<0.01).
cases (r = 0.35, p = 0.01). TAC showed a slight correlation with triglyceride lev-
Oxidative stress index was 239 (194-303) in the els in all cases (r = 0.44, p<0.01). TAC showed a mod-
patients with subclinical hypothyroidism and 174±41 erate correlation with BMI in all cases (r = 0.46,
in the healthy controls. A statistically significant differ- p<0.01).
ence of OSI levels was observed between two groups (p Figure 2 shows the comparison of paraoxonase
= <0,01). OSI showed a strong correlation with TSH activity, arylesterase activity, TAC, TOS, and OSI val-
levels in all cases (r = 0.60, p < 0,01). OSI showed a ues of the patients with subclinical hypothyroidism
strong correlation with TOS levels in all cases (r = 0.94, and the healthy cases.
p < 0,01). OSI showed a moderate negative correlation
with glucose levels in all cases (r = -0.52, p < 0,01).
Total oxidant level was 5.9 (5.4-7.4) in the pa- Discussion
tients with subclinical hypothyroidism and 3.9±0.8 in
the healthy controls. A statistically significant differ- SH is the most commonly encountered thyroid
ence of TOS levels was observed between two groups dysfunction (12). In patients with SH, the mecha-
(p <0,01). TOS showed a strong correlation with TSH nism of atherosclerosis may be attributed to lipid ab-
level in all cases (r = 0.69, p<0.01). TOS levels showed normalities (1, 3-5). While some studies revealed
a moderate correlation with total antioxidant capacity higher levels of serum cholesterol in the cases with
in all cases (r = 0.46, p <0.01). TOS showed a moder- SH, others showed no differences between SH pa-
ate negative correlation with glucose levels in all cases tients and healthy controls (13-15). Subclinical hy-
(r = -0.56 , p<0.01). pothyroidism is a risk factor for atherosclerosis due to
Total antioxidant capacity was 2.5±0.2 in the pa- the increased levels of LDL cholesterol and to de-
tients with subclinical hypothyroidism and 2.3±0.2 in creased levels of HDL cholesterol (1, 3-5). In some
the healthy controls. A statistically significant differ- studies, it was shown that normal serum level of TSH
ence of TAC levels was observed between two groups has an inverse effect on the levels of serum lipopro-
(p <0,01). TAC showed a moderate correlaytion with teins (16-18). An increase of 1 mIU/ml in the level of
urea levels in the healthy control group (r = 0.54, p = serum TSH increases serum total cholesterol concen-
10-cebeci:cebeci 28-02-2012 11:46 Pagina 219

Oxidative stress in subclinica hypothyroidism 219

tration by 0.09 mmol/L (3.5 mg/dl) in women and by During the acute phase reaction, a significant de-
0.16 mmol/L (6.2 mg/dl) in men (16). Due to these crease was observed in the PON1 activity (27). Mack-
lipid abnormalities, subclinical hypothyroidism may ness et al. reported that serum PON1 activity and
be considered as a risk factor for atherosclerosis (19, concentration was decreased within 2 hours following
20). In the Rotterdam study (61), in the post- the onset of the symptoms of myocardial infarction,
menopausal women, a strong correlation was found that the level of PON1 remained unchanged during
between subclinical hypothyroidism and atheroscle- 42 days following the myocardial infarction although
rotic cardiovascular diseases, independent from classi- the acute phase reaction was over, and that this de-
cal risk factors as smoking, hypertension, hypercholes- crease of PON1 activity might be pre-existing (28).
terolemia and diabetes mellitus. In the study per- These data support the idea that PON 1 may be play-
formed by Ba kol et al. (22), it was found that lipid ing a role in the atherosclerotic process.
peroxidation plays an important role in the pathogen- In our study, we found that serum paraoxonase
esis of atherosclerosis developed during the hypothy- activity was significantly lower in the patients with
roidism. Many investigators reported the protective subclinical hypothyroidism compared to control group
effect of HDL against the oxidation of LDL in sever- (p=0.01). In the study performed by Başkol et al. (22),
al studies. PON 1, an antioxidant enzyme found in PON 1 activity was found to be lower in the pre-treat-
the structure of HDL, contributes to the protective ef- ment patients compared to control group and post-
fect of HDL by preventing the oxidation of LDL treatment cases of hypothyroidism. Post-treatment
(6,7). Durrington et al. (23), in the study in which mean PON 1 activity for hypothyroidism showed a
they aimed to realize the hypothesis that states that significant increase but still remained significantly
PON 1 is responsible to destruct the lipid peroxides lower compared to control group. In the study con-
before the accumulation on LDL, observed that puri- ducted by Millionist et al. (29), PON 1 activity was
fied PON 1 is effective in the prevention of the lipid found to be similar among the patients with subclini-
peroxidation of LDL. In the study performed by Avi- cal hypothyroidism and control group. In another
ram et al. (24), they observed that although PON 1 study performed by Azizi et al. (30), both the patients
alone has a greater effect for the prevention of LDL with hyperthyroidism and hypothyroidism showed a
oxidation compared to Lecithin Cholesterole acyl lower PON 1 activity compared to control group.
transferase (LCAT) and apo A1, the total effect of the In our study, in addition, paraoxonase did not
combination of PON 1, LCAT and apo A1 was show any correlation with HDL in the group with
stronger than that of PON 1 alone. Platelet activator subclinical hypothyroidism (r=0.18, p=0.37). In the
factor acethile transfearse( PAFAH) activity observed study performed by Jayakumari et al. (31), in the
on LDL prevents coronary artery disease indepen- healthy controls, while PON1 activity was positively
dently from the genetic effect. By contrast, PAFAH correlated with HDL cholesterol, in the presence of
activity observed on HDL is not related to the disso- coronary artery disease, they showed a negative corre-
ciation of the enzymes like in LDL, but to PON 1 lation. However, in the study performed by enturk et
(25). It was reported that, if HDL has no PON 1 ac- al. (32), no correlation was found between PON 1 ac-
tivity, PAFAH can’t protect LDL against lipid perox- tivity and HDL levels in the patients with acute coro-
idation (9). In many studies, it was shown that HDL- nary syndrome.
dependent PON prevents not only LDL oxidation but PON 1 is an ester hydrolase with both
also HDL oxidation (26). This effect is related to the arylesterase and paraoxonase activities. Polymorphism
ability of PON to hydrolyze the lipoprotein-mediated has an effect on its ability to prevent the LDL oxida-
peroxides. It was suggested that a low PON1 serum tion. Polymorphism does not show an effect on the
activity despite the normal HDL levels would lead to arylesterase activity, which is considered as the main
a decrease in the protective effect of HDL against indicator of protein concentration independently of
LDL oxidation and thereby, to an increase in the inci- the changes of PON 1 activity. In a study performed,
dence of atherosclerosis. it was shown that arylesterase activity of PON 1 was
10-cebeci:cebeci 28-02-2012 11:46 Pagina 220

220 E. Cebeci, F. Alibaz Oner, M. Usta, S. Yurdakul, M. Erguney

decreased by approximately 50% during LDL oxida- oxidative stress compared to control group (p<0.01).
tion. In our study, serum arylesterase activity was In addition, oxidative stress index was significantly
found to be significantly lower in the patients with higher in the group with subclinical hypothyroidism
subclinical hypothyroidism compared to control group compared to healthy controls (p<0.01).
(p=0.03). In the study conducted by Coria et al. (33), While total antioxidant capacity provides infor-
arylesterase activity did not show a difference among mation about all antioxidants existing in the organism,
women with obvious hypothyroidism, subclinical hy- malonylaldehyde (MDA) is a lipid peroxidation mark-

formed by Şenturk et al. (32), serum arylesterase ac-

pothyroidism and euthyroidism. In the study per- er used in the increased oxidative stress-related lipid
peroxidation. In our study, we found significantly in-
tivity was lower in the patients with acute coronary creased total antioxidant capacity in the group with
syndrome. In the study performed by Gamboa et al. subclinical hypothyroidism compared to control group
(34), in the Mexican patients with chronic heart dis- (p<0.01). In the study performed by Torun et al. (39),
ease, both paraoxonase and arylesterase activity were it was investigated how hypothyroidism and subclini-
found to be significantly lower compared to control cal hypothyroidism influence serum MDA and TAC
group. and, as a result, MDA was found to be higher in the
As mentioned before, since PON1 enzyme pre- patients with hypothyroidism and subclinical hy-
vents the oxidation of lipid peroxides considered as a pothyroidism compared to control group but, TAC
major factor especially in atherosclerosis, it is a part of levels did not show a significant difference between
antioxidant defense system. PON hydrolyzes not only the groups.
the lipoprotein-derived peroxides but also the hydro- The genetic structure of PON 1 varies across the
gen peroxide. Hydrogen peroxide is the main reactive individuals, populations and environmental condi-
oxygen species produced by arterial wall cells during tions. PON 1 is influenced by nutritional style. In
the atherogenesis and, under oxidative stress, it is con- many studies, the relation between the intake of an-
verted to reactive oxygen particle, which causes to tioxidant and atherogenic conditions was investigated
LDL oxidation and passes to subendothelium easily. (40, 41). In the previous studies, it was shown that
Hydrolization of hydrogen peroxide by PON is im- serum PON activity was lower in obese patients. In
portant in the elimination of potent oxidants that play the study performed by Ferretti et al. (42), it was
a role in the atherosclerosis. shown that increased oxidative stress observed in the
The knowledge about the mechanism by which obese women might be associated with the decrease of
hypothyroidism influence the oxidative stress is limit- PON1 activity. In another study performed by Tabur
ed and conflicting and very few is known about oxida- et al. (43), no significant difference was found between
tive stress observed in the subclinical hypothyroidism. obese group and healthy control group in terms of
In the study performed by Resch et al. (35), it was PON/ARE activity. In our study, a significant differ-
shown that both hyperthyroidism and hypothyroidism ence was observed between the patients with subclin-
were associated with increased oxidative stress involv- ical hypothyroidism and the healthy cases in terms of
ing enzymatic and non-enzymatic antioxidants. In the BMI (26±2 vs. 23±3) (p<0.01). Therefore, although it
study performed by Sarandöl et al. (36), increased ox- is thought that obesity contributes to this result of de-
idative stress was observed in subclinical hypothy- creased PON/ARE activity, the relation between obe-
roidism. In the study performed by Erdamar et al (37), sity and PON/ARE is controversial.
an increase of the development of reactive oxygen Consequently, in the subclinical hypothyroidism,
species and of impaired antioxidant system in both the paraoxonase and arylesterase activities were signifi-
patients with hyperthyroidism and hypothyroidism. cantly lower and oxidative stress was significantly
In the animal study performed by Venditti et al. (38), higher. Again, in subclinical hypothyroidism, lower
the rats with hypothyroidism showed an increased paraoxonase and arylesterase activities indicated in-
predisposition for oxidative stress in the heart and its creased oxidative damage. This may be useful to eluci-
muscles. In our study, we found significantly increased date the formation mechanism of atherosclerosis in
10-cebeci:cebeci 28-02-2012 11:46 Pagina 221

Oxidative stress in subclinica hypothyroidism 221

subclinical hypothyroidism. Moreover, these results 14. Geul KW, Sluisveld ILL, Grobbee DE, et al. The impor-
suggested that paraoxonase and arylesterase activities tance of thyroid microsomal antibodies in the development
of elevated serum TSH in middle – aged women: Associa-
may be also used for the determination of therapeutic tion with serum lipids. Clin Endocrimal 1993; 39: 375-80.
response and during the follow-up. Large, random- 15. Staub JJ, Althaus BU, Engler H, et al. Spectrum of subclin-
ized, controlled studies with greater patient sample are ical and overt hypothyroidism: effect on thyrotrophin, pro-
warranted. lactin and thyroid reverse, and metabolic impact on periph-
eral target tissues. Am J Med 1992; 92: 631-41.
Limiting points of our study may be listed as fol- 16. Bindels AJ, Westendorp RG, Forlich M, et al. The preve-
lows: small number of patients; significantly higher lance of subclinical hypothyroidism at different total plas-
BMI in the patient group; exclusion of coronary artery ma cholesterol levels in middle aged men and women: a
disease in our groups in terms of symptoms, anamne- need far case-finding? Clin Endocrinol 1999; 50: 217-220.
17. Michalopoulous G, Alevizaki M, Piperingos G, et al. High
sis and electrocardiogram.
serum cholesterol levels in persons with high normal TSH
levels: should one extend the definition of subclinical hy-
pothyroidism. Fur J Endocrinol 1998; 138: 141-5.
References 18. Bakler SJL, Ter Matten JC, Popp-Snijders C, et al. The re-
lationship between thyrothropin and low density lipopro-
1. Canaris GJ, Manowitz NR, Major G, Ridgway EC. The tein cholesterolis modified by insulin sensitivity in healthy
Colorado thyroid disease prevelance study. Arch Intern Med euthyroid subjects. J Clin Endocrinol Metab 2001; 86: 1206-
2000; 160: 526-34. 11.
2. Zulewski H, Muller B, Exer P, Miserez AR, Staub JJ. 7 Es- 19. Kahaly GJ, Dillmann WH. Thyroid hormone action in the
timation of tissue hypothyroidism by a new clinical heart. Endocrine Reviews 2005; 26 704-28.
score:evaluation of patients with various grades of hypothy- 20. Fazio S, Palmieri EA, Lombardi G, Biondi B. Effects of
roidism and controls. J Clin Endocrinol Metab 1997; 82: thyroid hormone on the cardiovascular system. Recent
771-6. progress in Hormone Research 2004; 59 31-50.
3. Tanis BC, Westendorp RGJ, Smelt AHM. Effect of thy- 21. Hak AE, Pols HAP, Visser TJ, et al. Subclinical hypothy-
roid substitution on hypercholesterolemia in patients with roidism is an independent risk factor for atherosclerosis and
subclinical hypothyroidism: a reanalysis of intervention myocardial infarction in elderly women: The Rotterdam
studies. Clin Endocrinol 1996; 44: 643-9. Study. Ann Intern Med 2000; 132: 270-8.
4. Kahaly GJ. Cardiovascular and atherogenic aspects of sub- 22. Başkol G, Atmaca H, Tanrıverdi F, Başkol M, Koçer C,
clinical hypothroidism. Thyroid 2000; 10: 665-79. Bayram F. Oxidative stress and enzymatic antioxidant sta-
5. Panese MD, Ladenson PW, Meinert CL, et al. Effect of tus in patients with hypothyroidism before and after treat-
thyroxine therapy on serum lipoproteins in patients with ment. Exp Clin Endocrinol Diabetes 2007; 115 (8): 522-6.
mild thyroid failure: a guantitative review of the literature. 23. Durrington PN, Mackness B, Mackness MI. The hunt for
J Clin Endocrinol Metab 2000; 85: 2993-3001. nutritional and pharmacological modulators of paraoxonase
6. Mackness MI, Arrol S, Durrington PN. Paraoxonase pre- [Editorial] Arterioscler Thromb Vasc Biol 2002; 22: 1248-50.
vents accumulation of lipoperoxides in low-density lipopro- 24. Aviram M, Rosenblat M, Billecke S, et al. Human serum
tein. FEBS Lett 1991; 286: 152-4. paraoxonase (PON1) is inactivated by oxidised low density
7. Ekmekçi Ö, Donma O, Ekmekçi H. Paraoksonaz Cerrah- lipoprotein and preserved by antioxidants. Free Radic Biol
paşa Tıp Dergisi. 2004; 35(2). Med 1999; 26: 892-904.
8. Scandinavian Simvastatin Survival Study Group. Ran- 25. Mackness MI, Arrol S, Abbott CA, Durrington PN. Pro-
domised Trial Of Cholesterol Lowering n 4444 Patient tection of low-density lipoprotein against oxidative modifi-
With Coronary Heart Disease. Lancet 1994; 344: 1383-9. cation by high-density lipoprotein associated paraoxonase.
9. Durrington PN, Mackness B, Mackness MI. Paraoxonase Atherosclerosis 1993; 104: 129-35.
and Atherosclerosis. Arterioscler Thromb Vasc Biol 2001; 21: 26. Berliner JA, Navab M, et al. Atherosclerosis: basic mecha-
473-80. nisms. Oxidation, inflammation, and genetics. Circulation
10. Erel O. A new automated colorimetric method for measur- 1995; 91: 2488-96.
ing total oxidant status. Clin Biochem 2005; 38: 1103-11. 27. Navab M, Hama SY, Van Lenten BJ, et al. Mildly oxidized
11. Erel O. A novel automated method to measure total an- LDL induced an increased apolipoprotein J/paraoxonase
tioxidant response against potent free radical reactions. Clin ratio. J Clin Invest 1997; 99: 2005-20.
Biochem 2004; 37: 112-9. 28. Ayub A, Mackness MI, Arrol S, Mackness B, Patel J, Dur-
12. Fatourechi V. Subclinical thyroid disease. Mayo Clin Proc rington PN. Serum paraoxonase after myocardial infarc-
2001; 76: 413-6. tion. Arterioscler Thromb Vasc Biol 1999; 19: 330-5.
13. Tunbridge WMG, Evered DC, Hall R, et al. The spectrum 29. Milionis HJ, Tambaki AB, Kanioglou CN, Elisaf MS, Tse-
of thyroid disease in a community: the Whickham survey. lepis AD, Tsatsoulis A. Thyroid substitution therapy in-
Clin Endocrinal 1977; 7: 481-93. duced high-density lipoprotein-associated platelet-activat-
10-cebeci:cebeci 28-02-2012 11:46 Pagina 222

222 E. Cebeci, F. Alibaz Oner, M. Usta, S. Yurdakul, M. Erguney

ing factor-acetylhyrolase in patient with subclinical hy- thyroid state on lipid peroxidation, antioxidant defences,
pothyroidism: a potential antiatherogenic effect. Thyroid and susceptibility to oxidative stress in rat tissues. J En-
2005; 15 (5): 455-60. docrinol 1997; 155 (1): 151-7.

İşbilen E,Tütüncü NB. Serum total antioxidant status an

30. Azizi F, Raiszadeh F, Solati M, Etemadi A, Rahmani M, 39. Torun AN, Kulaksızoğlu S, Kulaksızoğlu M, Pamuk BO,
Arabi M. Serum paraoxonase 1 activity is decreased in thy-
roid dysfunction J Endocrinol Invest 2003; 26: 703-9. lipid peroxidation marker malondialdehyde levels in overt
31. Jayakumari N,Thejaseebai G. High prevelance of low and subclinical hypothyroidism. Clin Endocrinol (Oxford)
serum paraoxonase-1 in subjects with coronary artery dis- 2009; 70 (3): 469-74.

32. Şentürk T, Sarandol E, Gululu S, et al. Serum arylesterase

ease. J Clin Biochem Nutr 2009; 45 (3): 278-84. 40. Hennekens C, Buring J, Manson J, Stampfer M, Rosner B,
Cook N. Lack of effect of long-term supplementation with
activity is negatively correlated with inflammatory markers beta carotene on the incidence of malignant neoplasm and
in patients with acute coronary syndromes. Saudi Med J cardiovascular disease. N Engl J Med 1996; 334: 1145-59.
2009; 30 (3): 334-9. 41. Catapano A, Maggi F, Tragni E. Low density lipoprotein
33. Coria MJ, Pastran AI, Gimenez MS. Serum oxidative stress oxidation, antioxidants, and atherosclerosis. Curr Opin Car-
parametres of women with hypothyroidism. Acta Biomed diol 2000; 15: 355-63.
2009; 80 (2): 135-9. 42. Ferretti G, Bacchetti T, Moroni C, et al. Paraoxonase activ-
34. Gamboa R, Regalado JC, Huesca-Gómez C, et al. Low ity in high-density lipoproteins: a comparison between
paraoxonase and arylesterase plasma activities in Mexican healthy and obese females. J Clin Endocrinol Metab 2005;
patients with coronary artery disease. Arch Cardiol Mex 90 (3): 1728-33.
2008; 78 (4): 360-8. 43. Tabur S, Torun AN, Sabuncu T, et al. Non-diabetic meta-
35. Helsel G, Tatzber F, Sinzinger H. Antioxidant status in bolic syndrome and obesity do not affect serum paraox-
thyroid dysfunction. Clin Chem Lab Med 2002; 40 (11): onase and arylesterase activities but do affect oxidative
1132-4. stress and inflammation. . Eur J Endocrinol 2009 Dec 18.
36. Sarandöl E, Taş S, Dirican M, Serdar Z. Oxidative stress
and serum paraoxonase activity in experimental hy-
poyhrodism:effect of vitamin E supplementation. Cell
Accepted: November 19th 2011
Biochem Funct 2005; 23 (1): 1-8. Correspondence: Fatma Alibaz Oner
37. Erdamar H, Demirci H, Yaman H, et al. The effect of hy- Merkez mahallesi, Ozdenler sokak,
pothyroidism, hyperthyroidism,and their treatment on pa- Osmanbeyevleri A2 blok,
rameters of oxidative stress and antioxidant status. Clin Daire:13 Güngören/İstanbul/Tur
Chem Lab Med 2008; 46 (7): 1004-10. Telephone : 0090 505 6821848
38. Venditti P, Balestrieri M, Di Meo S, De Leo T. Effect of E-mail: [email protected]