Background
Methods
Study population
Ethics, consent and permissions
Covariate assessment
Mortality ascertainment
Oxidative stress serum marker measurement
Analytical study sample
Statistical analyses
Baseline characteristics | HAPIEE Poland | HAPIEE Czech Republic | HAPIEE Lithuania | ESTHER Germany | ||||
---|---|---|---|---|---|---|---|---|
Cases (Deaths) | Eligible controls | Cases (Deaths) | Eligible controls | Cases (Deaths) | Eligible controls | Cases (Deaths) | Controls | |
Total sample size | 525 | 1498 | 518 | 1776 | 390 | 1278 | 269 | 3,758 |
Age (years) | 62.9 (56.7; 67.0)* | 62.1 (55.8; 66.5) | 63.6 (58.6; 67.4) | 63.0 (57.9; 66.8) | 66.5 (61.1; 70.3) | 66.1 (60.5; 70.1) | 74.1 (70.0; 78.1)* | 69.2 (64.3; 74.0) |
45 to <60 | 190 (36.2) | 594 (39.7) | 154 (29.7) | 559 (31.5) | 79 (20.3) | 292 (22.9) | 10 (3.7)* | 345 (9.2) |
60 to <65 | 126 (24.0) | 355 (23.7) | 144 (27.8) | 518 (29.2) | 83 (21.3) | 265 (20.7) | 18 (6.9)* | 681 (18.1) |
65 to <70 | 198 (37.7) | 507 (33.9) | 198 (38.2) | 634 (35.7) | 124 (31.8) | 391 (30.6) | 42 (15.6)* | 1020 (27.1) |
70 to <85 | 11 (2.1) | 42 (2.8) | 22 (4.3) | 65 (3.7) | 104 (26.7) | 330 (25.8) | 199 (74.0)* | 1712 (45.6) |
Male sex | 357 (68.0) | 1015 (67.8) | 339 (65.4) | 1170 (65.9) | 261 (66.9) | 830 (65.0) | 158 (58.7)* | 1636 (43.5) |
Education | ||||||||
Low | 90 (17.2)* | 168 (11.2) | 90 (17.5)* | 175 (10.0) | 68 (17.8)* | 130 (10.3) | 192 (73.3) | 2633 (71.1) |
Medium | 322 (61.5)* | 842 (56.2) | 377 (73.5)* | 1296 (73.7) | 181 (47.4)* | 463 (36.6) | 59 (22.5) | 852 (23.0) |
High | 112 (21.4)* | 488 (32.5) | 46 (9.0)* | 287 (16.3) | 133 (34.8)* | 672 (53.1) | 11 (4.2) | 218 (5.9) |
BMI (kg/m2) | 27.4 (24.5; 30.9) | 27.9 (25.1; 30.7) | 28.7 (25.7; 32.0)* | 28.0 (25.5; 30.9) | 28.5 (25.4; 32.8) | 29.0 (25.7; 32.1) | 28.3 (24.9; 31.2) | 27.8 (25.1; 30.9) |
<20 | 13 (2.5) | 24 (1.6) | 10 (1.9)* | 20 (1.1) | 11 (2.8)* | 10 (0.8) | 5 (2.0) | 47 (1.3) |
20 to <25 | 130 (24.9) | 330 (22.1) | 92 (17.8)* | 344 (19.4) | 74 (19.0)* | 236 (18.5) | 60 (23.4) | 857 (23.2) |
25 to <30 | 222 (42.5) | 682 (45.6) | 207 (40.0)* | 827 (46.6) | 154 (39.5)* | 516 (40.4) | 112 (43.6) | 1625 (44.0) |
30 to <35 | 110 (21.1) | 362 (24.2) | 149 (28.8)* | 450 (25.4) | 98 (25.1)* | 369 (28.9) | 52 (20.2) | 859 (23.3) |
≥35 | 47 (9.0) | 98 (6.6) | 60 (11.6)* | 134 (7.6) | 53 (13.6)* | 147 (11.5) | 28 (10.9) | 304 (8.2) |
Smoking | ||||||||
Never | 124 (23.8)* | 598 (40.0) | 140 (27.5)* | 761 (43.6) | 176 (46.2) * | 742 (58.7) | 100 (38.8)* | 2119 (57.3) |
Former | 175 (33.5)* | 510 (34.1) | 192 (37.6)* | 598 (34.3) | 99 (26.0) * | 295 (23.3) | 123 (47.7)* | 1310 (35.4) |
Current | 223 (42.7)* | 386 (25.8) | 178 (34.9)* | 386 (22.1) | 106 (27.8) * | 227 (18.0) | 35 (13.6)* | 271 (7.3) |
Alcohol consumption (g/day) | 0 (0; 11.4)* | 0 (0; 25.4) | 11.4 (2.7; 31.9)* | 14.3 (5.7; 30.3) | 0 (0; 8) | 1.4 (0; 10.3) | 3.4 (0; 13.5)* | 6.7 (0; 14.4) |
Vigorous physical activity | 331 (67.8)* | 1078 (75.4) | 298 (60.8)* | 1295 (74.7) | 176 (46.4)* | 742 (58.7) | 87 (41.6)* | 2067 (62.4) |
Total cholesterol (mg/dL) | 218 (192; 251) | 219 (195; 247) | 213 (186; 239)* | 218 (194; 247) | 220 (190; 251)* | 225 (200; 255) | 211 (180; 249)* | 233 (202; 265) |
<200 | 180 (34.3) | 443 (29.7) | 206 (39.9)* | 550 (31.0) | 124 (31.8)* | 323 (25.4) | 102 (38.1)* | 868 (23.1) |
200 to <280 | 297 (56.6) | 930 (62.1) | 272 (52.6)* | 1088 (61.3) | 230 (59.0)* | 801 (62.9) | 135 (50.4)* | 2278 (60.7) |
≥280 | 48 (9.1) | 125 (8.3) | 39 (7.5)* | 138 (7.8) | 36 (9.2)* | 149 (11.7) | 31 (11.6)* | 609 (16.2) |
HDL cholesterol (mg/dL) | 51 (42; 61)* | 52 (44; 61) | 48 (40; 58)* | 49 (41; 60) | 53 (43; 63)* | 54 (46; 65) | 54 (45; 64)* | 59 (49; 70) |
<40 | 97 (18.5)* | 187 (12.5) | 132 (25.5) | 369 (20.9) | 72 (19.0)* | 133 (10.6) | 38 (14.2)* | 221 (5.9) |
40 to <80 | 392 (74.7)* | 1237 (82.6) | 359 (69.4) | 1313 (74.3) | 280 (73.7)* | 1024 (81.7) | 207 (77.2)* | 3098 (82.5) |
≥80 | 36 (6.9)* | 74 (4.9) | 26 (5.0) | 86 (4.9) | 28 (7.4)* | 96 (7.7) | 23 (8.6)* | 436 (11.6) |
CRP (mg/L) | 2.6 (1.1; 5.6)* | 1.7 (0.8; 3.1) | 2.7 (1.12; 5.6)* | 1.9 (0.9; 3.6) | 2.7 (1.2; 5.6)* | 1.6 (0.8; 3.2) | 2.8 (1.3; 6.2)* | 1.8 (0.9; 3.7) |
≤3 | 294 (56.0)* | 1100 (73.4) | 281 (54.3)* | 1218 (68.6) | 214 (54.9)* | 931 (72.9) | 143 (53.2)* | 2567 (68.3) |
>3 to ≤10 | 165 (31.4)* | 328 (21.9) | 185 (35.7)* | 474 (26.7) | 125 (32.1)* | 276 (21.6) | 96 (35.7)* | 967 (25.7) |
>10 | 66 (12.6)* | 70 (4.7) | 52 (10.0)* | 84 (4.7) | 51 (13.1)* | 71 (5.6) | 30 (11.2)* | 224 (6.0) |
eGFR (mL/min/1.73 m2) | 89.2 (76.1; 97.5) | 88.6 (77.7; 95.7) | 78.2 (64.9; 90.4)* | 80.1 (69.3; 90.6) | 85.0 (70.0; 93.4) | 86.5 (74.1; 94.2) | 63.9 (51.8; 76.9)* | 71.8 (62.7; 80.7) |
≥60 | 487 (92.7)* | 1440 (96.1) | 426 (82.2)* | 1600 (90.1) | 336 (86.2)* | 1184 (92.6) | 163 (60.6)* | 3001 (80.0) |
<60 | 38 (7.2)* | 58 (3.9) | 92 (17.8)* | 176 (9.9) | 54 (13.9)* | 94 (7.4) | 106 (39.4)* | 757 (20.1) |
History of hypertension | 323 (61.9)* | 837 (55.9) | 300 (58.6)* | 902 (50.9) | 248 (65.1) | 788 (62.4) | 221 (82.2)* | 2637 (70.2) |
History of diabetes | 111 (21.2)* | 207 (13.8) | 123 (24.0)* | 243 (13.7) | 56 (14.7)* | 91 (7.2) | 108 (40.2)* | 892 (23.7) |
History of MI | 110 (21.1)* | 147 (9.9) | 69 (14.1)* | 104 (6.1) | 71 (18.6)* | 121 (9.6) | 50 (18.6)* | 217 (5.8) |
History of stroke | 31 (6.0)* | 33 (2.2) | 40 (8.2)* | 59 (3.5) | 35 (9.2)* | 68 (5.4) | 46 (17.1)* | 262 (7.0) |
History of cancer | 52 (9.9)* | 67 (4.5) | 53 (10.2)* | 93 (5.2) | 58 (14.9)* | 104 (8.1) | 94 (34.9)* | 428 (11.4) |
d-ROMs (Carr U) | 368 (324; 425)* | 349 (309; 394) | 404 (350; 470)* | 381 (335; 439) | 372 (330; 421)* | 356 (317; 393) | 369 (320; 406)* | 350 (305; 395) |
≤340 | 178 (33.9)* | 650 (43.4) | 102 (19.7)* | 483 (27.2) | 123 (31.5)* | 498 (39.0) | 96 (35.7)* | 1649 (43.9) |
341–400 | 167 (31.8)* | 514 (34.1) | 146 (28.2)* | 564 (31.8) | 138 (35.4)* | 500 (39.1) | 94 (34.9)* | 1250 (33.3) |
401–500 | 143 (27.2)* | 314 (21.0) | 185 (35.7)* | 561 (31.6) | 101 (25.9)* | 258 (20.2) | 70 (26.0)* | 789 (21.0) |
>500 | 37 (7.0)* | 20 (1.3) | 85 (16.4)* | 168 (9.5) | 28 (7.2)* | 22 (1.7) | 9 (3.3)* | 70 (1.9) |
TTL (μmol/L) | 509 (445; 566)* | 518 (464; 570) | 406 (363; 452) | 411 (371; 450) | 313 (273; 357)* | 321 (283; 359) | 303 (239; 356) * | 335 (284; 383) |
Cause of death | ||||||||
CVD | 165 (32.0) | n.a. | 189 (36.6) | n.a. | 155 (39.7) | n.a. | 51 (31.7) | n.a. |
Cancer | 235 (45.5) | n.a. | 235 (45.5) | n.a. | 158 (40.5) | n.a. | 74 (46.0) | n.a. |
Non-CVD, non-cancer | 116 (22.5) | n.a. | 93 (18.0) | n.a. | 77 (19.7) | n.a. | 36 (22.4) | n.a. |
Unknown | 9 (n.a.) | n.a. | 1 (n.a.) | n.a. | 0 (n.a.) | n.a. | 108 (n.a.)a
| n.a. |
Results
Comparison of baseline characteristics of the analysed cohorts and of cases and controls
Cross-sectional associations of established risk factors for mortality and high oxidative stress levels
Risk factors for mortality | Odds of high oxidative stress by | |
---|---|---|
d-ROMsa
| TTLb
| |
Increasing age | – | ↑ |
Male sex | ↓ | ↓ |
Decreasing education | – | (↓)c
|
Increasing BMI | (↓)d
| ↑ |
Former smoking | ↑ | – |
Current smoking | ↑ | – |
No alcohol consumption | – | – |
High alcohol consumptione
| – | – |
No performance of vigorous physical activity | – | – |
Increasing total cholesterol | ↑ | – |
Decreasing HDL cholesterol | (↓)f
| – |
Increasing CRP | ↑ | ↑ |
Renal impairmentg
| – | ↑ |
History of hypertension | ↑ | – |
History of diabetes | – | – |
History of MI | ↑ | – |
History of stroke | – | – |
History of cancer | ↑ | – |
Longitudinal association of oxidative stress markers with mortality outcomes
Outcome | Oxidative stress marker | Modelling | ncases
| Model 1 | Model 2 | Model 3 | Model 4 |
---|---|---|---|---|---|---|---|
RR (95 % CI)a
| RR (95 % CI)b
| RR (95 % CI)c
| RR (95 % CI)d
| ||||
All-cause mortality | d-ROMs | ≤340 Carr U | 499 | Ref | Ref | Ref | Ref |
341–400 Carr U | 545 | 1.27 (1.07–1.51)* | 1.21 (1.04–1.40)* | 1.20 (1.03–1.40)* | 1.13 (0.96–1.32) | ||
401–500 Carr U | 499 | 1.86 (1.58–2.17)* | 1.60 (1.35–1.89)* | 1.53 (1.29–1.83)* | 1.32 (1.10–1.59)* | ||
>500 Carr U | 159 | 4.48 (2.87–7.00)* | 3.79 (2.08–6.90)* | 2.99 (1.62–5.52)* | 2.30 (1.40–3.77)* | ||
d-ROMs | Increase per 1 SDe
| 1702 | 1.44 (1.35–1.53)* | 1.34 (1.25–1.43)* | 1.28 (1.19–1.36)* | 1.20 (1.12–1.29)* | |
TTL | Decrease per 1 SDf
| 1702 | 1.17 (1.04–1.33)* | 1.19 (1.07–1.32)* | 1.14 (1.06–1.23)* | 1.12 (1.04–1.21)* | |
CVD mortality | d-ROMs | ≤340 Carr U | 157 | Ref | Ref | Ref | Ref |
341–400 Carr U | 178 | 1.29 (1.00–1.67)* | 1.28 (0.97–1.70) | 1.28 (0.89–1.82) | 1.14 (0.83–1.56) | ||
401–500 Carr U | 171 | 1.71 (1.32–2.22)* | 1.78 (1.31–2.43)* | 1.81 (1.28–2.54)* | 1.49 (1.04–2.13)* | ||
>500 Carr Ug
| 54 | 5.16 (2.35–11.31)* | 5.09 (2.67–9.69)* | 4.86 (2.38–9.95)* | 4.34 (2.06–9.15)* | ||
d-ROMs | Increase per 1 SDe
| 560 | 1.53 (1.35–1.72)* | 1.44 (1.27–1.64)* | 1.37 (1.19–1.58)* | 1.30 (1.12–1.51)* | |
TTL | Decrease per 1 SDf
| 560 | 1.31 (1.17–1.47)* | 1.30 (1.15–1.48)* | 1.27 (1.10–1.47)* | 1.25 (1.09–1.45)* | |
Cancer mortality | d-ROMs | ≤340 Carr U | 198 | Ref | Ref | Ref | Ref |
341–400 Carr U | 224 | 1.27 (1.01–1.61)* | 1.18 (0.92–1.51) | 1.17 (0.91–1.52) | 1.08 (0.83–1.41) | ||
401–500 Carr U | 200 | 1.71 (1.32–2.21)* | 1.48 (1.12–2.75)* | 1.41 (1.05–1.89)* | 1.16 (0.85–1.57) | ||
>500 Carr U | 80 | 5.29 (3.16–8.85)* | 4.34 (2.31–8.16)* | 3.82 (1.79–8.18)* | 2.50 (1.31–4.78)* | ||
d-ROMs | Increase per 1 SDe
| 702 | 1.42 (1.29–1.56)* | 1.35 (1.20–1.52)* | 1.30 (1.14–1.47)* | 1.19 (1.05–1.35)* | |
TTL | Decrease per 1 SDf
| 702 | 1.05 (0.92–1.19) | 1.07 (0.96–1.19) | 1.01 (0.90–1.13) | 0.98 (0.87–1.09) | |
Non-CVD, non-cancer mortality | d-ROMs | ≤340 Carr U | 103 | Ref | Ref | Ref | Ref |
341–400 Carr U | 99 | 1.15 (0.80–1.67) | 0.94 (0.52–1.68) | 0.97 (0.51–1.82) | 0.85 (0.48–1.49) | ||
401–500 Carr U | 99 | 2.14 (1.51–3.05)* | 1.49 (0.91–2.45) | 1.51 (0.89–2.55) | 1.16 (0.67–2.01) | ||
>500 Carr U | 21 | 3.32 (1.68–6.59)* | 1.98 (0.94–4.15) | 1.93 (0.83–4.45) | 1.56 (0.69–3.53) | ||
d-ROMs | Increase per 1 SDe
| 322 | 1.41 (1.22–1.63)* | 1.26 (1.08–1.47)* | 1.27 (1.07–1.51)* | 1.15 (0.96–1.37) | |
TTL | Decrease per 1 SDf
| 322 | 1.23 (1.07–1.42)* | 1.27 (1.02–1.60)* | 1.19 (0.94–1.48) | 1.15 (0.93–1.43) |
Additive risks by d-ROMs levels and TTL
High oxidative stress by | Proportion of population | ncases
| RR (95 % CI)c
| ||
---|---|---|---|---|---|
d-ROMsa
| TTLb
| ESTHER | HAPIEE controls | ESTHER + HAPIEE | ESTHER + HAPIEE |
No | No | 59 % | 49 % | 227 | Ref |
No | Yes | 18 % | 25 % | 108 | 1.34 (0.91–1.97) |
Yes | No | 16 % | 18 % | 155 | 1.72 (1.27–2.32)* |
Yes | Yes | 7 % | 9 % | 70 | 2.47 (1.58–3.98)* |
Subgroup analyses
Outcome | Stratum | ncases
| Increase of d-ROMs by 1 SDa
| Decrease of TTL by 1 SDb
|
---|---|---|---|---|
RR (95 % CI)c
| RR (95 % CI)c
| |||
Stratified by cohort/country | ||||
All-cause mortality | HAPIEE Poland | 525 | 1.29 (1.14–1.46)* | 1.14 (1.01–1.28)* |
HAPIEE Czech Republic | 518 | 1.33 (1.17–1.51)* | 1.05 (0.93–1.19) | |
HAPIEE Lithuania | 390 | 1.47 (1.25–1.71)* | 1.31 (1.10–1.57)* | |
ESTHER (Germany) | 269 | 1.33 (1.18–1.49)* | 1.31 (1.15–1.48)* | |
CVD mortality | HAPIEE Poland | 165 | 1.54 (1.21–1.95)* | 1.22 (0.98–1.53) |
HAPIEE Czech Republic | 189 | 1.56 (1.22–2.00)* | 1.25 (0.99–1.56) | |
HAPIEE Lithuania | 155 | 1.40 (1.06–1.85)* | 1.48 (1.06–2.06)* | |
ESTHER (Germany) | 51 | 1.24 (0.94–1.63) | 1.39 (1.06–1.84)* | |
Cancer mortality | HAPIEE Poland | 235 | 1.17 (0.98–1.41) | 1.06 (0.89–1.26) |
HAPIEE Czech Republic | 235 | 1.36 (1.13–1.63)* | 0.95 (0.79–1.14) | |
HAPIEE Lithuania | 158 | 1.60 (1.25–2.04)* | 1.18 (0.89–1.55) | |
ESTHER (Germany) | 74 | 1.40 (1.13–1.74)* | 1.21 (0.96–1.53) | |
Stratified by age | ||||
All-cause mortality | 45 to <60 yearsd
| 423 | 1.23 (1.04–1.45)* | 1.16 (1.01–1.34)* |
60 to <70 years | 933 | 1.39 (1.27–1.53)* | 1.16 (1.05–1.29)* | |
70 to <85 yearse, f
| 303 | 1.33 (1.17–1.52)* | 1.35 (1.18–1.55)* | |
CVD mortality | 45 to <60 yearsd
| 126 | 1.42 (1.01–2.00)* | 1.24 (0.91–1.69) |
60 to <70 yearsd
| 322 | 1.64 (1.35–2.00)* | 1.31 (1.09–1.56)* | |
70 to <85 yearse, f
| 90 | 1.28 (0.97–1.69) | 1.65 (1.22–2.24)* | |
Cancer mortality | 45 to <60 yearsd
| 177 | 1.21 (0.81–1.81) | 1.20 (0.96–1.50) |
60 to <70 yearsd
| 392 | 1.41 (1.21–1.64)* | 1.02 (0.86–1.21) | |
70 to <85 yearse, f
| 94 | 1.46 (1.13–1.87)* | 1.17 (0.89–1.52) | |
Stratified by sex | ||||
All-cause mortality | Women | 587 | 1.28 (1.13–1.44)* | 1.25 (1.05–1.50)* |
Men | 1115 | 1.40 (1.29–1.53)* | 1.18 (1.08–1.28)* | |
CVD mortality | Womend
| 157 | 1.42 (1.08–1.87)* | 1.28 (0.98–1.69) |
Men | 385 | 1.50 (1.27–1.76)* | 1.33 (1.13–1.56)* | |
Cancer mortality | Women | 257 | 1.31 (1.05–1.65)* | 1.16 (0.96–1.40) |
Men | 445 | 1.39 (1.21–1.59)* | 1.06 (0.93–1.21) | |
Stratified by history of MI | ||||
All-cause mortality | No history of MI | 1286 | 1.33 (1.22–1.41)* | 1.17 (1.04–2.61)* |
History of MIg
| 375 | 1.39 (1.17;1.65 )* | 1.19 (0.97–1.63) | |
CVD mortality | No history of MI | 379 | 1.35 (1.14–1.57)* | 1.22 (1.04–1.43)* |
History of MId, g
| 165 | 1.45 (1.04–2.02)* | 1.19 (0.88–1.61) | |
Stratified by history of cancer | ||||
All-cause mortality | No history of cancer | 1382 | 1.32 (1.23–1.42)* | 1.16 (1.05–1.29)* |
History of cancerg
| 257 | 1.49 (1.24–1.77)* | 1.24 (1.00–1.54)* | |
Cancer mortality | No history of cancer | 533 | 1.29 (1.15–1.45)* | 1.01 (0.89–1.14) |
History of cancerg
| 169 | 1.53 (1.19–1.97)* | 1.16 (0.91–1.47) | |
Stratified by inflammatory status | ||||
All-cause mortality | CRP ≤3 mg/L | 933 | 1.19 (1.08–1.31)* | 1.12 (0.97–1.30) |
CRP >3 mg/L | 769 | 1.26 (1.15–1.38)* | 1.16 (1.05–1.28)* | |
CVD mortality | CRP ≤3 mg/Ld
| 265 | 1.26 (1.00–1.58)* | 1.10 (0.90–1.35) |
CRP >3 mg/L | 275 | 1.28 (1.07–1.54)* | 1.22 (1.01–1.48)* | |
Cancer mortality | CRP ≤3 mg/L | 394 | 1.22 (1.04–1.43)* | 1.06 (0.90–1.26) |
CRP >3 mg/L | 308 | 1.27 (1.10–1.46)* | 1.07 (0.91–1.26) | |
Stratified by time-point of event during follow-up | ||||
All-cause mortality | ≤ year 2 | 419 | 1.46 (1.29–1.66)* | 1.29 (1.11–1.50)* |
> year 2 to ≤ year 4 | 597 | 1.31 (1.17–1.46)* | 1.18 (1.06–1.33)* | |
> year 4 to ≤ year 6 | 433 | 1.25 (1.09–1.43)* | 1.17 (1.02–1.33)* |