|Year : 2017 | Volume
| Issue : 2 | Page : 121-126
Association of hypertension and activity of angiotensin converting enzyme in malaria patients attending Sheik Muhammad Jidda General Hospital, Kano State, Nigeria
AM Abdulazeez1, M Ya'u2, B Kurfi2
1 Center for Biotechnology Research, Bayero University, Kano, Nigeria
2 Department of Biochemistry, Faculty of Basic Medical Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
|Date of Web Publication||5-Oct-2017|
Department of Biochemistry, Faculty of Basic Medical Sciences, College of Health Sciences, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
Background: Peptides of the renin angiotensin aldosterone system (RAAS) have been implicated in the pathogenesis of malaria infection; however, available data are limited. Thus, this study was aimed at determining the association between hypertension and activity of angiotensin converting enzyme (ACE) in malaria patients attending Sheikh Muhammad Jiddah General Hospital, Kano State, Nigeria. Materials and Methods: Four hundred and fifty consenting adults (300 malaria positive and 150 control participants) were evaluated. Data on sociodemographic characteristics were obtained using a questionnaire. ACE level was determined as described by Cushman and Cheung (1971) and blood pressure (BP) was evaluated using standard methods. Statistical Analysis: ACE activity and BP were expressed as mean ± SEM. Comparison between groups was carried out using one-way analysis of variance. Pearson's Chi-square (χ2) test was employed to establish association between Plasmodium infection, hypertension, sex, age, educational, and occupational status. P <0.05 was regarded as statistically significant. Results: A total of 300 (66.6%) patients tested positive for malaria, of which 60 (20%) were hypertensive. The prevalence differed significantly by gender, age group, and occupational status. The serum ACE activity was significantly lower in male (1.54 ± 1.04 μmol/min/ml) and female (2.01 ± 1.29 μmol/min/ml) patients with malaria compared to controls (7.09 ± 2.42 and 7.48 ± 2.42 μmol/min/ml, for males and females, respectively); and this further decreased with severity of infection. Moreover, the ACE activity of malaria patients with hypertension (11.67 ± 0.5 and 10.60 ± 0.40 μmol/min/ml) was significantly higher than nonhypertensive (3.20 ± 1.31 and 3.16 ± 0.74 μmol/min/ml) male and female patients, respectively. Conclusions: There was a significant association between the activity of ACE and hypertension in malaria infection, showing that ACE might play a significant role in the outcome of malaria.
Keywords: Angiotensin converting enzyme, hypertension, malaria, prevalence
|How to cite this article:|
Abdulazeez A M, Ya'u M, Kurfi B. Association of hypertension and activity of angiotensin converting enzyme in malaria patients attending Sheik Muhammad Jidda General Hospital, Kano State, Nigeria. Niger J Basic Clin Sci 2017;14:121-6
|How to cite this URL:|
Abdulazeez A M, Ya'u M, Kurfi B. Association of hypertension and activity of angiotensin converting enzyme in malaria patients attending Sheik Muhammad Jidda General Hospital, Kano State, Nigeria. Niger J Basic Clin Sci [serial online] 2017 [cited 2019 Jul 19];14:121-6. Available from: http://www.njbcs.net/text.asp?2017/14/2/121/216057
| Introduction|| |
Malaria is one of the most important global health problem, with approximately 189–327 million clinical cases reported worldwide and nearly a million deaths annually. Malaria infection caused by Plasmodium falciparum alone is associated with approximately 230 million cases and is responsible for most of the severe cases of the disease. Hypertension on the other hand is one of the most common clinical conditions which still remains one of the most important public health problem in the world. It is defined as systolic blood pressure ≥140 mmHg and diastolic blood pressure ≥90 mmHg. There are some indications that the burden of noncommunicable diseases including hypertension is increasing in epidemic proportions in Africa, and it is projected that up to three quarters of the world's hypertensive population will be in economically developing countries by the year 2025. In Nigeria, malaria accounts for an estimated 100 million cases and over 300,000 deaths per year, whereas hypertension affects 11.2% Nigerians (i.e., about 4.33 million). With increased prevalence of hypertension and endemicity of malaria in Nigeria, the resultant greater economic and health burden will no doubt be felt due to its population size.
Studies have demonstrated that standardized mean blood pressures (BPs) are higher in many parts of Asia and sub-Saharan Africa than those in high-income countries, resulting in a rise of cardiovascular disease in low- and middle-income countries (LMIC) against the background of continuing high burden of infectious diseases, one of which is malaria. Although malaria and hypertension do not have an obviously direct cross influence, both diseases have been shown to have physiopathologic similarities such as endothelial dysfunction, ischemia, and production of proinflammatory cytokines. Furthermore, recent studies have suggested that peptides of the renin angiotensin aldosterone system (RAAS) play a significant role in the pathogenesis of malaria and may influence its severity. The impairment of endothelial function, a key phenomenon of severe P. falciparum malaria, has been shown to occur due to homeostatic imbalance and the antagonistic interaction of nitric oxide (NO) and angiotensin II (Ang II) in several vascular diseases. However, the biologic mechanisms are still poorly understood in malaria.
Ang II is the main active product of RAAS that acts on the adrenal cortex, causing aldosterone release that stimulates reabsorption of sodium and water, which increases blood pressure. Ang II is produced by the action of angiotensin converting enzyme (ACE), a zinc metallopeptidase, on angiotensin I, an inactive decapeptide. ACE also plays important roles in the kinin-kallikrein cascade, where it metabolizes bradykinin, a strong vasodilator, forming the inactive metabolite bradykinin. In contrast, recent studies have shown that the actions of Ang II via the type 2 receptor are counter regulatory to those mediated via the AT1 receptor because Ang II acts via AT2 receptor to produce a vasodilator effect through bradykinin-dependent activation of endothelial nitric oxide synthase. Several studies have demonstrated the protective effect of Ang II on malaria., Other reports have shown that angiotensin peptides can cause impairment of the erythrocyte cycle of plasmodium, reducing the parasite growth in vitro,, though the biologic mechanisms have not been established. This has prompted research regarding the prevalence of hypertension in malaria infection in different parts of the world to pave the way for better understanding of whether malaria could have a possible driving evolutionary force for hypertension. This study was therefore aimed at determining the prevalence and risk factors of hypertension and to evaluate the activity of ACE in severe and non-severe malaria patients attending Sheik Muhammad Jidda Specialist Hospital, Kano State, Nigeria.
| Materials and Methods|| |
This was a cross-sectional study involving 450 male and female patients who were referred (between July to September, 2015) to the Haematology Department of Sheikh Muhammad Jiddah General Hospital, Kano State, Nigeria. Three hundred patients tested positive for malaria infection, whereas 150 tested negative (controls). The patients were chosen via simple random sampling. Approval was sought from the Hospital Management Board, Kano State, with an ethical clearance number HMB/GEN/488/VOL. 1. Individuals who consented and were between the ages of 18 and 80 years were included in the study, whereas those below 18 years and pregnant women were excluded. Those who refused to give their consent were also excluded. A standard questionnaire was made available. Sociodemographic data collected included gender, age, socioeconomic and educational status, as well as awareness about hypertension.
Determination of blood pressure
BP of individual patients was determined using a digital BP monitor (Boots Upper Arm Blood Pressure Monitor, Omron HEM-742-UK). Hypertension was defined as systolic BP greater than or equal to 140 mmHg and diastolic BP as greater than or equal to 90 mmHg.
Determination of parasitemia
Venous blood (5 cm 3) was aseptically collected from the patients and parasitemia determined as described by Cheesbrough. Patients were considered having severe P. falciparum malaria if they met the predefined, modified WHO criteria for severe malaria (hyperparasitemia >10% parasitemia).
Determination of ACE activity
The assay for ACE activity was determined using the Cushman and Cheung method, with some modifications. Briefly, blood was collected by venipuncture and serum separated by centrifuging at 2000 xg and 4°C for 10 minutes. About 50 μl of serum was added to 50 μl deionized water and the reaction was started by adding 0.2 ml of 5 mmol/L hippuric-histidyl-leucine (HHL). This was incubated at 37°C for 15 minutes. The reaction was terminated by adding 0.25 ml of 1.0 N hydrochloric acid and then 2.0 ml ethyl acetate to extract the hippuric acid formed by the action of ACE. This was centrifuged at 3600 xg for 2 min, and 1 ml of upper layer was transferred into a microcentrifuge tube and heated by dry bath at 100°C for 15 minutes to remove ethyl acetate by evaporation. The resulting hippuric acid was dissolved in 3.0 ml distilled water, and the absorbance was read at 228 nm. Serum enzyme activity was expressed in units, which corresponded to 1 μmol of hippuric acid released by hydrolysis of HHL per minute per milliliter serum.
ACE activity and BP were expressed as mean ± SEM. Comparison between groups was computed using one-way analysis of variance (ANOVA). Least significant difference (LSD) post-hoc test was applied for multiple comparisons between the groups. Pearson's Chi-square (χ2) test was employed to establish association between Plasmodium infection, hypertension, sex, age, and educational and occupational status. P < 0.05 was regarded as statistically significant.
Data analysis was carried out using Student Package for the Social Sciences version 20.0 (IBM Corporation).
| Results|| |
Out of 450 participants, 265 (58.9%) were males and 185 (41.1%) were females [Table 1]. The overall prevalence of malaria infection was 66.6%. There was a significant (P < 0.05) difference between males and females (47.4 vs 94.6%; χ2 = 110.4, P = 0.0001), age groups (χ2 = 35.6, P = 0.001), and occupational status (χ2 = 14.2, P = 0.01). The highest prevalence based on age (83.9%) was found in patients between the ages of 18 and 29, whereas those above 70 years had the least prevalence (36.8%). With respect to occupation, the highest prevalence was among the unemployed (79.3%) whereas retirees had the least prevalence (53.3%) [Table 2].
|Table 2: Prevalence and distribution of malaria among the participants according to age, gender, and educational and occupational status (n=450)|
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[Table 3] shows the prevalence of hypertension in malaria-positive patients according to age and gender. Out of the 300 malaria-positive patients, 60 (20%) were hypertensive. The gender-related prevalence was significantly (P < 0.05) different (χ2 = 4.20, P = 0.04), with the highest prevalence evident in females above 70 years compared to males (57.1 vs 14.3%), followed by those between the ages of 60 and 69 (44.0%).
|Table 3: Prevalence of hypertension among the malaria positive patients according to age and gender (n=300)|
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Regarding age group, the prevalence differed significantly (χ2 = 101.4, P = 0.0001), with those above 60 years having the highest prevalence (72%). None of those aged 18–29 years had hypertension while those between 30 and 39 years had a prevalence of 11.4% [Table 3].
The occupation-related prevalence of hypertension in malaria-positive patients is presented in [Table 4]. The prevalence in retirees (50%) was significantly (χ2 = 40.1, P = 0.0001) higher than that recorded for employed (8.7%) and unemployed (28.4%) patients.
|Table 4: Prevalence of hypertension among the malaria positive patients according to occupational status (n=300)|
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The activity of ACE decreased significantly (P < 0.05) in male and female patients with malaria compared to malaria-negative patients. Furthermore, there was a significant (P < 0.05) difference in ACE levels of male (1.54 ± 1.04 μmol/min/ml) and female (2.01 ± 1.29 μmol/min/ml) patients with malaria, as well as those in the control group [Table 5]. Based on severity, ACE activity was significantly (P < 0.05) lower in both male and female patients with severe malaria than those with mild or moderate malaria [Table 6].
|Table 5: Serum angiotensin converting enzyme (ACE) activity of malaria.positive and negative patients (n=450)|
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|Table 6: Serum angiotensin converting enzyme (ACE) activity based on severity of malaria in malaria positive participants (n=300)|
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The ACE activity of malaria-positive patients with hypertension was significantly (P < 0.05) higher than that of nonhypertensive patients. However, no statistical differences (P > 0.05) were observed between male and female hypertensive and nonhypertensive malaria-positive patients. The systolic and diastolic BP was significantly (P < 0.001) higher in hypertensive patients than nonhypertensive patients [Table 7].
|Table 7: Blood pressure and serum angiotensin converting enzyme (ACE) activity in hypertensive and non-hypertensive malaria positive patients (n=300)|
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| Discussion|| |
The prevalence of malaria infection in the study population was 66.6%, which falls within the recent estimated risk map of less than 20% to over 70% in some areas in Nigeria. According to Health reporters, there were over 22,000 deaths from malaria infection in Kano State in 2015. Several studies also reported very high prevalence of 62.5%, 51.7%, and 61.35%, respectively, within Kano metropolis.,, These findings show that malaria continues to be a leading cause of morbidity and mortality in Kano State, northwestern Nigeria. In conformity with the findings of this study, were high prevalence rates of 64.0%, 59.6%, and 58.0% reported in Kebbi, Awka, and Abuja, respectively. However, a higher prevalence was reported in Aba (86.4%) and Umuahia (74.4%), whereas an extraordinary population-based prevalence rate (99.2%) was reported among pregnant women in Enugu State. However, other studies have reported lower prevalence of malaria – 35.7% in patients attending the General Hospital, Makarfi, Kaduna State; 39.2% of 360 patients who visit primary healthcare facilities in Kano State; 36.6% in Plateau; and 27.29% in Sokoto. This variation can be attributed to different climatic conditions, less rainfall, and surface water that serve as mosquito breeding sites, along with the socioeconomic pattern of the population.
This study demonstrated that gender, age, and occupational status were significant risk factors associated with malaria infection among patients of this study area. The higher prevalence rate among female than that in male patients observed in this study agrees with previous findings reported by Azfar et al. who demonstrated a higher prevalence of malaria infection in females (56%) than males (44%). In addition, Gobir  reported a higher prevalence rate (61%) in females than males (38%) within Kano metropolis. However, the present finding contradicts the studies by Akanbi et al. and Abdullahi et al. who reported higher prevalence in males than females. Although there is no established scientific fact regarding the positive correlation between gender and susceptibility to malaria infection, some studies have demonstrated that the vague understandings of the methods of malaria transmission due to illiteracy  and lifestyle such as involvement in outdoor household responsibilities like cooking and washing, inability to access healthcare when needed, as well as the rate of unemployment among female gender in the region  may play significant roles.
This study also revealed that malaria prevalence significantly (P < 0.05) decreased as age group increased. This increment was higher among those aged 18–29 years (83.9%), followed by 30–39 years (66.0%) and the lowest prevalence among those >70 years (36.8) [Table 2]. This was in line with a previous report by Kanu et al. that, in Aba and Umuahia, there was a progressive decline in the prevalence of malaria infection from younger ages to those above 60 years of age. The high infection rate in this age group could be due to inadequate protection against mosquito bites or insufficient knowledge about malaria transmission. Moreover, the age group is made up of youths who are vulnerable to incessant bites of malaria vectors by exposing their bodies, especially when the weather is hot as they are least likely to use insecticide-treated nets.,,
The high malaria prevalence among unemployed (79.3%) patients is consistent with previous reports from other African countries demonstrating that malaria is more common among people of lower socioeconomic status who often live in poor housing conditions that increase their exposure to infection.,,,
Sixty out of the 300 malaria positive patients were hypertensive, giving a prevalence rate of 20%. This was within the prevalence rate of hypertension of 8.0–46.0% and 14.0–20.0% recorded from different parts of Nigeria. It also agrees with the prevalence rate of 20.2% reported in Benin City, south-south Nigeria  and overall prevalence among adults in Nigeria. The significant (P < 0.05) difference observed in male and female patients (χ2 = 4.20, P = 0.04), the different age groups (χ2 = 101.4, P = 0.0001), and occupational status (χ2 = 40.06, P = 0.0001) of these patients shows that gender, age, and occupational status are important risk factors associated with hypertension in malaria-positive patients. Although there is paucity of information on the prevalence of hypertension in malaria, previous studies have indicated that malaria contributes to the burden of hypertension in highly endemic areas, particularly in LMIC. This has been attributed to the following – malaria in pregnancy leads to low birth weight in children and increases the incidence of hypertension later in life; malaria is associated with stunting and malnutrition in childhood, which predisposes to the development of hypertension in later life; and malaria also results in chronic inflammation, which predisposes to cardiovascular diseases.
Genetic and functional studies suggest that high levels of Ang II may confer protection against cerebral malaria by strengthening the integrity of the endothelial brain barrier. A genetic association study carried out in Orissa, India to search for a possible influence of polymorphisms in ACE 1 and ACE2 on the outcome of malaria showed that the D allele of ACE I/D polymorphism, which increases Ang II production, is associated with mild malaria. This same polymorphism has also been associated with hypertension. In fact, studies by Gallego-Delgado and Rodriguez  provided evidence that these polymorphisms and increased plasma levels of Ang II in people with African genetic background confer protection from severe malaria in childhood, but are also responsible for the deleterious effects of hypertension in adulthood. The association of this polymorphism with malaria and hypertension can be explained by the fact that D/D genotype is associated with high ACE levels, which converts Ang I to Ang II. This was consistent with the results of the present study, where the levels of ACE were significantly (P < 0.05) higher in patients with mild malaria compared to those with moderate and severe malaria. In addition, significantly (P < 0.05) high ACE levels were observed in malaria-positive patients with high blood pressure. Ang II causes hypertension due to its vasoconstriction property, but the molecular mechanism of its protective action on severe malaria has not been established, although it is believed to confer protection by strengthening the integrity of the endothelial brain barrier.
| Conclusion|| |
The high ACE activity in blood of hypertensive malaria patients and those with mild malaria suggests that ACE activity may probably play a significant role in the pathology of malaria infection.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]