Serum Human Epididymal Protein 4 is Associated with Depressive Symptoms in Patients with Chronic Obstructive Pulmonary Disease.

Background: Previous studies have suggested that patients with chronic obstructive pulmonary disease (COPD) have a higher incidence of depression and an increased risk of developing various depression-related complications. We aimed to elucidate the association between the serum human epididymal protein 4 (HE4) level and depressive symptoms in patients with COPD.
Methods: The data on 219 participants with COPD from The Irish Longitudinal Study on Ageing (TILDA) were analyzed for the association between serum HE4 levels and depressive symptoms, accounting for relevant confounding factors. All the COPD participants were prospectively followed up for a median period of 48 months. Cox proportional hazards analysis was used to evaluate the predictive value of serum HE4 for predicting depression events in these COPD patients.
Results: Multivariate linear regression analysis revealed that serum HE4 was independently associated with the depression score after adjusting for age, sex, BMI, current smoking status, current drinking status, admission systolic and diastolic BP, CVD history and laboratory measurements in patients with COPD at baseline (Sβ= 0.149; 95% CI, 0.069-0.201; P<0.001). Multivariate Cox proportional hazards analysis revealed that serum HE4 (HR=2.216, 95% CI 1.691-5.109, P<0.001) was an independent prognostic factor for depression events in these COPD patients.
Conclusion: Our results showed that serum HE4 is significantly and independently associated with depression events. Serum HE4 may enable the early recognition of depressive symptoms among COPD patients.

Introduction

Previous studies have suggested a close association between chronic obstructive pulmonary disease (COPD) and depression.1,2 Patients with COPD have a high risk of depression, which is associated with poor treatment adherence and poor prognosis, as well as a high prevalence of depression-related complications, including cardiovascular diseases (CVDs) and all-cause mortality.3–5 The incidence of depression is higher in individuals with COPD than in those without COPD.6 Although the precise mechanisms are currently poorly understood, increasing the levels of inflammation and oxidative stress in COPD may play an important role in increasing the risk of depressive symptoms.7–9 Therefore, identifying valuable predictors or controllable risk factors is very significant to prevent and treat depression in patients with COPD. The early prediction of depression events in COPD patients may provide an opportunity to develop strategies to reduce the medical burden and even improve prognosis.

Human epididymis protein 4 (HE4), a secretory protein highly expressed in the human epididymis, is encoded by the WFDC2 gene located on chromosome 20q12-13.1.10 The mature HE4 protein is a 20- to 25-kDa glycoprotein found on membranes, in the cytoplasm of cells and in circulation. Studies have reported initially that HE4 is highly expressed in malignant tumors, such as ovarian cancer and endometrial cancer tumors.11–13 However, other studies have also shown that HE4 is moderately expressed in multiple normal and abnormal tissues in the human body, such as the respiratory tract and other tissues.14,15 Higher HE4 expression in the respiratory tract plays a very important role in the process related to immune defense and the inflammatory response.14,15 Other WFDC proteins have also been correlated with inflammatory processes.16–18 Previous studies have shown the strong links between depression and the chronic and systemic inflammatory levels. As a chronic inflammatory disease, COPD can hasten the occurrence of depression and contribute to a higher rate of depression.19–21 Given the close association between HE4 and inflammation,16–18 we hypothesized that HE4 might be associated with depressive symptoms in COPD patients.

Until now, few studies have explored the association between the serum HE4 levels and the depression score in patients with COPD. This study aimed to investigate whether increased HE4 levels contribute to the increased risk of depression events, independent of confounding factors. This study was the first to explore the prognostic value of HE4 for predicting depression events in COPD patients.

Materials and Methods

Study Population

Study participants from The Irish Longitudinal Study on Ageing (TILDA) were evaluated in this study. TILDA, comprising middle-aged and elderly adults (age ≥49 years), is a large prospective cohort study with repeated assessments at 2-year intervals in the Republic of Ireland. A nationally representative sample was obtained from all residential addresses in the Republic of Ireland using the RANSAM sampling procedure, with a response rate of 62% (N=8594) for wave 1 (2009–2011).22 Details on the method and design of the cohort study were published elsewhere.22 In summary, the TILDA study comprised (1) a self-completed questionnaire; (2) a computer-aided personal interview (CAPI) performed by trained interviewers in the included subjects’ homes; and (3) a health examination performed by well-trained research nurses. All the subjects who completed the CAPI and self-completed questionnaire were invited to attend one of two health centers for a health examination. As one part of the comprehensive health examination, all the subjects completed a health assessment, which included accurate measurements of biochemical tests. Our study included the subjects who completed the CAPI, self-completed questionnaire and health examination during wave 1 who had accurate serum HE4 data to analyze the associations between serum HE4 and the depression score and who had a complete depression score in wave 3 (a follow-up period of 4 years). Details on the measuring method of HE4 and serum indicators were published elsewhere.22 In our study, participants who had a self-reported doctor’s diagnosis of a COPD history (N=219) in wave 1 were included for the analysis. The guidelines the diagnosis of COPD was confirmed by post-bronchodilator spirometry According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Included subjects with a cancer history (N=11) were excluded from the study. In general, the anonymized TILDA data are available to scientific research personnel who meet the criteria for access from the Interuniversity Consortium for Political and Social Research at the University of Michigan and the Irish Science Data Archive at University College Dublin. TILDA also approves applications for privileged access to the data set via a website called the “hot desk” (). According to the Declaration of Helsinki guidelines, the TILDA study was approved by the Trinity College Research Ethics committee, and all participants provided informed written consent.

Depression Score

In wave 1, the Center for Epidemiological Studies Depression (CES-D) scale was used to calculate the depression score.23 A cut-off score of 16 was considered indicative of depressive symptoms.24 In wave 3, a short form of the CES-D scale was used, and a cut-off score of 10 indicated a depression event.24 The CES-D scale has been used widely in epidemiological studies and is appropriate for use in our study with middle-aged and elderly subjects.

Statistical Analyses

The Kolmogorov–Smirnov test was used to assess the normality of the data. The data that were not normally distributed were expressed as medians (interquartile range [IQR]). Normally distributed data were presented as means ± SD. Categorical variables were presented as n (%). Multivariate linear regression analysis was performed to identify the independent association between the serum HE4 levels and depression score in COPD patients in the wave at baseline. The Cox model with time-dependent covariates was used to identify the independent prognostic value of the HE4 levels for depression events in patients with COPD. We adjusted for confounding factor data relevant to COPD and depression even if the factors were not significantly associated with depression in the univariate analysis because they are key clinical variables and may be associated with depression in the multivariate but not univariate analyses. Additionally, sensitivity analysis by adding “taking antidepressant medications” as a covariate was further performed to assess the association between the serum HE4 and depression events. Stratified analysis by adding “CVD history (≥2)” as a covariate was also performed to assess whether the association of serum HE4 with depression events was affected by CVD history. All the analyses were performed using SPSS 25.0. P ≤ 0.05 was considered to be statistically significant.

Results

Characteristics of the Study Subjects at Baseline (N=219)

To assess the serum levels of HE4 in patients with COPD, 438 age- and sex-matched subjects (match 1:2) without COPD were selected as the control group. The serum HE4 levels in patients with COPD were significantly higher than those of the control subjects (). The characteristics of the patients with COPD are presented in Table 1. The mean age of all the COPD patients was 69.5 (57.4–78.6) years, and the number of men was 125 (57.1%). The mean depression score was 7.4±4.2 in the patients with COPD.

Table 1

Clinical Characteristics in 219 COPD Patients at Baseline

Variables	All COPD Patients(n=219)
Age (years)	69.5 (57.4–78.6)
Gender (male), n (%)	125 (57.1)
BMI (kg/m2)	31.4 (24.1–35.3)
Current smoker, n (%)	18 (8.2)
Current drinker, n (%)	151 (68.9)
Systolic BP (mmHg)	139.3 (132.9–142.7)
Diastolic BP (mmHg)	81.6 (78.4–85.2)
Taking antidepressant medications, n (%)	27 (12.3)
Depression score	7.4±4.2
CVD history
Hypertension, n (%)	137 (62.6)
Coronary heart disease, n (%)	42 (19.2)
Stroke, n (%)	14 (6.4)
Others, n (%)	6 (2.7)
Laboratory measurements
Glycosylated haemoglobin (mmol/L)	44.6±9.38
C-reactive protein (mg/L)	5.60±10.32
Triglycerides (mmol/L)	1.73±1.10
Cholesterol (mmol/L)	4.61±1.15
HDL (mmol/L)	1.34±0.25
LDL (mmol/L)	2.73±1.51
HE4 (pmol/L)	122.4±15.9

Notes: Data are presented as mean ± SD for normally distributed data, as median (interquartile range) for nonnormally distributed data, and as n (%) for categoric variables.

Abbreviations: COPD, chronic obstructive pulmonary diseases; BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease; CRP, C-reactive protein; HDL, high-density lipoprotein; LDL, low-density lipoprotein; HE4, human epididymal protein 4.

Serum HE4 Was Independently Associated with the Depression Score in 219 Patients with COPD

To assess the association between the serum HE4 levels in COPD patients and the depression score, multivariate linear regression analysis was performed (Table 2). The crude model indicated that higher serum HE4 levels were significantly associated with the depression score without adjustment. After adjusting for age, sex, BMI, current smoking status, current drinking status, admission systolic and diastolic BP and CVD history, the results of Model 1 were found to be similar to those of the crude model. This association remained statistically significant and changed minimally after adding laboratory measurements to Model 2.

Table 2

The Association Between the HE4 and Depression Score in 219 Patients with COPD by Multivariate Linear Regression Analysis

Variables	R2	Sβ	95% CI	P value
Crude	0.043	0.180	0.081–0.274	<0.001
Model 1	0.071	0.166	0.076–0.228	<0.001
Model 2	0.128	0.149	0.069–0.201	<0.001

Notes: Crude: No adjustment. Model 1: Adjusted for age, gender, BMI, current smoker, current drinker, admission systolic and diastolic BP and CVD history. Model 2: Adjusted for age, gender, BMI, current smoker, current drinker, admission systolic and diastolic BP, CVD history and laboratory measurements.

Abbreviations: COPD, chronic obstructive pulmonary diseases; HE4, human epididymal protein 4; BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease.

Cox Proportional Hazards Analyses of the Prediction of Depression Events in Patients with COPD

All the included COPD patients (N=219) were prospectively followed up for a median period of 48 months. Depression events occurred in 38 of the included COPD patients. To determine whether the serum HE4 levels were independently associated with depression events, multivariate Cox proportional hazards regression analysis was performed (Table 3), revealing that HE4 (HR=2.216, 95% CI: 1.691–5.109, P<0.001) was an independent prognostic factor for depression events after adjusting for age, sex, BMI, current smoking status, current drinking status, admission systolic and diastolic BP, CVD history and laboratory measurements. Kaplan-Meier analysis demonstrated that COPD patients with serum HE4 levels above the mean (122.4 [pmol/L]) had a significantly higher rate of depression events than those with serum HE4 levels below the mean value (Log rank test, P<0.001, data not shown).

Table 3

Cox Proportional Hazard Analysis for Predicting Depression Events in 219 Patients with COPD

Variables	Crude	Model 1	Model 2
HE4 (per 1-SD increase)
Quartile 1	1.000 (ref.)	1.000 (ref.)	1.000 (ref.)
Quartile 2	1.619 (1.130–3.738)	1.554 (1.121–3.528)	1.549 (1.120–3.491)
Quartile 3	2.337 (1.725–4.549)	2.119 (1.629–4.397)	2.103 (1.610–4.219)
Quartile 4	2.562 (1.813–5.649)	2.355 (1.703–5.300)	2.216 (1.691–5.109)
P-trend	<0.001	<0.001	<0.001

Notes: Crude: No adjustment. Model 1: Adjusted for age, gender, BMI, current smoker, current drinker, admission systolic and diastolic BP and CVD history. Model 2: Adjusted for age, gender, BMI, current smoker, current drinker, admission systolic and diastolic BP, CVD history and laboratory measurements.

Abbreviations: COPD, chronic obstructive pulmonary diseases; HE4, human epididymal protein 4; BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease

We performed an additional sensitivity analysis to evaluate the association of the serum HE4 with depression events (end points) in COPD subjects by adding “taking antidepressant medications” as a covariate (Table 4). Sensitivity analysis showed that higher HE4 levels were still independently associated with a higher risk of depression events (HR=2.024, 95% CI: 1.482–4.584, P<0.001). Additionally, stratified analysis showed that the significant association between the serum HE4 levels and depression events in COPD patients was not affected by CVD history (Table 5).

Table 4

Cox Proportional Hazard Analysis for Predicting Depression Events in 219 Patients with COPD by Sensitivity Analysis

Variables	Crude	Model 1	Model 2
HE4 (per 1-SD increase)
Quartile 1	1.000 (ref.)	1.000 (ref.)	1.000 (ref.)
Quartile 2	1.514 (1.119–3.518)	1.433 (1.110–3.319)	1.322 (1.009–3.149)
Quartile 3	2.285 (1.516–4.235)	2.013 (1.428–4.090)	1.994 (1.329–3.986)
Quartile 4	2.447 (1.726–5.318)	2.251 (1.581–5.009)	2.024 (1.482–4.584)
P-trend	<0.001	<0.001	<0.001

Notes: Crude: taking antidepressant medications. Model 1: Adjusted for age, gender, BMI, current smoker, current drinker, admission systolic and diastolic BP, CVD history and taking antidepressant medications. Model 2: Adjusted for age, gender, BMI, current smoker, current drinker, admission systolic and diastolic BP, CVD history, laboratory measurements and taking antidepressant medications.

Abbreviations: COPD, chronic obstructive pulmonary diseases; HE4, human epididymal protein 4; BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease.

Table 5

Cox Proportional Hazard Analysis for Predicting Depression Events in 219 Patients with COPD by Stratified Analysis

Variables	Crude	Model 1	Model 2
CVD history (≥2)
HE4 (per 1-SD increase)	2.346 (1.645–5.401)	2.228 (1.592–5.110)	2.214 (1.579–5.105)
P value	<0.001	0.009	0.012
CVD history (<2)
HE4 (per 1-SD increase)	2.451 (1.712–5.537)	2.340 (1.609–5.226)	2.197 (1.568–5.011)
P value	<0.001	<0.001	<0.001

Notes: Crude: No adjustment. Model 1: Adjusted for age, gender, BMI, current smoker, current drinker, admission systolic and diastolic BP. Model 2: Adjusted for age, gender, BMI, current smoker, current drinker, admission systolic and diastolic BP and laboratory measurements.

Abbreviations: COPD, chronic obstructive pulmonary diseases; HE4, human epididymal protein 4; BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease.

Discussion

In this study, multivariate Cox proportional hazards analysis suggested that serum HE4 was an independent prognostic factor for depression events in patients with COPD. We first showed that serum HE4 was closely associated with the depression score at baseline and depression events after a follow-up of 4 years, a finding that may be partly or mostly explained by the mechanistic research performed in previous studies.19–21 These studies demonstrated that chronic inflammation caused by COPD promotes depression.25–28 The increased HE4 levels may be the result of the aggravation of inflammation in COPD patients, and may explain why higher serum HE4 levels are associated with an increased risk of depression events in COPD patients, a finding that is consistent with our hypothesis and results. Additionally, some studies have suggested that increased HE4 levels are closely related to renal dysfunction.29,30 Our COPD subjects have no history of kidney disease and their eGFR values were normal; thus, the influence of renal function abnormalities on our results was excluded. Studies have also reported that HE4 is associated with cancer (eg, ovarian, cervical, lung, and breast) and some other serious diseases.11–13 To eliminate the impact of the diseases on this study, COPD patients with a cancer history were excluded from the baseline assessment. It is clinically significant to determine the independent risk factors or predictors of depressive symptoms in COPD patients. The early detection of depression events in these COPD patients may help develop strategies to reduce the medical burden and improve the prognosis. Our results implied that serum HE4 might be a highly sensitive biomarker for the early recognition of depression events in COPD patients.

Our study has several strengths, including the population-based sample size. The results of the study mainly contribute to the literature in three different ways. First, the data were from TILDA, a longitudinal study of a national sample of the middle-aged and elderly population. The data analysis of studies with a follow-up of 4 years proves that higher serum HE4 levels are closely related to the occurrence of depression outcomes, expanding the rare longitudinal research on the association between HE4 and depression presently. Second, we first found a positive correlation between the HE4 levels and depression in a middle-aged and elderly population with COPD after adjusting for multiple relevant confounding factors. Finally, to better explain a wide range of potential confounding factors, our results using continuous mood scores avoided arbitrary cut-offs of continuous mood traits. This association was significant after adjustment for possible confounders.

Finally, our study had some limitations. First, many participants in the TILDA study were not included in our study because some data were lost, leading to some deviations in our results. Time-varying confounding factors, such as the BMI, in our study, may interfere with our results on the associations between the serum HE4 levels and depression events. Second, we used self-reported measures to define major depression, possibly resulting in misclassification. Third, more studies must be performed to identify the value of the serum HE4 levels for predicting depression. Given the close relationships between serum HE4 and many malignant tumors or renal function, our results are not applicable to the general population.

Conclusions

Serum HE4 is an independent prognostic factor for predicting depression events in patients with COPD. Serum HE4 might allow the early recognition of COPD patients at risk of developing depression.