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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 6  |  Page : 911-917
Correlation of urinary monocyte chemo-attractant protein-1 with other parameters of renal injury in type-II diabetes mellitus


1 Department of Internal Medicine, Cairo University, Egypt
2 Department of Medical Biochemistry, Cairo University, Egypt

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   Abstract 

Diabetic nephropathy (DN) is the leading cause of end-stage renal disease in the western world. Increased number of interstitial macrophages has been observed in biopsies from patients with DN. Monocyte chemo-attractant protein-1 (MCP-1) is the strongest known chemo­tactic factor for monocytes and is upregulated in DN. We examined urinary levels of MCP-1 in patients with type-2 diabetes mellitus (DM) to assess its possible correlation with other para­meters of renal injury. The urinary MCP-1 level was assessed in 75 patients with type-2 DM (25 patients each with no microalbuminuria, with macroalbuminuria and, with renal impairment) and compared them with matched healthy control subjects. The HbA1c and estimated glomerular fil­tration rate (eGFR) derived from the abbreviated Modification of Diet in Renal Disease (MDRD) equation were examined in the study groups in relation to the urinary MCP-1. The urinary MCP-1 level was significantly higher in patients with micro and macroalbuminuria (167.41 ± 50.23 and 630.87 ± 318.10 ng/gm creatinine respectively) as compared with normoalbuminuric patients and healthy controls (63.85 ± 21.15 and 61.50 ± 24.81 ng/gm creatinine, p< 0.001). MCP-1 correlated positively with urine albumin/creatinine ratio (ACR) (r= 0.75, p< 0.001), HbA1c (r= 0.55, p< 0.001) and inversely with eGFR (r=-0.60, p< 0.001). Our findings suggest that hyperglycemia is associated with increased urinary levels of MCP-1 that is closely linked to renal damage as reflected by proteinuria and eGFR levels. Collectively, these findings suggest that MCP-1 is in­volved in the pathogenesis of diabetic nephropathy through its various stages.

Keywords: Monocyte chemo-attractant protein, Diabetes, Renal injury

How to cite this article:
Ibrahim S, Rashed L. Correlation of urinary monocyte chemo-attractant protein-1 with other parameters of renal injury in type-II diabetes mellitus. Saudi J Kidney Dis Transpl 2008;19:911-7

How to cite this URL:
Ibrahim S, Rashed L. Correlation of urinary monocyte chemo-attractant protein-1 with other parameters of renal injury in type-II diabetes mellitus. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Jun 24];19:911-7. Available from: http://www.sjkdt.org/text.asp?2008/19/6/911/43464

   Introduction Top


Diabetic nephropathy (DN) is the most im­portant cause of chronic renal failure worldwide. Diabetic renal injury involves a renal in­flammatory response induced by the diabetic milieu. [1],[2] Macrophages are thought to play an important pathogenic role in tubulointerstitial damage in DN. [3],[4] Increased numbers of glome­rular and interstitial macrophages have been observed in rat models of experimental dia­betes and in biopsies of patients with DN. [5]

Monocytes are attracted to damaged tissue by monocyte specific chemokines. [6] Monocyte chemo-attractant protein-1 (MCP-1) is the strongest known chemotactic factor for mono­cytes and is upregulated in many renal diseases including DN. [7],[8] The development of DN in streptozotocin-treated mice was associated with increased kidney MCP-1 production, which occurred mostly in the tubules. [2] MCP-1 posi­tive cells have been detected in the interstitium of type-2 diabetic patients with DN. [9] Plasma MCP-1 level was found to be significantly higher in proteinuric type-1 diabetic patients and correlated positively with blood sugar levels. [10] MCP-1 exerts various effects on monocytes including the induction of supe­roxide anions, production of cytokines and expression of adhesion molecules. [11],[12]

Renal MCP-1 expression is induced by ele­vated glucose level, tubular reabsorbed pro­tein, advanced glycosylated end-products (AGE) and angiotensin-II (AT-II). [2],[13],[14] Treatment of db/db mice with soluble receptor for advanced glycation end-products (AGE) prevented re­cruitment of macrophages to the glomeruli and reduced albuminuria. [15] Similarly, blockade of the renin-angiotensin system in type-2 diabetic patients with DN reduces urinary MCP-1 le­vels and improves renal function. [16]

In the present study, we measured urinary levels of MCP-1 in a cohort of type-2 diabetic patients with and without microalbuminuria to investigate its role through various stages of DN. We studied the relationship between MCP­1 on the one hand and the degree of glycemic control, as indicated by glycosylated hemo­globin (HBA1c), and estimated glomerular filtration rate (eGFR) derived from the abbre­viated Modification of Diet in Renal Disease formula (MDRD), on the other hand. [17],[18]


   Patients and Methods Top


The study was conducted on 75 type-2 dia­betic patients who were followed-up in the internal medicine outpatient clinic at the Cairo University Hospital between March and August 2005. The clinical features of the study subjects are summarized in [Table 1]. All subjects gave consent for this study and the study protocol was approved by the Cairo University Hospital research committee. The study patients were divided into three subgroups according to the urinary albumin/creatinine ratio (ACR) estima­ted from three overnight first-voided urine samples. [19] The groups were as follows:

a . Group-1 included 25 diabetic patients with normoalbuminuria (ACR < 30 ug/mg in at least 2 of 3 samples). [20],[21] There were 11 males and 14 females with mean age of 54.75 ± 3.53 years in this group. The mean duration of dia­betes was 4.07 ± 2.05 years, and mean HbA1c level was 7.22 ± 0.862. Three patients (12%) were smokers and four (16%) were receiving anti-hypertensive medications.

b . Group-2 included 25 diabetic patients with microalbuminuria (ACR 30-299 ug/mg in 2 samples). [20],[21] There were 13 males and 12 fe­males with mean age of 52.15 ± 7.73 years in this group. The mean duration of diabetes was 5.76 ± 3.67 years, and mean HbA1c level was 7.31 ± 1.37. Five patients (20%) were smokers and 12 (48%) were receiving anti-hypertensive medications.

c . Group-3 included 25 diabetic patients with macroalbuminuria (ACR > 300 ug/mg in 2 of 3 samples). [20],[21] There were 12 males and 13 females with mean age of 53.41 ± 9.89 years in this group. The mean dura-tion of diabetes was 6.83 ± 3.45 years, and mean HbA1c level was 8.66 ± 1.13. Four patients (16%) were smokers and 18 (72%) were receiving anti­hypertensive medications.

In addition, 25 age and gender matched healthy volunteers served as controls. They included 14 males and 11 females with mean age of 51.98 ± 6.78 years.

Assessment of renal function

Serum creatinine was measured using a modified kinetic Jaffe reaction. [22] Abbreviated MDRD formula was used to estimate GFR as follows: [17],[18]

MDRD GFR (mL/min/1.73 m 2 ) = 186.3 x sCr -1.154 × Age -0.203 (x0.742 for women)

MCP-1 assay

MCP-1 urine levels were measured with solid phase enzyme linked immunosorbent assay (Quantikine MCP-1 ELISA; R&D Systems, Minneapolis, MN). [16] Freshly voided urine samples were collected, and centrifuged at 2500 rpm for 10 minutes at 4°C, then stored at -20°C until tested.

Glycosylated hemoglobin was assessed by colorimetric method (Stanbio laboratory, Texas, USA).

Statistics

Data were expressed as means ± standard deviation, unless stated otherwise. The Stu­dent's t test was used for group comparisons of the quantitative parameters. The relationship between urinary MCP-1 and the clinical and laboratory variables of the study subjects was analyzed by Spearman correlation test. Statis­tical significance was defined as p< 0.05.


   Results Top


[Table 1] shows the baseline characteristics of the study groups. Compared to the normo­albuminuric group, patients with macroalbumi­nuria had longer duration of diabetes (p= 0.03). The HbA1c level was significantly higher in macroalbuminuric patients compared to normo and microalbuminuric groups (p < 0.05). Micro­albuminuric and macroalbuminuric diabetic groups had mean eGFR of 68.72 ± 14.90 and 55.25 ± 22.31 mL/min/1.73m 2 respectively, which is significantly reduced compared to normoalbuminuric diabetic patients and healthy controls (93.83 ± 27.27 and 98.07 ± 12.72 mL /min/1.73 m2 respectively), p< 0.05.

Urinary MCP-1 levels

Urinary MCP-1 level was significantly higher in the microalbuminuric (167.41 ± 50.23 ng /gm creatinine) and macroalbuminuric patients (630.86 ± 318.10 ng/gm creatinine) compared to the normoalbuminuric patients (63.85 ± 21.15 ng/gm creatinine) and healthy controls (61.50 ± 24.81 ng/gm creatinine) (p< 0.001) [Figure 1]. Patients with macroalbuminuria had significantly higher urinary MCP-1 than mic­roalbuminuric patients (p < 0.001). There was no significant difference in urinary MCP-1 level between the normoalbuminuric patients and healthy controls (p= 0.34).

Associations

Among the study groups, a positive corre­lation was found between urinary MCP-1 level on the one hand and ACR (r= 0.75, p< 0.001) [Figure 2], HbA1c % (r = 0.55, p < 0.001), systolic blood pressure (SBP) (r = 0.56, p < 0.05), and diastolic blood pressure (r = 0.47, p < 0.05) on the other hand. Raised urinary MCP-1 inversely correlated with the eGFR among the study groups (r = -0.60, p < 0.001) [Figure 3], but not with serum creatinine (r = 0.23, p = 0.09). In addition, ACR correlated di­rectly with HbA1c levels (r = 0.65, p < 0.001) and inversely with eGFR (r = -0.60, p < 0.001) in the study subjects. No significant correlation was found between urinary MCP-1 and age, gender, duration of diabetes and BMI (p> 0.05). HbA1c did not correlate with eGFR level among the study groups (r = -0.31, p = 0.06).


   Discussion Top


The main findings of the current study were that urinary MCP-1 levels were increased in diabetic patients with micro and macroalbumi­nuria compared to normoalbuminuric diabetics and healthy controls. Moreover, urinary MCP­1 level was closely linked to other known parameters of renal injury including albumin excretion rate, systolic and diastolic blood pre­ssure values, and inversely correlated with estimated GFR.

Several studies have shown associations of MCP-1 and renal injury in diabetic patients. [8],[9],[10] Urinary MCP-1 levels were significantly ele­vated in type-2 diabetic patients with macro­albuminuria and advanced tubulointerstial le­sions. [8],[23],[24] In addition, urinary MCP-1 excre­tion was correlated with the number of MCP-1 positive cells in the interstitium in the renal biopsy specimens. [9] Recent studies have sug­gested that MCP-1 synthesis in mesangial cells is induced by elevated glucose and advanced glycated end products, tubular reabsorbed pro­tein, mechanical stretch, angiotensin II and aldosterone with NF-uB activation. [2],[13],[14],[25],[26] Blockade of the renin angiotensin system in type-2 diabetic patients with diabetic nephro­pathy with angiotensin converting enzyme inhibitors (ACEIs) reduced urinary MCP-1 levels and improved renal function. [16] The thia­zolidinedione rosiglitazone, was also reported to diminish stretch-induced NF-uB activation with reduction of urinary MCP-1 pro-duction. [26] Collectively, these findings suggest that upregu­lation of MCP-1 may be a common regulatory pathway involved early in the pathogenesis of DN with subsequent recruitment of macro­phages and T cells, fibroblast activation with increased collagen deposition with progressive tubulointerstitial fibrosis. [3],[27]

Consistent with the results of previous stu­dies, [8],[13] we showed a significant positive corre­lation between glycemic control as indicated by HbA1c level and urinary MCP-1 in diabetic patients. High glucose was reported to upregu­late MCP-1 expression in human mesangial cells through activation of NF-iB activity. [13] In addition, AGE have been implicated in the pathogenesis of DN through direct induction of MCP-1 expression in human mesangial cells. [28] Because normoalbuminuric diabetic patients had normal urinary MCP-1 in our study, hyperglycemia per se, is necessary but not sufficient in determining increased MCP-1 expression. It could be possible that prolonged hyperglycemia, AGE, high oxidative burden and local activation of renin-angiotensin acting together can induce MCP-1 expression in gene­tically predisposed patients. [2],[10],[13],[14]

Urinary MCP-1 levels positively correlated with AER in diabetic patients in our study. It has been reported that glycated albumin in­creased renal MCP-1 expression and urinary MCP-1 levels increased with increasing albu­minuria in diabetic patients. [8] Urinary MCP-1 levels also significantly correlated with the degree of albuminuria and urinary N-acetyl­glucosamine (NAG), a sensitive marker of renal tubular damage, in type-2 diabetic pa­tients, in a recent study. [23] These results suggest that MCP-1 is produced in renal tubular cells in proportion to the degree of proteinuria and its increased level contributes to renal tubular damage. [23] Urinary MCP-1 excretion was also increased in proteinuric non-diabetic kidney disease such as IgA nephropathy confirming its role in renal tubular damage in proteinuric states. [29]

Urinary MCP-1 levels inversely correlated with eGFR as estimated by abbreviated MDRD equation. [17] This equation was developed by the MDRD study to predict GFR as measured by using accepted methods (I-iothalamate clearance), and is recommended by K/DOQI guidelines to estimate renal function in adults. [18] The inverse association between MCP-1 level and eGFR confirms its use as a marker that reflects accurately the degree of renal damage as estimated by glomerular filtration. Simi­larly, urinary MCP-1 levels correlated positively with SBP and DBP levels, which usually increase with development of micro/macro­ albuminuria in diabetic patients. On the other hand, there was no significant correlation between urinary MCP-1 and serum creatinine; this finding could be explained by the well­ known poor correlation between serum crea­tinine and GFR in adults. [30]

No correlation was found in this study bet­ween urinary MCP-1 and age, gender, duration of diabetes, and BMI. These findings are con­sistent with previous reports. [31] These data suggest that urinary MCP-1 is a good marker for renal damage in type 2-diabetic patients that is not affected by other demographic para­meters.

In conclusion, we have shown increased urinary MCP-1 level in type-2 diabetic patients that significantly correlates with other para­meters of renal injury including albuminuria and reduced glomerular filtration rate. These data suggest that DN could be an immune mediated renal disorder with potential role for anti-inflammatory agents in altering disease progression.

 
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Correspondence Address:
Salwa Ibrahim
Department of Internal Medicine, Cairo University
Egypt
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    Figures

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