|Year : 2019 | Volume
| Issue : 2 | Page : 387-393
|The role of matrix metalloproteinases 2 in atherosclerosis of patients with chronic kidney disease in type 2 diabetes
Amin R Soliman1, Khaled M Sadek1, Karem K Thabet1, Dina H Ahmed2, Osama M Mohamed1
1 Department of Internal Medicine and Nephrology, Kasr Al-Aini School of Medicine, Cairo University, Cairo, Egypt
2 Department of Chemical Pathology, Kasr Al-Aini School of Medicine, Cairo University, Cairo, Egypt
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|Date of Submission||22-Dec-2017|
|Date of Decision||04-Feb-2018|
|Date of Acceptance||05-Feb-2018|
|Date of Web Publication||23-Apr-2019|
| Abstract|| |
Matrix metalloproteinase-2 (MMP2) has been implicated in chronic disease and cardiovascular disease. However, there is no knowledge about the correlations between serum levels of MMP-2, proteinuria and atherosclerosis in patients with diabetic nephropathy (DN). We investigated whether serum MMP-2 levels were associated with proteinuria, intima-media thickness (IMT) in DN patients. Diabetic patients not on hemodialysis (n = 50) were enrolled for the study. MMP-2 levels were measured using an ELISA system. IMT was evaluated by highresolution ultrasonography. Univariate analyses revealed that MMP-2 (P = 0.013) were independent correlates of proteinuria. Further, multivariate analyses revealed that MMP-2 levels (P = 0.001) were independent correlates of IMT. MMP-2 levels were significantly (P = 0.001) higher in patients with atherosclerosis than those without it. The present study demonstrates that serum levels of MMP-2 were one of the independent correlates of proteinuria and IMT in patients with DN. Our results suggest that serum MMP-2 levels may be one of the risk factors for renal damage and atherosclerosis in DN patients.
|How to cite this article:|
Soliman AR, Sadek KM, Thabet KK, Ahmed DH, Mohamed OM. The role of matrix metalloproteinases 2 in atherosclerosis of patients with chronic kidney disease in type 2 diabetes. Saudi J Kidney Dis Transpl 2019;30:387-93
|How to cite this URL:|
Soliman AR, Sadek KM, Thabet KK, Ahmed DH, Mohamed OM. The role of matrix metalloproteinases 2 in atherosclerosis of patients with chronic kidney disease in type 2 diabetes. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Oct 14];30:387-93. Available from: http://www.sjkdt.org/text.asp?2019/30/2/387/256846
| Introduction|| |
Diabetic nephropathy (DN) remains the leading cause of end-stage renal disease (ESRD) in the western world, responsible for nearly half of all new ESRD cases in the USA. DN develops in 20–25% of patients with type diabetes mellitus (DM), between 20% and40% of patients with type 2-DM ultimately develop DN, which in the US is the most common cause of ESRD requiring dialysis. Recently, several papers have reported that proteinuria is not only a marker of chronic kidney disease (CKD) but also it could cause renal damage in patients with CKD., Further, there is a growing body of evidence demonstrating that proteinuria is an independent risk factor for cardiovascular disease (CVD) as well. These observations suggest the link of proteinuria to CKD and CVD. However, the underlying mechanisms by which proteinuria could cause renal and vascular damage in patients with CKD are not fully understood.
Matrix metalloproteinase-2 (MMP2) plays a key role in the development of atherosclerosis and its complications through remodeling of extracellular matrix and activation of cytokines, chemokines, and growth factors. Endothelial cells (EC), vascular smooth muscle cells, and inflammatory cells, including monocytes and macrophages, are the main sources of MMP activity in the vessel wall. The critical role of MMPs in the pathogenesis of atherosclerosis is supported by several lines of evidence, including observations in MMP knockout and transgenic mice. The plasma MMP-2 level is shown to be positively correlated with serum creatinine (SCr) levels in patients with CKD., In addition, Pawlak et al have demonstrated that plasma MMP-2 but not MMP-9 significantly increased in hemodialysis (HD) patients and correlated with intima-media thickness (IMT) levels. To the best of our knowledge, there are no data about the correlations between the serum level of MMP-2, proteinuria, and carotid atherosclerosis in patients with DN who were not yet started on dialysis. Therefore, we first investigated whether the serum MMP-2 level was associated with proteinuria in patients with DN. Then, we explored the association between serum MMP-2 levels and surrogate markers of CVD such as IMT in our patients.
| Patients and Methods|| |
The study involved diabetic patients not yet on HD in Kasr Al-Aini University Hospital (54.84 ± 6.77 years old, 32 males and 18 females). They were divided into two groups according to the presence or absence of proteinuria. The proteinuric group was further subdivided into two small groups according to the presence or absence of atherosclerosis. The diagnosis of CKD and its staging were determined according to the National Kidney Foundation Disease Outcome Quality Initiative. We excluded patients with active inflammatory disease and cancers. The study also recruited a control group comprising 25 healthy nondiabetic patients (45.68 ± 4.81 years old, 14 males and 11 females) for the measurement of Egyptian serum MMP2 level.
In the study, patients were recruited from referrals to the diabetes outpatient clinic and nephrology outpatient clinic, Cairo University Hospitals. The Local Ethical Committee at El Kasr Al-Aini hospital approved the study protocol. Informed consent was obtained from all patients. The medical history was ascertained by a questionnaire. Height and weight were measured, and body mass index (kg/m2) was calculated as an index of the presence or absence of obesity. Blood pressure (BP) was measured in the sitting position (first) and supine position (second) at 3-min intervals using an upright standard sphygmomanometer. Vigorous physical activity and smoking were avoided for at least 30 min before BP measurement.
Fasting blood was drawn from the antecubital vein for determinants of lipids (total cholesterol, high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol, and triglycerides), blood urea nitrogen, and Cr. Spot urine was collected for determination of proteinuria (g/g Cr). The serum level of MMP-2 was determined using a commercially available enzyme-linked immunosorbent assay (ELISA) kit (Boster biological technology co., Ltd, Pleasanton, USA).
All patients were subjected to estimation of GFR by using the Modification of Diet in Renal Disease Equation. IMT in the carotid artery were evaluated by high-resolution ultra-sonography.
| Statistical Analysis|| |
Results are presented as mean ± SD. Univariate analysis was performed for determinants of proteinuria. Mean MMP-2 levels were compared using analysis of covariance adjusted for age, sex, DM duration, creatinine level, and A/C ratio. Statistical significance was defined as P = 0.05. All statistical analyses were performed with the use of the Statistical Package for the Social Science (SPSS) version. 17.0 software (SPSS Inc. Chicago, IL, USA). was used for data analysis. Mean and standard, deviation were used for quantitative data description, median and range for nonnormally distributed data. Wilcoxon test was used for comparison of two independent groups. Comparison and coefficient correlation between groups were done using r value. P-value is statistically significant if <0.05 level.
| Results|| |
Demographical data of the patients are presented in [Table 1]. The average serum level of MMP-2 was 9.55 ± 5.5 pg/mL [Table 2]. Serum MMP-2 levels in DN patients were significantly higher (P <0.001) than those in age- and sex-matched normal controls (3.96 ± 2.45 pg/mL [Table 2]. MMP-2 levels in patients with DN were significantly higher than those in patients without DN (12.55 ± 6.36 vs. 6.56 ± 4.65 pg/mL, P <0.001). Total HDL and LDL cholesterol were 27.62 ± 7.77 and 77.80 ± 29.79 mg/dL, respectively. Average mean IMT was 0.685 ± 0.16 mm.
|Table 2: Circulating matrix metalloproteinase-2 serum levels (mean ± standard deviation ).|
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Correlation between renal function and serum MMP-2 levels Univariate analysis showed that serum Cr (P = 0.001) and eGFR (P = 0.001) were significantly correlated with serum MMP-2 levels in DN patients [Figure 1] and [Figure 2], whose findings were consistent with previous observations.
|Figure 1: Linear regression line of serum MMP2 levels and serum creatinine in patients with DN (n = 25).|
MMP2: Matrix metalloproteinase-2, DN: Diabetic nephropathy.
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|Figure 2: Linear regression line of serum MMP2 levels and eGFR in patients with DN (n = 25).|
MMP2: Matrix metalloproteinase-2, eGFR: estimated glomerular filtration rate.
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Correlates of proteinuria Univariate analysis revealed, total cholesterol (P <0.001), LDL-cholesterol (P <0.001), and MMP-2 (P <0.001; [Figure 3]) significantly correlated with proteinuria.
|Figure 3: Linear regression line of serum MMP2 levels and A/C ratio in patients with DN (n = 25).|
MMP2: Matrix metalloproteinase-2, DN: Diabetic nephropathy.
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Correlates of atherosclerosis Univariate analysis revealed that IMT levels were significantly correlated with MMP-2 (P <0.001; [Figure 4]). Analysis of covariance adjusted for age, sex, DM duration, creatinine level, and A/C ratio found that MMP2 level is significantly higher in patient with atherosclerosis P <0.001. Analysis revealed that serum MMP-2 was independent predictors of atherosclerosis defined by IMT.
|Figure 4: Linear regression line of serum MMP2 levels and IMT in patients with DN (n = 25).|
MMP2: Matrix metalloproteinase-2, IMT: Intima-media thickness, DN: Diabetic nephropathy.
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| Discussion|| |
The salient findings of the present study are: (1) serum MMP-2 levels are significantly higher in patients with DN than those in normal healthy subjects; (2) serum MMP-2 levels are one of the independent correlates of proteinuria in DN patients; (3) MMP-2 levels are one of the independent predictors of atherosclerosis. These observations suggest that MMP-2 is one of the causative risk factors that could link proteinuria to renal and vascular damage in patients with CKD. We found that MMP2 level is significantly higher in the DN group with mean value 12.55 ± 6.36 than the DM group with mean value 6.56 ± 4.65 and the control group with a mean value 3.96 ± 2.45. (P <0.001). This result is similar to Nagano et al and Chang et al, but conflicting with the result of Rysz et al.
Nagano et al investigated whether serum MMP-2 levels were associated with proteinuria, IMT, and the presence of carotid atherosclerotic plaque in CKD patients, the study done over CKD patients without HD (n = 99), the study found that the serum MMP2 levels are significantly higher (P <0.01) in patients with CKD than those normals.
Chang et al investigated the relationships between circulating MMP-2 and -9 and renal function in patients with chronic kidney disease. The study done over CKD patients not on HD (n = 60), the study found that SCr concentrations and MMP-2 activities were significantly higher (P <0.001) while MMP-9 activity and creatinine clearance were significantly lower (P <0.05 and P <0.001, respectively) in CKD patients, as compared with those that of controls.
Rysz et al investigated the level of serum MMPs MMP-2 and MMP-9 and metalloproteinase tissue inhibitors TIMP-1 and TIMP-2 in DN, the study done over DN patients with HD (n = 20), the study found that MMP-2 was lowered in both groups of DM2 and CRF patients vs. normal control P <0.001. The result of Rysz et al can be explained as this study done on DN patient with ESRD, whereas in this study, we used patients in CKD stage III and IV not reaching dialysis.
The mean plasma level of MMP2 in our DN patients was 12.55 ± 6.36 pg/dL while in Nagano et al was 1.488 ± 0.504 μg/mL and in Chang et al was 98.43 ± 3.13 ng/mL.
The exact reasons for different MMP2 levels can be attributed to the change in the ELISA kits used in the measurement of levels of MMP2 which may be the main reason, also the racial difference between Asian and Egyptian could explain this difference.
In the study, we also found a significant positive correlation between serum MMP2 with IMT with mean value 0.96 ± 0.12 mm (P = 0.001). This result is similar to the findings of Nagano et al and Pasterkamp et al. Takamiya et al investigated whether serum MMP-2 levels were associated with proteinuria, IMT, and the presence of carotid atherosclerotic plaque in CKD patients, the study done over CKD patients without HD (n = 99), the study found that MMP-2 levels were significantly (P <0.01) higher in patients with atherosclerotic plaque than those without it. Pasterkamp et al investigated the association between the remodeling mode and the localization of macrophages and MMPs in coronary atherosclerotic segments. And found that both secreted and active MMP-2 are elevated in human atherosclerotic lesions. This finding could make MMP2 used as early marker of atherosclerosis in patients with DN.
Regulation of MMPs expression and activity in physiological or pathological vascular remodeling is induced by hemodynamics, injury, inflammation, and oxidative stress., In CKD, a condition where these processes are enhanced, it is expected that MMP dysregulation is intensified, particularly in late CKD stages and HD. Persistent, low-grade inflammation in CKD is attributed to the production of proinflammatory cytokines combined with their decreased renal clearance, the CKD-associated metabolic acidosis, the uremic milieu-induced oxidative and carbonyl stress, the chronic or frequent recurrent infections, and thrombotic events. In addition, dialysis-related factors, such as membrane biocompatibility, water and dialysate purity, and microbiological quality, further contribute and sustain inflammation in ESRD. This uremia-inflammation interplay in CKD underlies the accelerated atherosclerosis and increased IMT, the arterial stiffening, and increased vascular calcification of both intima and media and impairs the vascular repair process with the detrimental consequences of neointimal hyperplasia. Moreover, plaque morphology, composition, and vulnerability differ in CKD, as coronary and carotid plaques of CKD patients were shown to be more calcified, more unstable, and frequently ruptured and containing less fibrous tissue.,
Central to the pathogenesis of these processes and plaque formation are the EC dysfunction and vascular smooth muscle cell (VSMC) migration and their phenotypic shift to a more proliferative and secretory state.
In this study, we also found that serum MMP2 shows a significant positive correlation with A/C ratio (P = 0.002). This result is supported with Nagano et al and Mazanowska et al. Nagano et al et al found that age and SCr-adjusted MMP-2 levels were significantly increased (P = 0.001) in proportion to the increasing levels of proteinuria. Mazanowska et al studied the level of plasma and urine MMPs (MMP-2 and MMP-9) and tissue inhibitors of metalloproteinases (TIMP-1 and TIMP-2) in proteinuric renal transplant recipients (RTRs). The factors were determined by enzyme-linked immunosorbent assay in 150 RTRs. it showed that proteinuria correlated positively with plasma MMP-2.
These observations suggest that MMP2 is one of the causative risk factors that could link proteinuria to renal damage in patients with DN.
Since this study is a cross-sectional one, future longitudinal and/or interventional studies are needed to assess the question of whether an elevation in MMP-2 was a cause or a consequence of renal and vascular damage in patients with CKD and if MMP-2 is a biomarker for CVD in patients with DN.
| Limitations|| |
We did not use control group for the atherosclerotic group. We only used the Egyptian control group for MMP2 level. The small number of patients in this study with atherosclerosis is another limiting factor.
We did not make stratifications to the level of proteinuria and atherosclerosis with the correlation of MMP2 level due to a small number of patients in the study.
| Conclusion|| |
The present study demonstrates that serum levels of MMP-2 were one of the independent correlates of proteinuria and IMT in patients with DN. Our results suggest that serum MMP-2 levels may be one of the risk factors for renal damage and atherosclerosis in DN patients.
Conflict of interest: None declared.
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Khaled M Sadek
Department of Internal Medicine and Nephrology, Kasr Al-Aini School of Medicine, Cairo University, Cairo
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]
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