El-Zarka et al., 2018, AJMS 1(1): 7-13. DOI:10.5455/ajms.

Arabian Journal of Medical Sciences

http://www.ajms.tk

Adiponectin as a potential biomarker of diabetic nephropathy

Ayman EL-Zarkaa,*, Aida Solimanª, Sahar Bessab, Tarek Mohamedc
ªDepartment of Biochemistry, Faculty of Science, Suez Canal University, Egypt
b
Department of Internal Medicine, Faculty of Medicine, Tanta University, Egypt
c
Department of Biochemistry, Faculty of Science, Tanta University

Abstract
Diabetic nephropathy (DN) is a progressive kidney disease associated with diabetes
Keywords: mellitus that may lead to end-stage renal disease. Adiponectin (ADP) is a protein
Diabetic nephropathy; hormone produced by white adipose tissue and has vasoprotective properties. Adi-
Adiponectin;
HbA1c; ponectin level attributes to and associates with diabetic complications. Herein, we
microalbuminuria assess the potentiality of detecting ADP level as a DN marker. This study included
sixty age- and sex- matched subjects which were subdivided into three groups: twenty
healthy (control) subjects, twenty type 2 diabetes patients with nephropathy (microal-
Received Jul 12,
buminuria 30-300 mg/dL), and twenty type 2 diabetes patients without nephropathy
Revised Jul 28,
Published Aug 2, 2018 (normoalbuminuria <30 mg/dL). Mean serum ADP levels were significantly in-
creased in all patients with type 2 diabetes with or without nephropathy as compared
to the control group with higher levels in those with nephropathy. Serum ADP lev-
els were positively correlated with fasting blood glucose, glycosylated hemoglobin
(HbA1c), microalbuminuria, serum creatinine and urea.The most independent risk
*Corresponding author: factors for occurrence of microvascular complications may reflect the role of ADP
Ayman_elzarka@yahoo.com
as a predictor and prognostic marker of DN among patients with type 2 diabetes.

1. Introduction
tect against progression to macroalbuminuria.
Diabetes mellitus (DM) is a chronic metabolic
Many biologically active peptides, such as angi-
disorder which is correlated with high risk of an-
otensin II, endothelin, neuropeptide Y and uroten-
giopathy, retinopathy, nephropathy and neuropa-
sin II, are expressed in the kidney and involved
thy. Improvements in glycemic control may help
in the pathogenesis of DN (Caroccia et al., 2017).
to decrease these complications (Pradeep and
Adiponectin (ADP), a vasodilator regulatory pep-
Haranath, 2014). Diabetic nephropathy (DN) is
tide that is also expressed in the kidney and can
considered as one of the main potential cause of
prevent albuminuria and other renal disorders
end-stage renal disease worldwide (Narres et al.,
mainly through enhancing the disrupted renal en-
2016). Patients with DN have low but abnormal
dothelial function, decreasing oxidative stress,
levels of albumin in urine [this called microal-
and increasing endothelial nitric oxide synthase
buminuria, in which urinary albumin/creatinine
(eNOs) expression and peroxisome prolifera-
ratio (ACR) ranged from 30 to 300 mg/g] which
tor-activated receptor (PPAR)-α (Zha et al., 2017).
usually is accompanied with low glomerular fil-
Therefore, in the present study ADP levels were
tration rate and hypertension. Early detection of
evaluated as an early predictor and prognostic
DN are important as early intervention can pro-
marker of DN among patients with type 2 diabetes.
7
 El-Zarka et al., 2018, AJMS 1(1): 7-13. DOI:10.5455/ajms.1
2. Subjects and methods
This study included sixty subjects; of them twen-
ty apparently healthy age and sex matched sub-
jects were considered as a control group and the
remaining forty were type 2 diabetic patients (se-
lected from those admitted to Diabetes Unit, Inter-
nal Medicine Department, Tanta University Hos-
pital, Egypt) which were subdivided into twenty
patients without nephropathy normoalbuminuria
<30 mg/g), and twenty patients with nephropathy
(microalbuminuria 30-300 mg/g). Exclusion cri-
teria: type 2 diabetes mellitus with cancer, severe
renal failure, liver and heart diseases. All patients’
histories were collected from the hospital records.
Blood samples (2 mL from each subject) were
collected in EDTA tube to measure fasting blood glu-
cose (FBG) and glycosylated hemoglobin (HbA1c).
Other blood samples were collected in plain tubes
and were allowed to clot then centrifuged at 4000
rpm for 15 minutes and the obtained serum was
utilized for estimation of creatinine, urea and se-
rum adiponectin. Second morning urine samples
were collected for estimation of microalbumin.
Blood glucose, serum creatinine and urea and spot
urine microalbumin were determined using commer-
cial kits obtained from Biomed Diagnostics (Han-
nover, Germany). HbAlc level was measured accord-
ing to method described by (Karami and Baradaran,
2014) using NycoCard READER technique supplied
by (Axis-Shield, Norway). Serum adiponectin lev-
el was assessed by ELISA technique following the
manufacturer protocol (AssayMax, Cat #EA2500-1,
USA) as previously described (Tsao et al., 2002).
The statistical analysis was performed using anal-
ysis of variance (ANOVA) by SPSS version 21. Per-
son’s correlation coefficient was used to estimate the
correlation between variables. Areas under receiver
operating characteristic (ROC-AUC) curve was used
to assess the sensitivity of laboratory parameters in
diagnosis of nephropathy among patients with type 2
diabetes depending on estimating the cut off values:
(0.6-0.69) poor, (0.7-0.79) fair, (0.8-0.89) good, (0.9-
1.0) excellent values. Data was represented as mean ±
standard deviation and significance was set at p<0.05.
8
3. Results
There was no significant difference between age,
sex and disease duration among the studied groups
while diabetic patient with and without nephrop-
athy have significant higher body mass index
(BMI) compared to control subjects (Table 1).
A significant increase in serum creatinine, blood
urea and serum ADP was noticed among patients
with type 2 diabetes with or without nephropathy as
compared to control group (Table 2). Patients with
type 2 diabetes with nephropathy showed a signifi-
cant increase in fasting blood glucose (FBG), HbA1c
and albumin/creatinine ratio (ACR) as compared to
patients without nephropathy and control group.
ACR was positively correlated (P<0.05) with FBG
(r=0.587, P=0.03), HbA1c (r=0.497, P=0.04), serum
creatinine (r=0.812, P=0.0001), blood urea (r=0.642,
P=0.0001), and serum ADP (r=0.654, P=0.01) in pa-
tients with type 2 diabetes and nephropathy (Table 3).
On the other hand, serum ADP was posi-
tively correlated (P<0.05) with FBG (r=0.392,
P=0.01), HbA1c (r=0.451, P=0.01), serum cre-
atinine (r=0.364, P=0.01), blood urea (r=0.499,
P=0.001), and ACR (r=0.480, P=0.001) in patients
with type 2 diabetes and nephropathy (Table 4).
The ROC-AUC curve showed thatACR (AUC=1.000)
and serum ADP (AUC=0.981) were most sensitive pa-
rameters followed by serum creatinine (AUC=0.858),
FBG (AUC=0.761), HbA1c (AUC=0.725)
and lastly blood urea (AUC=0.703) (Fig. 1).
Multivariate regression analysis, which denoted beta
coefficient for predictors of DN among patients with
type 2 diabetes, showed that ACR (β = 0.003, p=0.026)
and ADP (β= 0.718, p= 0.0001). This indicates that
urinary ADP is an independent predictor of diabet-
ic nephropathy in type 2 diabetic patients (Table 5).
 El-Zarka et al., 2018, AJMS 1(1): 7-13. DOI:10.5455/ajms.1
Table (1): Distribution of the studied groups according to sex, age, body mass index (BMI) and
duration of diabetes.
Paramerters Control group DM without nephropa- DM with nephropathy
(n= 20) thy (n=20) n=(20)

Age(years) 56.5 ± 2 57 ± 2.6 58.2 ± 2.4

F test Scheffe test 2.651ns
Sex(M/F) 10/10 11/9 9/11
X2 1.003
P value 0.7530
BMI (Kg/m2) 23.4 ± 1.4 27.8 ± 0.94 28.8± 1.13
F test 62.028*
Scheffe test I vs II, P* = 0.001 , I vs III, P*= 0.001
DM Duration (years) 8.6± 1.4 9.2± 1.02
F test 1.965ns
Scheffe test

Data are presented as mean±SD.

Table (2): Biochemical data of the studied groups.

Paramerters Control group DM without nephropa- DM with nephropathy
(n= 20) thy (n=20) n=(20)
Fasting blood glucose (mg/dL) 91.8± 11.4 173.7 ± 17.3 198.1± 6.29
F test 165.64*
Scheffe test I vs II, P* = 0.001, I vs III, P*= 0.001, II vs III, P*= 0.001
HbA1c (%) 5.26 ± 0.32 7.4± 0.52 8.02± 0.71
F test 139.69*
Scheffe test I vs II, P* = 0.001, I vs III, P*= 0.001, II vs III, P*= 0.01
Serum creatinine (mg/dL) 0.91 ± 0.15 0.99 ± 0.19 1.69 ± 0.25
F test 31.07*
Scheffe test I vs II, P* = 0.001, I vs III, P*= 0.001
Blood Urea (mg/dL) 33.9 ± 7.3 42.1 ± 7.1 62.7 ± 12.2
F test 86.373*
Scheffe test I vs II, P* = 0.001, I vs III, P*= 0.001
ACR (mg/g) 10.8 ± 4.3 17 ± 7.9 90.4 ± 48.9
F test 47.132*
Scheffe test I vs II, P* = 0.05, I vs III, P*= 0.001, II vs III, P*= 0.001
Serum Adiponectine (ng/mL) 90 ± 8.1 107.4 ± 14.7 118.6 ± 14.7
F test 5.953*
Scheffe test I vs III, P*= 0.01, II vs III, P*= 0.05

Data are presented as mean±SD

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 El-Zarka et al., 2018, AJMS 1(1): 7-13. DOI:10.5455/ajms.1

Table (3): The correlation between ACR and other Table (4): The correlation between ADP and other
parameters in patients with type 2 diabetes and ne- parameters in patients with type 2 diabetes and ne-
phropathy. phropathy.

Parameters r-values Parameters r-values

Age(years) 0.060 Age(years) 0.0458

BMI(kg/m2) 0.213 BMI(kg/m2) 0.023

Duration of diabetes (years) 0.190 Duration of diabe-

0.039
tes (years)
FBG(mg/dL) 0.587* FBG(mg/dL) 0.390**
HbA1c(%) 0. 497* HbA1c(%) 0.451**
Creatinine(mg/dL) 0. 812*** Creatinine(mg/dL) 0.364**
Urea(mg/dL) 0. 642*** Urea(mg/dL) 0.449***
Serum adiponectin (ng/mL) 0. 654** ACR (mg/g) 0.480***
r : Pearson’s correlation coefficient, * p < 0.05, ** p
r : Pearson’s correlation coefficient, ** p < 0.01,
< 0.01, *** p < 0.001
*** p < 0.001

Fig.1. Area under ROC curve was denoting sensitivity of different measured parame-
ters for diagnosis of nephropathy in patient with type 2 diabetes.

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 El-Zarka et al., 2018, AJMS 1(1): 7-13. DOI:10.5455/ajms.1

Table (5) Multivariate regression analysis for pre- without nephropathy showed a significant change
dictors of DN among patients with type 2 diabetes. in HbA1c and FBG levels with fair predictive
Multivariate regression. ROC-AUC values of 0.725 and 0.761 respec-
Parameters β St.error t p-value tively. These results were consistent with Kita-
oka et al., (2016), who indicated that nephropa-
ACR 0.003 0.001 2.331 0.026* thy progressors had higher HbA1c and FBG than
nonprogressors. Microalbuminuria significantly
ADP 0.718 0.151 4.769 0.0001* correlated with HbA1c and FBG in the select-
ed patients with type 2 diabetes and nephropathy
Creatinine 0.006 0.003 1.944 0.060 which was consistent with Sheikh et al., (2009).
Herein, age factor is not associated with DN
Urea -0.005 0.003 -1.906 0.065 which was on the contrary to findings of Cheng et
al., (2013), who reported that older age is a risk fac-
HbA1C 0.201 0.265 0.757 0.454 tor of DN. Microalbuminuria in patients with type
2 diabetes and nephropathy has shown insignificant
FBS -0.005 0.008 -0.718 0.478 correlation with age factor and BMI which was sim-
ilar to the findings reported by Afkhami-Ardekani et
al., (2008). In contrast, Lim et al., (2009) and Sheikh
et al., (2009) reported a significant correlation be-
4. Discussion tween microalbminuria prevalence and both age and
There are several risk factors that make people with BMI in patients with type 2 diabetes and nephrop-
diabetes more prone to kidney disease. One is poor athy as compared to those without nephropathy.
control of blood glucose. People with hypertension Our obtained data revealed that patients with
or a family history of hypertension are more likely type 2 diabetes exhibited a significant elevation in
to develop renal disease than those without a fam- serum ADP level compared to controls. Similarly,
ily history. The time factor is also important; the Saraheimo et al., (2005) also reported higher serum
longer the duration of diabetes the higher the risk ADP level in patients with type 1 diabetic nephrop-
of renal disease (Reutens et al., 2008). The remark- athy, and this higher level was correlated with renal
able increase in number of diabetic people may insufficiency. However, (von Eynatten et al., 2009)
consequently lead to high rate of DN. Hence, it is found that when patients with nephropathy were ex-
crucial to decrease the complication of diabetes to cluded, serum ADP was significantly lower in pa-
prevent the development of DN (Fu et al., 2012). tients with type 2 diabetes than healthy individuals.
In the present study, patients with diabet- Our results showed that patients with type
ic nephropathy had a significant elevation in se- 2 diabetes and nephropathy had higher ADP lev-
rum creatinine, urea, and ACR when compared to els compared to those without nephropathy. ROC-
those without nephropathy. This was supports by AUC showed that serum ADP was (AUC=0.981)
ROC-AUC results which revealed excellent pre- near to ACR. These results were in accordance
dictive value of microalbuminuria (AUC=1.000) with the findings of (Koshimura et al., 2004) who
and good predictive values of serum creatinine found that serum ADP levels were much higher in
(AUC=0.858) and urea (AUC=0.703). These find- the patients with nephropathy than in those with-
ings were consistent with (Fiseha, 2015) who con- out nephropathy and these levels are elevated as
cluded that microalbuminuria is essential for early the severity of DN increased. The early renal ab-
detection of DN in patients with type 2 diabetes. normalities in DN include glomerular hypertension
Our results revealed that patients with type and hyperfiltration. Sustained glomerular hyperten-
2 diabetes and nephropathy as compared to those sion together with several other factors, such as ad-
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 El-Zarka et al., 2018, AJMS 1(1): 7-13. DOI:10.5455/ajms.1
vanced glycation end-products, cytokines, hyperlipi-
demia, sorbitol, angiotensin II and growth factors,
causes thickening of glomerular basement mem-
brane and mesangial expansion eventually followed
by glomerulosclerosis. ADP has the ability to pass
through the glomerular filtration barrier to protect
against albuminuria and decrease renal endothelial
loss via preventing inflammation, fibrosis and oxida-
tive stress in kidneys (Christou and Kiortsis, 2014).
Serum ADP has insignificant correlation with
age and BMI in patients with type 2 diabetes and
nephropathy which was consistent with (Saraheimo
et al., 2005). Also, there was a significant correlation
between serum ADP level and HbA1c in the present
work. However, (Gligor et al., 2012) reported an in-
crease in the circulating ADP correlates with poor glu-
cose metabolic control in patients with type 2 diabe-
tes. Moreover the present study showed insignificant
correlation between serum ADP level and duration
of diabetes which was in contrast to the findings of
Saraheimo et al., (2005). A positive significant corre-
lation was observed in our work between serum ADP
level and FBG in patients with type 2 diabetes and
nephropathy which was in agreement with findings
of Nakamaki et al., (2011) who reported that hyperg-
lycemia causes renal damage by several mechanisms
including non-enzymatic glycation of protein, acti-
vation of hexosamine and increase intracellular ROS.
The present work demonstrated a positive sig-
nificant correlation between serum ADP and each
of serum creatinine and urea in patients with type 2
diabetes and nephropathy. These results were con-
sistent with Sangeeta et al., (2015) who suggested
that the increased serum ADP level in renal insuf-
ficiency may be partly due to decreased clearance
in the kidney. The vascular endothelial damage and
volume retention in nephropathy could be other
reasons. Taken together with the vasodilative ef-
fect in renal arteries, the production of ADP may be
augmented to preserve renal blood flow and GFR
when renal function deteriorates (Eissa et al., 2016).
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