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Xuebalib.Com.28678.Pdf Clinica Chimica Acta 412 (2011) 1407–1411 Contents lists available at ScienceDirect Clinica Chimica Acta journal homepage: www.elsevier.com/locate/clinchim Assessment of urinary γ-glutamyltransferase and alkaline phosphatase for diagnosis of diabetic nephropathy José A.M. De Carvalho a,b,c, Sílvia J. Piva a,b, Bruna S. Hausen a,b, Guilherme V. Bochi a,d, Michelle Kaefer c, Adriane C. Coelho c,e, Marta M.M.F. Duarte f, Rafael N. Moresco a,b,d,⁎ a Laboratório de Bioquímica Clínica, Departamento de Análises Clínicas e Toxicológicas, Centro de Ciências da Saúde, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil b Programa de Pós-Graduação em Ciências Farmacêuticas, Centro de Ciências da Saúde, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil c Hospital Universitário de Santa Maria, RS, Brazil d Programa de Pós-Graduação em Farmacologia, Centro de Ciências da Saúde, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil e Associação dos Diabéticos e Hipertensos, Santa Maria, RS, Brazil f Departamento de Ciências da Saúde, Universidade Luterana do Brasil, Santa Maria, RS Brazil article info abstract Article history: Background: Urinary biomarkers of tubular damage can be useful for early diagnosis of diabetic nephropathy. Received 19 November 2010 Thus, the aim of this study was to test the diagnostic accuracy of the urinary excretion of γ-glutamyltransferase Received in revised form 3 April 2011 (GGT) and alkaline phosphatase (ALP) for diagnosis of diabetic nephropathy (DN). Accepted 11 April 2011 Methods: Fasting glucose, fructosamine, serum creatinine, glomerular filtration rate (GFR), serum uric acid, Available online 17 April 2011 serum albumin, and urinary albumin, creatinine, GGT and ALP were assessed in 74 type 2 diabetic patients without nephropathy and 38 type 2 diabetic patients with nephropathy. Keywords: Results: Urinary GGT and ALP were threefold higher in type 2 diabetic patients with nephropathy. Significant Albuminuria b Alkaline phosphatase correlations were observed between urinary albumin and GGT (r=0.439, P 0.001) and urinary albumin and Diabetic nephropathy ALP (r=0.305, Pb0.01). Areas under the curve for GGT and ALP were 0.7696 (Pb0.001) and 0.7233 γ-glutamyltransferase (Pb0.001), respectively. At a cut-off value of 72 U/g creatinine, GGT demonstrated a sensitivity of 96.0% and a specificity of 52.6%. At a cut-off value of 20 U/g creatinine, ALP demonstrated a sensitivity and specificity of 83.8% and 36.8%, respectively. Conclusions: Urinary GGT and ALP have potential value in the diagnosis of nephropathy in type 2 diabetic patients, but GGT has a slightly higher ability to discriminate nephropathy than ALP. © 2011 Elsevier B.V. All rights reserved. 1. Introduction Diabetic nephropathy (DN) is defined as a rise in urinary albumin excretion rate, often associated with an increase in blood pressure. It Diabetes has become the most common single cause of end-stage is the leading cause of ESRD and carries an increased risk for renal disease (ESRD) in the U.S. and Europe. About 20–30% of patients cardiovascular mortality [2,3]. Microalbuminuria is the first sign of with type 1 or type 2 diabetes develop evidence of nephropathy, but diabetic renal impairment or incipient nephropathy [2–5] and is in type 2 diabetes, a considerably smaller fraction of these patients generally considered the best noninvasive predictor for the develop- progress to ESRD. A higher proportion of individuals with type 2 ment of diabetic nephropathy (DN) [6]. Assessment of albuminuria diabetes are found to have microalbuminuria and overt nephropathy status and renal function screening for microalbuminuria can be shortly after having the diagnosis of diabetes. This happens because performed by measurement of the albumin to creatinine ratio in a diabetes may be present for many years before its diagnosis is made random spot collection (preferred method); 24-h or timed collections and also because the presence of albuminuria may be less specific for are more burdensome and add little to prediction or accuracy [7,8]. the presence of diabetic nephropathy. Without specific interventions, Microalbuminuria is defined by urinary albumin levels ranging to 30– 20–40% of type 2 diabetic patients with microalbuminuria progress to 299 mg/g creatinine, and macroalbuminuria is defined by urinary overt nephropathy, but by 20 years after the onset of the overt albumin levels≥300 mg/g creatinine [9,10]. nephropathy, only ~20% may progress to ESRD [1]. DN is characterized by a series of ultrastructural changes in all renal compartments. The changes include basement membrane thickening, glomerular and tubular hypertrophy, mesangial expansion, glomer- ⁎ Corresponding author at: Universidade Federal de Santa Maria, Centro de Ciências ulosclerosis and tubulointerstitial fibrosis. While most attention has da Saúde, Departamento de Análises Clínicas e Toxicológicas, Avenida Roraima 1000, focused on glomerular changes, it is now increasingly recognized that Prédio 26, Sala 1216, 97105–900, Santa Maria, RS, Brazil. Tel.: +55 55 32208941; fax: +55 55 32208018. tubules play an important role in the pathogenesis of DN [11]. The E-mail address: [email protected] (R.N. Moresco). proximal tubule is susceptible to a variety of metabolic, hemodynamic 0009-8981/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.cca.2011.04.015 1408 J.A.M. De Carvalho et al. / Clinica Chimica Acta 412 (2011) 1407–1411 and inflammatory factors associated with hyperglycemia. Early analyzer. Glomerular filtration rate (GFR) was estimated by the tubular injury has been reported in patients with diabetes mellitus Modification of Diet in Renal Disease (MDRD) equation [20]. whose glomerular function is intact [12]. Chronic hypoxia could have a dominant pathogenic role in DN, not only in promoting progression 2.3. Statistics but also during initiation of the condition. Early loss of tubular and peritubular cells reduces production of 1,25-dihydroxyvitamin D3 and Data are presented as mean and standard deviation (SD) or median erythropoietin, which, together with dysfunction of their receptors and ranges. Categorical data were summarized as percentages, and caused by the diabetic state, diminishes the local trophic effects of the comparisons between groups were performed with χ2 test. Statistical hormones. This diminution could further compromise the functional differences between groups were evaluated by Mann–Whitney or and structural integrity of the parenchyma and contribute to the Kruskal–Wallis tests. Spearman's correlation was assessed to evaluate gradual decline of renal function [12]. the correlations between the variables. Multiple regression analysis Urinary markers, characteristic of tubular damage, are mainly was assessed to investigate whether some factors interfere in urinary composed of enzymes urinary or plasma proteins of low molecular GGT and ALP. Receiver operator characteristic (ROC) curve was weight that are normally freely filtered by the glomerulus [5].Their performed to quantify the overall ability of urinary GGT and ALP to increased excretion in urine results from the impaired reabsorption of discriminate between those type 2 diabetic patients with nephropathy plasma proteins by the tubular cells or from the increased secretion of and those without nephropathy. The sensitivity and specificity of such urinary enzymes by tubular epithelia cells, leading to tubular protein- assays were assessed by ROC curve. Statistical significance was uria [5,13,14]. Similarly, enzymes in urine are highly sensitive markers assumed at Pb0.05. Data were analyzed using GraphPad Prism ver of renal tubular damage. Some of the best characterized tubular proteins 4.00 for Windows (GraphPad Software, San Diego, CA) and Statistica and enzymes used to detect proximal tubular injury are α1-and 6.0 (StatSoft Inc., Tulsa, OK). β2-microglobulin, cystatin C, retinol-binding protein, α-glutathione S-transferase (GST), γ-glutamyltransferase (GGT), alkaline phosphatase 3. Results (ALP), lactate dehydrogenase (LD), and N-acetyl-glucosaminidase (NAG) [15,16]. Previous studies have demonstrated that determination Baseline characteristics of the study participants are described in of enzymuria could facilitate early detection of DN [11,17]. Thus, the aim Table 1. Biochemical parameters of the study participants are of this study was to test the diagnostic accuracy of the urinary excretion summarized in Table 2. Type 2 diabetic patients with nephropathy of GGT and ALP, which are two enzymes commonly measured by well- had significantly higher levels of fasting glucose, fructosamine, urinary established methods in the laboratory routine for diagnosis of DN. albumin, urinary GGT and ALP. Urinary GGT and ALP activity was threefold higher in type 2 diabetic patients with nephropathy than those patients without nephropathy, although a similar GFR observed 2. Materials and methods in the groups. Multiple regression showed that the association between higher urinary levels of these enzymes and nephropathy 2.1. Study population was independent of fasting glucose level, fructosamine level and smoking (Table 3). When the patients were divided according to the The study involved the following 2 groups: type 2 diabetic patients excretion of urinary albumin, patients with macroalbuminuria had without nephropathy (n=74; mean age±SD, 61.3±10.6 y), and type significantly higher levels of fasting glucose, urinary GGT and ALP, as 2 diabetic patients with nephropathy (n=38; mean age±SD, 57.4± shown in Table 4. No significant differences were observed for 12.6 y). Participants were recruited from the Associação dos Diabéticos fructosamine, GFR, serum creatinine, uric acid and serum albumin. (Diabetic Patient Association) located in Santa Maria city, Rio Grande We have shown a Venn diagram of positive albuminuria, positive do Sul, Brazil. Diabetic nephropathy has been defined based on the urinary GGT (over 72 U/g creatinine), and positive urinary ALP (over values of urinary albumin in a random urine sample according to the 20 U/g creatinine) to better understand the diagnostic values of criteria previously described [9,10,18]. Exclusion criteria consisted in urinary GGT and ALP for DN (Fig.
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