|Year : 2018 | Volume
| Issue : 4 | Page : 182-190
Serum and urinary pentraxin-3 levels in type 2 diabetes and its relation to diabetic nephropathy
Said M Al-Barshomy1, Mohamed El Sayed Mostafa1, George Emad Shaker1, Lamiaa A Wahab2
1 Department of Internal Medicine and Nephrology, Zagazig University, Zagazig, Egypt
2 Department of Clinical Pathology, Zagazig University, Zagazig, Egypt
|Date of Submission||20-Feb-2018|
|Date of Acceptance||26-Jul-2019|
|Date of Web Publication||14-Jan-2019|
Said M Al-Barshomy
Department of Internal Medicine and Nephrology, Zagazig University, Zagazig
Source of Support: None, Conflict of Interest: None
Background Diabetic nephropathy (DN) is the most common cause of end-stage renal disease. Microalbuminuria is the most popular method for detecting the early signs of DN. However, pathological changes occur before the onset of microalbuminuria. So, there is a need for another biomarkers that might provide a sensitive and fast means for identification of the progression of DN. Pentraxin 3 (PTX3) is an acute-phase glycoprotein and a soluble receptor acting as an opsonin. PTX3 protein is expressed in vascular endothelial cells and macrophages. Thereby, its levels may reflect more directly the inflammatory status of the vasculature.
Aim Evaluation of the levels of serum and urinary PTX3 in type 2 diabetes mellitus (T2DM) patients and its relation to DN.
Patients and methods Group A: 20 healthy volunteers (control group). Group B: 20 patients with normoalbuminuric T2DM. Group C: 20 patients with microalbuminuric T2DM. Group D: 20 patients with macroalbuminuric T2DM. Also all the participants divided into two subgroups: Group 1: 40 participants with no nephropathy (controls and normoalbuminuric patients). Group 2: 40 patients with nephropathy (microalbuminuric and macroalbuminuric patients).
Results There was no significant difference among all studied groups with respect to age, sex, lipid profile, urinary PTX3, C-reactive protein, and liver function test. Whereas BMI, hemoglobin level, HBA1C, fasting blood sugar, postprandial blood sugar, serum creatinine, estimated glomerular filtration rate, and 24 h urinary albumin excretion; showed high significant difference among all studied groups. Serum albumin and total protein levels were highly significantly decreased in macroalbumiuric group as a result of proteinuria compared to the other three groups Serum PTX3 showed high significant difference between nephropathic (micro and macroalbuminuric) group and non nephropathic group (control and normoalbuminuric). There were highly significant positive correlations between serum PTX3 and (fasting blood sugar, postprandial blood sugar, HBA1C, and 24 h urinary albumin) significant positive correlation with serum creatinine, whereas there were highly significant negative correlations between serum PTX3 and serum total protein and serum albumin.
Conclusion Serum PTX3 increased progressively with DN and may be a serum biomarker for early diagnosis of DN. Whereas urinary PTX3 has no relation to DN.
Keywords: diabetic nephropathy, CRF, pentraxin 3
|How to cite this article:|
Al-Barshomy SM, Mostafa MS, Shaker GE, Wahab LA. Serum and urinary pentraxin-3 levels in type 2 diabetes and its relation to diabetic nephropathy. Egypt J Intern Med 2018;30:182-90
|How to cite this URL:|
Al-Barshomy SM, Mostafa MS, Shaker GE, Wahab LA. Serum and urinary pentraxin-3 levels in type 2 diabetes and its relation to diabetic nephropathy. Egypt J Intern Med [serial online] 2018 [cited 2019 Mar 20];30:182-90. Available from: http://www.esim.eg.net/text.asp?2018/30/4/182/249969
| Introduction|| |
Diabetes mellitus (DM) is one of the most challenging health concerns of the 21st century .
The syndrome ‘diabetic nephropathy (DN)’ is a microvascular complication of both type 1 and type 2 diabetes .
DN is the most common cause of end-stage renal disease (ESRD) and contributes to 57% of patients with type 2 diabetes mellitus (T2DM). Although T2DM is a preventable and treatable cause of ESRD, the number of ESRD patients caused by T2DM has increased and accounts for more than 50% of incident dialysis patients .
The overall burden for people with DN is extremely high because of the strong associations of DN and cardiovascular disease with ESRD .
Microalbuminuria is the most popular method for detecting the early signs of DN . The progression of DN from proteinuria to renal failure is irreversible . Therefore, detection of microalbuminuria as early as possible in the course of the disease is important. The American Diabetes Association (ADA) recommends that all type 2 diabetic patients should do annual microalbumin urine test, starting at the time of diagnosis .
The development of clinical nephropathy is insidious, and macroalbuminuria [urinary albumin excretion rate (AER) >300 mg/24 h], the hallmark of the condition, is preceded by a phase of microalbuminuria (UAE 30–300 mg/24 h), which usually lasts 5–10 years. As albuminuria worsens and blood pressure increases, there is a relentless decline in estimated glomerular filtration rate (eGFR) and progression to ESRD  However, pathological changes have been reported to occur before the onset of microalbuminuria and about 20–30% of patients with type 2 diabetes, accompanied by renal insufficiency, showed normoalbuminuria .
A sizeable proportion (≥55%) . of DN patients with impaired eGFR (<60 ml min 1.73 m2) were not be diagnosed by albuminuria screening. To overcome these limitations, many clinicians additionally used creatinine in evaluating such patients. However, serum creatinine also depends on creatinine production, extrarenal elimination, and tubular handling . So, there is a need for detecting another biomarkers that might provide a sensitive and fast means for identification of the progression of DN .
Pentraxin 3 (PTX3) is an acute-phase glycoprotein and a soluble receptor acting as an opsonin. PTX3 protein is expressed in vascular endothelial cells and macrophages. Thereby, its levels may reflect more directly the inflammatory status of the vasculature .
PTX3 is one of the endothelium-specific inflammatory cytokines, representing directly the tissue inflammatory response, especially the one involving the vascular bed. Production of PTX3 is considered to be stimulated in many different tissues under the control of the primary inflammatory signal. In addition to vascular endothelial cells, it can be released by various cell types, such as macrophages, dendritic cells, etc. as a response to tissue damage and inflammation ,. PTX3 escalates the procoagulant effect of the endothelial cells  and reduces the endothelial repair by disabling the effect of the fibroblast growth factor. Furthermore, it accelerates the tissue damage and inhibits angiogenesis . Studies have shown that patients with small-vessel vasculitis or inflammatory conditions, such as coronary artery disease or myocardial infarction have high plasma levels of PTX3 ,. Further, high PTX3 values are related to vascular dysfunction in patients with T2DM .
Several clinical investigations have demonstrated that elevated plasma PTX3 levels are associated with cardiovascular and chronic kidney diseases ,.
The aim of this work was to study the levels of serum and urinary PTX3 in T2DM patients and evaluate its relation to DN.
| Patients and methods|| |
This case–control study was conducted in Internal Medicine, Nephrology Unit and Clinical Pathology Departments in Zagazig University Hospital during the period from October 2016 to October 2017.
This study was carried out on 80 patients divided into:
- Group A: 20 age and sex matched healthy volunteers (control group).
- Group B: 20 patients with normoalbuminuric T2DM.
- Group C: 20 patients with microalbuminuric T2DM.
- Group D: 20 patients with macroalbuminuric T2DM.
All participants divided into two groups:
- Group 1: 40 participants with no nephropathy (controls and normoalbuminuric patients).
- Group 2: 40 patients with nephropathy (microalbuminuric and macroalbuminuric patients).
Diagnosis of T2DM was based on the ADA diagnostic criteria (2016) and the stages of DN were based on the standard from ADA (2016), annual measurement of urinary albumin and eGFR in patients with type 2 diabetes starting at diagnosis. The T2DM patients were stratified into three subgroups according to their urinary AER in 24 h urine collections. Normal AER was defined as an AER persistently less than 20 µg/min/24 h, microalbuminuria as an AER between 20 and 200 µg/min/24 h and macroalbuminuria as an AER greater than 200 µg/min/24 h.
Participants who fulfilled one of the following criteria were excluded:
- Liver disease.
- Thyroid disease.
- Any active inflammatory diseases.
- Patients who received insulin therapy for at least 2 years.
- Patients on hemodialysis.
- Patients with history of drug intake including antibiotics, nonsteroidal anti-inflammatory drugs, corticosteroids, or cytotoxic medications at the time of the study.
All participants were submitted to the following:
- Patient consent for sampling.
- Full history taking: including age, sex, smoking, hypertension, and medications.
- General clinical examination.
- Anthropometric measurements: weight in kilograms, height in meters, and BMI. BMI=weight (kg)/height (m2).
- Laboratory investigations:
- Routine investigations:
- Complete blood count.
- Total cholesterol and triglycerides.
- Alanine transaminase, aspartate transaminase, and serum albumin.
- Fasting and random blood glucose.
- Serum creatinine.
- Plasma total protein.
- C-reactive protein (CRP).
- Calculation of eGFR using MDRD equation GFR (ml/min/1.73 m2)=175×(serum creatinine)-1.154×(age)−0.203×(0.742 if female) .
- 24 h urinary AER.
- All routine investigations are obtained from the patients files.
- Special investigations:
Serum and urinary PTX3 measurement: using a commercial enzyme-linked immunosorbent assay kit produced by BIOVENDO research and diagnostic products (USA).
| Results|| |
There was no significant difference among all studied groups with respect to age, sex, lipid profile, urinary PTX3, CRP, and liver function test. Whereas BMI, hemoglobin level, HBA1C, fasting blood sugar, postprandial blood sugar, serum creatinine, eGFR, and 24 h urinary albumin excretion; showed highly significant difference among all studied groups ([Table 1]).
There was a high significant difference between macroalbuminuric patients and the other three groups with respect to serum albumin and total protein levels, which were decreased in macroalbumiuric group as a result of proteinuria, other liver function tests showed no significant difference.
CRP showed no significant difference.
There was a significant difference among groups with respect to serum PTX3.It was more in macroalbuminuric group than microalbuminuric group than normoalbuminuric group than control group but urinary PTX3, showed no significant difference among different groups ([Table 2], [Figure 1]).
With respect to serum PTX3, high significant difference noticed between nephropathic (microalbuminuric and macroalbuminuric) group, and non-nephropathic group (control and normoalbuminuric).With respect to urinary PTX3 there was no significant difference ([Table 3], [Figure 2]).
|Table 3 Comparison of pentraxin 3 in nephropathy(micro and macroalbuminuric) and non-nephropathy (control and normoalbuminuric)|
Click here to view
There were highly significant positive correlations between serum PTX3 and (fasting blood sugar, random blood sugar, HBA1C) and 24 h AER and significant positive correlation with serum creatinine, whereas there were a highly significant negative correlations between serum PTX3 (serum total protein and serum albumin) and no correlation noticed between serum PTX3, GFR, CRP, urinary PTX3, serum cholesterol, and triglycerides.
Urinary PTX3 level was highly correlated significantly with serum CRP and significantly correlated to serum albumin level otherwise, it shows no correlation with any other parameters ([Table 4]).
|Table 4 Correlations between serum and urinary pentraxin 3 and other parameters|
Click here to view
| Discussion|| |
Podocyte dysfunction in renal microenvironments is an important feature in the pathogenesis of DN. Podocyte nephrin disintegration in the slit diaphragm has been observed to contribute to loss of protein excretion. Nephrin has been shown to act as a protein tyrosine kinase that triggers biologic reaction in maintaining podocyte function and renal filtration capacity in various renal disorders . Lin et al.  reported that diabetes lead to reduction of nephrin level in conjunction with nephrin deacetylation.
Suliman et al.  studied whether serum PTX3 levels are associated with albuminuria and endothelial dysfunction. They showed that PTX3 is significantly and independently associated with the levels of albuminuria. Moreover, they showed that in patients with type 2 diabetes, both PTX3 and albuminuria are independently associated with ED(Endothelial Damage) and carotid intima thickness. Altogether, the strong links among PTX3, albuminuria, and ED suggested a role for PTX3 in the development of atherosclerotic complications in chronic kidney disease.
Sun et al.  showed a crucial role for PTX3 in attenuating renal damage in DN. In mouse hyperglycemia induced nephropathy model, PTX3 treatment showed significantly increased expression of nephrin, acetylated nephrin, and Wilm’s tumor-1 protein (WT-1) when compared with control. The number of CD4+ T cells, CD8+ T cells, Ly6G+ neutrophils, and CD11b+ macrophages were all significantly lower in the PTX3-treated group than that in the control group in DN. The interlukin (IL)-4 and IL-13 levels in the PTX3- treated group were markedly higher than that in the control group in DN. Correspondingly, the PTX3-treated group showed increased numbers of Arg1-expressing or CD206-expressing macrophages compared with the control group. Furthermore, inhibition of PTX3-treated macrophages abrogated the alleviated renal damage induced by PTX3 treatment. They documented an innate immuneregulatory role for PTX3 in the kidney inflammatory response against streptozotocin (STZ)-induced DN. PTX3 treatment results in the development of M2 macrophages, which protects kidney from STZ-induced DN.
PTX3 is an acute-phase glycoprotein and a soluble receptor acting as an opsonin. PTX3 protein is expressed in vascular endothelial cells and macrophages. Thereby, its levels may reflect more directly the inflammatory status of the vasculature .
In our study, there was no significant difference of DN among groups with respect to age and sex in agreement with Abu Seman  but against Yilmaz  who found the ages of Turkish T2DM patients with DN (at 42 years old) are younger and their duration of diabetes are shorter. Also, Yamasaki and Kurimuri  observed that plasma PTX3 levels between males and females in a healthy Japanese population are different. Moloney et al.  have demonstrated that DN is 30% more frequent in males than in females. Gu  have also showed that DNA polymorphisms in the genes of sex-determining specific regions are associated with DN with gender-specific effects.
In our research, there was a significant difference among groups with respect to hemoglobin, but there were no statistical significance differences among the studied groups as regards, white blood cells, platelets.
In this study, with respect to all blood glucose parameters (fasting and random blood glucose and HBA1C) a high significant difference was remarked between control group and the other three groups, whereas among normoalbuminuric, microalbuminuric, macroalbuminuric groups, differences were less significant.
This agree with Idogun and Kasia  and Assal et al.  who found that impaired glycemic control by both glycosylated HbA1C and fasting blood glucose is associated with significant elevations in urinary albumin levels. Against our results Kundu et al.  and Sheikh et al.  found that impaired glycemic control is associated with significant elevations in urinary albumin levels with respect to glycosylated HbA1C but no significant difference pertaining to fasting blood glucose and postprandial blood glucose. Also Hovind and Tarnow  found that increased HbA1C as a marker of chronic hyperglycemia is the most established and unquestioned risk factor for diabetic kidney disease.
In our study there was no statistical significant difference between studied groups with respect to aspartate transaminase, alanine transaminase, total bilirubin
But, there was a high significant difference between macroalbuminuric patients and the other three groups with respect to serum albumin and total protein levels, which were decreased in macroalbuminuric group as a result of protienuria. In pathophysiology, proteinuria, a marker and potential contributor to renal injury, accompanies DN. Increased glomerular permeability will allow plasma proteins to escape into the urine.
This is supported by Viswanathan et al.  who found that serum albumin was significantly lower in macroalbuminuric group of DN. Also our study agreed with Jeong et al.  who found that progression of DN is accompanied by increasing urinary albumin excretion.
In our study there were significant differences between groups with respect to serum creatinine, which was contradictory with El-Hady et al.  as their study showed no significant difference in serum creatinine level between nephropathic diabetic patient and non nephropathic patients.
Also Abu Seman  found no significant difference with respect to serum creatinine level between control group, diabetic non nephropathic group, and DN group.
In our study no statistical difference between studied groups with respect to CRP was found.
In this study, high significant difference was noticed among all groups regarding eGFR by MDRD, it was highest in normoalbuminuric group as a result of hyperfiltration, decreasing from microalbuminuric to macroalbuminuric as a result of nephropathy.
Our study agreed with Chae et al.  who documented a significant difference between both nephropathic and non nephropathic groups with respect to eGFR. Also our study agree with Jeong et al.  who found that progression of DN is accompanied by declining eGFR. In our study there was a significant difference between control group and normoalbuminuric group with respect to eGFR. In agreement with Lu et al.  and MacIsaac et al. , who found significant difference between control and normoalbuminuric with respect to eGFR by MDRD. but against ,.
In our research, high significant difference noticed regarding urinary albumin in 24 hours, as it was highest in macroalbuminuric group with lowest eGFR and least in normoalbuminuric one with highest eGFR. This could be explained by American Diabetes Association  as albuminuria has long been regarded as a marker of the extent of glomerular damage; however, experimental and clinical studies suggest that albuminuria might also contribute to the development and progression of glomerular and tubulointerstitial lesions.
In our research, there was no significant difference with respect to total cholesterol and triglcerides among all studied groups. This is supported by Reverter et al. , Sigdel et al. , and Suchitra et al. . But Joven et al.  proved that, with the progression of albuminuria, there is more synthesis of plasma proteins including lipoproteins.
With respect to serum PTX3, high significant difference was noticed between nephropathic group (microalbuminuric and macroalbuminuric) and non nephropathic group (control and normoalbuminuric), as PTX3 level was highly significantly in nephropathic group.
This is supported by Yilmaz  who found that in patients with type 2 diabetes and proteinuria with normal renal function, PTX3 was significantly higher than in healthy volunteers.
Another support to our results Sulimąn et al.  discovered the strong links between PTX3 and albuminuria. This study showed that PTX3 is significantly and independently associated with the levels of albuminuria. Also, El-Hady et al.  study proved that serum PTX3 is elevated in microalbuminuric patient than healthy participants and normoalbuminuric patient. Moreover, they showed that in patients with type 2 diabetes, both PTX3 and albuminuria are independently associated with endothelial damage ‘ED’ and carotid intima thickness.
Yilmaz , proved similar association of PTX3 with DN is seen in Turkish patients with T2DM.
Contradictory with our study, Abu Seman  examined plasma PTX3 levels in a Malay cohort, including normal participants, T2DM patients with and without DN. Results proved that plasma PTX3 levels in T2DM patients with and without DN were lower as compared with NGT (normal glucose tolerance).
Dubin  have demonstrated that there are racial differences of PTX3 in term of association with kidney dysfunction.
Urinary PTX3 showed no significant difference among all groups in contrary to Pang et al.  who found significantly higher urinary PTX3 levels in active lupus nephritis patients compared to patients in remission and control.
| Conclusion|| |
Serum PTX3 increased progressively with DN and may be a serum biomarker for early diagnosis of DN, whereas urinary PTX3 has no relation to DN.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Matheson A, Willcox MD, Flanagan J et al.
Urinary biomarkers involved in type 2 diabetes: a review. Diabetes Metab Res Rev 2010; 26:150–171.
Parving HH. Nephrology forum: diabetic nephropathy: prevention and treatment. Kidney Int 2001; 60:2041–2055.
Lee YN. A report of the Malaysian dialysis registry of the national renal registry. Med J Malaysia 2008; 63 (C):5–8.
Tuttle KR, Bakris GL, Bilous RW et al.
Diabetic kidney disease: a report from an ADA Consensus Conference. Diabetes Care 2014; 37:2864–2883.
Mora-Fernández C, DomínguezPimentel V, de Fuentes MM et al.
Diabetic kidney disease: from physiology to therapeutics. J Physiol 2014; 592:3997–4012.
Lutale JJ, Thordarson H, Vetvik K. Microalbuminuria among type 1 and type 2 diabetic patients of African origin in Dar Es Salaam, Tanzania. BMC Nephrol 2007; 8:2.
American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2003; 26:S33.
Fioretto P, Mauer M. Histopathology of diabetic nephropathy. Semin Nephrol 2007; 27:195–207.
International Diabetes Federation: diabetes complicationsb, 6th ed. IDF Diabetes Atlas; 2013. 24–26.
Stevens LA, Levey AS. Measurement of kidney function. Med Clin North Am 2005; 89:457–473.
Tramonti G, Kanwar YS. Review and discussion of tubular biomarkers in the diagnosis and management of diabetic nephropathy. Endocrine 2013; 43:494–503.
Ciéslik XXXX, Hrycek A. Long pentraxin 3 (PTX3) in the light of its structure, mechanism of action and clinical implications. Autoimmunity 2012; 45:119–128.
Garlanda C, Hirsch E, Bozza S et al.
Non-redundant role of the long pentraxin PTX3 in anti-fungal innate immune response. Nature 2002; 420:182–186.
Alberti L, Gilardini L, Zulian A et al.
Expression of long pentraxin PTX3 in human adipose tissue and its relation with cardiovascular risk factors. Atherosclerosis 2009; 202:455–460.
Napoleone E, Di Santo A, Bastone A et al.
Long pentraxin PTX3 upregulates tissue factor expression in human endothelial cells: a novel link between vascular inflammation and clotting activation. Arterioscler Thromb Vasc Biol 2002; 22:782–787.
Rusnati M, Camozzi M, Moroni E et al.
Selective recognition of fibroblast growth factor-2 by the long pentraxin PTX3 inhibits angiogenesis. Blood 2004; 104:92–99.
Introna M, Vidal Alles V, Castellano M et al.
Cloning of mouse PTX3, a new member of the pentraxin gene family expressed at extrahepatic sites. Blood 1996; 87:1862–1872.
Fazzini F, Peri G, Doni A et al.
PTX3 in smallvessel vasculitides: an independent indicator of disease activity produced at sites of inflammation. Arthritis Rheum 2001; 44:2841–2850.
Yilmaz MI. Effect of renin angiotensin system blockade on pentraxin 3 levels in type-2 diabetic patients with proteinuria. Clin J Am Soc Nephrol 2009; 4:535–541.
Carrero ML, Stenvinkel P. Recent insights in inflammation-associated wasting in patients with chronic kidney disease. Contrib Nephrol 2011; 171:120–126.
Levey AS, Stevens LA, Schmid CH et al.
CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150:604–612.
Pichaiwong W, Hudkins KL, Wietecha T et al.
Reversibility of structural and functional damage in a model of advanced diabetic nephropathy. J Am Soc Nephrol 2013; 24:1088–1102.
Lin CL, Lee PH, Hsu YC et al.
MicroRNA-29a promotion of nephrin acetylation ameliorates hyperglycemia-induced podocyte dysfunction. J Am Soc Nephrol 2014; 25:1698–1709.
Suliman ME, Yilmaz MI, Carrero JJ et al.
Novel links between the long pentraxin 3, endothelial dysfunction, and albuminuria in early and advanced chronic kidney disease. Clin J Am Soc Nephrol 2008; 3:976–985.
Sun YM, Su Y, Li J et al.
Recent advances in understanding the biochemical and molecular mechanism of diabetic nephropathy. Biochem Biophys Res Commun 2015; 433:359–361.
Abu Seman N. Evaluation of the association of plasma pentraxin3 levels with type 2 diabetes and diabetic nephropathyin a Malay population. J Diabet Res 2013; 2013:298019.
Yamasaki K, Kurimura M. Determination of physiological plasma pentraxin 3 (PTX3) levels in healthy populations. Clin Chem Lab Med 2009; 47:471–477.
Moloney A, Tunbridge WM, Ireland JT et al.
Mortality from diabetic nephropathy in the United Kingdom. Diabetologia 1983; 25:26–30.
Gu HF. SOX2 has gender-specific genetic effects on diabetic nephropathy in samples from patients with type 1 diabetes mellitus in the GoKinD study. Gender Med 2009; 6:555–564.
Idogun ES, Kasia BE. Assessment of microalbuminuria and glycated hemoglobin in type 2 diabetes mellitus complications. Asian Paicfic J Trop Dis 2011; 1:203–205.
Assal HS, Tawfeek S, Rasheed EA et al.
Serum cystatin C and tubular urinary enzymes as biomarkers of renal dysfunction in type 2 diabetes mellitus. Clin Med Insights Endocrinol Diabetes 2013; 6:7–13.
Kundu D, Roy A, Mandal T et al.
Relation of microalbuminuria to glycosylated hemoglobin and duration of type 2 diabetes. Niger J Clin Pract 2013; 16:216–220.
Sheikh SA, Baig JA, Iqbal T et al.
Prevalence of microalbuminuria with relation to glycemic control in type-2 diabetic patients in Karachi. J Ayub Med Coll Abbottabad 2009; 21:83–86.
Hovind P, Tarnow L. Predictors for the development of microalbuminuria and macroalbuminuria in patients with type 1 diabetes: inception cohort study. BMJ 2004; 328:1105.
Viswanathan V, Snehalatha C, Kumutha R et al.
Serum albumin levels in different stages of type 2 diabetic nephropathy. Indian J Nephrol 2004; 14:89–92. [Full text]
Jeong J, Kwon SK, Kim HY. Effect of bicarbonate supplementation on renal function and nutritional indices in predialysis advanced chronic kidney disease. Electrolyte Blood Press 2014; 12:80–87.
Amr Abd El-Hady, Manal Aly, Alaa Mahmoud et al.
Study of plasma long pentraxin 3 as a marker of endothelial dysfunction in Egyptian patients with type 2 diabetes. Med J Cairo Univ 2012; 80:277–281.
Chae HW, Shin JI, Kwon AR et al.
Spot urine albumin to creatinine ratio and serum cystatin C are effective for detection of diabetic nephropathy in childhood diabetic patients. J Korean Med Sci 2012; 27:784–787.
Lu WN, Li H, Zheng FP et al.
Renal insufficiency and its associatedfactors in type 2 diabetic patients with normoalbuminuria. Zhonghua Nei Ke Za Zhi 2010; 49:24–27.
MacIsaac RJ, Tsalamandris C, Panagiotopoulos S et al.
Nonalbuminuric renal insufficiency in type 2 diabetes. Diabetes Care 2004; 27:195–200.
Murussi M, Gross JL, Silveiro SP. Glomerular filtration rate changes in normoalbuminuric and microalbuminuric Type 2 diabetic patients and normal individuals A 10-year follow-up. J Diabetes Complications 2006; 20:210–215.
Tidman M, Sjöström P, Jones I. A Comparison of GFR estimating formulae based upon s-cystatin C and s-creatinine and a combination of the two. Nephrol Dial Transplant 2008; 23:154–160.
American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2011; 34:S11–S61.
Reverter JL, Sentí M, Rubiés-Prat J et al.
Relationship between lipoprotein profile and urinary albumin excretion in type II diabetic patients with stable metabolic control. Diabetes Care 1994; 17:189–194.
Sigdel M, Rajbhandari N, Basnet S et al.
Micro-albuminuria among type 2 diabetes mellitus patients in Pokhara, Nepal. Nepal Med Coll J 2008; 10:242–245.
Suchitra MM, Sheshu Kumar M, Bitla AR et al.
Atherogenic dyslipidemia in diabetic nephropathy: lipoprotein (a), lipid ratios and atherogenic index. Int J Res Med Sci 2013; 1:455–459.
Joven J, Villabona C, Vilella E. Pattern of hyperlipoproteinemia in human nephrotic syndrome: influence of renal failure and diabetes mellitus. Nephron 1993; 64:565–569.
Dubin R. Racial differences in the association of pentraxin-3 with kidney dysfunction: the multi-ethnic study of atherosclerosis. Nephrol Dialysis Transplant 2011; 26:1903–1908.
Pang Y, Tan Y, Li Y et al.
Pentraxin 3 is closely associated with tubulointerstitial injury in lupus nephritis. Medicine (Baltimore) 2016; 95:e2520.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]