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Plasma and urinary matrix metalloproteinase-9 as a marker for detection of nephropathy in type 2 diabetic patients.


Diabetic nephropathy (DN) is a serious complication of diabetes mellitus, and can eventually progress to endstage renal disease. There are several distinct phases of development of DN. Functional changes occur in the nephron at the level of the glomerulus, including glomerular hyperfiltration and hyperperfusion, before the onset of any measurable clinical changes. [1] Subsequently, development of diabetic nephropathy mesangial expansion and changes in the matrix of glomerular and tubular basement membranes take place. [2, 3] Hyperglycemia is associated with an increase in mesangial cell proliferation and hypertrophy, as well as increased matrix production and basement membrane thickening. [4, 5] Mesangial cells are crucial for maintenance of glomerular capillary structure and for the modulation of glomerular filtration via smooth-muscle activity. In vitro studies have demonstrated that hyperglycemia is associated with increased mesangial cell matrix production and mesangial cell apoptosis. [6,7] The extracellular matrix (ECM) in the basement membrane of the kidney glomeruli is of particular importance for the filtration properties. Structural changes in mesangial and basement matrix are related to proteinuria and thus the progression of clinical diabetic nephropathy and kidney failure. [8]

The matrix metalloproteinases or matrixins (MMPs) are members of the large metzincin superfamily such as the astacins, serralysins, reprolysins, and adamalysins or disintegrin metalloproteinases (ADAMs). In the classical view, MMPs are collectively capable of degrading all components of the ECM and basement membrane, restricting their functions to tissue remodeling and maintenance; they are now recognized as being responsible for mediating crucial functions in a variety of processes, particularly related to immunity and repair, such as cell migration, leukocyte activation, antimicrobial defense, and chemokine processing. [9-11] MMP-9 (Gelatinase B) is released by neutrophils, monocytes, macrophages, and eosinophils in the course of inflammatory response. MMP-9 is also involved in cytokine cleavage, growth factor mobilization, and tissue remodeling. [12] MMPs have been shown to be increased in several diseases. MMP-2 (Gelatinase A) and MMP-9 (Gelatinase B) are the most important MMPs in normal kidneys and basement membrane homeostasis. [13,14] So the objective of this study was to evaluate plasma and urinary MMP-9 levels in type 2 diabetic patients with normoalbuminuria and microalbuminuria and find out association with albumin-to-creatinine ratio (ACR).

Materials and Methods

A total of 50 type 2 diabetic patients of both sexes with more than 5 year diabetic duration, aged between 35 and 60 years on oral hypoglycemic drugs, attending diabetic out-patient department of Rajah Muthiah Medical College and Hospital, Annamalai University, Annamalainagar, Tamil Nadu, India, were selected for our study. The included diabetic patients were categorized into two groups based on ACR. Groups were divided as follows: 25 patients with normoalbuminuria (<30 mg/g creatinine), 25 patients with microalbuminuria (30-299 mg/g creatinine). We excluded the patients based on the following criteria: patients on insulin, smokers, alcoholics, tobacco chewers, abnormal urinary sediment, urinary tract infection, history of other renal disease and active or chronic persistent infection or inflammatory disorders, neoplastic disorders, uncontrolled thyroid disorders, severe liver dysfunction, history of acute myocardial infarction, stroke, and occlusive peripheral vascular disease. Twenty-five healthy individual age, sex-matched subjects were selected as control. The informed consent was obtained from all the study subjects and the study was approved by the Institutional Human Ethics Committee (IHEC). Experiments were done in accordance with Helsinki declaration of 1975.

Biochemical Analysis

A fasting blood and urine samples were obtained from the subjects immediately after enrollment. Blood samples were centrifuged at 2000xg for 10 min. Samples were analyzed for routine investigations blood sugar, lipid profile (total cholesterol, HDL, triglycerides), glycosylated hemoglobin (HbA1C) and urine microalbumin, urinary creatinine. Plasma and urinary MMP-9, insulin assessed by ELISA, and the 2 h post-prandial venous plasma glucose (PPBS) estimation was also done.

Statistical analysis

Statistical analysis were carried out with SPSS 20.0. Values were expressed as mean [+ or -] standard deviation, and p-value < 0.05 was considered statistically significant. Normally distributed data were analyzed by using one-way ANOVA. The Pearson's correlation test was used for correlation analysis.


The plasma and urinary MMP-9 levels are significantly elevated in type 2 DM with microalbuminuria compared to normoalbuminuric type 2DM, and also there is significant elevation observed in normoalbuminuric type 2 DM compared to controls [Tables 1-4].


Diabetic nephropathy is characterized by excessive deposition of ECM proteins in the mesangium and basement membrane of the glomerulus and in renal tubulointerstitium. The basement membrane changes, accompanied by glomerular hyper filtration, and increased glomerular hydrostatic pressure leading to microalbuminuria. [15, 16] However, the mesangial changes appear to be the main cause of declining renal function in DN. Declining glomerular function correlates well with the extent of these changes in both types of diabetes. [17, 18] The major physiologic regulators of ECM degradation in the glomerulus are matrix metalloproteinases (MMPs). [19, 20]

In this study, we observed that plasma and urinary levels of MMP-9 were significantly increased in diabetic patients with normoalbuminuria compared to control subjects, and significantly increased in microalbuminuria patients compared to normoalbuminuria type 2 diabetic patients. It has been suggested that in type2 diabetic patients, the development of microalbuminuria was preceded by a significant increase in plasma MMP-9 concentration [21-23] Hao and Yu, [24] Uemura et al. [25] have found that hyperglycemia induces activity and expression of MMP-2 and -9 in rat aortic smooth muscle cells and mouse vascular tissue and plasma. Chronic incubation with high glucose increased MMP-9 promoter activity, mRNA and protein expression, and gelatinase activity in bovine aortic endothelial cells, and also MMP-9 known to be activated in a cellular environment under oxidant stress and with reduced NO bioavailability. [26] Endothelial NOS (eNOS) dysfunction, coupled with activation of NAD(P)H-dependent oxidase, is largely responsible for enhanced superoxide production in human diabetic vascular tissue. [27] Therefore, oxidative stress and limited NO bioavailability could be a cause elevation of MMP-9 in type2 DM.

In addition, we observed that plasma and urinary MMP-9 levels showed strong positive correlation with ACR, HbA1C, and HOMA-IR. Chronic hyperglycemia produces reactive oxygen species (ROS), protein glycation reactions that lead to the formation of advanced glycation end products (AGEs).[28] MMP-9 is induced or repressed by a variety of soluble factors such as cytokines and growth factors. Endogenous tissue inhibitors of MMPs (TIMPs) regulate their activation, and TIMP-1 shows greater preference for MMP-9 than any other. [29,30] High glucose as well as glycated albumin and AGE induce Transforming growth factor-[beta] (TGF-[beta]) over expression in mesangial cells in culture [31-33] and is a key regulator of ECM synthesis in renal cells. Three mammalian TGF-[beta] isoforms, TGF-[beta]1, -[beta]2, and -[beta]3, are recognized, of which TGF-[beta]1 is the most potent promoter of ECM accumulation. Expression of TGF-[beta] isoforms occurs in different patterns in renal fibrosis. [34,35] Several studies have implicated TGF-[beta]1 in renal fibrosis because this cytokine both stimulates ECM deposition and inhibits matrix degradation. [36] The TGF-[beta]1 gene product is translated in a latent form that may be activated by MMP-9 mediated proteolytic cleavage when MMP-9 interacts with CD44, a receptor for the extracellular glycosaminoglycan hyaluronan (HA), at the cell surface. [37, 38] Studies have shown that increased monocyte activation and differentiation activated macrophages that can further induce inflammatory cytokines, resulting in increased activation and expression of matrix metalloproteinase (MMPs), particularly MMP-9. [39-41] A balance between ECM synthesis and degradation is required for maintaining the structural and functional integrity of the glomerulus. Any changes in MMP expression or activity will directly alter the ECM turnover, which may lead to glomerular scarring and a decline in renal function.[42 43] Therefore, evaluation of plasma and urinary MMP-9 has been regarded as an index of progressive renal damage in diabetic patients.


In conclusion, plasma and urinary MMP-9 might be useful to detect early stages of nephropathy in T2DM patients. Hence, measurement of plasma and urinary MMP-9 could be useful diagnostic markers for the assessment of renal changes in type 2 diabetic patients even before the appearance of microalbuminuria. Further large-scale studies are needed to confirm it.

DOI: 10.5455/ijmsph.2015.09042015292


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K Balu Mahendran (1), S Sethupathy (1), KK Perumal (2), R Inmozhi (1), K Santha (1)

(1) Department of Biochemistry, Rajah Muthiah Medical College and Hospital, Annamalai University, Annamalainagar, Tamil Nadu, India.

(2) Department of Medicine, Rajah Muthiah Medical College and Hospital, Annamalai University, Annamalainagar, Tamil Nadu, India.

Correspondence to: K Santha, E-mail:

Received April 9, 2015. Accepted April 28, 2015
Table 1: Baseline and biochemical parameters
in control and type 2 diabetic subjects

Parameters                  Control (n = 25)       Normoalbuminuria
                                                       (n = 25)

Age                        47.6 [+ or -] 4.3      48.3 [+ or -] 6.5
Body mass index            25.4 [+ or -] 1.5      26.8 [+ or -] 3.7
Waist/hip ratio            0.90 [+ or -] 0.04     0.92 [+ or -] 0.06
DM duration (years)                --              8.2 [+ or -] 2.1
Systolic BP (mm Hg)        114.1 [+ or -] 7.1   124.5 [+ or -] 16.2a *
Diastolic (mm Hg)          73.8 [+ or -] 3.3     79.1 [+ or -] 7.9a *
Urine albumin-to-          18.3 [+ or -] 2.6    23.4 [+ or -] 3.5a **
  creatinine ratio
  (mg/gm of creatinine)
Serum urea (mg/dl)         24.3 [+ or -] 4.6     28.1 [+ or -] 5.4a *
Serum creatinine (mg/dl)    0.6 [+ or -] 0.1       0.7 [+ or -] 0.2

Parameters                     Microalbuminuria
                                   (n = 25)

Age                          50.8 [+ or -] 5.5b *
Body mass index                25.8 [+ or -] 3.2
Waist/hip ratio               0.92 [+ or -] 0.04
DM duration (years)            8.9 [+ or -] 2.8
Systolic BP (mm Hg)         127 [+ or -] 13.1 b **
Diastolic (mm Hg)            78.7 [+ or -] 7.6b *
Urine albumin-to-          161.8 [+ or -] 70.7b,c **
  creatinine ratio
  (mg/gm of creatinine)
Serum urea (mg/dl)          33.4 [+ or -] 12.2b **
Serum creatinine (mg/dl)     0.9 [+ or -] 0.3b **

Data are expressed as mean [+ or -] SD; ** p < 0.001;
* p < 0.05 was considered statistically significant.

(a) Comparison between normal and type
2 diabetic patients with normoalbuminuria.

(b) Comparison between normal and type
2 diabetic patients with microalbuminuria.

(c) Comparison between type 2 diabetic
patients with normoalbuminuria and microalbuminuria.

Table 2: FBS, PPBS, HbA1C, insulin, lipid profile and matrix
metalloproteinase-9 (MMP-9) levels in control and
type 2 diabetic subjects

Parameters                     Control            Normoalbuminuria
                               (n = 25)               (n = 25)

FBS (mg/dl)               81.9 [+ or -] 5.9    128.3 [+ or -] 40.1a **
PPBS (mg/dl)              108.1 [+ or -] 9.8    191.7 [+ or -] 56a **
HbA1C                      5.4 [+ or -] 0.4     7.2 [+ or -] 0.8a **
Serum cholesterol         168.8 [+ or -] 9.0   186.8 [+ or -] 20.4a **
Serum triglycerides       95.5 [+ or -] 7.4    130.5 [+ or -] 39.3a **
HDL cholesterol (mg/dl)   43.7 [+ or -] 2.4     39.4 [+ or -] 3.0a **
LDL cholesterol (mg/dl)   105.9 [+ or -] 9.1   121.3 [+ or -] 16.5a **
Insulin (pIU/mL)           6.5 [+ or -] 0.7     10.9 [+ or -] 4.1a **
HOMA-IR                   1.3 [+ or -] 0.17     3.4 [+ or -] 1.6a **
Plasma MMP-9 (ng/ml)       5.8 [+ or -] 1.2     10.4 [+ or -] 2.0a **
Urine MMP-9 (ng/mg of      2.6 [+ or -] 0.6     6.1 [+ or -] 2.1a **

Parameters                     Microalbuminuria
                                   (n = 25)

FBS (mg/dl)                 145.9 [+ or -] 53.6b **
PPBS (mg/dl)                 221 [+ or -] 82.1b **
HbA1C                      8.0 [+ or -] 1.1b **,c *
Serum cholesterol           193.8 [+ or -] 21.8b **
Serum triglycerides         141.8 [+ or -] 38.1b **
HDL cholesterol (mg/dl)      38.3 [+ or -] 2.3b **
LDL cholesterol (mg/dl)     127.1 [+ or -] 20.8b **
Insulin (pIU/mL)             13.2 [+ or -] 5.0 **
HOMA-IR                    4.6 [+ or -] 2.2b **, c *
Plasma MMP-9 (ng/ml)      14.0 [+ or -] 3.2b **, c **
Urine MMP-9 (ng/mg of     11.6 [+ or -] 6.7b **, c **

Data are expressed as mean [+ or -] SD; ** p < 0.001;
* p < 0.05 was considered statistically significant.

(a) Comparison between normal and type 2 diabetic patients with

(b) "Comparison between normal and type 2 diabetic patients with

(c) Comparison between type 2 diabetic patients with
normoalbuminuria and microalbuminuria.

Table 3: Correlation between plasma MMP-9 and measured

Parameters           Correlation
                     coefficient (r)

Albumin-to-          0.706 **
  creatinine ratio
Urine MMP-9          0.758 **
FBS                  0.428 **
PPBS                 0.447 **
HbA1C                0.654 **
HOMA-IR              0.503 **
Cholesterol          0.434 **
TGL                  0.496 **
HDL                  -0.597 **
LDL                  0.402 **

** Correlation is significant at the 0.01 level (two-tailed).

Table 4: Correlation between urinary MMP-9 and measured

Parameters           Correlation
                     coefficient (r)

Albumin-to-          0.755 **
  creatinine ratio
FBS                  0.216
PPBS                 0.227
HbA1C                0.488 **
HOMA-IR              0.280 *
Cholesterol          0.387 **
TGL                  0.374 **
HDL                  -0.456 **
LDL                  0.372

* Correlation is significant at the 0.05 level (two-tailed).

** Correlation is significant at the 0.01 level (two-tailed).
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Title Annotation:Research Article
Author:Mahendran, K. Balu; Sethupathy, S.; Perumal, K.K.; Inmozhi, R.; Santha, K.
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Date:Oct 1, 2015
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