Investigation of new biomarkers that can be used for the diagnosis of asymptomatic diabetic peripheral artery disease (PAD): Serum netrin-1 levels can be a potential biomarker for the diagnosis of PAD

Abstract

Diabetic peripheral arterial disease (PAD) is strongly associated with cardiovascular and cerebrovascular diseases that contribute to a high risk of mortality and morbidity. Diagnostic tests that can predict the development of diabetic PAD in the asymptomatic period are inadequate, and new potential biomarkers are needed. This study was prepared to investigate the diagnostic values of serum netrin-1, endothelin-1, oxidative stress parameters, and L-arginine/methylarginine derivatives for diabetic asymptomatic PAD. 386 type-2 diabetes mellitus patients who were clinically asymptomatic for PAD were screened for PAD by ankle-brachial index (ABI) measurement. At the same time, 40 patients with PAD were included in the study group, and 41 patients without PAD were included in the control group. Ready-to-use commercial kits were used to calculate serum netrin-1, endothelin-1, and oxidative stress markers. Serum netrin-1 median values were found to be significantly higher in the group with diabetic PAD than in the group without (OR [CI 95%]: 1.434 [1.136-1.964], p: 0.036). While a significant positive correlation relationship was detected between total oxidative status and netrin-1 and LDL, a negative significant correlation relationship was detected between ADMA and eGFR. No significant difference was detected between the groups regarding serum endothelin-1, oxidative stress parameters, and L-arginine/methylarginine derivatives. As a result, this study showed that serum netrin-1 levels are high in asymptomatic diabetic PAH patients and can be a possible biomarker in the detection of asymptomatic PAH.

Keywords

• Diabetes mellitus
• oxidative stress
• PAD
• netrin-1
• endothelin-1
• ADMA

References

1. Tavintharan S, Cheung N, Lim SC, Tay W, Shankar A, Shyong Tai E, et al. Prevalence and risk factors for peripheral artery disease in an Asian population with diabetes mellitus. Diabetes and Vascular Disease Research. 2009;6(2):80-6.
2. Mascarenhas JV, Albayati MA, Shearman CP, Jude EB. Peripheral arterial disease. Endocrinology and metabolism clinics. 2014;43(1):149-66.
3. Tsai AW, Folsom AR, Rosamond WD, Jones DW. Ankle-brachial index and 7-year ischemic stroke incidence: the ARIC study. Stroke. 2001;32(8):1721-4.
4. Jude EB, Oyibo SO, Chalmers N, Boulton AJ. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes care. 2001;24(8):1433-7.
5. Velioglu Y, Yuksel A. Complete blood count parameters in peripheral arterial disease. The Aging Male. 2019;22(3):187-91.
6. Delaney CL, Smale MK, Miller MD. Nutritional considerations for peripheral arterial disease: a narrative review. Nutrients. 2019;11(6):1219.
7. Berti-Hearn L, Elliott B. A closer look at lower extremity peripheral arterial disease. Nursing2022. 2018;48(1):34-41.
8. Serafini T, Kennedy TE, Gaiko MJ, Mirzayan C, Jessell TM, Tessier-Lavigne M. The netrins define a family of axon outgrowth-promoting proteins homologous to C. elegans UNC-6. Cell. 1994;78(3):409-24.

9. Van Gils JM, Derby MC, Fernandes LR, Ramkhelawon B, Ray TD, Rayner KJ, et al. The neuroimmune guidance cue netrin-1 promotes atherosclerosis by inhibiting the emigration of macrophages from plaques. Nature immunology. 2012;13(2):136-43.
10. S Adiyanti S, Loho T. Acute kidney injury (AKI) biomarker. 2012.
11. Craven RA, Vasudev NS, Banks RE. Proteomics and the search for biomarkers for renal cancer. Clinical Biochemistry. 2013;46(6):456-65.
12. Ramesh G. Role of Netrin-1 beyond the brain: from biomarker of tissue injury to therapy for inflammatory diseases. Recent patents on biomarkers. 2012;2(3):202-8.
13. Yang X, Sun H, Tang T, Zhang W, Li Y. Netrin-1 promotes retinoblastoma-associated angiogenesis. Annals of Translational Medicine. 2021;9(22).
14. Wu W, Lei H, Shen J, Tang L. The role of netrin-1 in angiogenesis and diabetic retinopathy: a promising therapeutic strategy. Discovery medicine. 2017;23(128):315-23.
15. Dakouane-Giudicelli M, Alfaidy N, Bayle P, De Nonneville AT, Studer V, Rozenberg P, et al. Hypoxia-inducible factor 1 controls the expression of the uncoordinated-5-B receptor, but not of netrin-1, in first trimester human placenta. International Journal of Developmental Biology. 2012;55(10-11-12):981-7.
16. Nguyen A, Cai H. Netrin-1 induces angiogenesis via a DCC-dependent ERK1/2-eNOS feed-forward mechanism. Proceedings of the National Academy of Sciences. 2006;103(17):6530-5.
17. Furchgott RF, Zawadzki JV. The obligatory role of endothelial cells in the relaxation of arterial smooth muscle by acetylcholine. nature. 1980;288(5789):373-6.
18. Malassine A, Cronier L, Mondon F, Mignot T, Ferre F. Localization and production of immunoreactive endothelin-1 in the trophoblast of human placenta. Cell and tissue research. 1993;271:491-7.
19. D’haeseleer M, Beelen R, Fierens Y, Cambron M, Vanbinst A-M, Verborgh C, et al. Cerebral hypoperfusion in multiple sclerosis is reversible and mediated by endothelin-1. Proceedings of the National Academy of Sciences. 2013;110(14):5654-8.
20. Iglarz M, Clozel M. Mechanisms of ET-1-induced endothelial dysfunction. Journal of cardiovascular pharmacology. 2007;50(6):621-8.
21. Böhm F, Ahlborg G, Johansson B-L, Hansson L-O, Pernow J. Combined endothelin receptor blockade evokes enhanced vasodilatation in patients with atherosclerosis. Arteriosclerosis, thrombosis, and vascular biology. 2002;22(4):674-9.
22. Etli M, Savas HB. Ischemia Modified Albumin as a Novel Biochemical Indicator in Peripheral Artery Patients. Journal of Clinical & Experimental Investigations. 2021;12(3).
23. Caturano A, D’Angelo M, Mormone A, Russo V, Mollica MP, Salvatore T, et al. Oxidative stress in type 2 diabetes: impacts from pathogenesis to lifestyle modifications. Current Issues in Molecular Biology. 2023;45(8):6651-66.
24. Wu G. Amino acids: metabolism, functions, and nutrition. Amino acids. 2009;37:1-17.
25. Wu G, Meininger CJ, McNeal CJ, Bazer FW, Rhoads JM. Role of L-arginine in nitric oxide synthesis and health in humans. Amino acids in nutrition and health: Amino acids in gene expression, metabolic regulation, and exercising performance. 2021:167-87.
26. El‐Missiry M, Othman A, Amer M. l‐Arginine ameliorates oxidative stress in alloxan‐induced experimental diabetes mellitus. Journal of Applied Toxicology: An International Journal. 2004;24(2):93-7.
27. Das UN, Repossi G, Dain A, Eynard AR. L-arginine, NO and asymmetrical dimethylarginine in hypertension and type 2 diabetes. Front Biosci. 2011;16(1):13-20.
28. Settergren M, Böhm F, Malmström R, Channon K, Pernow J. L-arginine and tetrahydrobiopterin protects against ischemia/reperfusion-induced endothelial dysfunction in patients with type 2 diabetes mellitus and coronary artery disease. Atherosclerosis. 2009;204(1):73-8.
29. Tanhäuserová V, Tomandl J, Pácal L, Klepárník M, Malúšková D, Bartáková V, et al. ADMA, SDMA and L-arginine/ADMA ratio but not DDAH genetic polymorphisms are reliable predictors of diabetic nephropathy progression as identified by competing risk analysis. Kidney and Blood Pressure Research. 2013;36(1):200-8.
30. Ismaeel A, Papoutsi E, Miserlis D, Lavado R, Haynatzki G, Casale GP, et al. The nitric oxide system in peripheral artery disease: connection with oxidative stress and biopterins. Antioxidants. 2020;9(7):590.
31. Guo X, Xing Y, Jin W. Role of ADMA in the pathogenesis of microvascular complications in type 2 diabetes mellitus. Frontiers in Endocrinology. 2023;14:1183586.
32. Chamberlain JJ, Rhinehart AS, Shaefer Jr CF, Neuman A. Diagnosis and management of diabetes: synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Annals of internal medicine. 2016;164(8):542-52.
33. Golledge J. Update on the pathophysiology and medical treatment of peripheral artery disease. Nature Reviews Cardiology. 2022;19(7):456-74.
34. Thijssen DH, Carter SE, Green DJ. Arterial structure and function in vascular ageing: are you as old as your arteries? The Journal of physiology. 2016;594(8):2275-84.
35. https://nefroloji.org.tr/tr/formul-ve-hesaplamalar.
36. Aboyans V, Criqui MH, Abraham P, Allison MA, Creager MA, Diehm C, et al. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation. 2012;126(24):2890-909.
37. Vogt MT, Cauley JA, Newman AB, Kuller LH, Hulley SB. Decreased ankle/arm blood pressure index and mortality in elderly women. Jama. 1993;270(4):465-9.
38. Horowitz JD, Heresztyn T. An overview of plasma concentrations of asymmetric dimethylarginine (ADMA) in health and disease and in clinical studies: methodological considerations. Journal of Chromatography B. 2007;851(1-2):42-50.
39. Kızmaz M, Marakoğlu K, Kıyıcı A, Ay E. Plasma netrin-1 levels significantly increase in smokers. Clinical Biochemistry. 2016;49(10-11):832-4.
40. Yang Sl, Zhu Ly, Han R, Sun Ll, Li Jx, Dou Jt. Pathophysiology of peripheral arterial disease in diabetes mellitus: 糖尿病周围动脉疾病的病理生理机制. Journal of diabetes. 2017;9(2):133-40.
41. Ramkhelawon B, Yang Y, van Gils JM, Hewing B, Rayner KJ, Parathath S, et al. Hypoxia induces netrin-1 and Unc5b in atherosclerotic plaques: mechanism for macrophage retention and survival. Arteriosclerosis, thrombosis, and vascular biology. 2013;33(6):1180-8.
42. Ramkhelawon B, Hennessy EJ, Ménager M, Ray TD, Sheedy FJ, Hutchison S, et al. Netrin-1 promotes adipose tissue macrophage retention and insulin resistance in obesity. Nature medicine. 2014;20(4):377-84.
43. Jain A, Coffey C, Mehrotra V, Flammer J. Endothelin-1 traps as a potential therapeutic tool: from diabetes to beyond? Drug discovery today. 2019;24(9):1937-42.
44. Cohen RA. Dysfunction of vascular endothelium in diabetes mellitus. Circulation. 1993;87:V67-V76.
45. Golfman L, Hata T, Beamish R, Dhalla N. Role of endothelin in heart function in health and disease. The Canadian journal of cardiology. 1993;9(7):635-53.
46. Totsune K, Sone M, Takahashi K, Ohneda M, Itoi K, Murakami O, et al. Immunoreactive endothelin in urine of patients with and without diabetes mellitus. Journal of cardiovascular pharmacology. 1991;17:S423-4.
47. Tsunoda K, Abe K, Sato T, Yokosawa S, Yoshinaga K. Decreased conversion of big endothelin‐1 to endothelin‐1 in patients with diabetes mellitus. Clinical and experimental pharmacology and physiology. 1991;18(10):731-2.
48. Fernandez-Cruz A, Martin P, Fernandez L, Sanchez J, Ibarra J, Moya J, et al. Plasma endothelin is increased in young essential hypertensives but not in elderly essential or diabetic hypertensives. Journal of Hypertension. 1993;11:S146-S7.
49. Veglio F, Bertello P, Pinna G, Mulatero P, Rossi A, Gurioli L, et al. Plasma endothelin in essential hypertension and diabetes mellitus. Journal of human hypertension. 1993;7(4):321-5.
50. Kanno K, Hirata Y, Shichiri M, Marumo F. Plasma endothelin-1 levels in patients with diabetes mellitus with or without vascular complication. Journal of cardiovascular pharmacology. 1991;17:S475-6.
51. Gruden G, Cavallo-Perin P, Bazzan M, Stella S, Vuolo A, Pagano G. PAI-1 and factor VII activity are higher in IDDM patients with microalbuminuria. Diabetes. 1994;43(3):426-9.
52. Rubin SA, Levin ER. Clinical review 53: The endocrinology of vasoactive peptides: synthesis to function. The Journal of Clinical Endocrinology & Metabolism. 1994;78(1):6-10.
53. Azizi S, Mahdavi R, Vaghef‐Mehrabany E, Maleki V, Karamzad N, Ebrahimi‐Mameghani M. Potential roles of Citrulline and watermelon extract on metabolic and inflammatory variables in diabetes mellitus, current evidence and future directions: A systematic review. Clinical and Experimental Pharmacology and Physiology. 2020;47(2):187-98.
54. Tseng C-H, Chong C-K, Tseng C-P, Tai T-Y. The association between urinary albumin excretion and ankle-brachial index in elderly Taiwanese patients with type 2 diabetes mellitus. Age and ageing. 2008;37(1):77-82.
55. Wattanakit K, Folsom A, Criqui M, Kramer H, Cushman M, Shea S, et al. Albuminuria and peripheral arterial disease: results from the multi-ethnic study of atherosclerosis (MESA). Atherosclerosis. 2008;201(1):212-6.
56. Juutilainen A, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Type 2 Diabetes as a “Coronary Heart Disease Equivalent” An 18-year prospective population-based study in Finnish subjects. Diabetes care. 2005;28(12):2901-7.
57. Hanai K, Babazono T, Nyumura I, Toya K, Tanaka N, Tanaka M, et al. Asymmetric dimethylarginine is closely associated with the development and progression of nephropathy in patients with type 2 diabetes. Nephrology Dialysis Transplantation. 2009;24(6):1884-8.
58. Tarnow L, Hovind P, Teerlink T, Stehouwer CD, Parving H-H. Elevated plasma asymmetric dimethylarginine as a marker of cardiovascular morbidity in early diabetic nephropathy in type 1 diabetes. Diabetes care. 2004;27(3):765-9.
59. Pitkänen OM, Martin JM, Hallman M, Åkerblom HK, Sariola H, Andersson SM. Free radical activity during development of insulin-dependent diabetes mellitus in the rat. Life sciences. 1992;50(5):335-9.
60. Vincent AM, Russell JW, Low P, Feldman EL. Oxidative stress in the pathogenesis of diabetic neuropathy. Endocrine reviews. 2004;25(4):612-28.
61. Binjawhar DN, Alhazmi AT, Bin Jawhar WN, MohammedSaeed W, Safi SZ. Hyperglycemia-induced oxidative stress and epigenetic regulation of ET-1 gene in endothelial cells. Frontiers in Genetics. 2023;14:1167773.
62. Verges B. Lipid modification in type 2 diabetes: the role of LDL and HDL. Fundamental & clinical pharmacology. 2009;23(6):681-5.
63. Aoua H, Nkaies Y, Ben Khalfallah A, Sakly M, Aouani E, Attia N. Association between Small Dense Low-Density Lipoproteins and High-Density Phospolipid Content in Patients with Coronary Artery Disease with or without Diabetes. Laboratory Medicine. 2020;51(3):271-8.
64. Ahmad S, Zaib S. An Evaluation of Biomarkers as Determinants of Peripheral Arterial Disease in those with Diabetes Mellitus. ChemistrySelect. 2023;8(13):e202300297.
65. Durrington P, Mackness B, Mackness M. Paraoxonase and atherosclerosis. Arteriosclerosis, thrombosis, and vascular biology. 2001;21(4):473-80.
66. Chi YW, Jaff MR. Optimal risk factor modification and medical management of the patient with peripheral arterial disease. Catheterization and Cardiovascular Interventions. 2008;71(4):475-89.