1
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Fleming K, Weaver N, Peel R, Hure A, McEvoy M, Holliday E, Parsons M, Acharya S, Luu J, Wiggers J, Rissel C, Ranasinghe P, Jayawardena R, Samman S, Attia J. Using the AUSDRISK score to screen for pre-diabetes and diabetes in GP practices: a case-finding approach. Aust N Z J Public Health 2021; 46:203-207. [PMID: 34762354 DOI: 10.1111/1753-6405.13181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 09/01/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To identify the optimal AUSDRISK threshold score to screen for pre-diabetes and diabetes. METHODS A total of 406 adult patients not diagnosed with diabetes were screened in General Practices (GP) between May and October 2019. All patients received a point of care (POC) HbA1c test. HbA1c test results were categorised into diabetes (≥6.5% or ≥48 mmol/mol), pre-diabetes (5.7-6.4% or 39-47 mmol/mol), or normal (<5.7% or 39 mmol/mol). RESULTS Of these patients, 9 (2%) had undiagnosed diabetes and 60 (15%) had pre-diabetes. A Receiver Operator Characteristic (ROC) curve was constructed to predict the presence of pre-diabetes and diabetes; the area under the ROC curve was 0.72 (95%CI 0.65-0.78) indicating modest predictive ability. The optimal threshold cut point for AUSDRISK score was 17 (sensitivity 76%, specificity 61%, + likelihood ratio (LR) 1.96, - likelihood ratio of 0.39) while the accepted cut point of 12 performed less well (sensitivity 94%, specificity 23%, +LR=1.22 -LR+0.26). CONCLUSIONS The AUSDRISK tool has the potential to be used as a screening tool for pre-diabetes/diabetes in GP practices. A cut point of ≥17 would potentially identify 75% of all people at risk and three in 10 sent for further testing would be positive for prediabetes or diabetes. Implications for public health: Routine case-finding in high-risk patients will enable GPs to intervene early and prevent further public health burden from the sequelae of diabetes.
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Affiliation(s)
- Kerry Fleming
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, New South Wales.,Endocrinology and Diabetes Service and Diabetes Alliance, Hunter New England Health Local Health District (HNELHD), New south Wales.,Hunter Medical Research Institute, Newcastle, New South Wales
| | - Natasha Weaver
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, New South Wales.,Hunter Medical Research Institute, Newcastle, New South Wales
| | - Roseanne Peel
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, New South Wales.,Hunter Medical Research Institute, Newcastle, New South Wales
| | - Alexis Hure
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, New South Wales.,Hunter Medical Research Institute, Newcastle, New South Wales
| | - Mark McEvoy
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, New South Wales.,La Trobe Rural Health School, College of Science, Health and Engineering, Victoria
| | - Elizabeth Holliday
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, New South Wales.,Hunter Medical Research Institute, Newcastle, New South Wales
| | - Martha Parsons
- Endocrinology and Diabetes Service and Diabetes Alliance, Hunter New England Health Local Health District (HNELHD), New south Wales
| | - Shamasunder Acharya
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, New South Wales.,Endocrinology and Diabetes Service and Diabetes Alliance, Hunter New England Health Local Health District (HNELHD), New south Wales.,Division Of Medicine, HNELHD, New South Wales
| | - Judy Luu
- Endocrinology and Diabetes Service and Diabetes Alliance, Hunter New England Health Local Health District (HNELHD), New south Wales.,Division Of Medicine, HNELHD, New South Wales
| | - John Wiggers
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, New South Wales.,HNELHD, New South Wales
| | - Chris Rissel
- The University of Sydney, Camperdown, New south Wales
| | - Priyanga Ranasinghe
- Department of Pharmacology, Faculty of Medicine, University of Colombo, Sri Lanka
| | - Ranil Jayawardena
- Department of Pharmacology, Faculty of Medicine, University of Colombo, Sri Lanka.,Department of Physiology, Faculty of Medicine, University of Colombo, Sri Lanka
| | - Samir Samman
- School of Life and Environmental Sciences, University of Sydney, New South Wales
| | - John Attia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, New South Wales.,Hunter Medical Research Institute, Newcastle, New South Wales.,Division Of Medicine, HNELHD, New South Wales
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Shigefuku R, Iwasa M, Eguchi A, Tempaku M, Tamai Y, Suzuki T, Takei Y. Serum Copeptin and Zinc-α2-glycoprotein Levels Are Novel Biomarkers of Tolvaptan Treatment in Decompensated Cirrhotic Patients with Ascites. Intern Med 2021; 60:3359-3368. [PMID: 34719623 PMCID: PMC8627803 DOI: 10.2169/internalmedicine.7291-21] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/21/2021] [Indexed: 12/17/2022] Open
Abstract
Objective The efficacy of tolvaptan, an orally active vasopressin V2-receptor antagonist, has recently been reported in patients with massive ascites unresponsive to conventional diuretics. However, the effect of tolvaptan varies among patients. Recently, the prognostic role of the tolvaptan response in cases of decompensated liver cirrhosis (LC) has been attracting increasing attention. Using serum copeptin (vasopressin precursor), zinc-α2-glycoprotein (ZAG), cystatin C (renal biomarker), neutrophil gelatinase-associated lipocalin (NGAL) and liver-type fatty acid-binding protein (L-FABP), we explored which factors portend a good response to tolvaptan in LC patients with ascites. Methods We enrolled 113 LC patients and divided them into the tolvaptan treatment group and non-treatment group. Tolvaptan (3.75 or 7.5 mg/day) was administrated to 38 LC patients with ascites, and a follow-up assessment was performed after a 7-day tolvaptan treatment regimen. Results We determined the predictive ability for kidney and/or liver damage of serum copeptin, ZAG, cystatin C, NGAL and L-FABP levels in all patients. After 7-day tolvaptan treatment, 19 patients had lost more than 1.5 kg of body weight (Responders), while 19 showed no marked change in their body weight (Non-responders). Basal blood urea nitrogen (BUN) (p=0.0014), serum copeptin (p=0.0265) and serum ZAG levels (p=0.0142) were significantly higher in the Non-responders than in the Responders. BUN (odds ratio 7.43, p=0.0306), copeptin (odds ratio 9.12, p=0.0136) and ZAG (odds ratio 7.43, p=0.0306) were determined to be predictive factors of drug responsiveness using a multivariate logistic regression analysis. Conclusion Serum BUN, copeptin and ZAG levels predict the patient response to tolvaptan, even when measured prior to treatment.
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Affiliation(s)
- Ryuta Shigefuku
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Japan
| | - Motoh Iwasa
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Japan
| | - Akiko Eguchi
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Japan
| | - Mina Tempaku
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Japan
| | - Yasuyuki Tamai
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Japan
| | - Tatsuya Suzuki
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Japan
| | - Yoshiyuki Takei
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Japan
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3
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Xu D, You J, Chen G, Su H, Zhang L, Cui L, Li Z, Huang G, Feng C. Changes of Serum Zinc- α2-Glycoprotein Level and Analysis of Its Related Factors in Gestational Diabetes Mellitus. J Diabetes Res 2021; 2021:8879786. [PMID: 33681385 PMCID: PMC7910037 DOI: 10.1155/2021/8879786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/17/2021] [Accepted: 02/06/2021] [Indexed: 11/17/2022] Open
Abstract
Previous studies have discovered that zinc-α2-glycoprotein (ZAG) is related to insulin resistance and lipid metabolism. The aim of the study is to explore the change of serum ZAG and its related factors in gestational diabetes mellitus (GDM). Eighty newly diagnosed GDM patients were enrolled in the case group, and 80 normal pregnant women were selected as the control group. The differences of baseline data between the two groups were compared, and the change of serum ZAG level and its relationship with related indexes was analyzed. Compared to the control group, the level of serum ZAG in GDM women decreased (P < 0.001). What is more, the serum ZAG level of overweight and normal subjects in two groups was also found to have statistical differences. The Pearson correlation (or Spearman correlation) analysis showed that serum ZAG level was negatively correlated with FPG, FINS, HOMA-IR, and TG (all P < 0.05) and positively correlated with HDL (P < 0.05). Multiple linear regression showed that HDL and HOMA-IR were independent factors of serum ZAG (P < 0.05). The level of serum ZAG in patients with gestational diabetes mellitus decreased, and HDL and HOMA-IR are the influencing factors in the case group.
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Affiliation(s)
- Dongmei Xu
- Department of Health, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Jie You
- Department of Clinical Nutrition, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Guixia Chen
- Department of Health, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Hongli Su
- Department of Obstetrics and Gynecology, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, Henan 450007, China
| | - Li Zhang
- Department of Health, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Lingling Cui
- Department of Nutrition and Food Hygiene, School of Public Health, Zhengzhou University, Zhengzhou Henan 450001, China
| | - Zhonglei Li
- Department of Nutrition and Food Hygiene, School of Public Health, Zhengzhou University, Zhengzhou Henan 450001, China
| | - Guoling Huang
- Department of Financial, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Caiying Feng
- Department of Clinical Nutrition, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
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Moh A, Seah N, Low S, Ang K, Sum CF, Subramaniam T, Kwan PY, Lee S, Tang WE, Lim SC. Zinc-α2-glycoprotein is associated with non-albuminuric chronic kidney disease progression in type 2 diabetes: a retrospective study with 4-year follow-up. Diabet Med 2020; 37:1919-1926. [PMID: 32353891 DOI: 10.1111/dme.14313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2020] [Indexed: 12/11/2022]
Abstract
AIM To investigate the association between baseline plasma zinc-α2-glycoprotein and non-albuminuric chronic kidney disease progression in type 2 diabetes. METHODS Adults with normoalbuminuria at entry (n=341; age 57±10 years, 52% men) were analysed. Chronic kidney disease progression was defined as a decrease in chronic kidney disease stage and a decline of ≥25% in estimated GFR from baseline. Baseline plasma zinc-α2-glycoprotein levels were quantified by immunoassay, and analysed either as a continuous variable or by tertiles in Cox proportional hazards models. Model discrimination was assessed using Harrell's C-index. A sensitivity analysis was performed on a subset of individuals who maintained normoalbuminuria during follow-up. RESULTS Chronic kidney disease progression occurred in 54 participants (16%). Zinc-α2-glycoprotein levels were elevated in chronic kidney disease progressors (P = 0.011), and more progressors were assigned to the higher zinc-α2-glycoprotein tertile than non-progressors. In the unadjusted Cox model, zinc-α2-glycoprotein, both as a continuous variable (hazard ratio 1.72, 95% CI 1.08-2.75) and tertile 3 (vs tertile 1; hazard ratio 2.14, 95% CI 1.10-4.17), predicted chronic kidney disease progression. The association persisted after multivariable adjustment. The C-index of the Cox model increased significantly after incorporation of zinc-α2-glycoprotein into a base model comprising renin-angiotensin system antagonist usage. Sensitivity analysis showed that zinc-α2-glycoprotein independently predicted chronic kidney disease progression among individuals who maintained normoalbuminuria during follow-up. CONCLUSIONS Plasma zinc-α2-glycoprotein is associated with chronic kidney disease progression, and may serve as a useful early biomarker for predicting non-albuminuric chronic kidney disease progression in type 2 diabetes.
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Affiliation(s)
- A Moh
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - N Seah
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - S Low
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
- Diabetes Centre, Admiralty Medical Centre, Khoo Teck Puat Hospital, Singapore
| | - K Ang
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - C F Sum
- Diabetes Centre, Admiralty Medical Centre, Khoo Teck Puat Hospital, Singapore
| | - T Subramaniam
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
- Diabetes Centre, Admiralty Medical Centre, Khoo Teck Puat Hospital, Singapore
| | - P Y Kwan
- National Healthcare Group Polyclinics, Singapore
| | - S Lee
- National Healthcare Group Polyclinics, Singapore
| | - W E Tang
- National Healthcare Group Polyclinics, Singapore
| | - S C Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
- Diabetes Centre, Admiralty Medical Centre, Khoo Teck Puat Hospital, Singapore
- Saw Swee Hock School of Public Health, National University Hospital, Singapore
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Insights into predicting diabetic nephropathy using urinary biomarkers. BIOCHIMICA ET BIOPHYSICA ACTA-PROTEINS AND PROTEOMICS 2020; 1868:140475. [DOI: 10.1016/j.bbapap.2020.140475] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/27/2020] [Accepted: 06/14/2020] [Indexed: 12/20/2022]
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6
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Beige J, Drube J, von der Leyen H, Pape L, Rupprecht H. Früherkennung mittels Urinproteomanalyse. Internist (Berl) 2020; 61:1094-1105. [DOI: 10.1007/s00108-020-00863-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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7
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Shufang H, Kui C, Li Y, Yu Z. Diagnostic Values of Urinary Biomarkers in Early Diagnosis of Diabetic Nephropathy. INT J PHARMACOL 2019. [DOI: 10.3923/ijp.2019.851.856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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8
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Abstract
Proteome analysis has been applied in multiple studies in the context of chronic kidney disease, aiming at improving our knowledge on the molecular pathophysiology of the disease. The approach is generally based on the hypothesis that proteins are key in maintaining kidney function, and disease is a clinical consequence of a significant change of the protein level. Knowledge on critical proteins and their alteration in disease should in turn enable identification of ideal biomarkers that could guide patient management. In addition, all drugs currently employed target proteins. Hence, proteome analysis also promises to enable identifying the best suited therapeutic target, and, in combination with biomarkers, could be used as the rationale basis for personalized intervention. To assess the current status of proteome analysis in the context of CKD, we present the results of a systematic review, of up-to-date scientific research, and give an outlook on the developments that can be expected in near future. Based on the current literature, proteome analysis has already seen implementation in the management of CKD patients, and it is expected that this approach, also supported by the positive results generated to date, will see advanced high-throughput application.
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9
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Shokry E, Filho NRA. Insights into cerumen and application in diagnostics: past, present and future prospective. Biochem Med (Zagreb) 2019; 27:030503. [PMID: 29180914 PMCID: PMC5696747 DOI: 10.11613/bm.2017.030503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/16/2017] [Indexed: 12/11/2022] Open
Abstract
Cerumen or earwax is an emerging bio-fluid in clinical diagnosis that has been very little exploited during the past decades in spite of its high diagnostic potential. It is highly abundant in diagnostic biomarkers such as genetic material, lipids, proteins, chemical elements, internal and external metabolites (e.g. hormones, volatile organic compounds, amino acids, xenobiotics etc.) reaching earwax from the blood circulation. Thus, it is able to reflect not only physiology, pathophysiology of the human body but can also detect recent and long term exposure to environmental pollutants, without the need of invasive blood tests and in the same time overcoming many disadvantages faced by using other diagnostic biological fluids. This review discusses the biology, functions, chemistry of earwax, past and current approaches for the study of its chemical composition, emphasizing how a detected variation in its composition can offer information of high clinical value, which can be useful in diagnosis of many diseases such as metabolic disorders and tumours as well as in forensic applications. It also presents details about techniques of sample collection, storage, and analysis. Moreover, it highlights concerns about the use of earwax for diagnostic purposes, which should be addressed to make earwax diagnostics a reality in the future.
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Affiliation(s)
- Engy Shokry
- Laboratório de Métodos de Extração e Separação, Instituto de Química, Universidade Federal de Goiás, Goiânia, Brazil
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Chen C, Wang C, Hu C, Han Y, Zhao L, Zhu X, Xiao L, Sun L. Normoalbuminuric diabetic kidney disease. Front Med 2017; 11:310-318. [PMID: 28721497 DOI: 10.1007/s11684-017-0542-7] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/26/2017] [Indexed: 12/20/2022]
Abstract
Diabetic kidney disease (DKD) is one of the primary causes of end-stage renal disease (ESRD). Early diagnosis is very important in preventing the development of DKD. Urinary albumin excretion rate (UAER) and glomerular filtration rate (GFR) are widely accepted as criteria for the diagnosis and clinical grading of DKD, and microalbuminuria has been recommended as the first clinical sign of DKD. The natural history of DKD has been divided into three stages: normoalbuminuria, microalbuminuria, and macroalbuminuria. However, this clinical paradigm has been questioned recently, as studies have shown that a portion of diabetes mellitus (DM) patients with normoalbuminuria have progressive renal insufficiency, referred to as normoalbuminuric diabetic kidney disease (NADKD) or nonalbuminuric diabetic nephropathy. Epidemiologic research has demonstrated that normoalbuminuric diabetic kidney disease is common, and the large number of NADKD patients suggests that the traditional paradigm needs to be shifted. Currently, the pathogenesis of NADKD remains unclear, but many clinical studies have identified some clinical and pathological features of NADKD. In addition, the long-term outcomes of NADKD patients remain controversial. In this article, we reviewed the latest studies addressing the pathogenesis, pathology, treatment and prevention of NADKD.
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Affiliation(s)
- Chao Chen
- Department of Nephrology, Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Chang Wang
- Department of Nephrology, Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Chun Hu
- Department of Nephrology, Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Yachun Han
- Department of Nephrology, Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Li Zhao
- Department of Nephrology, Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Xuejing Zhu
- Department of Nephrology, Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Li Xiao
- Department of Nephrology, Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Lin Sun
- Department of Nephrology, Second Xiangya Hospital, Central South University, Changsha, 410011, China.
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Xu L, Yu W, Niu M, Zheng C, Qu B, Li Y, Wang J, Huang P, Wang O, Gong F. Serum ZAG Levels Were Associated with eGFR Mild Decrease in T2DM Patients with Diabetic Nephropathy. Int J Endocrinol 2017; 2017:5372625. [PMID: 28352283 PMCID: PMC5352973 DOI: 10.1155/2017/5372625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 12/07/2016] [Accepted: 12/26/2016] [Indexed: 12/26/2022] Open
Abstract
Objective. To investigate the changes of serum zinc-α2-glycoprotein (ZAG) in type 2 diabetes mellitus (T2DM) with eGFR mild decrease. Subjects and Methods. A total of 438 T2DM patients (61.3 ± 4.0 y) were recruited and the demographic, anthropometric, and biochemical parameters were all collected. Serum ZAG levels were determined by commercially available ELISA kits. Results. The proportion of T2DM patients with the high tertile ZAG levels was 11.9% higher in patients with mildly decreased estimated glomerular filtration rate (eGFR) (<90 mL/min/1.73 m2) than those with the low tertile ZAG levels (P = 0.038). The probability of the eGFR < 90 mL/min/1.73 m2 in patients with the high ZAG levels was 94% higher than those with the low serum ZAG levels after adjusting for age, gender, and education [OR = 1.94, 95% CI (1.17-3.23), P = 0.0094]. This phenomenon was more likely to be observed in the condition of uACR ≥ 2.7 mg/mmol, WC ≥ 90 cm for men, or WC ≥ 85 cm for women. Conclusion. Serum ZAG levels were firstly found to be related with eGFR in T2DM patients. The patients with the high tertile ZAG levels were more likely to have mildly eGFR decrease, especially for female patients with higher uACR and bigger WC.
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Affiliation(s)
- Lingling Xu
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Weihong Yu
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Meng Niu
- Department of Endocrinology, Traditional Chinese Medicine Hospital of Muping District of Yantai City, Yantai, Shandong, China
| | - Caixia Zheng
- Department of Ophthalmology, Traditional Chinese Medicine Hospital of Muping District of Yantai City, Yantai, Shandong, China
| | - Bin Qu
- Department of Ophthalmology, Traditional Chinese Medicine Hospital of Muping District of Yantai City, Yantai, Shandong, China
| | - Yan Li
- Department of Ophthalmology, Traditional Chinese Medicine Hospital of Muping District of Yantai City, Yantai, Shandong, China
| | - Jing Wang
- Department of Ophthalmology, Traditional Chinese Medicine Hospital of Muping District of Yantai City, Yantai, Shandong, China
| | - Ping Huang
- Department of Ophthalmology, Traditional Chinese Medicine Hospital of Muping District of Yantai City, Yantai, Shandong, China
| | - O. Wang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Fengying Gong
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
- *Fengying Gong:
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Wang Y, Li YM, Zhang S, Zhao JY, Liu CY. Adipokine zinc-alpha-2-glycoprotein as a novel urinary biomarker presents earlier than microalbuminuria in diabetic nephropathy. J Int Med Res 2016; 44:278-86. [PMID: 26857862 PMCID: PMC5580061 DOI: 10.1177/0300060515601699] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 07/26/2015] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To investigate the role of zinc-alpha-2-glycoprotein (ZAG) in the early stage of diabetic nephropathy, in patients with type 2 diabetes mellitus (T2DM). METHODS This cross-sectional observational study recruited patients with longstanding T2DM and healthy control subjects. Patients with T2DM were further stratified based on their urine albumin-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR). Serum and urine concentrations of ZAG were determined using an enzyme-linked immunosorbent assay. RESULTS Eighty patients with T2DM and 20 healthy control subjects were enrolled in the study. Mean ± SD concentrations of ZAG in serum and urine were both significantly higher in patients with T2DM (serum: 38.29 ± 22.72 mg/l; urine: 53.64 ± 29.48 mg/g) compared with concentrations in healthy control subjects (serum: 21.61 ± 8.83 mg/l; urine: 28.17 ± 10.64 mg/g). Serum ZAG concentration was positively correlated with serum creatinine and eGFR. Urine ZAG concentration was positively correlated with UACR. Urine concentration of ZAG in the higher eGFR group was higher than that in the normal eGFR group (41.26 ± 13.67 versus 32.05 ± 8.55 mg/g, respectively). CONCLUSION These preliminary findings suggest that ZAG might be a potentially useful biomarker for early diagnosis of diabetic nephropathy in patients with T2DM.
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Affiliation(s)
- Yuan Wang
- Department of Nephrology, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Yan-Mei Li
- Department of Nephrology, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Shu Zhang
- Department of Nephrology, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Jiu-Yang Zhao
- Department of Nephrology, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Chun-Yan Liu
- Department of Nephrology, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
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13
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Gluhovschi C, Gluhovschi G, Petrica L, Timar R, Velciov S, Ionita I, Kaycsa A, Timar B. Urinary Biomarkers in the Assessment of Early Diabetic Nephropathy. J Diabetes Res 2016; 2016:4626125. [PMID: 27413755 PMCID: PMC4927990 DOI: 10.1155/2016/4626125] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 05/12/2016] [Indexed: 12/12/2022] Open
Abstract
Diabetic nephropathy (DN) is a frequent and severe complication of diabetes mellitus (DM). Its diagnosis in incipient stages may allow prompt interventions and an improved prognosis. Towards this aim, biomarkers for detecting early DN can be used. Microalbuminuria has been proven a remarkably useful biomarker, being used for diagnosis of DN, for assessing its associated condition-mainly cardiovascular ones-and for monitoring its progression. New researches are pointing that some of these biomarkers (i.e., glomerular, tubular, inflammation markers, and biomarkers of oxidative stress) precede albuminuria in some patients. However, their usefulness is widely debated in the literature and has not yet led to the validation of a new "gold standard" biomarker for the early diagnosis of DN. Currently, microalbuminuria is an important biomarker for both glomerular and tubular injury. Other glomerular biomarkers (transferrin and ceruloplasmin) are under evaluation. Tubular biomarkers in DN seem to be of a paramount importance in the early diagnosis of DN since tubular lesions occur early. Additionally, biomarkers of inflammation, oxidative stress, podocyte biomarkers, and vascular biomarkers have been employed for assessing early DN. The purpose of this review is to provide an overview of the current biomarkers used for the diagnosis of early DN.
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Affiliation(s)
- Cristina Gluhovschi
- Division of Nephrology, University of Medicine and Pharmacy “V. Babes”, 300041 Timisoara, Romania
- *Cristina Gluhovschi:
| | | | - Ligia Petrica
- Division of Nephrology, University of Medicine and Pharmacy “V. Babes”, 300041 Timisoara, Romania
| | - Romulus Timar
- Department of Diabetes and Metabolic Diseases, University of Medicine and Pharmacy “V. Babes”, 300041 Timisoara, Romania
| | - Silvia Velciov
- Division of Nephrology, University of Medicine and Pharmacy “V. Babes”, 300041 Timisoara, Romania
| | - Ioana Ionita
- Division of Hematology, University of Medicine and Pharmacy “V. Babes”, 300041 Timisoara, Romania
| | - Adriana Kaycsa
- Department of Biochemistry, University of Medicine and Pharmacy “V. Babes”, 300041 Timisoara, Romania
| | - Bogdan Timar
- Department of Diabetes and Metabolic Diseases, University of Medicine and Pharmacy “V. Babes”, 300041 Timisoara, Romania
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Guo Z, Liu X, Li M, Shao C, Tao J, Sun W, Li M. Differential urinary glycoproteome analysis of type 2 diabetic nephropathy using 2D-LC-MS/MS and iTRAQ quantification. J Transl Med 2015; 13:371. [PMID: 26608305 PMCID: PMC4660682 DOI: 10.1186/s12967-015-0712-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/23/2015] [Indexed: 01/20/2023] Open
Abstract
Background Diabetic nephropathy (DN) is the leading cause of chronic kidney failure and end-stage kidney disease. More accurate and non-invasive test for the diagnosis and monitoring the progression of DN is urgently needed for the better care of such patients. Methods In this study we utilized urinary glycoproteome to discover the differential proteins during the course of type 2 DN. The urinary glycoproteins from normal controls, normalbuminuira, microalbuminura, and macroalbuminuria patients were enriched by concanavalin A (ConA) and analyzed by 2DLC/MS/MS and isobaric tags for relative and absolute quantitation quantification. Results A total of 478 proteins were identified and 408 were annotated as N-linked glycoproteins. A total of 72, 107 and 123 differential proteins were identified in normalbuminuria, microalbuminuria and macroalbuminuria, respectively. By bioinformatics analysis, in normalbuminruia state, cell proliferation and cell movement were activated, which might reflect the compensatory phase during the disease development. In micro- and macro-albuminuria, cell death and apoptosis was activated, which might reflect the de-compensatory phase. Pathway analysis showed acute phase proteins, the member of high density lipoprotein and low density lipoprotein proteins were changed, indicating the role of the inflammatory response and lipid metabolism abnormality in the pathogenesis of DN. Six selected differential proteins were validated by Western Blot. Alpha-1-antitrypsin (SERPINA1) and Ceruloplasmin are the two markers with excellent area under curve values (0.929 and 1.000 respectively) to distinguish the microalbuminuria and normalbuminuria. For the first time, we found pro-epidermal growth factor and prolactin-inducible protein were decreased in macroalbuminuria stage, which might reflect the inhibition of cell viability and the activation of cell death in kidney. Conclusions Above data indicated that urinary glycoproteome could be useful to distinguish the differences in protein profiles in different stages in DN, which will help better individualized care of patients in DN. Electronic supplementary material The online version of this article (doi:10.1186/s12967-015-0712-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zhengguang Guo
- Core Facility of Instrument, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dong Dan San Tiao, Beijing, 100005, China.
| | - Xuejiao Liu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifuyan, Wangfujing Street, Beijing, China.
| | - Menglin Li
- National Key Laboratory of Medical Molecular Biology, Department of Physiology and Pathophysiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dong Dan San Tiao, Beijing, 100005, China.
| | - Chen Shao
- The Center for Biomedical Information, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dong Dan San Tiao, Beijing, 100005, China.
| | - Jianling Tao
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifuyan, Wangfujing Street, Beijing, China.
| | - Wei Sun
- Core Facility of Instrument, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dong Dan San Tiao, Beijing, 100005, China.
| | - Mingxi Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifuyan, Wangfujing Street, Beijing, China.
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Nakayama A, Kubota R, Sakatsume M, Suzuki H, Katayama A, Kanamori K, Shiba K, Iijima S. Cellulose Acetate Membrane Electrophoresis Based Urinary Proteomics for the Identification of Characteristic Proteins. J Clin Lab Anal 2015; 30:359-67. [PMID: 26453827 DOI: 10.1002/jcla.21863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 05/07/2015] [Accepted: 06/27/2015] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Analysis of urinary proteins using cellulose acetate membrane electrophoresis (CAME) is a useful and challenging method for the recognition of damaged sites in the kidney. However, protein content of each CAME fraction is still not completely understood. METHODS In this study, an effective method of protein extraction from each band fractionated by CAME was established, which enabled us to examine the extracted proteins by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and mass spectrometry. RESULTS Proteins were extracted from the gel and analyzed by mass spectrometry. In all, 31 proteins were identified, including 20 urinary proteins that were newly identified in the CAME-based analysis. CONCLUSION This methodology was useful for identifying the proteins responsible for creating unique bands on CAME in a urine sample of a patient with drug-induced interstitial nephritis. These findings provide in-depth characterization of urinary protein contents in each CAME fraction.
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Affiliation(s)
- Aki Nakayama
- Faculty of Health Science Technology, Bunkyo Gakuin University, Tokyo, Japan.
| | - Ryo Kubota
- Department of Health Sciences, Saitama Prefectural University, Saitama, Japan
| | - Minoru Sakatsume
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Hidenori Suzuki
- Department of Pharmacology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Akira Katayama
- Department of Biochemistry and Molecular Biology, Nippon Medical School, Tokyo, Japan
| | - Kiyoko Kanamori
- Faculty of Health Science Technology, Bunkyo Gakuin University, Tokyo, Japan
| | - Kiyoko Shiba
- Division of Health Care Science, Graduate School of Health Care Science, Bunkyo Gakuin University, Tokyo, Japan
| | - Shiro Iijima
- Faculty of Health Science Technology, Bunkyo Gakuin University, Tokyo, Japan.,Division of Health Care Science, Graduate School of Health Care Science, Bunkyo Gakuin University, Tokyo, Japan
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Bergman N, Bergquist J. Recent developments in proteomic methods and disease biomarkers. Analyst 2015; 139:3836-51. [PMID: 24975697 DOI: 10.1039/c4an00627e] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Proteomic methodologies for identification and analysis of biomarkers have gained more attention during recent years and have evolved rapidly. Identification and detection of disease biomarkers are important to foresee outbreaks of certain diseases thereby avoiding surgery and other invasive and expensive medical treatments for patients. Thus, more research into discovering new biomarkers and new methods for faster and more accurate detection is needed. It is often difficult to detect and measure biomarkers because of their low concentrations and the complexity of their respective matrices. Therefore it is hard to find and validate methods for accurate screening methods suitable for clinical use. The most recent developments during the last three years and also some historical considerations of proteomic methodologies for identification and validation of disease biomarkers are presented in this review.
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Affiliation(s)
- Nina Bergman
- Analytical Chemistry, BMC, Department of Chemistry, Uppsala University, Sweden.
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17
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Guo Z, Zhang Y, Zou L, Wang D, Shao C, Wang Y, Sun W, Zhang L. A Proteomic Analysis of Individual and Gender Variations in Normal Human Urine and Cerebrospinal Fluid Using iTRAQ Quantification. PLoS One 2015. [PMID: 26222143 PMCID: PMC4519152 DOI: 10.1371/journal.pone.0133270] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Urine and cerebrospinal fluid (CSF) are two important biofluids used for disease biomarker discovery. For differential proteomic analysis, it is essential to evaluate individual and gender variations. In this study, we characterized urinary and CSF proteomes of 14 healthy volunteers with regard to individual and gender variations using 2DLC-MS/MS analysis and 8-plex iTRAQ quantification. A total of 968/512 urinary/CSF proteins were identified, with 406/280 quantified in all individuals. The median inter-individual coefficients of variation (CVs) were 0.262 and 0.183 for urinary and CSF proteomes, respectively. Cluster analysis showed that male and female urinary proteomes exhibited different patterns, though CSF proteome showed no remarkable gender differences. In comparison with CSF proteome, urinary proteome showed higher individual variation. Further analysis revealed that individual variation was not correlated with protein abundance. The minimum sample size for proteomic analysis with a 2-fold change was 10 (4/5 for males/females using iTRAQ quantification) for urinary or 8 for CSF proteome. Intracellular proteins leaked from exfoliative cells tended to have higher CVs, and extracellular proteins secreted from urinary tract or originating from plasma tended to have lower CVs. The above results might be beneficial for differential proteomic analysis and biomarker discovery.
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Affiliation(s)
- Zhengguang Guo
- Core Facility of Instrument, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dong Dan San Tiao, Beijing, China, 100005
| | - Yang Zhang
- Department of Neurosurgery/China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, 6 Tian Tan Xi Li, Beijing, China, 100050
| | - Lili Zou
- Core Facility of Instrument, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dong Dan San Tiao, Beijing, China, 100005
| | - Danqi Wang
- Core Facility of Instrument, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dong Dan San Tiao, Beijing, China, 100005
| | - Chen Shao
- National Key Laboratory of Medical Molecular Biology, Department of Physiology and Pathophysiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dong Dan San Tiao, Beijing, China, 100005
| | - Yajie Wang
- Core Laboratory for Clinical Medical Research, Beijing Tiantan Hospital, Capital Medical University, 6 Tian Tan Xi Li, Beijing, China, 100050
- Department of Clinical Laboratory Diagnosis, Beijing Tiantan Hospital, Capital Medical University, 6 Tian Tan Xi Li, Beijing, China, 100050
| | - Wei Sun
- Core Facility of Instrument, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dong Dan San Tiao, Beijing, China, 100005
- * E-mail: (WS); (LZ)
| | - Liwei Zhang
- Department of Neurosurgery/China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, 6 Tian Tan Xi Li, Beijing, China, 100050
- * E-mail: (WS); (LZ)
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Tramonti G, Kanwar YS. Review and discussion of tubular biomarkers in the diagnosis and management of diabetic nephropathy. Endocrine 2013; 43:494-503. [PMID: 23086402 PMCID: PMC3670820 DOI: 10.1007/s12020-012-9820-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 10/09/2012] [Indexed: 01/14/2023]
Abstract
The prevalence of diabetic nephropathy has tremendously increased with the relentless rise in the incidence of diabetes over the last couple decades. Diabetic nephropathy is a leading cause of morbidity and mortality, and it invariably leads to an end-stage renal disease (ESRD). In an effort to delay the onset of ESRD systematic screening and appropriate management are needed to evaluate the progression of renal damage in diabetic nephropathy. The reliability of current tests in predicting the onset, progression and response to various regimens for diabetic nephropathy is still under debate; and it has engendered a search for more sensitive and specific urinary biomarkers, especially those reflective of tubular dysfunctions. It is well-known that there is a good correlation between the degree of damage to the tubulo-interstitial compartment and the deterioration of renal functions. In view of this, the utility of urinary biomarkers, reflective of tubular injury, reported in the literature is discussed in this brief review.
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Affiliation(s)
- Gianfranco Tramonti
- Dipartimento di Medicina Interna – Sezione di Nefrologia, Università di Pisa, Italy
| | - Yashpal S. Kanwar
- Department of Pathology, Feinberg School of Medicine, Northwestern University, 303 E. Chicago Avenue, Chicago, Illinois 60611, USA
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The Application of SILAC Mouse in Human Body Fluid Proteomics Analysis Reveals Protein Patterns Associated with IgA Nephropathy. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:275390. [PMID: 23762118 PMCID: PMC3671237 DOI: 10.1155/2013/275390] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 04/18/2013] [Indexed: 01/07/2023]
Abstract
Body fluid proteome is the most informative proteome from a medical viewpoint. But the lack of accurate quantitation method for complicated body fluid limited its application in disease research and biomarker discovery. To address this problem, we introduced a novel strategy, in which SILAC-labeled mouse serum was used as internal standard for human serum and urine proteome analysis. The SILAC-labeled mouse serum was mixed with human serum and urine, and multidimensional separation coupled with tandem mass spectrometry (IEF-LC-MS/MS) analysis was performed. The shared peptides between two species were quantified by their SILAC pairs, and the human-only peptides were quantified by mouse peptides with coelution. The comparison for the results from two replicate experiments indicated the high repeatability of our strategy. Then the urine from Immunoglobulin A nephropathy patients treated and untreated was compared by this quantitation strategy. Fifty-three peptides were found to be significantly changed between two groups, including both known diagnostic markers for IgAN and novel candidates, such as Complement C3, Albumin, VDBP, ApoA,1 and IGFBP7. In conclusion, we have developed a practical and accurate quantitation strategy for comparison of complicated human body fluid proteome. The results from such strategy could provide potential disease-related biomarkers for evaluation of treatment.
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In-depth proteomic analysis of the human cerumen—A potential novel diagnostically relevant biofluid. J Proteomics 2013; 83:119-29. [DOI: 10.1016/j.jprot.2013.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 03/07/2013] [Accepted: 03/09/2013] [Indexed: 11/17/2022]
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Wang C, Li C, Gong W, Lou T. New urinary biomarkers for diabetic kidney disease. Biomark Res 2013; 1:9. [PMID: 24252392 PMCID: PMC4177619 DOI: 10.1186/2050-7771-1-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 01/04/2013] [Indexed: 11/10/2022] Open
Abstract
Diabetic kidney disease is the leading cause of end-stage renal disease in developed and developing countries. Microalbuminuria is the gold standard for detection and prediction of diabetic kidney disease and cardiovascular risk disease in clinical practice. However, microalbuminuria has several limitations, such as lower sensitive, larger variability. It is urgent to explore higher sensitivity and specificity for earlier detection of diabetic kidney disease and more accurate prediction of the progression to end stage renal disease. We reviewed some new and important urinary biomarkers, such as: transferrin, immunoglobulin G, immunoglobulin M, Cystanic C, podocytes, type IV collagen, 8-oxo-7, 8-dihydro-2'-deoxyguanosine, ceruloplasmin, monocyte chemoattractant protein-1 and so on. We need good quality, long-term, large longitudinal trials to validate published biomarkers and find new biomarkers, considering biomarkers reviewed here are from small cross-sectional studies.
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Affiliation(s)
- Cheng Wang
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, 510630, China.
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