|Year : 2015 | Volume
| Issue : 1 | Page : 21-26
Association of plasma fibrinogen and serum high-sensitivity C-reactive protein in type 2 diabetes mellitus
RajLaxmi Sarangi1, Srikrushna Mahapatra2, Somanath Padhi3
1 Department of Biochemistry, Pondicherry Institute of Medical Sciences, Puducherry; Department of Biochemistry, Maharaja Krushna Chandra Gajapati Medical College and Hospital, Berhampur, India
2 Department of Biochemistry, Maharaja Krushna Chandra Gajapati Medical College and Hospital, Berhampur; Department of Biochemistry, Shriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
3 Department of Pathology, Pondicherry Institute of Medical Sciences, Puducherry, India
|Date of Submission||15-Aug-2015|
|Date of Acceptance||18-Sep-2015|
|Date of Web Publication||9-Nov-2015|
Department of Biochemistry, Pondicherry Institute of Medical Sciences, Puducherry - 605 014
Source of Support: None, Conflict of Interest: None
Introduction: Impaired fibrinolysis and low-grade systemic inflammation are postulated to be associated with the pathogenesis of type 2 diabetes mellitus (T2DM) with its micro and macrovascular complications. However, this mechanism is complex and poorly understood.
Materials and Methods: Fasting plasma glucose (FPG), plasma fibrinogen, serum high-sensitivity C-reactive protein (hs-CRP), and lipid parameters were measured among eighty, nonobese, adult type 2 diabetic males (age: 40–65 years) (without complications [n = 40, Group 2], with retinopathy [n = 16, Group 3], with hypertension [n = 24, Group 4]), and compared with age- and gender-matched healthy controls (n = 40, Group 1).
Results: The mean age of subjects in Groups 1, 2, 3, and 4 were 51 ± 7.2, 49 ± 5.3, 51.5 ± 7.2, and 49.3 ± 5.3 years, respectively (P = 0.33). Fibrinogen, FPG, and hs-CRP were significantly higher among diabetics than controls (P < 0.001). Fibrinogen was found to be significantly higher (P = 0.01) among diabetics with complications than without complications, though the results were similar between retinopathy group (Group 3) and hypertension group (Group 4) (462.3 ± 63.9 vs. 459.1 ± 53.3 mg/dl, respectively, P > 0.05). Significant positive correlation was noted between fibrinogen and hs-CRP among Group 2 (r = 0.37, P = 0.02), Group 3 (r = 0.67, P = 0.005), and Group 4 (r = 0.74, P = 0.000). On linear regression analysis, the association between fibrinogen and hs-CRP was found to be significant among all diabetic subgroups. Association of fibrinogen with lipid parameters was inconsistent in all subgroups.
Conclusion: Fibrinogen may be considered as an inflammatory biomarker in T2DM, and fibrinogen-lowering agents may be useful in lowering the morbidity and mortality.
Keywords: Fibrinogen, high sensitivity C-reactive protein, type 2 diabetes mellitus
|How to cite this article:|
Sarangi R, Mahapatra S, Padhi S. Association of plasma fibrinogen and serum high-sensitivity C-reactive protein in type 2 diabetes mellitus. J Curr Res Sci Med 2015;1:21-6
|How to cite this URL:|
Sarangi R, Mahapatra S, Padhi S. Association of plasma fibrinogen and serum high-sensitivity C-reactive protein in type 2 diabetes mellitus. J Curr Res Sci Med [serial online] 2015 [cited 2021 Jul 30];1:21-6. Available from: https://www.jcrsmed.org/text.asp?2015/1/1/21/168919
| Introduction|| |
Type 2 diabetes mellitus (T2DM) and its associated complications have attained global pandemic proportions over the last decade with India being dubiously tagged as the "diabetes capital" of the world. The current number of diabetes patients worldwide could be 150 million which would double by the year 2030. It is estimated that India and China will remain the two countries with the highest numbers of people with diabetes (79.4 million and 42.3 million, respectively) by 2030.
T2DM is now considered as a disorder of innate immune system, and diabetogenesis is the result of persistent low-grade systemic inflammation, oxidative stress, and endothelial dysfunction, leading to a hypercoagulable state with associated micro and macrovascular complications., There is substantiative evidence to suggest that a prothrombotic state exists in diabetes due to impaired fibrinolysis leading to increased blood viscosity and platelet aggregation. Plasma fibrinogen is a liver-derived acute phase reactant which plays a vital role in the common pathway of the coagulation cascade. This has been shown to be a strong and independent predictor of silent myocardial ischemia in general population., Association between increased fibrinogen levels with hyperglycemia in T2DM is poorly understood, and it is postulated that increased fibrinogen may also contribute to the increased cardiovascular risk in T2DM unrelated to other risk factors.
The objectives of this study were to (i) assess plasma fibrinogen, serum high-sensitivity C-reactive protein (hs-CRP), and lipid parameters in patients of T2DM with or without vascular complications, (ii) study the association between fibrinogen and hs-CRP, and (iii) test the hypothesis that fibrinogen may serve as an inflammatory biomarker in T2DM.
| Materials and Methods|| |
Following the approval of the Institutional Ethics Committee, an observational, cross-sectional study was carried out over a period of 18 months (December 2008–June 2010) in a Tertiary Care Hospital where 120 adult (40–65 years), nonobese (body mass index [BMI] <25 kg/m 2) males gave their consents to participate in the study. The participants were subdivided into four subgroups: (i) Healthy, age, gender, and BMI-matched controls (n = 40, Group 1), (ii) those with T2DM (newly diagnosed or on physical activity/dietary modifications/drugs) with no obvious complications (n = 40, Group 2), (iii) those with T2DM with retinopathy, diagnosed based upon fundoscopic examination (n = 16, Group 3), and (iv) those with T2DM with newly diagnosed systemic hypertension (systolic blood pressure ≥150 mmHg and diastolic blood pressure ≥90 mmHg) or those under antihypertensive medications as per 2014 JNC 8 guidelines (n = 24, Group 4). All subjects with history of smoking, alcohol intake, inflammatory and/or infective disorders, known prior malignancies, and major adverse coronary events were excluded from the study.
Following an overnight (12 h) fast, blood samples (10 ml) were collected under aseptic conditions from anterior cubital vein in all the subjects. One milliliter was kept in fluoride for glucose estimation and 4 ml sample was kept for the estimation of plasma fibrinogen using oxalate as an anticoagulant. Remainder of the sample was placed in a plain dry sterile vial without any anticoagulant at 37°C for clot formation. After clot retraction, serum was separated by centrifugation at 3000 rpm for 10 min. Fasting plasma glucose (FPG, ref. 75–100 mg/dl), serum total cholesterol (TC, ref. 130–250 mg/dl), triglyceride (TG, ref. <160 mg/dl), and high-density lipoprotein cholesterol (HDLC, ref. 30–55 mg/dl) were measured using commercially available kits (Oxidase-peroxidase method) in a spectrophotometer. Low-density lipoprotein cholesterol was calculated (c-LDL, ref. 70–165 mg/dl) by applying Freidewald's formula (c-LDL = [TC − TG/5] − HDLC). Diabetes mellitus was defined as FPG of ≥ 126 mg/dl or as receiving anti-hyperglycemic drug treatment. Levels of serum hs-CRP (ref. 1–3 mg/L) were estimated by enzyme-linked immunosorbent assay (KITELISA, ELISCAN; Catalogue No. CRO16CM). Plasma fibrinogen was measured by Tyrosinase method in a spectrophotometer.
Quantitative data were presented as mean ± standard deviation. ANOVA with multiple comparisons was used to determine the difference between variables among subgroups. Pearson correlation (r) was used to assess the degree of association between variables in different groups. Linear regression analysis was used to quantify the association between variables among different subgroups. P ≤ 0.05 was considered statistically significant and SPSS 17 was used for analyses (IBM SPSS 17 software, USA).
| Results|| |
Age, duration of diabetes, and observed biochemical parameters among all the subjects are presented in [Table 1]. The mean age of subjects among Groups 1, 2, 3, and 4 were 51 ± 7.2, 49 ± 5.3, 51.5 ± 7.2, and 49.3 ± 5.3 years, respectively (P = 0.33). Among diabetics, those with retinopathy (Group 3) had longer duration of diabetes compared to other diabetics (P = 0.08). Biochemical parameters such as FPG, fibrinogen, hs-CRP, TC, TG, and c-LDL were significantly higher (P < 0.001) among diabetic subjects than controls, whereas HDLC was lower among diabetics than the controls (P = 0.06). Among diabetics, fibrinogen was found to be significantly higher (P = 0.01) among those with complications than without complications (Group 2); but the results were similar between retinopathy group (Group 3) and hypertension group (Group 4) (462.3 ± 63.9 vs. 459.1 ± 53.3 mg/dl, P > 0.05). Similarly, serum hs-CRP levels were highest among retinopathy group (6.59 ± 2.94 mg/dl) compared to other two groups (Groups 2 and 4) (P = 0.01), though the levels among latter two groups were similar (4.2 ± 2.64 vs. 5.28 ± 1.16 mg/dl, P > 0.05). The results of lipid parameters such as TC, TG, and c-LDL were similar among diabetic subgroups (P > 0.05).
|Table 1: Comparative characteristics of different parameters between control and study subjects (n = 120)|
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Among all study subjects (n = 120), it was observed that fibrinogen had a very significant positive correlation (P = 0.000) with hs-CRP (r = 0.73), FPG (r = 0.55), TC (r = 0.54), TG (r = 0.49), and c-LDL (r = 0.50), but mildly significant (P = 0.06) and had negative correlation with HDLC (r = −0.17) [Table 2]. However, there was significant positive correlation noted between fibrinogen and hs-CRP among Group 2 (r = 0.37, P = 0.02), Group 3 (r = 0.67, P = 0.005), and Group 4 (r = 0.74, P = 0.000); and a positive but insignificant correlation (P > 0.05) was noted between fibrinogen and FPG among Groups 2 and 4. The association of fibrinogen with lipid parameters was found to be weak among all the diabetic subjects [Table 3], [Figure 1]a [Figure 1]b [Figure 1]c.
|Table 2: Correlation of plasma fibrinogen with other biochemical parameters among control and diabetic subjects (n=120)|
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|Table 3: Correlation of plasma fibrinogen with other biochemical parameters among diabetic subjects without any complications, those with retinopathy, and those with hypertension|
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|Figure 1: Linear correlation between plasma fibrinogen and serum high sensitivity C-reactive protein among subjects with type 2 diabetes mellitus with or without complications. There was significant, positive association between two markers among diabetic subjects without complication (a) (r = 0.37, P = 0.02), with retinopathy (b) (r = 0.67, P = 0.005), and with hypertension (c) (r = 0.74, P = 0.000). r: Pearson correlation coefficient and P < 0.05 was considered as statistically significant|
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On linear regression analysis, there was a positive linear association noted between fibrinogen (dependent variable) and hs-CRP (constant variable) among subjects without complications (β [regression coefficient] =0.37, P = 0.02), with retinopathy (β =0.67, P = 0.005), and with hypertension (β =0.75, P = 0.00). The linear regression equation for fibrinogen (mg/dl) was 281.29 + 0.37 × hs-CRP; 366.33 + 0.67 × hs-CRP; and 278.30 + 0.75 × hs-CRP among diabetics without complication, with retinopathy, and with hypertension, respectively [Table 4].
|Table 4: Linear regression analysis depicting the relation between plasma fibrinogen (dependent variable) with serum hs-CRP (constant variable) among subjects with T2DM|
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| Discussion|| |
We demonstrated significantly higher fibrinogen levels among diabetic subjects with complications than those without complications, and this was found to be highest (P < 0.05) among retinopathy subjects. A significant positive linear correlation between fibrinogen and hs-CRP was also observed among all diabetic subjects, though this association was highest among hypertensive diabetics. The relationship between fibrinogen and hs-CRP was also found to be significant in linear regression analysis [Table 1],[Table 2],[Table 3],[Table 4]. We, therefore, hypothesized that hyperfibrinogenemia is possibly linked to the underlying inflammation in T2DM and its associated vascular complications.
Zhao et al. studied the relationship between activated partial thromboplastin time (APTT) and fibrinogen levels with FPG and HbA1C among diabetic subjects. The APTT values in the diabetic, high-risk diabetic, or impaired fasting glucose group were significantly shorter than the euglycemic group. Fibrinogen levels were significantly higher in the diabetic and high-risk diabetic groups than euglycemic subjects. Similar results were also observed by several other authors in different studies., Ang et al. postulated that elevated fibrinogen levels (≥375 mg/dl) and increased BMI (≥25 kg/m 2) in diabetic subjects may be associated with lower inhibition of platelet reactivity with antiplatelet drug clopidogrel, leading to increased risk of cardiovascular disease.
Studies relating fibrinogen and hs-CRP in T2DM associated angiopathy have shown conflicting results.,,,,, Takebayashi et al. showed a significant positive correlation between these two markers in diabetic microangiopathy, though no conclusive association was noted with coronary vascular disease (macroangiopathy). Bosevski et al. showed a significant impact of fibrinogen and CRP on the development of peripheral vascular disease among type 2 diabetic patients. A recent study from China showed a significant positive correlation among fibrinogen, hs-CRP, FPG, HbA1C, and fibrinogen was shown to be an independent predictor of coronary artery disease. Another study also postulated that, elevated fibrinogen and fibrin degradation product (FDP) level and reduced fibrinogen/FDP ratio were associated with presence of coronary artery disease in patients with T2DM. Recent prospective, randomized control trials have also shown that increased tissue plasminogen activator inhibitor (PAI-1) (an inhibitor of fibrinolysis) was an independent risk factor for the onset of diabetic retinopathy (DR), and intensive glycemic control was associated with decreased progression of retinopathy in those with fibrinogen < 296 mg/dl (odds ratio 0.55 [95% confidence interval: 0.31–1.00], P = 0.03). On the contrary, a past Indian study had shown that PAI-1, fibrinogen, and von Willebrand factor (vWF) activity were significantly increased among diabetic subjects compared to healthy controls, though only PAI-1 and vWF were significantly associated with microvascular complications than those without complications.
It has been postulated that glycosylation of fibrinogen in T2DM leads to an altered conformation resulting in impaired fibrinolysis. Furthermore, insulin resistance in diabetic subjects leads to or may be associated with enhanced PAI activity which increases with age. Significant association between fibrinogen and hs-CRP in our study is a strong supporter of the above-said hypothesis. However, this association was weak among retinopathy groups which was possibly the result of very small sample size in that category.
Our observation supports the hypothesis that inflammation and impaired fibrinolysis may play a pathogenetic role in T2DM and its associated micro and macrovascular complications. Strong association between fibrinogen and hs-CRP also points to the fact that fibrinogen may be considered as an inflammatory marker in T2DM. Understanding the dysglycemia-inflammation-coagulation paradigm may be useful in lowering the future cardiovascular risk in T2DM. Smaller sample size, gender bias, and nature of the study design were the major drawbacks of our study. Furthermore, we did not study the effect of drugs as well as other anthropometric parameters, which might have influenced our outcome. Therefore, our results need to be interpreted with caution, and future prospective studies are needed to validate our findings.
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Conflicts of interest
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| References|| |
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.
Sarangi R, Padhi S, Mahapatra S, Bhumika N. Serum nitric oxide metabolites and high sensitivity C-reactive protein are important biomarkers in nonobese, Indian type 2 diabetic males. Int J Diabetes Dev Ctries 2012;32:163-8.
Garg MK, Dutta Mk, Brar KS. Inflammatory markers in metabolic syndrome. Int J Diabetes Dev Ctries 2012;32:131-7.
Grant PJ. Diabetes mellitus as a prothrombotic condition. J Intern Med 2007;262:157-72.
Nguyen TT, Alibrahim E, Islam FM, Klein R, Klein BE, Cotch MF, et al.
Inflammatory, hemostatic, and other novel biomarkers for diabetic retinopathy: The multi-ethnic study of atherosclerosis. Diabetes Care 2009;32:1704-9.
McBane RD 2nd
, Hardison RM, Sobel BE. BARI 2D Study Group. Comparison of plasminogen activator inhibitor-1, tissue type plasminogen activator antigen, fibrinogen, and D-dimer levels in various age decades in patients with type 2 diabetes mellitus and stable coronary artery disease (from the BARI 2D trial). Am J Cardiol 2010;105:17-24.
James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al.
2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014;311:507-20.
American Diabetes Association. Standards of medical care in diabetes-2011. Diabetes Care 2011;34 Suppl 1:S11-61.
Varley H. Practical Clinical Biochemistry. 4th
ed. New Delhi: CBS Publishers; 1988. p. 233-45.
Zhao Y, Zhang J, Zhang J, Wu J. Diabetes mellitus is associated with shortened activated partial thromboplastin time and increased fibrinogen values. PLoS One 2011;6:e16470.
Sapkota B, Shrestha SK, Poudel S. Association of activated partial thromboplastin time and fibrinogen level in patients with type II diabetes mellitus. BMC Res Notes 2013;6:485.
Lippi G, Franchini M, Targher G, Montagnana M, Salvagno GL, Guidi GC, et al.
Epidemiological association between fasting plasma glucose and shortened APTT. Clin Biochem 2009;42:118-20.
Ang L, Palakodeti V, Khalid A, Tsimikas S, Idrees Z, Tran P, et al.
Elevated plasma fibrinogen and diabetes mellitus are associated with lower inhibition of platelet reactivity with clopidogrel. J Am Coll Cardiol 2008;52:1052-9.
Lee S, Kim IT, Park HB, Hyun YK, Kim YJ, Song SO, et al.
High-sensitivity C-reactive protein can predict major adverse cardiovascular events in Korean patients with type 2 diabetes. J Korean Med Sci 2011;26:1322-7.
Bertoni AG, Burke GL, Owusu JA, Carnethon MR, Vaidya D, Barr RG, et al.
Inflammation and the incidence of type 2 diabetes: The Multi-Ethnic Study of Atherosclerosis (MESA). Diabetes Care 2010;33:804-10.
Festa A, D'Agostino R Jr, Tracy RP, Haffner SM; Insulin Resistance Atherosclerosis Study. Elevated levels of acute-phase proteins and plasminogen activator inhibitor-1 predict the development of type 2 diabetes: The insulin resistance atherosclerosis study. Diabetes 2002;51:1131-7.
Takebayashi K, Suetsugu M, Matsutomo R, Wakabayashi S, Aso Y, Inukai T. Correlation of high-sensitivity C-reactive protein and plasma fibrinogen with individual complications in patients with type 2 diabetes. South Med J 2006;99:23-7.
Bosevski M, Bosevska G, Stojanovska L. Influence of fibrinogen and C-RP on progression of peripheral arterial disease in type 2 diabetes: A preliminary report. Cardiovasc Diabetol 2013;12:29.
Hong LF, Li XL, Luo SH, Guo YL, Zhu CG, Qing P, et al.
Association of fibrinogen with severity of stable coronary artery disease in patients with type 2 diabetic mellitus. Dis Markers 2014;2014:485687.
Xiong WX, Shen Y, Dai DP, Lu L, Zhang Q, Zhang RY, et al.
Clinical utility of the ratio between circulating fibrinogen and fibrin (ogen) degradation products for evaluating coronary artery disease in type 2 diabetic patients. Chin Med J (Engl) 2015;128:727-32.
Azad N, Agrawal L, Emanuele NV, Klein R, Bahn GD, McCarren M, et al.
Association of PAI-1 and fibrinogen with diabetic retinopathy in the Veterans Affairs Diabetes Trial (VADT). Diabetes Care 2014;37:501-6.
Madan R, Gupt B, Saluja S, Kansra UC, Tripathi BK, Guliani BP. Coagulation profile in diabetes and its association with diabetic microvascular complications. J Assoc Physicians India 2010;58:481-4.
Jotic A, Milicic T, Covickovic Sternic N, Kostic VS, Lalic K, Jeremic V, et al.
Decreased insulin sensitivity and impaired fibrinolytic activity in type 2 diabetes patients and nondiabetics with ischemic stroke. Int J Endocrinol 2015;2015:934791.
[Table 1], [Table 2], [Table 3], [Table 4]