Sudan Journal of Medical Sciences Volume 14, Issue no. 3, DOI 10.18502/sjms.v14i3.5213 Production and Hosting by Knowledge E Research Article High Sensitive C Reactive Protein in Sudanese Type 2 Diabetic Patients Hala Abdalazeem Aljack (PhD)1,2, Omer Fadul Edris (PhD)3, Amar Mohamed Ismail (PhD)3 1Department of Clinical Chemistry, Faculty of Medical Laboratory Science, Omdurman Islamic University, Khartoum-Sudan 2Department of Clinical Chemistry, Faculty of Medical Laboratory Science, Al-Neelain University, Khartoum-Sudan 3Department of Biochemistry and Molecular Biology, Faculty of Science and Technology, Al- Neelain University, Khartoum-Sudan Abstract Background: Researchers proved the association between inflammatory condition, high sensitive C reactive protein (hs-CRP), and cardiovascular diseases (CVDs) in type 2 diabetes mellitus (DM). Therefore, this study aimed to assess the hs-CRP level in type 2 DM patients and their relation to diabetes cardiovascular complications. Materials and methods: In a case-control study, 205 previously diagnosed type 2 DM patients and 100 controls were included. Serum high Sensitive C Reactive Protein (hs-CRP) was estimated immune-turbidimetrically using Cobas C-311® fully automated analyzer. Also, triglyceride (TG), total cholesterol (TC), high-density lipoprotein (HDL-C), and low-density lipoprotein (LDL-C) were measured. Results: Type 2 DM patients had an increased level of hs-CRP (p-value 0.020). Females had higher levels of hs-CRP, TC, HDL-C, and LDL-C than males (p-value 0.005, 0.000, 0.000, and 0.000, respectively). Moreover, patients who received statin drugs had decreased levels of hs-CRP, TC, and LDL-C (p-value 0.030, 0.000, and 0.000, respectively). The correlation analysis revealed hs-CRP correlates positively with BMI (r: 0.56, P-value 0.000). Conclusion: The data showed that type 2 DM patients had higher hs-CRP. Moreover, hs-CRP positively associated with BMI. Therefore, obesity might be related to CVDs in type 2 DM patient. Keywords: High sensitive C reactive protein, cardiovascular diseases, type 2 DM, obesity, Sudan. 1. Introduction Diabetes mellitus (DM) is a chronic metabolic disorder, characterized by hyperglycemic condition due to a defect in secretion of insulin by β cells of pancreas or defect in How to cite this article: Hala Abdalazeem Aljack (PhD), Omer Fadul Edris (PhD), Amar Mohamed Ismail (PhD) (2019) “High Sensitive C Reactive Protein in Sudanese Type 2 Diabetic Patients,” Sudan Journal of Medical Sciences, vol. 14, issue no. 3, pages 132–142. DOI 10.18502/sjms.v14i3.5213 Page 132 Corresponding Author: Hala Abdalazeem Aljack; Department of Clinical Chemistry, Omdurman Islamic University, Faculty of Medical Laboratory Science, Alshigla street, Khartoum, 11111, Sudan. Tel: 00249915503549 Fax: 382 email: hala.abdalazeem@yahoo.com Received 21 February 2019 Accepted 12 May 2019 Published 28 June 2019 Production and Hosting by Knowledge E Hala Abdalazeem Aljack et al. This article is distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use and redistribution provided that the original author and source are credited. Editor-in-Chief: Prof. Mohammad A. M. Ibnouf http://www.knowledgee.com mailto:hala.abdalazeem@yahoo.com https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Sudan Journal of Medical Sciences Hala Abdalazeem Aljack et al insulin action. [1-3]. Recently, DM become the most common chronic disorder, (4) with increasing prevalence worldwide (5). It was estimated that 425 million people had DM in 2017, and the number is expected to rise to 629 million by 2045 [6]. In Sudan, the prevalence of DM is rising from 9.3% in 2010 to 10.6 % in four states in 2013 [7]. Type 2 diabetes mellitus is a complex condition, results from the resistance of insulin action combined with impaired pancreatic function [8]. If left uncontrolled, Type 2 DM can cause chronic microvascular and macrovascular complications [9]. Some previous studies confirmed that Type 2 DM gradually causes chronic low-grade inflammation, which plays a vital role in the progression of diabetic complications [10]. Type 2 DM patients are at a high risk to develop CVDs, and the risk increased when patients suffer from nephropathy [11]. The CVDs are observed to increase in type 2 DM with elevated inflammatory markers [12]. The inflammatory marker hs-CRP is a pentameric protein synthesized by hepatic cells under the control of cytokines [11]. It has been identified as a reliable predictor marker for CVDs [13-15]. Previous studies documented that, diabetic patients undergo high serum hs-CRP level [16], that lead to the activation of inflammatory pathways and progression of CVD [17, 18]. Accordingly, this study was conducted to determine whether the hs-CRP is associated with CVDs in type 2 DM patients. 2. Materials and Methods This case-control study was conducted in the Military Hospital at Khartoum state during period from 2015 to 2019. Randomly 205 type 2 DM patients (111 females and 94 males), and 100 apparently healthy control matched in age and gender were selected. DM patients with inflammatory, liver, and/or renal diseases were excluded. After written informed consents, 5 ml venipuncture blood was collected. The study was approved by the local committee of Al-Neelain University, Sudan (issued in May 2015). 2.1. Measurement of BMI Body mass index (BMI) was calculated using (weight kg/hight m2) formula. DOI 10.18502/sjms.v14i3.5213 Page 133 Sudan Journal of Medical Sciences Hala Abdalazeem Aljack et al 2.2. Measurement of hs-CRP Serum level of hs-CRP were measured by Cobas C-311® (Roche Diagnostics, Germany) using the Particle enhanced immunoturbidimetric method Human CRP agglutinates with latex particles coated with monoclonal anti-CRP antibodies, and then the precipitate was determined turbidimmetrically. 2.3. Measurement of lipid profile Serum TG, TG, and HDL-cholesterol were estimated by Cobas C-311® automated chem- istry analyzer (Roche Diagnostics, Germany). 2.4. TG measurement Using the principle enzymatic colorimetric method which based on complete hydrolysis of triglycerides by lipoprotein lipase to glycerol, followed by oxidation and peroxidation process to form a red dyestuff. The color intensity of the red dyestuff formed is directly proportional to the triglyceride concentration and can be measured photometrically. 2.5. TC measurement Estimation of total cholesterol based on serial enzymatic reactions leads to the formation of red quinone-imine dye, which can be measured photometrically. The color intensity of the dye formed is directly proportional to the cholesterol concentration. 2.6. HDL-C measurement In the presence of magnesium ions, dextran sulfate selectively forms water-soluble complexes with LDL, VLDL, and chylomicrons. The cholesterol concentration of HDL- cholesterol is determined enzymatically after the formation of a purple-blue dye. The color intensity of this dye is directly proportional to the cholesterol concentration and is measured photometrically. DOI 10.18502/sjms.v14i3.5213 Page 134 Sudan Journal of Medical Sciences Hala Abdalazeem Aljack et al 2.7. LDL-C measurement Levels of LDL-C were calculated using the Friedwald equation [19] as follow: 𝐿𝐷𝐿 − 𝐶 = 𝑇𝐶 − (𝐻𝐷𝐿 − 𝐶 + 𝑇𝐺 5 ) 2.8. Statistical analysis All statistical analyses were performed using the SPSS software (Statistical Package for the Social Sciences) (version 21.0; SPSS Inc.). Descriptive statistic (frequency and per- centage) were obtained. Independent t-test was employed to compare mean between groups. Pearson’s correlation was used to correlate between study parameters and vari- ables. Quantitative variables were demonstrated as mean±SD; significant differences were considered as P-value ≤ 0.05. 3. Results The study comprised of 205 Type 2 diabetic patients and 100 subjects as control. The demographic and general characteristics of the population are shown in (Table 1). The mean level of hs-CRP was significantly increased in the diabetic group (4.83±0.42) compared with non-diabetic (3.48±0.38) with (p-value 0.020), while there was a significant decrease in HDL-C level in diabetic (39.4±8.88) compared with non- diabetic group (45.2±12.4) with (p-value 0.000). Also, the mean levels of TG, TC, and LDL-C, showed insignificant differences when the diabetic group compared to the non-diabetic group (Table 2). The results of the study showed the mean level of hs-CRP was significantly higher in female (5.91±2.61) compared with male (3.54±2.55) with (p-value 0.005). Furthermore, the lipid profile results showed a significant increase in TC, HDL-C, and LDL-C mean levels in female compared with male (p-value 0.000) as shown in (Table 3). Patients group who take cholesterol-lowering agent (statin) had significantly lower levels of hs-CRP, TC and LDL-C as compared with untreated Patients (p-value 0.030, 0.000 and 0.000, respectively), while other parameter showed insignificant differences between two groups (Table 4). DOI 10.18502/sjms.v14i3.5213 Page 135 Sudan Journal of Medical Sciences Hala Abdalazeem Aljack et al In correlation analysis, hs-CRP level correlates positively with BMI (r: 0.56 p-value 0.000), while no correlation observed according to age, duration of disease and lipid profile as in (Table 5). Table 1: General baseline characteristics of patients and control groups. Characteristics Diabetic group Non-diabetic group BMI 28.0±4.60 25.8±4.66 Control of Diabetes Controlled: 64 (31.2%) Uncontrolled: 141 (68.8%) - Education status Low: 36 (18%) Moderate: 132 (65%) High: 35 (17%) Low: 33 (33%) Moderate: 50 (50%) High: 15 (15%) Life style Low: 69 (35.0%) Moderate: 113 (57.4%0) Good: 15 (7.6%) Low: 52 (53.1%) Moderate: 41 (41%) Good: 5 (5.0%) Cholesterol lowering agent Yes: 84 (47.2%) No: 94 (52.8%) - Table 2: Compersion of serum hs-CRP and lipid profile in diabetic and non-diabetic groups. Parameter Diabetic group (Mean±SD) Non-diabetic group (Mean±SD) P-value hs-CRP (mg/l) 4.83±0.42 3.48±0.38 0.020 TG (mg/dl) 117±48.3 114±60.4 0.620 T.Cholestrol (mg/dl) 171±33.7 163±42.2 0.055 HDL-Cholestrol (mg/dl) 39.4±8.88 45.2±12.4 0.000 LDL-Cholestrol (mg/dl) 101±35.8 103±31.1 0.647 The results expressed as (Mean±SD) and P value less than 0.05 was considered statistically significant. DOI 10.18502/sjms.v14i3.5213 Page 136 Sudan Journal of Medical Sciences Hala Abdalazeem Aljack et al Table 3: Compersion of study parameters in patients groups classified according to gender. Parameters Male (Mean±SD) Female (Mean±SD) P-value hs-CRP (mg/l) 3.54±2.55 5.91±2.61 0.005 TG (mg/dl) 119±60.2 121±62.7 0.794 T.Cholestrol (mg/dl) 150±39.1 171±40.1 0.000 HDL-Cholestrol (mg/dl) 37.1±7.51 41.4±9.49 0.000 LDL-Cholestrol (mg/dl) 91.3±34.5 109±35.0 0.000 The results expressed as (Mean±SD) and P-value less than 0.05 was considered statistically significant. Table 4: Compersion of study parameters in the patient groups classified according to intake of cholesterol- lowering agent. Parameters Cholesterol-lowering used (Mean±SD) Cholesterol-lowering nonused (Mean±SD) P-value hs-CRP (mg/l) 3.52±3.23 4.98±5.43 0.030 TG (mg/dl) 121±69.1 125±58.8 0.706 T.Cholestrol (mg/dl) 146±38.2 176±40.7 0.000 HDL-Cholestrol (mg/dl) 38.8±8.71 39.0±8.35 0.847 LDL-Cholestrol (mg/dl) 85.8±32.1 114±33.9 0.000 The results expressed as (Mean±SD) and P-value less than 0.05 was considered statistically significant. Table 5: Pearson’s correlation of hs-CRP with BMI, age, duration of disease and lipid profile. Correlation R P-value BMI 0.56** 0.000 age -0.12 0.094 duration of disease -0.01 0.942 TG -0.020 0.778 T.Cholestrol 0.046 0.512 HDL-Cholestrol -0.043 0.544 LDL-Cholestrol 0.66 0.350 (R): Pearson correlation test, (-) negative correlation. A P-value of less than 0.05 was considered statistically significant. DOI 10.18502/sjms.v14i3.5213 Page 137 Sudan Journal of Medical Sciences Hala Abdalazeem Aljack et al 4. Discussion In this study, we found that type 2 DM is prevalent in females than males. The predom- inance of females with diabetes is attributed to the hormonal effects, the higher ability of the body to store iron and physical inactivity; indeed, most of them were housewives [20]. In our study, the majority of patients are elderly and overweight. Thus postulated combination of genetic predisposition, environmental, nutritional factors, obesity, physi- cal inactivity, stress, and aging [21], might be involved in Sudanese type2 DM. Moreover, patients personal data revealed low to moderate education and socioeconomic status. A previous study observed low educational level correlate with DM, and socioeconomic status inversely associated with DM prevalence [22]. Serum hs-CRP level was significantly higher in type 2 DM patients than non dia- betic group. This finding in agreement with the previous study that, pro-inflammatory cytokine hs-CRP was significantly higher in type 2 diabetic patients [23, 24]. Recently, the inflammatory pathway plays a critical role in type 2 pathogenesis, development, and progression of diabetes complications [11]. On the other hand, in accordance with previous reports [25, 26], we found that women had higher hs-CRP levels than with men. In fact that gender difference has not yet completely understood, many studies speculated that adiposity, hormones replacement therapy, postmenopausal are associated with higher levels of CRP in women [26]. Furthermore, female type 2 DM patients had higher levels of TC, HDL-C, and LDL-C than the diabetic males which is in line with previous studies [27]. The findings may attributed to the effect of sex hormones and distribution of body fat leading to these differences [27]. Moreover, patients who received Statin treatment revealed lower levels of hs-CRP, TC, and LDL-C. A previous evidence suggest that, therapy with atorvastatin lead to reduced hs-CRP and LDL-C levels in patients with type 2 DM [28]. Likewise, previous reports revealed proportional association between hs-CRP level and BMI [29], our study showed a positive relationship between hs-CRP and BMI. Meanwhile, no correlations noted with lipid profile. Since CRP used to predict CVDs even in patients with low LDL-C, indeed its stability in blood and not affecting by food intake [30]. The limitations of this study are frist the number controls is not equal to patients. Second there are no pre-investigations done to patients, therefore the selection depend on previous clinical investigation. DOI 10.18502/sjms.v14i3.5213 Page 138 Sudan Journal of Medical Sciences Hala Abdalazeem Aljack et al 5. Conclusion The study concludes that, the hs-CRP level is increased in type 2 DM patients. Females had higher hs-CRP than males. Furthermore, atorvastatin reduces hs-CRP level. 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