MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEATH HANOI MEDICAL UNIVERSITY ====== TRAN THI THU HUONG STUDY ON THE CLINICAL, SUBCLINICAL CHARACTERISTICS AND THE ASSOCIATION OF SOME AGT GENE POLYMORP[.]
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEATH HANOI MEDICAL UNIVERSITY ====== TRAN THI THU HUONG STUDY ON THE CLINICAL, SUBCLINICAL CHARACTERISTICS AND THE ASSOCIATION OF SOME AGT GENE POLYMORPHISMS WITH DIABETIC KIDNEY DISEASE Specialism : Intrarenal – Urinary Code number : 9720107 SUMMARY OF MEDICAL DOCTORAL THESIS HA NOI - 2023 THE THESIS HAS BEEN COMPLETED AT HANOI MEDICAL UNIVERSITY Academic Supervisors: Assoc Prof PhD Đang Thi Viet Ha Reviewer 1: Prof PhD Nong Van Hai Reviewer 2: Assoc Prof PhD Le Viet Thang Reviewer 3: Assoc Prof PhD Đinh Thi Kim Dung The thesis is presented in front of board of university examiner and reviewer lever at This thesis can be found at: - National Medical Informatics Library - Library of Hanoi Medical University THE LIST OF WORKS HAS PUBLISHED AND RELATED TO THE THESIS Tran Thi Thu Huong, Nguyen Thi Thuy Hang, Nguyen Trong Ha, et al (2019) Study on the association between estimated glomerular filtration rate and ACR levels in patients with diabetes mellitus and diabetic nephropathy Journal of Diabetes and Endocrinology (Kỷ yếu Hội nghị Nội tiết- ĐTĐ- RLCH toàn quốc lần thứ IX), p109-113 Tran Thi Thu Huong, Tran Van Khanh, Dang Thi Viet Ha (2019) AGT Met235Th polymorphism and diabetic kidney disease in patients with type diabetes Vietnam Medical Journal, (August-Special issue), p 429-436 Tran Thi Thu Huong, Tran Van Khanh, Dang Thi Viet Ha, et al (2021) Study on the association between AGT M235T polymorphism with diabetic kidney disease Journal of Medical Research, p58-65 LIST OF ABBREVIATION ACE ACR AT1 AngII BN KDIGO MLCT RAAS Angiotensin-converting enzyme (Enzym chuyển đổi angiotensin) Albumin niệu/Creatinin niệu Ratio Angiotensin II týp (Thụ thể angiotensin ) Angiotensin II Bệnh nhân Kidney Disease Improving Global Outcomes Mức lọc cầu thận Renin Angiotensin Aldosterone System INTRODUCTION Significance of the study Diabetic Kidney Disease (DKD) is a chronic kidney disease that belongs to the group of microvascular complications caused by diabetes Some diabetic patients, despite well-controlled blood glucose and blood pressure, can still have DKD; and the disease can progress to the end stage with different incidences in different ethnic groups1 This difference can be caused the genetic factors Among these genetic factors, the increased metabolic activity influenced by changes in the expression of genes encoding enzymes of the renin-angiotensin-aldosterone system (RAAS) in DKD patients has been shown to be the main cause of some serious kidney disorders6,7 Therefore, the aims of our current study are to: Describing clinical and subclinical characteristics of DKD in patients with type diabetes Analyzing the association of gene polymorphisms of AGT M235T, CMA(-1903)G>A and CYP11B2 (-344)T>C with DKD in the study group of patients 2 New contributions of the thesis The thesis has found a systematic association between the AGT, CMA, and CYP11B2 gene polymorphism with DKD This is also the first thesis in Vietnam that deals with genetic issues in DKD The thesis has found an association between the variant CMA (-1903) G>A and CYP11B2 (-344) T>C with DKD The increased activity in the conversion of angiotensinogen (encoded by the AGT gene) to AngII by the RAAS enzymes in DKD patients may be influenced by changes in the gene expression caused by high blood glucose An example of our study was the association of the variant CMA (-1903) G>A with DKD, and the individuals having the heterozygous GA genotype had a 2.15 times higher risk of DKD than individuals having the homozygous GG genotype (OR=2.15; 95%CI: 1.18-3.19) Another example was the association of the CYP11B2 (344) T>C polymorphism with DKD, and the individuals having the homozygous TT genotype had a 1, 88 times higher risk of the disease than the individuals having the genotype TC+CC (OR=1.88; 95%CI: 1.12-3.16) For the polymorphism AGT M235T, the CC homozygous genotype accounted for a high proportion of the DKD patients of the study There did not find any significant difference in the AGT M235T polymorphism between the DKD group and the control group, which also confirmed that the genotype distribution of the Kinh and Vietnamese people with DKD was different from other ethnic groups around the world Structure of the thesis The thesis consists of 126 pages, including introduction (2 pages), document overview (33 pages), study subjects and methods (22 pages), results (36 pages), discussion (30 pages) ), conclusion (2 pages) and recommendation (1 pages) The thesis includes 41 tables, 27 figures, diagrams, 168 references (Vietnamese: 10 and English: 158) CHAPTER 1: OVERVIEW 1.1 Genetic factors in the pathogenesis of DKD Genetic factors have been shown to contribute an important role in the development of DKD Evidences for this contribution has been demonstrated from family studies The analysis of genetic factors involved in the pathogenesis of DKD and diabetes includes main mechanisms as follows: - Disorders caused by chronic hyperglycemia: + RAAS activation and AngII biosynthetic signals in DKD + SNP rs699 of AGT gene is a substitution from T to C in exon 2, leading to the substitution from methionine (M) to threonine (T) at codon 268 (M268T), which is located at amino acid 235 The threonine variant rs699 is associated with increased plasma AGT and increased insulin resistance -Modulation of receptor signaling chains involved in AngII biosynthesis and renal mediators: + In the podocytes, there are genes (AGT, CMA/ACE) and CMA gene encoding the synthesis of Chymase enzyme which predominately converts angiotensin I to AngII in DKD Connected modulation of receptor signaling in cardiovascular and renal cells +The CYP11B2 gene encodes the cytochrome P450 enzyme, which catalyzes the biosynthesis of aldosterone stimulated by Ang II and expressed in the paraglomerular apparatus Connecting signal modulation to increased aldosterone due to incomplete RAAS inhibition in some DKD patients receiving ACE/ARB drugs - Promotion of kidney damage: + AngII and its mediators proliferate in the mesangial spaces and glomerular cells as the result of chronic hyperglycaemia causing structural changes in the kidney; + The layer of podocytes is gradually lost, causing albuminuria from transient to permanent Due to tubular damage during acute albuminuria is not fully reabsorbed, tubular obstruction activates proinflammatory signals and renal fibrosis + Hypertension, metabolic disorders, chronic nephritis and renal fibrosis are the risk factors contributing to the progression of renal failure Genetic susceptibility to these risk factors may predispose to DKD and promote faster progression to late stages 1.2 ACR concentration in assessing the activity level of DKD: KDIGO 2007 recommends the ACR (Albumin/Creatinin Ratio) of random urine samples used in the screening and diagnosis of DKD as follows: - Normal albuminuria was defined as ACR 300mg/g) - Albuminuria was determined to be positive after excluding possible causes of transient hyperalbuminuria such as acute hyperglycemia, acute bacterial infection, etc 1.3 Classification of the activity level of DKD according to the albumin concentration and glomerular filtration rate of the Japan Diabetes Association 2014: Based on clinical efficacy assessment, renal and cardiovascular events and all-cause mortality were significantly increased in albuminuria-positive diabetic patients compared with normal albuminuria All-cause mortality was increased in patients having albuminuria with glomerular filtration rate A and CYP11B2 (-344)T>C genes 2.2 METHODS 2.1.1 Methods The study was conducted by a descriptive cross-sectional method All patients were studied according to the steps consistent with the patient record 2.2.2 Sample size of the study: Apply the following formula to calculate sample size: in which: p0 = 0,20: The rate of 20% of individuals with homozygous CC genotype in the control group (type diabetes patients without kidney disease) in Asian Indian subjects in the study by Prasad et al; p1= 0,42: Rate of 42% of individuals with CC homozygous genotype in the disease group (type diabetes with kidney disease) in the study of Prasad et al; ε= 0,25: The desired relative precision (the odds ratio (OR) obtained from the study is not more than 25% different from the true OR value of the population) α=0,05: The level of statistical significance 5% corresponding to 95% confidence level and coefficient = 1.96 Substituting the formula: the sample size between the two groups of patients and controls is 1:1 to calculate the minimum sample size for each study group of 83 patients In fact, 237 subjects who met the requirements of the study were selected, including 117 patients in the case group (type diabetes with kidney disease) and 120 patients in the control group (type diabetes without kidney disease) 2.2.3 Data Analysis: The data were collected according to the sample medical records and analyzed by SPSS 21.0 software The estimation was considered to be statistically significant if p < 0.05 (more than 95% confidence) CHAPTER 3: RESULTS The group of DKD patients was collected according to the selection and exclusion criteria of the study The selected control group has the same age and gender ratio as the case group The results from the study of 117 DKD patients and 120 controls to evaluate the association of AGT (M235T), CMA (-1903)G>A, CYP11B2(-344)T>C with DKD gave the following results: 3.1 Age and gender characteristics of the subjects in the study: Patients aged 60 years or older account for a high percentage (87.2%); The average age of the patients is 67.8 years old (SD: 7.8 years old) age There was no significant difference in age between the case group and the control group with p>0.05 The rate of male patients was 42.7% and the rate of female patients was 57.3%; There was no significant difference between the rate of male patients and the rate of female patients with p>0.05 3.2 Clinical and subclinical characteristics of the case group and the control group Parameters Average ± SD; (min –max) Duration of diabetes (years) HATT (mmHg) HATr (mmHg) st ACR time (mg/g) ACR 2nd time (mg/g) ACR 3rd time (mg/g) Blood CRP (mg/g) Blood leukocyte (G/L) Fasting blood glucose (mmol/L) HbA1c % Glomerular filtration rate (ml/phút/1,73m2) Blood urea (mmol/L) Blood creatinine (mmol/L) Blood uric acid (mmol/L) Blood protein (mmol/L) Blood albumin (mmol/L) Cholesterol (mmol/L) Triglycerid (mmol/L) LDL-C (mmol/L) HDL-C (mmol/L) Case n=117 13,56 ± 5,72 (3 - 27) 143,67 (14,52) 83,33 (7,07) 472, 14 (531,7) 482,09 (523,65) 454,66 (471,87) 2,12 (1,59) 7,92 (1,51) 9,27 (3,20) 7,71 (2,13) 51,53 (20,65) 9,02 (4,34) 133,78 (74,67) 425,17 (117,73) 75,94 (5,33) 41,65 (3,63) 5,55 (1,76) 2,82 (1,63) 3,24 (1,11) 1,22 (0,55) Control n=120 15,69 ± 4,90 (10 - 30) 127,91 (14,35) 77,75 (6,14) p 0,04***