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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 1  |  Issue : 3  |  Page : 262-266

Alteration of plasma gdf-11 levels in type 2 diabetes patients with cardiovascular complications: A pilot study


1 Drug Discovery Research Center, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, Haryana, India
2 Division of Cardiology, Mediciti Hospitals, Hyderabad, Andhra Pradesh, India

Date of Web Publication23-Feb-2016

Correspondence Address:
Sanjay K Banerjee
Drug Discovery Research Center, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, 3rd Milestone, Faridabad - Gurgaon Expressway, P. O. Box No. 04, Faridabad - 121 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-5414.177246

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  Abstract 

Background: Patients with type 2 diabetes mellitus (T2DM) have an increased risk of cardiovascular diseases. Scientific literature reported that growth differentiation factor-11 (GDF-11) has an important role to prevent aging of the heart and decreases with age. However, there is no study to look at plasma GDF-11 levels in diabetes and diabetes associated with cardiovascular complications in India. Therefore, the present study was designed to know the alteration of GDF-11 levels in Indian patients having diabetes and diabetes with cardiovascular complications. Methods: Plasma GDF-11 levels were measured from total 89 age-matched (35-65) subjects by ELISA method. All patients were divided into five groups; control (CT, n = 20), T2DM (n = 15), T2DM with hypertension (T2DM_HTN, n = 14), coronary artery disease (CAD, n = 20), and CAD with T2DM (T2DM_CAD, n = 20). Clinical parameters such as glycated haemoglobin A1c (HbA1c), fasting blood sugar, creatinine, lipid profile, uric acid, and systolic and diastolic blood pressure were measured in all the patients. Results: Plasma GDF-11 levels were measured in all the study groups. We have observed that GDF-11 levels were significantly decreased in T2DM, T2DM_HTN, CAD, and T2DM_CAD subjects compared to CT subjects. Our data indicated that plasma GDF-11 levels were inversely associated with age but did not show any correlation with fasting blood glucose and Hb1Ac levels. Conclusion: Plasma GDF-11 levels were decreased in Indian patients associated with diabetes and diabetes with cardiovascular complications. Further studies are required to understand the role of decreased plasma GDF-11 levels on disease progression and development of cardiovascular complications in diabetes.

Keywords: Coronary artery diseases, growth differentiation factor-11, hypertension, type 2 diabetes


How to cite this article:
Adela R, Reddy P N, Banerjee SK. Alteration of plasma gdf-11 levels in type 2 diabetes patients with cardiovascular complications: A pilot study. J Pract Cardiovasc Sci 2015;1:262-6

How to cite this URL:
Adela R, Reddy P N, Banerjee SK. Alteration of plasma gdf-11 levels in type 2 diabetes patients with cardiovascular complications: A pilot study. J Pract Cardiovasc Sci [serial online] 2015 [cited 2018 Sep 21];1:262-6. Available from: http://www.j-pcs.org/text.asp?2015/1/3/262/177246


  Introduction Top


Prevalence of diabetes is reaching pandemic proportion in young population due to lack of physical exercise and unhealthy diet. As per the International Diabetes Federation Diabetes Atlas (Sixth Edition 2014), the number of people with diabetes is 382 million worldwide and going to rise to 592 million by 2035. The burden of diabetes, causing 5.1 million deaths, has taken up some 548 billion dollars spent in 2013. [1] The increasing morbidity and mortality in type 2 diabetes mellitus (T2DM) subjects were observed due to cardiovascular complications. Type 2 diabetes is associated with macrovascular and microvascular complications. The prevalence, incidence, and mortality of cardiovascular diseases are 2-8-fold higher in persons with diabetes than those without diabetes. [2]

Diabetes is an important risk factor for cardiovascular complications such as hypertension (HTN) and coronary artery disease (CAD). Cardiovascular disease is considered as the most occurring cause of death and increasing rapidly in developing nations. Many factors involved in the development of cardiovascular diseases are smoking, gender, blood pressure, hyperlipidemia, renal failure, and diabetes. [3] Chronic and low-grade inflammation along with oxidative stress has been identified as an essential component of both T2DM and cardiovascular diseases. [4] Identifying crucial biomarkers or inflammatory mediators will help to track the disease progression and find the specific therapeutic intervention.

Growth differentiation factor-11 (GDF-11), a cytokine belongs to transforming growth factor-β super family and also known as bone morphogenetic protein-11. [5] Recently, researchers from the Harvard Stem Cell Institute identified that GDF-11 protein prevents age-related cardiac hypertrophy and reverts back enlarged and weakened aged mice hearts to young and healthy one. [6] GDF-11 works like myostatin to modulate metabolic function. [5] Although the role of GDF-11 on aging and hypertrophy heart is well-known, its role in diabetic patients with cardiovascular complications is unexplored. In the present study, we measured plasma GDF-11 levels in diabetes and diabetes with cardiovascular complication patients, and found the association with glycated hemoglobin A1c (HbA1c) and fasting blood glucose (FBS) levels.


  Methods Top


Five different groups of random sample of total 89 male and female patients aged between 35 and 65 years patients were recruited from the Mediciti Hospitals, Hyderabad. Subjects were residents of Hyderabad city and region of Telangana, India. The proposed protocol was approved by the Institutional Review Board of the Mediciti Ethics Committee, Hyderabad. All the subjects before participation have given written informed consent. The procedures were performed in accordance with Helsinki Declaration.

Subjects were categorized as control (CT), T2DM, T2DM with HTN (T2DM_HTN), CADs without diabetes, and T2DM with CAD (T2DM_CAD).

In the CT (n = 20) group, we have selected healthy subjects without any chronic health problems and pharmacological interventions. T2DM (n = 15) patients were selected on the basis of HbA1c levels (more than 6.5%) and previous history of diabetes. T2DM with HTN (T2DM_HTN, n = 14) patients were selected based on diabetes criteria as described before, blood pressure levels ≥140/90 mm Hg. and previous history of diabetes and HTN. CADs (n = 20) patients were identified as single or multivessel disease and ≥40% stenosis at least in one major epicardial coronary artery by coronary angiography and absence of type 2 diabetes. CAD patients with T2DM (CAD_T2DM, n = 20) patients will be identified as type 2 diabetes in the presence of CADs as described in previous groups. Clinical or laboratory evidence of chronic disease such as liver failure, renal failure (plasma creatinine levels >1.5 mg/dl), type 1 diabetic, cancer, thyroid disease, and pregnant patients were excluded from the study.

CAD patients were identified in the Cardiac Catheterization Unit of Mediciti Hospital. After coronary angiogram, all patients were evaluated by cardiologists in the inpatient setting. If patients were found to have any evidence of CAD, demographic, clinical, and angiographic data were collected from all CAD patients. Fasting sample was collected prior to the percutaneous coronary intervention or coronary artery bypass graft.

Sample collection process

Clinical histories, demographics, and physical examination including anthropometry measurements were collected before the blood collection from the patient. Blood samples were drawn to the BD® EDTA Vacutainer tube and BD® Vacutainer Red color-coded tubes and then centrifuged at 2500 g for 15 min at 4°C within 30 min of collection. The plasma and serum samples were transferred to 1.2 ml cryovials by making different aliquots and stored at −80°C until analysis.

Anthropometric measurement and biochemical parameters

Height and weight were obtained by using standardized techniques as described previously. [2] The body mass index (BMI) was calculated as the weight in kilograms divided by the square of the height in meters (weight [kg]/height [m 2 ]). FBS levels were measured by the FreeStyle optimum glucometer (Abbott Diabetes Care, Australia). HbA1c levels were measured by the Bayer A1C Now + Multi-Test A1C System (Catalog Number 08842610). Creatinine (Siemens Number DF33A) and uric acid (Siemens Number BA4007) were measured by Siemens automated analyzer (Dimension Xpand + ).

Plasma growth differentiation factor-11 measurement

GDF-11 levels were determined in human plasma by using a sandwich ELISA kit purchased form mybiosource (Cat: MBS164794) with an intraassay coefficient variation (CV) <10% and interassay CV <12%. The GDF-11 assay was performed according to manufacturer's instructions. The assay measurement range was 10-3000 ng/L. The absorbance of the solution was read on a plate reader at 450 nm using BioTek Microplate Reader.

Statistical analysis

Normally distributed variables data were expressed as mean ± standard error of the mean and those that were not normally distributed (determined using Kolmogorov-Smirnov test) were expressed as median ± interquartile range. Kruskal-Wallis test followed by Dunn's multiple comparison analysis was used to find the significance in both the diseased groups with CT. The significance was set to P < 0.05, unless otherwise mentioned. The Spearman rank correlation was used to assess the correlation of GDF-11 levels with FBS, glycated hemoglobin (HbA1c), age, and BMI. Kruskal-Wallis analysis done by GraphPad Prism version 5.01 (GraphPad Software, Inc., La Jolla, CA) and correlation analysis were performed by the SigmaPlot version 11.0 (Systat Software, Inc, San Jose, CA).


  Results Top


Growth differentiation factor-11 levels in control, type 2 diabetes mellitus, and type 2 diabetes mellitus with hypertension subjects

GDF-11 levels were measured in CT, T2DM, and T2DM_HTN subjects [Table 1]. We found that GDF-11 levels were significantly (P < 0.05) decreased in T2DM (294.0 ng/L {272.7-331.3}) and T2DM_HTN (288.0 ng/L {259.0-460.0}) as compared with CT (439.3 ng/L {378.0-478.0}) subjects [Figure 1]a.
Figure 1: (a) Plasma growth differentiation factor-11 concentrations in control, diabetes and diabetes with hypertensive subjects. Data were represented as a box (median [interquartile range]) and whisker plots. **P < 0.001 versus control subjects, **P < 0.0.1,*P < 0.05 versus control subjects. (b) Plasma growth differentiation factor-11 concentrations in control, coronary artery disease and coronary artery disease with diabetes subjects. Data were represented as a box (median [interquartile range]) and whisker plots. *P < 0.05 versus control subjects.

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Table 1: Clinical and biochemical characteristics of study groups

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Growth differentiation factor-11 levels in control, coronary artery disease and type 2 diabetes mellitus with coronary artery disease subjects

We found that GDF-11 levels were significantly (P < 0.05) decreased in CAD (294.0 ng/L {272.7-331.3}) and T2DM_CAD (288.0 ng/L {259.0-460.0}) as compared with CT (493.3 ng/L {378.0-478.0}) subjects [Figure 1]b.

Growth differentiation factor-11 levels based on duration of diabetes

All the diabetic subjects from T2DM, T2DM_HTN, and T2DM_CAD groups were further divided into two groups based on duration of diabetes, i.e., "below 5 years" and "above 5 years." We did not find any significant (P = 0.9789) change in the plasma GDF-11 levels in diabetic duration between "below 5 years" (330.7 ng/L {289.3-466.7}) and "above 5 years" (331.3 ng/L {285.0-414.0}) [Figure 2]a.
Figure 2: (a) Human plasma growth differentiation factor-11 levels in two group of patients having diabetic duration below 5 years and above 5 years. Data were represented as box (median [interquartile range]) and whisker plots. (b) Human plasma growth differentiation factor-11 levels in two group of patients based on gender male and female. Data were represented as box (median [interquartile range]) and whisker plots.

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Growth differentiation factor-11 levels based on gender

GDF-11 levels in all the subjects from CT, T2DM, T2DM_HTN, CAD, and T2DM_CAD groups were further divided into male and female. We did not find any significant (P = 0.7657) change in the plasma GDF-11 levels in male (341.3 ng/L {304.0-438.7}) and female (363.7 ng/L {299.7-451.3}) subjects [Figure 2]b.

Correlation of plasma growth differentiation factor-11 levels with age, body mass index, fasting blood glucose, and hemoglobin A1c

Higher GDF-11 levels were negatively correlated with age (r = −0.286, P < 0.05) and we did not found any correlation with BMI (r = 0.0490, P = 0.698) [Figure 3]a and b. We also did not found any correlation of GDF-11 with FBS (r = −0.208, P < 0.0823) and HbA1c (r = −0.140, P < 0.0238) [Figure 3]c and d.
Figure 3: Scatter plots representing the relationship between (a) growth differentiation factor-11 and age (b) growth differentiation factor-11 and body mass index (c) growth differentiation factor-11 and fasting blood glucose, and (d) growth differentiation factor-11 and hemoglobin A1c.

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  Discussion Top


Previous scientific literature claimed that GDF11 is an anti-aging factor. Fadini et al. in 2015 showed that circulating GDF-11 levels were decreased with age. [7] Peripheral supplementation of GDF-11 protein in mice attenuated the age-related dysfunction of skeletal muscle. [8] In the recent years, researchers focused their interest on circulatory GDF-11 levels in heart diseases. GDF-11 levels reversed the age-related hypertrophy heart into a young heart. [6] GDF-11 is also an essential factor to regenerate pancreatic islets in diabetic patients. [9] Though there are few studies which correlate the plasma GDF-11 levels with aging and cardiovascular disease, there is no study to measure circulatory GDF-11 levels in diabetic patients associated with cardiovascular complication.

In the present study, GDF-11 levels were significantly decreased in type 2 diabetes, CAD, T2DM_HTN, and T2DM_CAD patients as compared with the CT subjects. Recently, Fadini et al. reported for the 1 st time that circulatory GDF-11 concentration decreases progressively with age in individuals without diabetes, especially when free from cardiovascular disease. [8] It was also reported that patients with higher incidence of cardiovascular disease show reduced levels of GDF-11 levels in the circulation. [7]

Similar to previous studies, [6],[7],[8] our data also showed that plasma GDF-11 concentrations decline with age in individuals with and without diabetes and cardiovascular disorder. Surprisingly, a previous study showed that the above correlation was completely lost in case of type 2 diabetic patients. [7] Our data also revealed that the levels of GDF-11 were not altered due to the duration of diabetes. When we did a correlation analysis to find the association of plasma GDF-11 levels with FBS level and glycated hemoglobin, we did not find any correlation. This indicates that the decrease in the levels of plasma GDF-11 is not specific for diabetes and not specific for gender differences. We have also shown the decrease of plasma GDF-11 levels in diabetes along with cardiovascular complications such as CAD and HTN. Patients with only CAD also showed decreased plasma GDF-11 levels. Although the mechanism is not clear, our findings may reflect that vascular dysfunction due to T2DM or CAD may be responsible for decreased plasma GDF-15 levels. It could be possible that accelerated aging due to vascular complication in type 2 diabetes, HTN, and CAD may be responsible for the decrease in plasma GDF-11 levels. Thus, administration of GDF-11 could be helpful to reduce the above complications. However, the plasma GDF-11 levels with age and disease condition are controversial. Egerman et al. in his study showed that increased GDF-11 protein levels were observed with age in rat skeletal muscle. However, serum GDF-11 levels in rat and human were not significantly increased. [10] It could be possible that the alteration of GDF-11 in skeletal muscle is different than plasma or other tissues. In contrast, Poggioli et al. explained that there is an age-dependent decline in GDF-11 levels in multiple mammalian species such as mice, rats, horses, and sheep. They also showed that exogenous GDF-11 administration rapidly activates SMAD signaling to reduce cardiomyocyte size. [11] This property of reducing cardiomyocytes can be useful against cardiac hypertrophy. Two more recent studies supported the above statement. Heidecker et al. showed that the low levels of GDF-11 and high levels of its inhibitor follistatin-like 3 are associated with adverse cardiovascular outcomes in humans. [12] Similarly, Olson et al. reported that high levels of GDF-11 are associated with lower prevalence of left ventricular hypertrophy. [13]

Though GDF-11 is explored as a target of anti-aging therapies, our data provide evidence that GDF-11 therapy may also be applicable for diabetes and CAD. Previously, it was shown that GDF-11 prevented cardiac hypertrophy induced by age but not by pressure overload. [6] It could be possible that GDF-11 therapy would be beneficial for diseases associated with age, such as diabetes, HTN, heart, lung, and kidney disease. Therefore, finding the regulation of GDF-11 in diabetes and cardiovascular disease conditions needs to be explored. Although the current study is a pilot study and number is very small, all groups were well characterized and matched, and all results are statistically analyzed. However, this is the very first investigation of plasma GDF-11 concentrations in diabetic patients and the first evidence that GDF-11 declines with diabetes and diabetes with cardiovascular complication.


  Conclusion Top


This study reported lower GDF-11 levels in diabetic subjects with or without cardiovascular complication. However, we did not find a significant correlation between GDF-11 levels with FBS and HbA1C levels. Further study is required to understand whether the decreased GDF-11 levels are due to disease pathogenesis or age-related factors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
International Diabetes Federation. Diabetes Atlas. 6 th ed. Avaialable from: https://www.idf.org/sites/default/files/Atlas-poster-2014_EN.pdf. [Last accessed on 2016 Jan 30].  Back to cited text no. 1
    
2.
Adela R, Nethi SK, Bagul PK, Barui AK, Mattapally S, Kuncha M, et al. Hyperglycaemia enhances nitric oxide production in diabetes: A study from South Indian patients. PLoS One 2015;10:e0125270.  Back to cited text no. 2
    
3.
Yamamoto S, Kon V. Mechanisms for increased cardiovascular disease in chronic kidney dysfunction. Curr Opin Nephrol Hypertens 2009;18:181-8.  Back to cited text no. 3
    
4.
Martín-Timón I, Sevillano-Collantes C, Segura-Galindo A, Del Cañizo-Gómez FJ. Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength? World J Diabetes 2014;5:444-70.  Back to cited text no. 4
    
5.
McPherron AC. Metabolic functions of myostatin and GDF-11. Immunol Endocr Metab Agents Med Chem 2010;10:217-31.  Back to cited text no. 5
    
6.
Loffredo FS, Steinhauser ML, Jay SM, Gannon J, Pancoast JR, Yalamanchi P, et al. Growth differentiation factor 11 is a circulating factor that reverses age-related cardiac hypertrophy. Cell 2013;153:828-39.  Back to cited text no. 6
    
7.
Fadini GP, Menegazzo L, Bonora BM, Mazzucato M, Persano S, Vigili de Kreutzenberg S, et al. Effects of age, diabetes, and vascular disease on growth differentiation factor 11: First-in-human study. Diabetes Care 2015;38:e118-9.  Back to cited text no. 7
    
8.
Sinha M, Jang YC, Oh J, Khong D, Wu EY, Manohar R, et al. Restoring systemic GDF11 levels reverses age-related dysfunction in mouse skeletal muscle. Science 2014;344:649-52.  Back to cited text no. 8
    
9.
Harmon EB, Apelqvist AA, Smart NG, Gu X, Osborne DH, Kim SK. GDF11 modulates NGN3+ islet progenitor cell number and promotes beta-cell differentiation in pancreas development. Development 2004;131:6163-74.  Back to cited text no. 9
    
10.
Egerman MA, Cadena SM, Gilbert JA, Meyer A, Nelson HN, Swalley SE, et al. GDF11 increases with age and inhibits skeletal muscle regeneration. Cell Metab 2015;22:164-74.  Back to cited text no. 10
    
11.
Poggioli T, Vujic A, Yang P, Macias-Trevino C, Uygur AN, Loffredo FS, et al. Circulating growth differentiation factor 11/8 levels decline with age. Circ Res 2015. pii: CIRCRESAHA.115.307521.  Back to cited text no. 11
    
12.
Heidecker B, Olson K, Beatty A, Dubin R, Kato S, Lawn R, et al. Low levels of growth differentiation factor 11 and high levels of its inhibitor follistatin-like 3 are associated with adverse cardiovascular outcomes in humans. JACC 2015;65 Suppl 10:A999.  Back to cited text no. 12
    
13.
Olson K, Beatty A, Heidecker B, Regan M, Whooley M, Ganz P. High levels of growth differentiation factor 11 are associated with lower prevalence of left ventricular hypertrophy: Data from the heart and soul study. JACC 2014;63:A780.  Back to cited text no. 13
    


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