THE MACROPHAGE ACTIVATION MARKER SOLUBLE CD 163 IS

THE MACROPHAGE ACTIVATION MARKER SOLUBLE CD 163 IS ASSOCIATED TO DIABETIC NEUROPATHY Signe Toft Andersen MD, Ph. D fellow Section of General Practice Department of Public Health Aarhus University

Background • Low-grade inflammation is associated to obesity and type 2 diabetes • Previous studies show an association between low-grade inflammation and diabetic neuropathy 1 • Low-grade inflammation in adipose tissue is characterised by a high number of activated macrophages 1 The MONICA/KORA Study Group

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Background • The macrophage-derived biomarker soluble CD 163 is secreted to the blood when the macrophages are activated • s. CD 163 is associated with obesity, insulin resistance and it predicts the development of type 2 diabetes in the general population 2 -5 • A trend towards higher s. CD 163 levels in both serum and cerebrospinal fluid was found in a pilot study of diabetic polyneuropathy in patients with type 2 diabetes 6 2 Axelsson J. Am J Kidney Dis 2006 Dec; 48(6): 916 -925. D. Eur J Clin Invest 2009 Aug; 39(8): 671 -679. 4 Shakeri-Manesch S. Int J Obes (Lond) 2009 Nov; 33(11): 1257 -1264. 5 Moller HJ et al. Clin Chem 2011 Feb; 57(2): 291 -297. 6 M. Kallestrup et al. Diab. Med 2014 Aug; 32, 54 -61. 3 Sporrer

Aim To investigate whether soluble CD 163 is associated with the presence of neuropathy among individuals with type 2 diabetes

Methods • Cross-sectional study on five year follow up on screen-detected type 2 diabetes patients from the ADDITION-DK trial 7 -8 • Diabetic polyneuropathy (DPN) was assessed by vibration perception threshold, using CASE IV • Cardiac autonomic neuropathy (CAN) was assessed using three standard tests (lying/standing, deep breathing and valsalva manoeuvre), using VAGUSTM 7 Sandbæk 8 Herman A et al; Diab Care 2014 Jul 37(7) WH et al; Diab Care 2015 Aug, 38(8)

• Five year follow up biobank serum analysed for s. CD 163 by ELISA • Logistic regression models with relevant adjustments.

Patient characteristics All, n 701 Demographic factors Age (years), median (IQR) Women, n (%) Diabetes duration (years) 64. 9 (64. 4; 65. 4) 271 (39) 5. 9 (5. 8; 6. 0) Clinical measurements BMI (kg/m 2), mean (95%CI) Systolic blood pressure(mm. Hg), median (IQR) 30. 7 (30. 3; 31. 1) 134 (132; 135) Blood measurements Hb. A 1 c (IFCC) (mmol/l), median(IQR) Hb. A 1 c (DCCT) (%), median (IQR) Ln s. CD 163, mean (95%CI) 46 (42; 51) 6. 4 (6. 0; 6. 9) 0. 77 (0. 74; 0. 80)

Results Diabetic polyneuropathy Odds ratios per doubling of s. CD 163 Adjustment DPN OR (95% CI) Age, sex 1. 72 (1. 14; 2. 62) Age, sex, BMI, Hb. A 1 c 1. 64 (1. 07; 2. 52) Age, sex, BMI, Hb. A 1 c, ACEi, insulin, metformin, statins, aspirin, systolic BP 1. 59 (1. 02; 2. 48) 9

Results Cardiac autonomic neuropathy Odds ratios per doubling of s. CD 163 Adjustment CAN early OR (95% CI) CAN manifest OR (95% CI) Age, sex 1. 28 (0. 90; 1. 84) 2. 41 (1. 44; 4. 02) Age, sex, BMI, Hb. A 1 c 1. 15 (0. 79; 1. 66) 2. 06 (1. 02; 3. 56) Age, sex, BMI, Hb. A 1 c, ACEi, insulin, metformin, statins, aspirins, systolic BP 1. 14 (0. 78; 1. 67) 2. 34 (1. 32; 4. 16) 10

Discussion • Screen-detected diabetes • Large cohort • Clinically usable measurements • Cross-sectional study

Conclusion Soluble CD 163 is associated to diabetic neuropathy. This indicates, that macrophage – related low grade inflammation, may play a role in the pathophysiology of diabetic neuropathy. Thanks to: Pia Deichgræber Daniel Witte Torsten Lauritzen Henning Andersen, Annelli Sandbæk Morten Charles

OR CAN any(181/678) CAN early (134/632) CAN manifest (47/545) Crude 1. 54 (1. 13; 2. 09) 1. 29 (0. 91; 1. 83) 2. 46 (1. 49; 4. 07) Age, sex 1. 53 (1. 11; 2. 10) 1. 29 (0. 90; 1. 84) 2. 41 (1. 44; 4. 02) + BMI 1. 43 (1. 03; 1. 97) 1. 17 (0. 81; 1. 70) 2. 35 (1. 39; 3. 96) + Hb. A 1 c 1. 33 (0. 97; 1. 87) 1. 15 (0. 79; 1. 66) 2. 06 (1. 20; 3. 56) + ACE inhib 1. 34 (0. 96; 1. 87) 1. 15 (0. 79; 1. 66) 2. 04 (1. 18; 3. 53) + Insulin 1. 34 (0. 96; 1. 87) 1. 15 (0. 79; 1. 70) 2. 06 (1. 20; 3. 61) + Metformin 1. 34 (0. 96; 1. 87) 1. 14 (0. 78; 1. 65) 2. 04 (1. 18; 3. 54) + Statin 1. 35 (0. 97; 1. 89) 1. 13 (0. 77; 1. 65) 2. 18 (1. 25; 3. 83) + Aspirin 1. 35 (0. 97; 1. 89) 1. 13 (0. 77; 1. 65) 2. 19 (1. 25; 3. 85) + Systolic BP 1. 37 (0. 98; 1. 93) 1. 14 (0. 78; 1. 67) 2. 34 (1. 32; 4. 16)

Patient characteristics CAN DPN 701 371 64. 9 (64. 4; 65. 4) 63. 6 (62. 9; 64. 3) 271 (39) 134 (36) 5. 9 (5. 8; 6. 0) 5. 3 (5. 2; 5. 5) 30. 7 (30. 3; 31. 1) 30. 7 (30. 2; 31. 1) Waist circumference (cm), mean (95%CI) 104 (103; 105) Systolic blood pressure(mm. Hg), median (IQR) 134 (132; 135) 135 (134; 137) Diastolic blood pressure(mm. Hg), median (IQR) 84 (83; 85) 85 (84; 86) 46 (42; 51) 45 (41; 51) 4. 3 (4. 2; 4. 3) 4. 4 (4. 3; 4. 5) Micro albuminuria (20 -200) (mg/l), n (%) 175 (25) 104 (28) Macro albuminuria (20 -200) (mg/l), n (%) 35 (5) 26 (7) 0. 77 (0. 74; 0. 80) 0. 79 (0. 74; 0. 83) 209 (30) 108 (29) All, n Demographic factors Age (years), median (IQR) Women, n (%) Diabetes duration (years) Clinical measurements BMI (kg/m 2), mean (95%CI) Blood measurements Hb. A 1 c (IFCC) (mmol/l), median(25 th, 75 th percentile) Cholesterol (total) (mmol/l) Ln s. CD 163, mean (95%CI) Self-reported Smoking daily, n (%)

s. CD 163 median (mg/L) (IQR) No DPN (n=283) 2. 12 (1. 82; 2. 82) With DPN ( n=88) 2. 51 (1. 80; 5. 07) s. CD 163 median(mg/L) (IQR) No CAN (n=520) 2. 07 (1. 89; 2. 58) CAN early (n=134) 2. 18 (1. 87; 2. 85) CAN manifest (n=47) 2. 50 (1. 85; 5. 55) 16