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\def\RunningAuthor{Ramya S et al. }
\firstPage{3478}
\articleType{Original article}
\receivedDate{23 Apr 2020}
\acceptedDate{29 May 2020}
\revisedDate{24 May 2020}
\journalVolume{2020, 11}
\journalIssue{3}
\journalDoi{ijrps.v11i3.2494}
\copyrightYear{2020}
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\def\journalTitle{International Journal of Research in Pharmaceutical Sciences}

\title{Study of High sensitive C - reactive protein and Gamma-glutamyl transferase in Type 2 Diabetes Mellitus with Hypertension}
\author{Ramya~S\textsuperscript{*}\textsuperscript{1},  
            Sureka~Varalakshmi~V\textsuperscript{2},  
            Uma~Maheswari~K\textsuperscript{3}, 
            Chandan~Bala~R\textsuperscript{4}~\\[5pt]{\textsuperscript{1}Department of Physiology, Faculty of Allied Health Sciences, Dr MGR Educational University and Research Institute, Maduravoyal, Chennai, Tamil Nadu, India}~\\{\textsuperscript{2}Department of Physiology, ACS Medical college and Hospital, Dr MGR Educational University and Research Institute, Maduravoyal, Chennai, Tamil Nadu, India}~\\{\textsuperscript{3}Department of Physiology, Karpaga Vinayaga Institute of Medical sciences, Chengalpet, Chennai, Tamil Nadu, India}~\\{\textsuperscript{4}Department of Renal Dialysis Technology, Faculty of Allied Health Sciences, Dr MGR Educational University and Research Institute, Maduravoyal, Chennai, Tamil Nadu, India}}

\begin{abstract}
C-reactive protein (CRP), produced by the hepatocytes is a primary inflammatory marker of T2DM. Higher levels of gamma-glutamyl transferase enzyme (GGT) and Hs CRP (High sensitive CRP)are associated  with the complication of poor glycemic control. This study was aimed to find the association of Hs CRP and GGT for cardiovascular risk factors in Type 2 diabetes mellitus (T2DM) and Hypertension in the suburbs of Chennai. This study includes 57 subjects with T2DM and Hypertension (Group A) and 62 subjects with T2DM (Group B) within the age group of 40-60 years. FBS, HbA1C, Hs CRP, GGT and blood pressure were determined. Mean values of FBS, blood HbA1C, Hs CRP and GGT were significantly higher among participants of Group A than Group B. Significant difference of FBS, HbA1C were found between the two groups. In contrast, no significant difference of GGT was found between the groups. Differences were considered statistically significant at two-sided \textit{P} \textless\ 0.05. Within the group, Hs CRP shows the significance and positive correlation with FBS, SBP and DBP. Still, GGT does not show any significance in Group A. In contrast, in Group B, both Hs CRP and GGT shows the importance and positive correlation with FBS and HbA1C. It is concluded that high levels of HsCRP are associated with T2DM and Hypertension, indicating increased cardiovascular risk, and it should be included in regular monitoring of type-2 diabetic patients.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}T2DM,\newline HYPERTENSION,\newline Hs CRP,\newline GGT.CARDIOVASCULAR RISK FACTORS
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Ramya~S~\\ Phone:\ + 91-9123532254~\\  Email:\ ramyabalaji2705@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
        \textsc{DOI:}\ \href{https://doi.org/10.26452/\@journalDoi}{\textcolor{blue}{\underline{\smash{https://doi.org/10.26452/\@journalDoi}}}}\par%
        \vspace*{-11pt}\hrulefill\\{\fontsize{9.12}{10.12}\selectfont Production and Hosted by}\par{IJRPS |~\href{www.ijrps.com}{www.ijrps.com}}\par%
        \vspace*{-2pt}{\fontsize{9.12}{10.12}\selectfont\textcopyright\ \@copyrightYear\ $|$ All rights reserved.}\par%
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\section{Introduction}
Type 2 diabetes mellitus (T2DM) is a global issue, and it is associated with disturbances in protein, carbohydrate and lipid metabolism due to decreased uptake of glucose into muscle and adipose tissue resulting in tissue damage and chronic vascular complications \unskip~\citep{808515:19300981,808515:19300980}. Chronic low-grade inflammation with  increased production of inflammatory markers has been  attributed to the development of T2DM \unskip~\citep{808515:19300970}.

Various Prevalence studies have shown that Hypertension is common among patients with T2DM and depends on duration, age, sex, race, glycemic control, and the presence of kidney disease. Furthermore, Hypertension is a risk factor for atherosclerotic cardiovascular disease and microvascular complications. It is the leading cause of morbidity and mortality for individuals with  T2DMand is the most significant cause for the direct and indirect effects of diabetes. \unskip~\citep{808515:19300958,808515:19300961}\unskip~\citep{808515:19300973}.

C-reactive protein (CRP), produced by the hepatocytes, is considered to be a primary inflammatory marker of T2DM. It markedly increased in both inflammatory, infectious diseases and it is a potential marker of cardiovascular risk in patients with Hypertension.\unskip~\citep{808515:19300964,808515:19300979}. Serum CRP above 3.0 mg/L is regarded as a worse cardiovascular prognosis, and more than 50\% of deaths in diabetic patients are attributed to cardiovascular diseases \unskip~\citep{808515:19300978,808515:19300968}. Higher CRP can initiate atherosclerosis and clot  formation, so, therefore, it will be advantageous to reduce the plasma levels of CRP \unskip~\citep{808515:19300980}. This HsCRP is the most evaluated biomarker for cardiovascular disease (CVD) risk prediction and techniques are available that can detect CRP in a sensitivity range of 0.01 to 10 mg/ l. \unskip~\citep{808515:19300977,808515:19300972}.

Gamma-glutamyl transferase (GGT), an enzyme, produced in many tissues, mainly derived from the liver \unskip~\citep{808515:19300974}  and it is  needed to maintain the levels of reduced glutathione, a major antioxidant. Increase in the levels of gamma-glutamyl transferase is an indicator for oxidative stress \unskip~\citep{808515:19300960}  and this leads to chronic inflammation which enhances inflammatory response and associated with complications of poor glycemic control. Studies have already reported that there is an association of Hs CRP as an inflammatory marker and GGT as an oxidative marker in T2DM and Hypertension \unskip~\citep{808515:19300970,808515:19300964,808515:19300960}. Our objective was to study the association of Hs CRP and GGT for cardiovascular risk factors in T2DM and Hypertension in the suburbs of Chennai.
    
\section{STUDY SETTINGS}
\textbf{Materials and Methods}

This study was conducted for three months among Type 2 Diabetes mellitus and Hypertensive patients who visited the General Medicine Department, ACS hospital, Chennai, institutional ethics committee approved the study protocol.


\begin{table*}[!htbp]
\caption{\boldmath {Gender Distribution} }
\label{tw-4565abe76107}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.11849999999999998\linewidth-2\tabcolsep}p{\dimexpr.11190000000000001\linewidth-2\tabcolsep}p{\dimexpr.1934\linewidth-2\tabcolsep}p{\dimexpr.22019999999999996\linewidth-2\tabcolsep}p{\dimexpr.1734\linewidth-2\tabcolsep}p{\dimexpr.1826\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{3}{p{\dimexpr(.42379999999999995\linewidth-2\tabcolsep)}}{} & \multicolumn{2}{p{\dimexpr(.3936\linewidth-2\tabcolsep)}}{\cAlignHack GROUP} & \cAlignHack Total\\
\rowcolor{kwdboxcolor} &  &  & \cAlignHack GROUP A - DIABETIC WITH HYPERTENSION & \cAlignHack GROUP B -  DIABETIC & \cAlignHack \\
\tblmidrule 
GENDER &
  MALE &
  Count &
  \cAlignHack 30 &
  \cAlignHack 26 &
  \cAlignHack 56\\
 &
   &
  \% within GROUP &
  \cAlignHack 52.6\% &
  \cAlignHack 41.9\% &
  \cAlignHack 47.1\%\\
 &
  FEMALE &
  Count &
  \cAlignHack 27 &
  \cAlignHack 36 &
  \cAlignHack 63\\
 &
   &
  \% within GROUP &
  \cAlignHack 47.4\% &
  \cAlignHack 58.1\% &
  \cAlignHack 52.9\%\\
TOTAL &
   &
  Count &
  \cAlignHack 57 &
  \cAlignHack 62 &
  \cAlignHack 119\\
 &
   &
  \% within GROUP &
  \cAlignHack 100.0\% &
  \cAlignHack 100.0\% &
  \cAlignHack 100.0\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Mean \ensuremath{\pm} standard deviation of FBS, HbA1C, Hs CRP, and GGT} }
\label{tw-63d4dc1d7c0c}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.10110000000000001\linewidth-2\tabcolsep}p{\dimexpr.26439999999999994\linewidth-2\tabcolsep}p{\dimexpr.09579999999999998\linewidth-2\tabcolsep}p{\dimexpr.1466\linewidth-2\tabcolsep}p{\dimexpr.2015\linewidth-2\tabcolsep}p{\dimexpr.19060000000000002\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{2}{p{\dimexpr(.3655\linewidth-2\tabcolsep)}}{\cAlignHack GROUP} & N & Mean & Std. Devaiation & Sig\\
\tblmidrule 
FBS &
  GROUP A - DIABETIC WITH HYPERTENSION &
  57 &
  201.9154 &
  78.43414 &
  \\
 &
  GROUP B -  DIABETIC &
  62 &
  172.1811 &
  68.38599 &
  0.029*\\
HbA1C &
  GROUP A - DIABETIC WITH HYPERTENSION &
  57 &
  9.000 &
  2.1335 &
  \\
 &
  GROUP B -  DIABETIC &
  62 &
  7.568 &
  2.3788 &
  0.001*\\
Hs-CRP &
  GROUP A - DIABETIC WITH HYPERTENSION &
  57 &
  7.347 &
  5.5656 &
  \\
 &
  GROUP B -  DIABETIC &
  62 &
  6.145 &
  6.1944 &
  0.050*\\
GGT &
  GROUP A - DIABETIC WITH HYPERTENSION &
  57 &
  35.212 &
  15.1873 &
  \\
 &
  GROUP B -  DIABETIC &
  62 &
  33.095 &
  23.9820 &
  0.101\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{*p\textless\ 0.05, *** p\textless\ 0.001}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Group A -Hs CRP Correlation with FBS, HbA1C, GGT, SBP, DBP} }
\label{tw-8f327d18742a}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.27110000000000003\linewidth-2\tabcolsep}p{\dimexpr.1011\linewidth-2\tabcolsep}p{\dimexpr.15190000000000001\linewidth-2\tabcolsep}p{\dimexpr.1641\linewidth-2\tabcolsep}p{\dimexpr.14129999999999999\linewidth-2\tabcolsep}p{\dimexpr.1705\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} &   FBS & HbA1C & GGT & SBP & DBP\\
\tblmidrule 
Correlation Coefficient &
  .179* &
  .028 &
  .162 &
  .341*** &
  .325**\\
Sig. (2-tailed) &
  .050 &
  .762 &
  .078 &
  .000 &
  .001\\
N &
  57 &
  57 &
  57 &
  57 &
  57\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{*p\textless\ 0.05, *** p \textless\ 0.001}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Group A - GGT Correlation with Hs CRP, FBS, HbA1C, SBP, DBP} }
\label{tw-d6d119f89b71}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.26040000000000003\linewidth-2\tabcolsep}p{\dimexpr.11979999999999999\linewidth-2\tabcolsep}p{\dimexpr.13990000000000002\linewidth-2\tabcolsep}p{\dimexpr.13729999999999999\linewidth-2\tabcolsep}p{\dimexpr.1587\linewidth-2\tabcolsep}p{\dimexpr.1839\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} & HsCRP & FBS & HbA1C & SBP & DBP\\
\tblmidrule 
Correlation Coefficient &
  .162 &
  .118 &
  .083 &
  .012 &
  .074\\
Sig. (2-tailed) &
  .078 &
  .195 &
  .367 &
  .901 &
  .423\\
N &
  57 &
  57 &
  57 &
  57 &
  57\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{*p\textless\ 0.05, *** p \textless\ 0.001}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Group B Correlation of Hs CRP with FBS, HbA1C, GGT} }
\label{tw-eff0d2fab9a4}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3985999999999999\linewidth-2\tabcolsep}p{\dimexpr.1818\linewidth-2\tabcolsep}p{\dimexpr.19970000000000002\linewidth-2\tabcolsep}p{\dimexpr.21990000000000002\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} & FBS & HbA1C & GGT\\
\tblmidrule 
Correlation Coefficient &
  .247** &
  .240** &
  .037\\
Sig. (2-tailed) &
  .005 &
  .006 &
  .675\\
N &
  62 &
  62 &
  62\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{**p{\textless}0.01}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Group B- Correlation of GGT with Hs-CRP, FBS and HbA1C} }
\label{tw-71cddc6b23fe}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.4087\linewidth-2\tabcolsep}p{\dimexpr.1697\linewidth-2\tabcolsep}p{\dimexpr.1636\linewidth-2\tabcolsep}p{\dimexpr.258\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} & Hs-CRP & FBS & HbA1C\\
\tblmidrule 
Correlation Coefficient &
  .037 &
  .183* &
  .210\ensuremath{^{**}}\\
Sig. (2-tailed) &
  .675 &
  .037 &
  .017\\
N &
  62 &
  62 &
  62\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{*p{\textless}0.05, ** p\textless\ 0.01}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\bgroup
\fixFloatSize{images/510592d8-506a-4f03-822c-43eb5a593b33-upicture1.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/510592d8-506a-4f03-822c-43eb5a593b33-upicture1.png}{\includegraphics{images/510592d8-506a-4f03-822c-43eb5a593b33-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Graphical representation of mean \ensuremath{\pm} standard deviation (FBS)}}
\label{f-218cd709c295}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/acbe67bd-8fc6-4052-bcbb-5b89c9debe1d-upicture2.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/acbe67bd-8fc6-4052-bcbb-5b89c9debe1d-upicture2.png}{\includegraphics{images/acbe67bd-8fc6-4052-bcbb-5b89c9debe1d-upicture2.png}}{}
\makeatother 
\caption{\boldmath {Graphical representation of mean \ensuremath{\pm} standard deviation (HbA1C)}}
\label{f-22317248078e}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/fbc02fe4-d5a7-4330-9706-1eeb9353b6a1-upicture3.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/fbc02fe4-d5a7-4330-9706-1eeb9353b6a1-upicture3.png}{\includegraphics{images/fbc02fe4-d5a7-4330-9706-1eeb9353b6a1-upicture3.png}}{}
\makeatother 
\caption{\boldmath {Graphical representation of mean \ensuremath{\pm} standard deviation (Hs-CRP)}}
\label{f-3fe1a9a0b6ed}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/7dcfeaee-48f7-4ab6-b596-8f1585605bed-upicture4.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/7dcfeaee-48f7-4ab6-b596-8f1585605bed-upicture4.png}{\includegraphics{images/7dcfeaee-48f7-4ab6-b596-8f1585605bed-upicture4.png}}{}
\makeatother 
\caption{\boldmath {Graphical representation of mean \ensuremath{\pm} standard deviation (GGT)}}
\label{f-ea5bfe13072e}
\end{figure}
\egroup
\textbf{Inclusion criteria}

The study population included 119 patients with Type2 diabetes mellitus. The age group of the study participants was 40-60 years, consists of 57 subjects with T2DM and Hypertension (Group A)and62 subjects with T2DM (GroupB). All the participants were provided with an information sheet, and informed written consent was obtained. A structured questionnaire including the demographic details, present and past medical history, surgical history, any recent infections, drug history and intake of steroids was obtained.

\textbf{Exclusion criteria}

Smokers, alcoholics and patients with chronic liver diseases, renal diseases, recent surgeries were excluded from the study.

\textbf{Methodology}

The recruited subjects were asked to visit the hospital after an overnight fast of 10 {\textendash} 12 hours, 5mlof the Blood sample was collected in EDTA tube. It was used to estimate the fasting blood glucose by glucose oxidase peroxidase enzymatic endpoint method, HbA1c by resin exchange method, Hs CRP by immunoturbidimetry \unskip~\citep{808515:19300959} and GGT by modified IFCC method \unskip~\citep{808515:19300971}. Liver enzymes, lipid profile, renal function test and blood parameters were also determined by using standard laboratory procedures.

Systolic pressure and diastolic pressure were determined by using digital sphygmomanometer in the sitting position on the left arm. Three recordings were taken after at least 10{\textendash}15 min of rest. Then, the average of the three readings was obtained.
    
\section{RESULTS}
A total of 119 subjects between the ages of 40 {\textendash}60 years, and it includes 56 males and 63 female Table~\ref{tw-4565abe76107}. Data were presented as mean \ensuremath{\pm} standard deviation, differences among groups were calculated using t-test or Mann-Whitney test for parametric and nonparametric variables, respectively. Chi-square test was used. Mean values of FBS, blood HbA1C, Hs CRP and GGT were significantly higher among participants of Group A than Group B (Figure~\ref{f-218cd709c295}, Figure~\ref{f-22317248078e}, Figure~\ref{f-3fe1a9a0b6ed} and Figure~\ref{f-ea5bfe13072e}). A significant difference of FBS, HbA1C were found between the two groups, whereas no significant difference of GGT was found between the groups Table~\ref{tw-63d4dc1d7c0c}. Differences were considered statistically significant at two-sided \textit{P} \textless\ 0.05. Statistical analysis was performed using Statistical Package for the SPSS 17  version.

The correlation analysis was performed by Kendall's tau method for nonparametric variables respectively. Hs CRP shows significance and positively correlated with FBS, SBP and DBP but GGT does not show any significance in Group A, whereas in Group B both Hs CRP and GGT shows significance and positive correlation with FBS and HbA1C. (Table~\ref{tw-8f327d18742a}, Table~\ref{tw-d6d119f89b71}, Table~\ref{tw-eff0d2fab9a4} and Table~\ref{tw-71cddc6b23fe}).
    
\section{Discussion}
In our study serum, Hs CRP Levels are significantly associated with T2DM in both Group A (T2DM and Hypertension) and Group B (T2DM) and shows a positive correlation with FBS, HbA1C, SBP and DBP.  It was found that diabetic patients had a significantly elevated median of HbA1c, HsCRP and GGT as compared to controls \unskip~\citep{808515:19300969,808515:19300967}. \unskip~\cite{808515:19300965} shows that high levels of Hs-CRP and GGT are associated with Hypertension and poor glycemic control, indicating increased cardiovascular risk. There was an elevated and significantly higher Hs CRP among hypertensive when compared with Normotensive, and a similar correlation was found in HsCRP with pre-hypertension with age-matched groups \unskip~\citep{808515:19300976}. Elevated HsCRP and Hypertensionleads to Increased cardiovascular risk. The combination of greatly increases the \unskip~\citep{808515:19300966,808515:19300962}. Similar results were found in Group A of our study where Hs CRP shows the significance and positively correlated with SBP and DBP.

On analysis of GGT values, there was a mean difference of GGT between the groups (Group A 35.2U/I and Group B 33U/I), but it does not show any significant differences in-between the Groups. Low-grade hepatic inflammation induced by hepatic steatosis results in increased production of GGT; this could cause oxidative stress. This increase in  GGT synthesis can lead to over utilization of glutathione. \unskip~\citep{808515:19300975}. Similarly, in this study also Hs CRP and GGT were significant and shows a positive correlation with FBS and HbA1C in Group B. Elevated serum GGT could be a cardiometabolic risk factor either as a mediator of low-grade systemic inflammation and oxidative stress results from elevated serum GGT could be a cardiometabolic risk factor due to transport of glutathione into the cells. \unskip~\citep{808515:19300963}. Statistical significance and correlation were not found for GGT   within the various variables of  T2DM and Hypertension.
    
\section{Conclusion}
It is concluded that increased levels of hs-CRP are associated in T2DM with Hypertension, which could lead to increased cardiovascular risk, and it should be included in the regular monitoring of diabetic patients. Further studies are needed to find the effect of GGT in diabetic and hypertension subjects using a bigger sample size.
    
\section{Abbreviations}
T2DM- Type 2 Diabetes Mellitus, FBS-Fasting blood sugar HbA1C {\textendash}Glycated haemoglobin, Hs CRP-High sensitive C-Reactive protein, GGT-Gamma-glutamyl Transferase, SBP-Systolic Blood Pressure, DBP-Diastolic blood pressure.
    
\section{Acknowledgement}
Thanks to all the subjects towards their contribution to this study.

\textbf{Funding Support}

There is no funding from any external sources.

\textbf{Conflict of Interest}

There is no conflict of interest among authors.
    

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