**2. Diabetic nephropathy**

#### **2.1 Research methods and study design**

This study is an observational study with a cross-sectional comparative study design. This study was conducted at three hospitals in Jambi Province, Indonesia, with a total sample of 60 people. Control this research is Diabetes Mellitus type 2 group without Diabetic Nephropathy patients diagnosed with type-2 Diabetes without impaired kidney function and two times the value examination, Albumin to Creatinine Ratio (ACR) <30 mg/g for 2–3 months mild/normal albuminuria levels. Diabetes mellitus with nephropathy diabetes has hemodialysis, decreased Glomerular Filtration Rate, and or persistent albuminuria.

The inclusion criteria in this study were over 20 years ago, had suffered from type-2 Diabetes for at least five years, had a medical record with routine laboratory examination data in the form of blood sugar and urinalysis, assessment of kidney function (urea levels and creatinine), ultrasound, and ACR examination at least two times in 3–6 months and were willing to participate in this study by signing the informed consent. Exclusion criteria in this study were patients with urinary tract infections, other kidney diseases such as kidney stones and kidney cysts (from medical records), pregnancy, and patients with autoimmune or immunocompromised diseases.

ELMO-1 and MMP-9 levels were examined using ELISA (Enzyme-linked Immunosorbent Assay). Sample this research from blood plasma; then carried out according to the ELISA kit instructions for human ELMO-1 from MyBioSource catalog number MBS9321199 and MMP-9 from RayBioR catalog number ELH-MMP9.

This research has passed ethics from the Faculty of Medicine's research ethics commission team, Andalas University, and received ethical clearance number 706/KEP/FK/2019. Data analysis used a t-test because the data distribution was normal.

*Influence Engulfment Cell Motility-1 (ELMO-1) Protein and Matrix Metalloproteases-9… DOI: http://dx.doi.org/10.5772/intechopen.98192*

### **2.2 Results**

## *2.2.1 Basic characteristics of research subjects*

The basic characteristics of the assessed research subjects are shown in **Table 1**. Based on the essential characteristics of research subjects, it is known that Type-2 Diabetes with Diabetic Nephropathy has systolic and diastolic blood pressure, fasting blood sugar levels, and blood sugar levels 2 hours after eating. Albumin to creatinine ratio (ACR) in urine is higher than non-diabetic nephropathy. And statistically significant. In contrast, the mean value of glomerular filtration rate (GFR) was lower in the Diabetic Nephropathy group and statistically significant.

### *2.2.2 Levels of plasma protein ELMO-1 and MMP-9*

ELMO-1 and MMP-9 protein levels between DM subjects with Diabetic Nephropathy and without Diabetic Nephropathy are presented in **Tables 2** and **3** below.

**Table 2** shows that the mean ELMO-1 plasma value was higher in the DM group with Diabetic Nephropathy and without Diabetic Nephropathy group, statistically significant (p < 0.05).

**Table 3** shows that the mean plasma MMP-9 value was higher in the DM group with Diabetic Nephropathy than the without Diabetic Nephropathy group. And this difference was statistically significant (p = 0.032).

#### **2.3 Discussion**

The Genome-Wide Association Studies in Japan in 2005 identified the part of Engulfment and cell motility-1 (ELMO-1) in diabetic nephropathy. A study using


#### **Table 1.**

*Basic characteristics of research subjects.*


#### **Table 2.**

*ELMO-1 plasma levels between DM subjects with diabetic nephropathy and without diabetic nephropathy.*


#### **Table 3.**

*Plasma levels of MMP-9 between DM subjects with ND and non-ND.*

diabetic rats found that increased ELMO-1 protein levels were in diabetic kidneys compared to normal rats [9]. Functions ELMO-1 proteins were phagocytosis of apoptotic cells and cell motility in mammals [7]. Failure to clear apoptotic cells can cause inflammation and autoimmunity damage [8].

In this study, there was no difference in age and gender. Because due to the nine samples' consecutive sampling technique, where there is a balanced age range between the case and control groups. There is a difference in age characteristics in the literature, stating that diabetic nephropathy is more common in old age. Because it is associated with a longer duration of disease in old age, and diabetes mellitus has been more than five years [11].

Based on patient characteristics, it is known that the mean value of glomerular filtration rate is lower in the diabetic group with Diabetic Nephropathy compared without Diabetic Nephropathy. This situation is because, in diabetic nephropathy, there is a more severe decrease in kidney function. The reduction in glomerular hydration rate in type-II DM patients is proportional to the degree of albuminuria. The more significant the reduction in glomerular filtration rate, the heavier the degree of albuminuria [11, 12].

In this study, the Diabetic Nephropathy group had a higher average blood pressure than non-ND Diabetes Mellitus. Blood pressure decreases the rate of glomerular psychopathy and albuminuria in Diabetic Nephropathy [13, 14]. The elevated blood pressure in diabetic nephropathy occurred due to disruption of the Renin-Angiotensin-Aldosterone System (RAA's) and decreased renal blood flow [13, 14].

In the study, ELMO-1 protein levels were higher in patients with diabetic nephropathy. ELMO-1 protein contributed to chronic glomerular injury progression through the increased accumulation of the extracellular matrix and decreased cell adhesion [14]. The extracellular matrix accumulation causes thickening of the glomerulus and renal tubules, a marker of advanced diabetes nephropathy [13].

This study reported higher plasma ELMO-1 and MMP-9 levels in diabetic patients with ND and was statistically significant (**Tables 2** and **3**). Functional studies on cultured cells and experimental animals show the role of the ELMO-1 protein in ND. Previous research has shown an increase in ELMO-1 signal with the *Influence Engulfment Cell Motility-1 (ELMO-1) Protein and Matrix Metalloproteases-9… DOI: http://dx.doi.org/10.5772/intechopen.98192*

in situ hybridization (FISH) method in the kidney of rats with nephropathy compared to those without nephropathy.

MMP-9 protein is a protein involved in the degradation of the extracellular matrix and glomerular turnover. Changes in MMP-9 expression are associated with the development of diabetic nephropathy. Hyperglycemia, an increase in advanced glycation end products, and oxidative stress that occurs in people with Diabetes increase the expression of MMP-9. MMP-9 protein cause of disrupts the integrity and increases the permeability of podocytes to albumin, and increases protein synthesis, which is involved in forming the extracellular matrix. All of these are processes that occur in Diabetes nephropathy [10, 15, 16].
