Egyptian Journal of Obesity, Diabetes and Endocrinology

: 2017  |  Volume : 3  |  Issue : 1  |  Page : 15--21

Study of advanced glycation endproducts and their receptors in Egyptian type 2 diabetic individuals with peripheral neuropathy

Alaa M Wafa1, Mamdoh R EL-Nahas1, Azza A Al Biaumy2, Yara M Mansour1,  
1 Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Clinical Pathology, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Correspondence Address:
Alaa M Wafa
Department of Internal Medicine, Diabetes and Endocrine Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura


Context Diabetic neuropathy is one of the commonest long-term complications of diabetes seen in routine healthcare and considered the most common cause of peripheral neuropathy in developed world. Aim The aim of our work was to measure advanced glycation endproducts (AGEs) and their receptors (RAGEs) in diabetic peripheral neuropathy (DPN), both painful and painless DPN. Patients and methods Our study was conducted on 50 type 2 diabetes mellitus patients with peripheral neuropathy, divided into two subgroups: the first group included 25 patients with painful DPN and the second group included 25 patients with painless DPN. Moreover, a third group included 20 diabetic patients without peripheral neuropathy, and a fourth group that included 20 healthy participants. All groups were subjected to full history taking and clinical examination, anthropometric parameters, the calculation of neuropathy disability score, and nerve conduction studies (peroneal, sural, and tibial nerves). Laboratory investigations included serum AGEs and RAGEs. Results Our study demonstrated that hemoglobin A1c, AGE, and RAGE showed statistically significant difference between the studied groups. Hemoglobin A1c was significantly high in both neuropathic and diabetic groups in comparison with control. Regarding AGE, it was statistically higher in neuropathic group than in control (P<0.011). On the contrary, RAGE was significantly higher in both neuropathic and diabetic groups rather than control (P<0.02). Although the neuropathic group has higher levels of AGE and RAGE than diabetic group, the difference was statistically nonsignificant. Significant difference was found between studied groups regarding nerve conduction studies of sural and tibial nerves. Statistically significant difference was found in the parameters of nerve conduction studies between neuropathic group and both non-neuropathic diabetic and control groups. Conclusion Our study concluded that AGE and RAGE are significantly higher in diabetic patients with neuropathy versus control, with more elevation in neuropathic group than in diabetic without neuropathy.

How to cite this article:
Wafa AM, EL-Nahas MR, Al Biaumy AA, Mansour YM. Study of advanced glycation endproducts and their receptors in Egyptian type 2 diabetic individuals with peripheral neuropathy.Egypt J Obes Diabetes Endocrinol 2017;3:15-21

How to cite this URL:
Wafa AM, EL-Nahas MR, Al Biaumy AA, Mansour YM. Study of advanced glycation endproducts and their receptors in Egyptian type 2 diabetic individuals with peripheral neuropathy. Egypt J Obes Diabetes Endocrinol [serial online] 2017 [cited 2018 May 26 ];3:15-21
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Full Text


Diabetes has been associated with different long-term macrovascular and microvascular complications. The macrovascular involves large vessels causing peripheral vascular disease, cardiovascular disease, and cerebrovascular disease. Microvascular complications include neuropathy, retinopathy, and nephropathy [1]. Diabetic peripheral neuropathy (DPN) was recognized by the American Diabetes Association as ‘the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes’ [2]. Long-term complications of diabetes have long been believed to be the result of prolonged hyperglycemia. However, blood glucose levels alone do not reveal the whole picture. Diabetic neuropathy is one of the commonest complications of diabetes, reaching 37.4% among uncontrolled diabetic individuals. In the USA, 11.9 million adults have been diagnosed as having diabetes, and of these, 3.9 million (32.7%) have DPN [3]. Painful DPN were found in ∼11% of all diabetic individuals [4]. A diabetic complications study by Herman et al. [5] in Egypt, which used the vibration perception threshold to define DPN, demonstrated that 22 and 18% of known and newly diagnosed diabetic individuals, respectively, had DPN. One study based on clinical neuropathic symptoms and nerve conduction studies (NCSs) found that 8.3% of 86 patients with newly diagnosed type 2 diabetes mellitus (T2DM) had DPN [6]. Using the diabetic neuropathy score and diabetic neuropathy examination score to define DPN in their study in the United Arab Emirates, Saadi et al. [7] demonstrated that 34.7% among 57 diabetic individuals had DPN.

Studies have shown that those who have higher levels of advanced glycation endproducts (AGEs) experience more microvascular and cardiovascular complications [8]. AGEs are groups of compounds that result from the nonenzymatic reaction of reducing sugars with free amino groups of biological molecules. Receptors of advanced glycation endproducts (RAGEs), which are signal transduction receptors that belong to the immunoglobulin superfamily, are expressed in a variety of cell types, such as neurons, monocytes, smooth muscle cells, lymphocytes, and endothelial cells [9]. The interaction between AGE and RAGEs leads to intracellular production of reactive oxygen species through electron transport chain, xanthine oxidase, NADPH oxidase, and arachidonic acid metabolism [10],[11]. AGEs detect the modification of myelin of the peripheral nerve, which becomes susceptible to phagocytosis, and determine segmental demyelination. Also AGEs responsible for modification of major axonal cytoskeleton proteins (e.g. actin, tubulin, and neurofilament), which cause atrophy of axon and impairment of axonal transport [12]. Study of AGEs represent one of the most promising areas of research, as it is thought to have an important role in the etiology of complications of diabetes mellitus (DM), and this will provide new possible targets for the management of both type 1 DM and T2DM and related complications [13].

The aim of our work was to measure AGEs and RAGEs in DPN, both painful and painless DPN.

 Patients and methods

Our study is a cross-sectional study, which was carried out in outpatient clinic and inpatient ward of specialized Internal Medical Hospital, Mansoura University. The study was approved by the Mansoura Faculty of medicine, ethics committee, and then it has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. A written informed consent was obtained from all participants before inclusion in the study.

Timing of the study

The study period was of 1 year between December 2014 and December 2015.

Groups of the study

The patients were divided into the following groups: neuropathic group had 50 T2DM patients with DPN and was divided into two subgroups: the first group included 25 patients with painful DPN and the second group included 25 patients with painless DPN. The third group included 20 diabetic patients without peripheral nerve dysfunction. The fourth group included 20 healthy individuals as controls from medical staff, with matched age and sex.

Exclusion criteria

Patients who refused to participate in the study, patients who had type 1 DM, patients with serum creatinine level more than 1.5 mg/dl, patients with long-term liver disease, patients with other causes of neuropathy, patients with severe debilitating diseases, pregnant females, those with other malignancies, and patients on chemotherapy or radiotherapy.


Clinical assessment

It included full history taking and thorough clinical examination, anthropometric parameters (BMI and waist circumference), the calculation of neuropathy disability score [14], and presence or absence of deep tendon reflexes and sensation (graded as 0, normal; 1, positive with reinforcement; 2, absent). Vibration perception threshold was tested with tuning fork 128 Hz on each malleolus, pain sensation by pin prick, temperature sensation by thermal pen, assessment of pain by visual analog pain scale.

Laboratory investigations

Laboratory investigations included urine analysis. Microalbumin level was assayed using competitive enzyme-linked immunosorbent assay (ELISA) test system for the quantitative measurement of human albumin level in urine, which was supplied by ORGENTEC Diagnostic GmbH (Mainz, Germany). Conventional laboratory tests included serum glucose and creatinine levels. Serum AGE was assayed by solid-phase sandwich ELISA assay, which was supplied by MyBiosowle (catalog number: MBS 704358), whereas RAGE was assayed by solidphase ELISA using Quanitikine RAGE ELISA Kit, which was supplied by R&D System (catalog number: DRG00). Serum of 1 ml was put into EDTA vacutainer tube for hemoglobin A1c (HbA1c) assay using fast cation exchange resin, which was supplied by Human Gesellschaft für Biochemica und Diagnostica mbH (Wiesbaden, Germany).

Nerve conduction studies

studies NCSs were performed with the use of sensory nerve to record the conduction velocity for peroneal nerve, sural nerve, and tibial nerve. DPN was diagnosed by NCSs and neuropathy disability score. Patients with DPN were divided by visual analog scale for pain into painful and painless groups.

Fundus examination

Fundus examination was done by digital retinal camera [15].


The results are shown in [Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6],[Table 7],[Table 8],[Table 9],[Table 10],[Table 11].{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}{Table 9}{Table 10}{Table 11}


Diabetic neuropathy is one of the commonest long-term complications seen in routine healthcare and considered the most common cause of peripheral neuropathy in developed countries [16]. It is, therefore, a major health problem with serious consequences for patients, and it results in a significant financial burden on the healthcare systems. This is especially true owing to the current global epidemic of DM. Hyperglycemia induces microvascular damage through different mechanisms: an increased flux of glucose and other sugars through the polyol pathway; an increased intracellular AGE formation; interaction between AGEs and RAGEs, leading to intracellular signaling, which disrupts cell function; a persistent activation of protein kinase C isoforms; and an increased hexosamine pathway activity. Selectively inhibiting each of these biochemical pathways has produced disappointing results [17]. Of particular interest is the accelerated formation of AGEs and their interaction with their receptors, RAGEs. The most important process responsible for AGE accumulation in diabetic patients is the nonenzymatic glycation reaction, or Maillard reaction. This can be globally seen as a different process; the final stage of which comprises a complex series of oxidation, dehydration, and cyclization reactions, which give rise to endogenous AGEs, that is, thermodynamically unstable compounds that typically accumulate on proteins with a long half-life, though they have been shown to form on proteins with a short half-life too, such as plasma proteins, lipoproteins, and intracellular proteins [18].

The other way in which these compounds accumulate in diabetic patients is through a defective renal excretion of AGEs, typical of diabetic nephropathy, because renal clearance is inversely related to plasma levels of AGEs. This gradually creates a vicious circle as the greater circulating pool of plasma AGEs in turn changes the shape and structure of many proteins at glomerular level (particularly type IV collagen and the mesangium), as well as interacting with specific receptors. These interactions are associated with a worsening chronic kidney disease and further impairment of glycoxidation product clearance [19]. Much attention has recently been paid to exogenous AGEs, harmful products of ‘browning’ (or the Maillard reaction) in different foods. Together with endogenous AGEs, these compounds form the majority of glycation free adducts, the greater proportion of circulating AGEs in diabetic and nondiabetic individuals. Among the various food processing methods, heating, sterilizing, and microwaves contribute to the generation of exogenous AGEs. Binding of AGEs to RAGEs has been suggested to contribute to the pathogenesis of diabetic vascular complications. Interaction of AGE with its receptor RAGE transduces multiple signals such as NADPH oxidase, mitogen-activated protein kinases, extracellular signal regulated kinases, and GTPase [20]. Activation of NADPH oxidase causes enhanced (reactive oxygen species) generation, which may lead to peroxidation and glycoxidation reactions that result in protein carbonyl formation, advanced oxidation protein product generation, and lipid peroxidation. These oxidative stress markers have been shown to be enhanced significantly in diabetic patients. Using pharmacological agents that are able to inhibit AGE formation and disrupt the RAGE-ligand axis either through downregulating membrane-bound RAGE or inducing the production of circulating RAGEs may be a possible means to decrease diabetic vascular complications [21].

This cross-sectional study was conducted at the inpatient and outpatient clinics of specialized medical hospital, Mansoura University, to asses AGEs and their receptors in both painful and painless DPN. The study comprised 50 patients with diabetic neuropathy (proved by NCSs); 25 patients had painful neuropathy, with 8% of patients showing marked degree of pain, whereas 8% showing least degree of pain. The other 25 patients had painless neuropathy. Moreover, there were 20 diabetic patients without neuropathy and 20 healthy individuals. All were enrolled by simple randomization.

Clinical data of our study revealed that there was no statistically significant difference between the different groups regarding age and sex. However, in all studied groups, the proportion of males was more than females (66 and 34%, respectively); this could be explained simply by refusal of females to do NCSs rather than increase prevalence of neuropathy in males. Hypertension and ischemic heart disease were significantly higher in the neuropathic group in comparison with the control group. This is shown in the study of comorbidity, with a significance of P value equal to 0.02. This may be because of high prevalence of dyslipidemia, hypertension, obesity, and other cardiovascular risk factors in diabetic patients. Ischemic heart disease is considered one of the most common causes of death in diabetic patients with peripheral neuropathy [22]. Painful and painless groups showed no statistically significant difference in age, sex, medication, and comorbidity.

The study of glycated products demonstrated that HbA1c was found to be significantly high in both neuropathic and diabetic groups versus control. Regarding AGE, it was statistically higher in neuropathic group compared with control (P<0.011). On the contrary, RAGE was significantly higher in both neuropathic and diabetic groups compared with the control group (P<0.02). Although the neuropathic group has higher level of AGE and RAGE than diabetic group, the difference was statistically nonsignificant. Our results are consistent with a study that showed a significant higher level of serum AGE level by ELISA in T2DM patients having microvascular complications. It showed that AGEs were ∼23% higher in diabetic patients compared with healthy participants and concluded that AGE level has been suggested to act as a predictor of cardiovascular disease mortality and diabetic nephropathy [22]. This also correlates with another study that stated that presence of RAGE in blood was significantly higher in diabetic individuals than controls (P<0.01) [23]. Another research work obtained the same results with a significance of P value equal to 0.028. It concluded that RAGE was independently associated with DPN in individuals with T2DM in a study conducted on 198 T2DM individuals, confirming the relationship between advanced glycoxidation and DPN, independently of other risk factors [24]. Interference of exogenous AGE with the sensitivity of the assay could be the cause of making the difference nonsignificant between neuropathic and diabetic groups in our study, so further studies should consider assessment of exogenous AGE. Correlations between AGE and RAGE and all other variables including age, sex, comorbidity, HbA1c, and parameters of NCS were done for our studied groups, but no statistically significant correlation was found. NCSs can diagnose diabetic neuropathy at a very early stage even before symptoms and signs set in, as demonstrated from a study conducted on 50 diabetic patients and 50 nondiabetic controls of comparable age and BMI [25]. This goes with our study where there was a statistically significant difference in all categories of nerve conduction regarding sural, tibial, and peroneal nerves between neuropathic group and both diabetic and control groups. Painful and painless groups did not show statistically significant difference regarding glycation endproducts and all parameters of NCS. The distinction between painful and painless neuropathy is not clear in the literature. In this study, we tried to study some of the pathogenetic mechanisms of diabetic neuropathy to accuse AGEs and their receptors as one of these mechanisms.


Our study concluded that AGE and RAGE are significantly higher in diabetic patients with neuropathy versus control. Although the neuropathic group has higher level of AGE and RAGE than diabetic group, the difference was statistically nonsignificant, so further studies are suggested to exclude conflicting agents.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Creager MA. Diabetes and vascular disease: pathophysiology, clinical consequences, and medical therapy: part I. Circulation 2003; 108:1527–1532.
2American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2007; 30(Suppl 1):S4–S41.
3Candrilli SD, Davis KL, Kan HJ, Lucero MA, Rousculp MD. Prevalence and the associated burden of illness of symptoms of diabetic peripheral neuropathy and diabetic retinopathy. J Diabetes Complications 2007; 21:306–314.
4Tesfaye S. Diabetic neuropathy. In: Sinclair AJ, editor. Diabetes in old age. Chichester, UK: Wiley-Blackwell; 2009.
5Herman WH, Aubert RE, Engelgau MM, Thompson TJ, Ali MA, Sous ES et al. Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications. Diabet Med 1998; 15:1045–1051.
6Partanen J, Niskanen L, Lehtinen J, Mervaala E, Siitonen O, Uusitupa M. Natural history of peripheral neuropathy in patients with non-insulin-dependent diabetes mellitus. N Engl J Med 1995; 333:89–94.
7Saadi H, Carruthers SG, Nagelkerke N, Al-Maskari F, Afandi B, Reed R et al. Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates. Diabetes Res Clin Pract 2007; 78:369–377.
8Kiuchi K. Increased serum concentrations of advanced glycation end products: a marker of coronary artery disease activity in type 2 diabetic patients. Heart 2001; 85:87–91.
9Méndez JD, Xie J, Aguilar-Hernández M, Méndez-Valenzuela V. Trends in advanced glycation end products research in diabetes mellitus and its complications. Mol Cell Biochem 2010; 341:33–41.
10Schmidt AM, Yan SD, Yan SF, Stern DM. The biology of the receptor for advanced glycation end products and its ligands. Biochim Biophys Acta 2000; 1498:99–111.
11Brownlee M. The pathobiology of diabetic complications: a unifying mechanism. Diabetes 2005; 54:1615–1625.
12Maina JN. Functional designs of the gas exchangers bioengineering aspects in the design of gas exchangers. Berlin Heidelberg: Springer; 2011.
13Sugimoto K, Yasujima M, Yagihashi S. Role of advanced glycation end products in diabetic neuropathy. Curr Pharm Des 2008; 14:953–961.
14Dyck PJ, Boes CJ, Mulder D, Millikan C, Windebank AJ, Dyck PJ, Espinosa R. History of standard scoring, notation, and summation of neuromuscular signs. A current survey and recommendation. J Peripher Nerv Syst 2005; 10:158–173.
15Vos T, Flaxman AD, Naghavi M, Lozano R, Michuad C, Ezzati M et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2163–2196.
16Brownlee M. Biochemistry and molecular cell biology of diabetic complications. Nature 2001; 414:813–820.
17Ahmed N. Advanced glycation endproducts – role in pathology of diabetic complications. Diabetes Res Clin Pract 2005; 67:3–21.
18Uribarri J, Tuttle KR. Advanced glycation end products and nephrotoxicity of high-protein diets. Clin J Am Soc Nephrol 2006; 1:1293–1299.
19Lin L, Park S, Lakatta EG. RAGE signaling in inflammation and arterial aging. Front Biosci 2009; 14:1403–1413.
20Imai S, Kozai H, Matsuda M, Hasegawa G, Obayashi H, Togawa C et al. Intervention with delivery of diabetic meals improves glycemic control in patients with type 2 diabetes mellitus. J Clin Biochem Nutr 2008; 42:59–63.
21American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2013; 36(Suppl 1): S67–S74.
22Gohda T, Tanimoto M, Moon JY, Gotoh H, Aoki T, Matsumoto M et al. Increased serum endogenous secretory receptor for advanced glycation end-product (esRAGE) levels in type 2 diabetic patients with decreased renal function. Diabetes Res Clin Pract 2008; 81:196–201.
23Grossin N, Wautier MP, Meas T, Guillausseau PJ, Massin P, Wautier JL. Severity of diabetic microvascular complications is associated with a low soluble RAGE level. Diabetes Metab 2008; 34:392–395.
24Aubert CE, Michel PL, Gillery P, Jaisson S, Fonfrede M, Morel F et al. Association of peripheral neuropathy with circulating advanced glycation end products, soluble receptor for advanced glycation end products and other risk factors in patients with type 2 diabetes. Diabetes Metab Res Rev 2014; 30:679–685.
25Verma A, Mahajan S, Khadayate P. 2015 Sensory nerve conduction studies in non-insulin dependent diabetes mellitus (NIDDM) patients without symptoms of peripheral neuropathy and healthy volunteers: a comparative study. Int J Basic Appl Physiol 2015; 2:158–162.