Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter March 14, 2015

First trimester concentrations of the TTR-RBP4-retinol complex components as early markers of insulin-treated gestational diabetes mellitus

  • Arrigo Fruscalzo EMAIL logo , Ambrogio P. Londero , Lorenza Driul , Andrea Henze , Laura Tonutti , Maria Ceraudo , Giuseppe Zanotti , Rodolfo Berni , Florian J. Schweigert and Jens Raila


Background: The objective of the study was to investigate the relationship between first trimester maternal serum levels of the TTR-RBP4-ROH complex components and the later insurgence of an altered glucose metabolism during pregnancy.

Methods: Retrospective case control study including 96 patients between the 12th and 14th week of gestation, 32 that developed gestational diabetes mellitus (GDM), respectively, 21 non-insulin-treated (dGDM) and 11 insulin-treated (iGDM), 20 large for gestational age fetuses (LGA) without GDM and 44 patients with normal outcome as control. Serum concentrations of RBP4 and TTR were assessed by ELISA; serum concentration of ROH by reverse-phase high performance liquid chromatography (rpHPLC). The molecular heterogeneity of TTR and RBP4 was analyzed after immunoprecipitation by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF-MS).

Results: iGDM patients were characterized by reduced TTR, RBP4 and ROH compared to controls (respectively, iGDM vs. controls, mean±SD: TTR 3.96±0.89 μmol/L vs. 4.68±1.21 μmol/L, RBP4 1.13±0.25 μmol/L vs. 1.33±0.38 μmol/L and ROH 1.33±0.17 μmol/L vs. 1.62±0.29 μmol/L, p<0.05). TTR containing Gly10 in place of Cys10 was lower in the iGDM group (p<0.05) compared to controls. In the final logistic regression model ROH significantly predicted the diagnosis of iGDM (OR 0.93, 95% CI 0.87–0.98, p<0.05).

Conclusions: First trimester maternal serum ROH, RBP4 and TTR represent potential biomarkers associated with the development of iGDM.

Corresponding author: Arrigo Fruscalzo, St. Franziskus-Hospital, Hohenzollernring 72, 48145 Münster, Germany, Phone: +49 02 51 9353917, Fax: +49 02 51 9354072, E-mail:


The authors would like to thank the study participants and the whole staff collaborating to the study, particularly during the step of sample collection and storage (Clinic of Obstetrics and Gynecology and Department of Laboratory Medicine, Institute of Clinical Pathology, University of Udine, Italy), as well during the step of sample examination (Institute of Nutritional Science, University of Potsdam, Germany). We are also grateful to Prof. Diego Marchesoni, Prof. Francesco Curcio, and Dr. Giuliana Stel for their helpful suggestions.

Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Financial support: None declared.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


1. Nolan CJ. Controversies in gestational diabetes. Best Pract Res Clin Obstet Gynaecol 2011;25:37–49.10.1016/j.bpobgyn.2010.10.004Search in Google Scholar PubMed

2. Oliveira D, Pereira J, Fernandes R. Metabolic alterations in pregnant women: gestational diabetes. J Pediatr Endocrinol Metab 2012;25:835–42.10.1515/jpem-2012-0175Search in Google Scholar PubMed

3. Coustan DR. Gestational diabetes mellitus. Clin Chem 2013;59:1310–21.10.1373/clinchem.2013.203331Search in Google Scholar PubMed

4. Ingenbleek Y, Young V. Transthyretin (prealbumin) in health and disease: nutritional implications. Annu Rev Nutr 1994;14: 495–533.10.1146/ in Google Scholar PubMed

5. Goodman DS. Plasma retinol-binding protein. In: Sporn MB, Roberts AB, Goodman DS, editors. The retinoids. Vol. 2. New York: Academic Press, 1984:41–88.Search in Google Scholar

6. Theodosiou M, Laudet V, Schubert M. From carrot to clinic: an overview of the retinoic acid signaling pathway. Cell Mol Life Sci 2010;67:1423–45.10.1007/s00018-010-0268-zSearch in Google Scholar PubMed

7. van Bennekum AM, Wei S, Gamble MV, Vogel S, Piantedosi R, Gottesman M, et al. Biochemical basis for depressed serum retinol levels in transthyretin-deficient mice. J Biol Chem 2001;276:1107–13.10.1074/jbc.M008091200Search in Google Scholar PubMed

8. Yeste D, Vendrell J, Tomasini R, Gallart LL, Clemente M, Simon I, et al. Retinol-binding protein 4 levels in obese children and adolescents with glucose intolerance. Hormone Res Paediatr 2010;73:335–40.10.1159/000308165Search in Google Scholar PubMed

9. Christou GA, Tselepis AD, Kiortsis DN. The metabolic role of retinol binding protein 4: an update. Horm Metab Res 2012;44:6–14.10.1055/s-0031-1295491Search in Google Scholar PubMed

10. Wiwanitkit V. Retinol-binding protein 4, insulin resistance and pregnancy. Metabolism 2012;61:e9.10.1016/j.metabol.2012.03.008Search in Google Scholar PubMed

11. Henze A, Frey SK, Raila J, Scholze A, Spranger J, Weickert MO, et al. Alterations of retinol-binding protein 4 species in patients with different stages of chronic kidney disease and their relation to lipid parameters. Biochem Biophys Res Commun 2010;393:79–83.10.1016/j.bbrc.2010.01.082Search in Google Scholar PubMed

12. Zhang Q, Kelly JW. Cys10 mixed disulfides make transthyretin more amyloidogenic under mildly acidic conditions. Biochemistry 2003;42:8756–61.10.1021/bi030077aSearch in Google Scholar PubMed

13. Fruscalzo A, Biasioli A, Londero AP, Ceraudo M, Stel G, Bertozzi S, et al. Retinol binding protein as early marker of fetal growth restriction in first trimester maternal serum. Gynecol Endocrinol 2013;29:323–6.10.3109/09513590.2012.743013Search in Google Scholar PubMed

14. Nanda S, Nikoletakis G, Markova D, Poon LC, Nicolaides KH. Maternal serum retinol-binding protein-4 at 11–13weeks’ gestation in normal and pathological pregnancies. Metabolism 2013;62:814–9.10.1016/j.metabol.2012.12.011Search in Google Scholar PubMed

15. Londero AP, Orsaria M, Grassi T, Calcagno A, Marzinotto S, Ceraudo M, et al. Placental hCG immunohistochemistry and serum free-Beta-hCG at 11–13 weeks’ gestation in intrauterine fetal demise. Histochem Cell Biol 2012;139:595–603.10.1007/s00418-012-1054-9Search in Google Scholar PubMed

16. International Association of D, Pregnancy Study Groups Consensus P, Metzger BE, Gabbe SG, Persson B, Buchanan TA, et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676–82.10.2337/dc09-1848Search in Google Scholar PubMed PubMed Central

17. Londero AP, Bertozzi S, Visentin S, Fruscalzo A, Driul L, Marchesoni D. High placental index and poor pregnancy outcomes: a retrospective study of 18 386 pregnancies. Gynecol Endocrinol 2013;29:666–9.10.3109/09513590.2013.798273Search in Google Scholar PubMed

18. Driul L, Londero AP, Salvador S, Fruscalzo A, Peris Bhat SA, Citossi A, et al. Retrospective analysis of one year of cesarean sections: indications and risk factors associated with intrapartum cesarean section. Minerva Ginecol 2010;62:403–14.Search in Google Scholar

19. Raila J, Henze A, Spranger J, Mohlig M, Pfeiffer AF, Schweigert FJ. Microalbuminuria is a major determinant of elevated plasma retinol-binding protein 4 in type 2 diabetic patients. Kidney Int 2007;72:505–11.10.1038/ in Google Scholar PubMed

20. Henze A, Raila J, Scholze A, Zidek W, Tepel M, Schweigert FJ. Does N-acetylcysteine modulate post-translational modifications of transthyretin in hemodialysis patients? Antioxid Redox Signal 2013;19:1166–72.10.1089/ars.2012.5125Search in Google Scholar PubMed

21. Laudes M, Oberhauser F, Bilkovski R, Schubert M, Udelhoven M, Wassmer G, et al. Human fetal adiponectin and retinol-binding protein (RBP)-4 levels in relation to birth weight and maternal obesity. Exp Clin Endocrinol Diabetes 2009;117:146–9.10.1055/s-0028-1100379Search in Google Scholar PubMed

22. Mazaki-Tovi S, Romero R, Vaisbuch E, Kusanovic JP, Chaiworapongsa T, Kim SK, et al. Retinol-binding protein 4: a novel adipokine implicated in the genesis of LGA in the absence of gestational diabetes mellitus. J Perinat Med 2010;38:147–55.10.1515/jpm.2010.044Search in Google Scholar PubMed PubMed Central

23. Tepper BJ, Kim YK, Shete V, Shabrova E, Quadro L. Serum retinol-binding protein 4 (RBP4) and retinol in a cohort of borderline obese women with and without gestational diabetes. Clin Biochem 2010;43:320–3.10.1016/j.clinbiochem.2009.10.013Search in Google Scholar PubMed PubMed Central

24. Chan TF, Chen HS, Chen YC, Lee CH, Chou FH, Chen IJ, et al. Increased serum retinol-binding protein 4 concentrations in women with gestational diabetes mellitus. Reprod Sci 2007;14:169–74.10.1177/1933719106298407Search in Google Scholar PubMed

25. Khovidhunkit W, Pruksakorn P, Plengpanich W, Tharavanij T. Retinol-binding protein 4 is not associated with insulin resistance in pregnancy. Metabolism 2012;61:65–9.10.1016/j.metabol.2011.05.019Search in Google Scholar PubMed

26. Abetew DF, Qiu C, Fida NG, Dishi M, Hevner K, Williams MA, et al. Association of retinol binding protein 4 with risk of gestational diabetes. Diabetes Res Clin Pract 2013;99:48–53.10.1016/j.diabres.2012.10.023Search in Google Scholar PubMed PubMed Central

27. Vascotto C, Salzano AM, D’Ambrosio C, Fruscalzo A, Marchesoni D, di Loreto C, et al. Oxidized transthyretin in amniotic fluid as an early marker of preeclampsia. J Proteome Res 2007;6:160–70.10.1021/pr060315zSearch in Google Scholar PubMed

28. Fruscalzo A, Schmitz R, Klockenbusch W, Kohler G, Londero AP, Siwetz M, et al. Human placental transthyretin in fetal growth restriction in combination with preeclampsia and the HELLP syndrome. Histochem Cell Biol 2012;138:925–32.10.1007/s00418-012-0997-1Search in Google Scholar PubMed

29. Pecks U, Seidenspinner F, Rower C, Reimer T, Rath W, Glocker MO. Multifactorial analysis of affinity-mass spectrometry data from serum protein samples: a strategy to distinguish patients with preeclampsia from matching control individuals. J Am Soc Mass Spectrom 2010;21:1699–711.10.1016/j.jasms.2009.12.013Search in Google Scholar PubMed

30. Gericke B, Raila J, Sehouli J, Haebel S, Konsgen D, Mustea A, et al. Microheterogeneity of transthyretin in serum and ascitic fluid of ovarian cancer patients. BMC Cancer 2005;5:133.10.1186/1471-2407-5-133Search in Google Scholar PubMed PubMed Central

31. Gericke B, Raila J, Deja M, Rohn S, Donaubauer B, Nagl B, et al. Alteration of transthyretin microheterogeneity in serum of multiple trauma patients. Biomark Insights 2007;2:299–306.10.1177/117727190700200014Search in Google Scholar

32. Henze A, Rohn S, Gericke B, Raila J, Schweigert FJ. Structural modifications of serum transthyretin in rats during protein-energy malnutrition. Rapid Comm Mass Spectrom 2008;22:3270–4.10.1002/rcm.3728Search in Google Scholar PubMed

33. Kishikawa M, Sass JO, Sakura N, Nakanishi T, Shimizu A, Yoshioka M. The peak height ratio of S-sulfonated transthyretin and other oxidized isoforms as a marker for molybdenum cofactor deficiency, measured by electrospray ionization mass spectrometry. Biochim Biophys Acta 2002;1588:135–8.10.1016/S0925-4439(02)00156-4Search in Google Scholar

34. Sapin V, Alexandre MC, Chaib S, Bournazeau JA, Sauvant P, Borel P, et al. Effect of vitamin A status at the end of term pregnancy on the saturation of retinol binding protein with retinol. Am J Clin Nutrit 2000;71:537–43.10.1093/ajcn/71.2.537Search in Google Scholar

35. Fruscalzo A, Londero AP, Biasizzo J, Bortolotti N, Bertozzi S, Curcio F, et al. Second trimester amniotic fluid retinol in patients developing preeclampsia. Arch Gynecol Obstet 2014. doi: 10.1007/s00404-014-3477-0.10.1007/s00404-014-3477-0Search in Google Scholar

36. Wang YZ, Ren WH, Liao WQ, Zhang GY. Concentrations of antioxidant vitamins in maternal and cord serum and their effect on birth outcomes. J Nutr Sci Vitaminol 2009;55:1–8.10.3177/jnsv.55.1Search in Google Scholar

37. Grissa O, Ategbo JM, Yessoufou A, Tabka Z, Miled A, Jerbi M, et al. Antioxidant status and circulating lipids are altered in human gestational diabetes and macrosomia. Translational Res 2007;150:164–71.10.1016/j.trsl.2007.03.007Search in Google Scholar

38. Krzyzanowska K, Zemany L, Krugluger W, Schernthaner GH, Mittermayer F, Schnack C, et al. Serum concentrations of retinol-binding protein 4 in women with and without gestational diabetes. Diabetologia 2008;51:1115–22.10.1007/s00125-008-1009-9Search in Google Scholar

39. Basu TK, Tze WJ, Leichter J. Serum vitamin A and retinol-binding protein in patients with insulin-dependent diabetes mellitus. Am J Clin Nutr 1989;50:329–31.10.1093/ajcn/50.2.329Search in Google Scholar

40. Martinoli L, Di Felice M, Seghieri G, Ciuti M, De Giorgio LA, Fazzini A, et al. Plasma retinol and alpha-tocopherol concentrations in insulin-dependent diabetes mellitus: their relationship to microvascular complications. Int J Vitam Nutr Res 1993;63:87–92.Search in Google Scholar

41. Basu TK, Basualdo C. Vitamin A homeostasis and diabetes mellitus. Nutrition 1997;13:804–6.10.1016/S0899-9007(97)00192-5Search in Google Scholar

42. Berry DC, Jin H, Majumdar A, Noy N. Signaling by vitamin A and retinol-binding protein regulates gene expression to inhibit insulin responses. Proc Natl Acad Sci USA 2011;108: 4340–5.10.1073/pnas.1011115108Search in Google Scholar PubMed PubMed Central

43. Andert CU, Sanchaisuriya P, Sanchaisuriya K, Schelp FP, Schweigert FJ. Nutritional status of pregnant women in Northeast Thailand. Asia Pacific J Clin Nutr 2006;15: 329–34.Search in Google Scholar

44. Kaestel P, Martinussen T, Aaby P, Michaelsen KF, Friis H. Serum retinol is associated with stage of pregnancy and the acute phase response in pregnant women in Guinea-Bissau. J Nutr 2012;142:942–7.10.3945/jn.111.155937Search in Google Scholar PubMed

45. Graham TE, Wason CJ, Bluher M, Kahn BB. Shortcomings in methodology complicate measurements of serum retinol binding protein (RBP4) in insulin-resistant human subjects. Diabetologia 2007;50:814–23.10.1007/s00125-006-0557-0Search in Google Scholar PubMed

Received: 2014-9-19
Accepted: 2015-2-10
Published Online: 2015-3-14
Published in Print: 2015-9-1

©2015 by De Gruyter

Downloaded on 27.2.2024 from
Scroll to top button