Association between plasma adipsin level and mild cognitive impairment in Chinese patients with type 2 diabetes: a cross-sectional study

Given its prevalence, type 2 diabetes mellitus (T2DM) is expected to affect 552 million people worldwide by 2030 according to the International Diabetes Federation (IDF) [1]. With its growing chronic complications, diabetes-induced cognitive dysfunction has received considerable attention from researches [2]. Previous researches demonstrated that patients with T2DM have an increased incidence of dementia and mild cognitive impairment (MCI), a transition phase between dementia and regular aging [3, 4]. T2DM results in a 60% increase in Alzheimer’s disease (AD) risk [5]. The exact mechanisms of diabetes-induced cognitive dysfunction are multifactorial. Insulin resistance (IR), dyslipidemia, neuroinflammation, hyperphosphorylation of TAU and abnormal accumulation of amyloid-beta (Aβ) peptide were reported [6, 7]. Nevertheless, the potential etiology and pathological mechanisms remain unclear.

IR is one of the principal distinctive features of T2DM, which exists throughout the entire diabetes course [8]. IR itself also leads to the production of Aβ and hyperphosphorylation of tau protein [9]. Prior studies suggested that systemic IR actuates brain IR [9], and leads to the reduction of cerebral glucose metabolic rate and worsened memory [10]. Indeed, accumulated evidence has suggested that AD is usually accompanied by profound IR; moreover, IR abnormalities also participate in the occurrence of T2DM-related early cognitive dysfunction and contribute to the progression of MCI to AD [11]. However, the precise mechanisms about diabetic MCI caused by IR remain uncertain.

Partial adipocytokines were thought to be involved in diabetic-related MCI. Pathological mechanisms such as cerebral IR, hyperinsulinemia, and inflammation have been discussed. Certain adipocytokines including leptin and adiponectin were reported to medicate early cognitive impairment caused by IR [12, 13]. Leptin-deficient mice with T2DM [14] show impaired cerebral insulin signaling, thereby leading to the activation of glycogen synthase kinase 3β(GSK3β), the production of Aβ, the hyperphosphorylation of tau protein, and subsequent cognitive impairment. The adipocytokine adiponectin can ameliorate insulin sensitivity by activating protein kinase (AMPK) phosphorylation, reaulting in neuroinflammation, neurodegeneration, Aβ production, and tau protein hyperphosporylation. Thus, IR plays an important role in T2DM, adipokine levels, and cognitive impairment. The adipokine adipsin (complement factor D), is a serine protease that was first found in 3 T3 adipocytes [15]. Patients suffering from DM have high serum and cerebrospinal fluid (CSF) levels of adipsin [16]. In mice, Lo et al. found that adipsin, together with its downstream receptor of C3a, C3aR1, acts on islets and finally stimulates insulin secretion [17]. This finding provided a link between IR and adipsin. The association between adipsin and IR has been confirmed in some investigations. Many human clinical studies presented a positive correlation between adipsin and IR, although contradictory clinical reports were found by Wang et al. [18]. Moreover, adipsin has also been reported to modulate lipid metabolism [19], ischemia-reperfusion [20], and insulin secretion [17], which are all implicated as risk factors of cognitive dysfunction. Thus, adipsin, probably plays a previously unrecognized role in T2DM-related cognitive dysfunction. Therefore, we hypothesized that adipsin might regulate IR - related susceptibility to early cognitive dysfunction in T2DM patients.

The present cross-sectional study aimed to evaluate the latent correlation between plasma adipsin levels and diabetes-related cognitive impairment. Further analysis may reveal the potential mechanisms of IR- related susceptibility to early cognitive impairment in T2DM patients.

The foremost results of this study were as follows: (1) Compared with the normal controls, individuals with cognitive dysfunction exhibited higher plasma adipsin levels. (2) After controlling for potential confounders such as levels of education, age, and sex, the plasma adipsin level was remarkably negatively correlated with MoCA, MMSE and VFT scores, which represent executive function [25] in the MCI group. (3) Increased plasma adipsin level was a major independent determinant for diabetic MCI. (4) Plasma adipsin level was positively associated with FCP and HOMA-IR in all subjects. In addition, FCP and HOMA-IR independently predicted adipsin levels.

Consistent with previous studies [26], our study demonstrated that T2DM patients with MCI exhibited worsened glucose homeostasis, as indicated by increased HbA1c and FBG in the MCI group. Moreover, HbA1c is an independent risk factor for poor cognitive performance. Yaffe et al. [27] reported that for patients with HbA1c ≥ 7%, the risk for developing MCI was increased by nearly fourfold in a large sample size study with a female population. Several mechanisms have been investigated, including accumulation of advanced glycation end-products, activation of protein kinase C and increased flux of hexosamine in brain endothelial cells that lead to vessel occlusion, alteration of angiogenesis and permeability, production of NF-κB that causes neuroinflammation, obstruction of Akt/CREB signaling pathway, and impaired insulin homeostasis of the brain [26, 28].

Moreover, increased plasma adipsin level was correlated with higher BMI and weight in the MCI group. Adipose tissue dysfunction and obesity exists in diabetes and contributes to the development of lipid metabolism disorder and MCI in patients with T2DM [29‐31]. Animal experiments indicated that circulating adipsin levels decreased in obese models [32], while human studies present diametrically opposite results [33]. The exact explanation for these discrepancies remains uncertain. One possible reason is that the expansion of fat mass in obesity may compensate to maintain higher circulating levels of adipsin [17]. Our results were consistent with most human studies. Maslowska et al. [34] reported that an obese group presented a high plasma adipsin levels, and a strong positive association was discovered between BMI and plasma adipsin. Analogous results were found in a cross-sectional study carried out on Arabs [35],in which a positive correlation was also discovered between adipsin and waist circumference. Schrover et al. [36] reported a strong positive relation between adipsin and BMI; moreover, visceral adipose tissue was related to higher plasma concentrations of adipsin. Conversely, adipsin is a serine protein in triglyceride synthesis through the ASP/adipsin pathway [19, 37]. Maslowska et al. [34] also verified that free fatty acidand BMI predicted adipsin levels. However, insignificant correlations were found between adipsin and TG and adipsin and WC in our study.

We also noted significantly higher FCP and HOMA-IR in the MCI group, thereby suggesting an association between elevated IR and MCI. Our findings are in line with previous research supporting the concept that IR contributes to the pathological mechanism of cognitive dysfunction [38]. Consistent with our study, Ekblad et al. [39] reported that IR predicted poor verbal fluency and acted as an independent risk factor of mild cognitive dysfunction in a population-based cohortwith an 11-year large follow-up survey. Insulin signaling in the brain induces the suppression ofGSK-3, which results in tau hyperphosphorylation and neurofibrillary formation, thereby causing damage or apoptosis of neurons [9].

Our correlation study of plasma adipsin level and IRrevealed that higher plasma adipsin level was correlated with higher FCP and HOMA-IR. Further multivariate analysis confirmed that the degree of HOMA-IR was an independent predictor of adipsin levels. Research on animals suggested that adipsin cleaves factor B, thereby catalyzing the formation of C3bBb, which cleaves C3 to liberate C3a. Then, together with its downstream receptor of C3a, C3aR1 acts on islets through augmenting intracellular adenosine-triphosphate (ATP) levels, thus motivating ATP-coupled respirations, increasing the concentration of cytosolic free Ca2+, and finally stimulating insulin secretion [17]. Interestingly, a dispute exists about the relationship between adipsin and IR. Our findings are consistent with some human studies. One recent cross-sectional study displayed significant positive correlations between adipsin levels and the HOMA-IR index in patients with polycystic ovary syndrome. In another study, IR was found to be an independent predictive factor of adipsin levels [40]. Similar findings were obtained by Derosa et al. [41], who suggested that increased HOMA-IR index was profoundly correlated with higher adipsin levels in obese subjects. However, an insignificant correlation was reported in a study on t Arabs with cardiovascular disease. Lo et al. [17] revealed that adipsin−/− mice are insulinopenic, and diabetic db/db mice injected with adipsin presented increased insulin secretion and improved glucose homeostasis. Wang et al. reported that serum adipsin levels were negatively correlated with IR, especially in subjects with BMI ≥ 25 kg/m². The disparity between results was not fully understood. One possible explanation is that the patients with T2DM employed in our research have not developed severe metabolic disorders, and a compensatory mechanism may have been triggered to retain normal insulin secretion. In addition, different study populations (patients with MCI in our report vs. subjects with cardiovascular disease by Calan et al. [41]), different races (Asians vs. Arabs), and different species (human vs. mice) may at least partly explain such discrepancies. Additionally, MCI subjects presented high adipsin levels. Further multivariate analyses demonstrated that, besides HbA1c, adipsin is an independent determinant for MCI individuals with T2DM. This outcome implies that a higher plasma adipsin level might play a previously unrecognized role in diabetic MCI caused by IR. Neuropsychological tests conducted in our study also indicated that the MMSE and MoCA scores, which represented global cognition, were inversely correlated to plasma adipsin levels. The influences on cognitive dysfunction were consistent with cognitive decline caused by insulin resistance in the past study conducted by Zhong Y et al. [42]. In our present study, although lower HOMA-IR was found in the MCI group, the further multivariable linear regression analyses discovered insignificant correlations about HOMA-IR and MoCA, MMSE, VFT scores. This may be due to the insufficient population. Furthermore, adipsin acts as an independent predictor of VFT, which represents the executive function. To the best of our knowledge, this is the unique research estimating the expressing of adipsin in cognitive impairment with T2DM.

One or more possible explanations may be reasonable for the observed results: 1) glucose dysregulation in T2DM patients with cognitive dysfunction promotes adipsin production as a compensatory mechanism to maintain normal insulin secretion [17], that leads to compensatory IR, which, in turn may contribute to impairment of cellular insulin signaling [43], reduction of brain insulin uptake, and increased levels of Aβ [10]. In addition, abnormal insulin signaling represents a risk to the dysfunction of the entorhinal cortex and hippocampus, finally leading to impaired memory and executive function [44]. 2) adipsin itself is related to CSF inflammation and increases grades of disturbed blood-CSF barrier function [16].

Several limitations exist in our research. First, the cross-sectional study design itself failed to explain any causal relationship between adipsin and cognitive impairment. Large-scale and multi-center prospective studies should be conducted to verify our inferences. Second, some clinical parameters such as education levels were collected through self-report and medical records, which could lead to recall bias. Third, the sample size in this study is not large enough and consists of the Chinese Han population, which might reduce the strength of the results. Furthermore, while we adjusted some confounding factors that may influence the logistic regression, the results may have been affected by other possible confounders (e.g., living environment and habits), which could not be controlled. Finally, we used the less invasive HOMA-IR method to evaluate IR; thus, more accurate indicators should be used to gain a better evaluation of IR.

In summary, the current study demonstrated that T2DM individuals with cognitive dysfunction presented increased plasma adipsin levels. Furthermore, high plasma adipsin level is an independent risk predictor of overall cognitive function and executive function. The data implied that adipsin could be a potential predictor of early cognitive dysfunction among Chinese patients with T2DM. Additionally, we obtained evidence that plasma adipsin level is significantly positively associated with FCP and HOMA-IR, which suggested that adipsin might facilitate the development of diabetic MCI caused by IR. Further prospective studies with large sample size should be conducted to confirmed our hypotheses and clarify whether adipsin is involved in diabetic MCI caused by IR.