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Gorst C, Kwok CS, Aslam S, Buchan I, Kontopantelis E, Myint PK, Heatlie G, Loke Y, Rutter MK, Mamas MA. Long-term Glycemic Variability and Risk of Adverse Outcomes: A Systematic Review and Meta-analysis. Diabetes Care 2015; 38:2354-69. [PMID: 26604281 DOI: 10.2337/dc15-1188] [Citation(s) in RCA: 349] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Glycemic variability is emerging as a measure of glycemic control, which may be a reliable predictor of complications. This systematic review and meta-analysis evaluates the association between HbA1c variability and micro- and macrovascular complications and mortality in type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS Medline and Embase were searched (2004-2015) for studies describing associations between HbA1c variability and adverse outcomes in patients with type 1 and type 2 diabetes. Data extraction was performed independently by two reviewers. Random-effects meta-analysis was performed with stratification according to the measure of HbA1c variability, method of analysis, and diabetes type. RESULTS Seven studies evaluated HbA1c variability among patients with type 1 diabetes and showed an association of HbA1c variability with renal disease (risk ratio 1.56 [95% CI 1.08-2.25], two studies), cardiovascular events (1.98 [1.39-2.82]), and retinopathy (2.11 [1.54-2.89]). Thirteen studies evaluated HbA1c variability among patients with type 2 diabetes. Higher HbA1c variability was associated with higher risk of renal disease (1.34 [1.15-1.57], two studies), macrovascular events (1.21 [1.06-1.38]), ulceration/gangrene (1.50 [1.06-2.12]), cardiovascular disease (1.27 [1.15-1.40]), and mortality (1.34 [1.18-1.53]). Most studies were retrospective with lack of adjustment for potential confounders, and inconsistency existed in the definition of HbA1c variability. CONCLUSIONS HbA1c variability was positively associated with micro- and macrovascular complications and mortality independently of the HbA1c level and might play a future role in clinical risk assessment.
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Affiliation(s)
- Catherine Gorst
- Institute of Population Health, Centre for Primary Care, University of Manchester, Manchester, U.K.
| | - Chun Shing Kwok
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, U.K. Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine and Institute of Primary Care and Health Science, University of Keele, Stoke-on-Trent, U.K
| | - Saadia Aslam
- Central University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Iain Buchan
- Farr Institute, University of Manchester, Manchester, U.K
| | - Evangelos Kontopantelis
- Institute of Population Health, Centre for Primary Care, University of Manchester, Manchester, U.K
| | - Phyo K Myint
- Epidemiology Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences, and Nutrition, University of Aberdeen, Aberdeen, Scotland, U.K
| | - Grant Heatlie
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, U.K
| | - Yoon Loke
- University East Anglia, Norwich, Norfolk, U.K
| | - Martin K Rutter
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K. Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester, Manchester, U.K
| | - Mamas A Mamas
- Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, U.K. Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine and Institute of Primary Care and Health Science, University of Keele, Stoke-on-Trent, U.K. Farr Institute, University of Manchester, Manchester, U.K
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Takenouchi A, Tsuboi A, Terazawa-Watanabe M, Kurata M, Fukuo K, Kazumi T. Direct association of visit-to-visit HbA1c variation with annual decline in estimated glomerular filtration rate in patients with type 2 diabetes. J Diabetes Metab Disord 2015; 14:69. [PMID: 26380227 PMCID: PMC4570746 DOI: 10.1186/s40200-015-0201-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 09/01/2015] [Indexed: 01/19/2023]
Abstract
Background/Aims This study examined associations of visit-to-visit variability of glycemic control with annual decline in estimated glomerular filtration rate (eGFR) in patients with type 2 diabetes attending an outpatient clinic. Methods Intrapersonal mean and coefficient of variation (CV) of 8-12 measurements of HbA1c and those of 4-6 measurements of fasting and post-breakfast plasma glucose (FPG and PPG, respectively) during the first 12 months after enrollment were calculated in a cohort of 168 patients with type 2 diabetes. Annual changes in eGFR were computed using 52 (median) creatinine measurements obtained over a median follow-up of 6.0 years. Multivariate linear regressions assessed the independent correlates of changes in eGFR. Results CV-HbA1c (standardized β、-0.257、p = 0.004) were significantly and log urine albumin/creatinine ratio (standardized β、-0.155、p = 0.085) and smoking (standardized β、-0.186、p = 0.062) tended to be associated with annual eGFR decline independently of mean HbA1c, age, sex, BMI, waist circumference, diabetes duration and therapy, means and CVs of FPG, PPG and systolic blood pressure, baseline eGFR, and uses of anti-hypertensive and lipid-lowering medications. Association between HbA1c variability and renal function decline was stronger in patients with albumin/creatinine ratio ≧ 30 mg/g than in those with normoalbuminuria (r = -0.400, p = 0.003 and r = -0.169, p = 0.07, respectively). Conclusions Consistency of glycemic control is important to preserve kidney function in type 2 diabetic patients, in particular, in those with nephropathy.
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Affiliation(s)
- Akiko Takenouchi
- Postgraduate School of Food Sciences and Nutrition, Nishinomiya, Japan
| | - Ayaka Tsuboi
- Postgraduate School of Food Sciences and Nutrition, Nishinomiya, Japan
| | - Mayu Terazawa-Watanabe
- Department of Food Sciences and Nutrition, School of Human Environmental Sciences, Nishinomiya, Japan
| | - Miki Kurata
- Department of Food Sciences and Nutrition, School of Human Environmental Sciences, Nishinomiya, Japan ; Research Institute for Nutrition Sciences, Mukogawa Women's University, 6-46, Ikebiraki-cho, Nishinomiya, Hyogo 663-8558 Japan
| | - Keisuke Fukuo
- Postgraduate School of Food Sciences and Nutrition, Nishinomiya, Japan ; Research Institute for Nutrition Sciences, Mukogawa Women's University, 6-46, Ikebiraki-cho, Nishinomiya, Hyogo 663-8558 Japan
| | - Tsutomu Kazumi
- Research Institute for Nutrition Sciences, Mukogawa Women's University, 6-46, Ikebiraki-cho, Nishinomiya, Hyogo 663-8558 Japan ; Diabetes Division, Sadamitsu Hospital, Kakogawa, Hyogo 675-0005 Japan
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Yang HK, Kang B, Lee SH, Yoon KH, Hwang BH, Chang K, Han K, Kang G, Cho JH. Association between hemoglobin A1c variability and subclinical coronary atherosclerosis in subjects with type 2 diabetes. J Diabetes Complications 2015; 29:776-82. [PMID: 25959788 DOI: 10.1016/j.jdiacomp.2015.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 04/04/2015] [Accepted: 04/14/2015] [Indexed: 12/29/2022]
Abstract
AIMS We examined the association between hemoglobin A1c (HbA1c) variability and subclinical coronary atherosclerosis in subjects with type 2 diabetes. METHODS We used the multidetector coronary computed tomography data collected from subjects with type 2 diabetes who did not have a history of cardiovascular disease or angina symptoms. HbA1c measurements preceding the date of cardiac imaging were retrospectively collected, and intraindividual SD (HbA1c-SD), CV and adjusted SD of HbA1c measurements were calculated. Subclinical coronary atherosclerosis was defined as calcium score >400 without any cardiac symptoms. RESULTS A total of 595 subjects were categorized according to the median value of each HbA1c variability indicators. The prevalence of subclinical coronary atherosclerosis was higher in higher HbA1c variability group compared with lower HbA1c variability group. Multivariable logistic regression analysis showed that higher HbA1c-SD and -CV were associated with the presence of subclinical coronary atherosclerosis, independent of mean HbA1c level in subjects with diabetes duration ≤10 years (OR [95% CI]; HbA1c-SD, 2.894 [1.105-7.584]; HbA1c-CV, 2.540 [1.022-6.316]). CONCLUSIONS Long-term stabilization of blood glucose level might be important in preventing subclinical coronary atherosclerosis in subjects with earlier period of type 2 diabetes.
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Affiliation(s)
- Hae Kyung Yang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Borami Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung-Hwan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kun-Ho Yoon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Hee Hwang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyungdo Han
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gunseog Kang
- Department of Statistics and Actuarial Science, Soongsil University
| | - Jae Hyoung Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Pallayova M, Mohammed A, Langman G, Taheri S, Dasgupta I. Predicting non-diabetic renal disease in type 2 diabetic adults: The value of glycated hemoglobin. J Diabetes Complications 2015; 29:718-23. [PMID: 25633572 DOI: 10.1016/j.jdiacomp.2014.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/28/2014] [Accepted: 12/08/2014] [Indexed: 11/17/2022]
Abstract
AIMS The indications for renal biopsy in type 2 diabetes mellitus (T2D) are not well established. We investigated the prevalence, spectrum, and predictors of biopsy-proven non-diabetic renal disease (NDRD) in T2D. METHODS An observational, single-center, retrospective study of T2D adults who underwent renal biopsies (N = 51) over 10 years for nephrotic-range proteinuria, microscopic hematuria, or rapidly declining renal function. RESULTS Thirty-five (68.6%) biopsies were diagnostic of NDRD, and 16 (31.4%) revealed isolated diabetic nephropathy. The most common NDRDs were interstitial nephritis (20%), progressive crescentic glomerulonephritis (14%), membranous nephropathy (11%), and focal segmental glomerulosclerosis (11%). The odds for NDRD declined by 97% in the presence of diabetic retinopathy (P < 0.001). The deterioration of HbA1c during the year before biopsy predicted NDRD even after adjusting for diabetic retinopathy (OR, 7.65; 95% CI, 1.36-123.04; P = 0.003). A model based on the interaction between the HbA1c values 12 months before biopsy and the absolute change in these values during the preceding year predicted NDRD with 73.7% sensitivity and 75% specificity (AUC, 0.77; 95% CI, 0.59-0.94). CONCLUSIONS This study demonstrated a considerably high prevalence of NDRD in T2D adults undergoing renal biopsy. The absence of diabetic retinopathy, lower HbA1c values 12 months before biopsy and greater deterioration in HbA1c prior to biopsy predicted NDRD in T2D. Further studies are needed to validate the findings.
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Affiliation(s)
- Maria Pallayova
- Renal Unit, Heartlands Hospital, Bordesley Green East, Birmingham, UK.
| | | | - Gerald Langman
- Department of Histopathology, Heartlands Hospital, Bordesley Green East, Birmingham, UK.
| | - Shahrad Taheri
- Collaborations for Leadership in Applied Health Research and Care for Birmingham and Black Country/National Institute for Health Research, University of Birmingham, Birmingham, UK; Diabetes Centre, Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital, Birmingham, UK.
| | - Indranil Dasgupta
- Renal Unit, Heartlands Hospital, Bordesley Green East, Birmingham, UK.
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Jun JE, Jin SM, Baek J, Oh S, Hur KY, Lee MS, Lee MK, Kim JH. The association between glycemic variability and diabetic cardiovascular autonomic neuropathy in patients with type 2 diabetes. Cardiovasc Diabetol 2015; 14:70. [PMID: 26041130 PMCID: PMC4462181 DOI: 10.1186/s12933-015-0233-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/26/2015] [Indexed: 12/31/2022] Open
Abstract
Background It is presently unclear whether glycemic variability is associated with diabetic cardiovascular autonomic neuropathy (CAN). The aim of this study was to examine whether short- and/or long-term glycemic variability (GV) contribute to CAN. Methods A total of 110 patients with type 2 diabetes who underwent three-day continuous glucose monitoring (CGM) completed five standardized autonomic neuropathy tests. Short-term GV was measured by the standard deviation (SD), coefficient of variation (CV) of glucose, and the mean amplitude of glycemic excursions (MAGE) in CGM. HbA1c variability was calculated from the intrapersonal SD, adjusted SD, and CV of serial HbA1c over 2-year period. CAN was defined as the presence of at least two abnormal parasympathetic function tests. The severity of CAN was evaluated by total scores of five autonomic function tests. Results In univariate analysis, not only SD and CV in CGM but also all parameters of HbA1c variability were significantly higher in the patients with CAN (n = 47, 42.7 %) than in those without CAN. In multivariate analysis, CV (Odds ratio [OR] 1.07, 95 % confidence interval [CI] 1.01–1.13; p = 0.033), but neither SD nor MAGE in CGM, independently correlated with the presence of CAN. All parameters of HbA1c variability, such as SD of HbA1c (OR 12.10 [95 % CI 2.29–63.94], p = 0.003), adjusted SD of HbA1c (OR 17.02 [95 % CI 2.66–108.86], p = 0.003), and log CV of HbA1c (OR 24.00 [95 % CI 3.09–186.48], p = 0.002), were significantly associated with the presence of CAN. The patients with higher HbA1c variability had an increased risk of advanced CAN. Conclusion CV in CGM and all parameters of HbA1c variability were independently associated with the presence of CAN in patients with inadequately controlled type 2 diabetes requiring CGM. Electronic supplementary material The online version of this article (doi:10.1186/s12933-015-0233-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ji Eun Jun
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 135-710, Republic of Korea.
| | - Sang-Man Jin
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 135-710, Republic of Korea.
| | - Jongha Baek
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Republic of Korea.
| | - Sewon Oh
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 135-710, Republic of Korea.
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 135-710, Republic of Korea.
| | - Myung-Shik Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 135-710, Republic of Korea.
| | - Moon-Kyu Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 135-710, Republic of Korea.
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 135-710, Republic of Korea.
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Parry HM, Deshmukh H, Levin D, Van Zuydam N, Elder DHJ, Morris AD, Struthers AD, Palmer CNA, Doney ASF, Lang CC. Both high and low HbA1c predict incident heart failure in type 2 diabetes mellitus. Circ Heart Fail 2015; 8:236-42. [PMID: 25561089 PMCID: PMC4366571 DOI: 10.1161/circheartfailure.113.000920] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Type 2 diabetes mellitus is an independent risk factor for heart failure development, but the relationship between incident heart failure and antecedent glycemia has not been evaluated. METHODS AND RESULTS The Genetics of Diabetes Audit and Research in Tayside Study study holds data for 8683 individuals with type 2 diabetes mellitus. Dispensed prescribing, hospital admission data, and echocardiography reports were linked to extract incident heart failure cases from December 1998 to August 2011. All available HbA1c measures until heart failure development or end of study were used to model HbA1c time-dependently. Individuals were observed from study enrolment until heart failure development or end of study. Proportional hazard regression calculated heart failure development risk associated with specific HbA1c ranges accounting for comorbidities associated with heart failure, including blood pressure, body mass index, and coronary artery disease. Seven hundred and one individuals with type 2 diabetes mellitus (8%) developed heart failure during follow up (mean 5.5 years, ±2.8 years). Time-updated analysis with longitudinal HbA1c showed that both HbA1c <6% (hazard ratio =1.60; 95% confidence interval, 1.38-1.86; P value <0.0001) and HbA1c >10% (hazard ratio =1.80; 95% confidence interval, 1.60-2.16; P value <0.0001) were independently associated with the risk of heart failure. CONCLUSIONS Both high and low HbA1c predicted heart failure development in our cohort, forming a U-shaped relationship.
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Affiliation(s)
- Helen M Parry
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom.
| | - Harshal Deshmukh
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Daniel Levin
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Natalie Van Zuydam
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Douglas H J Elder
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Andrew D Morris
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Allan D Struthers
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Colin N A Palmer
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Alex S F Doney
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Chim C Lang
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
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Saisho Y. β-cell dysfunction: Its critical role in prevention and management of type 2 diabetes. World J Diabetes 2015; 6:109-124. [PMID: 25685282 PMCID: PMC4317303 DOI: 10.4239/wjd.v6.i1.109] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 08/17/2014] [Accepted: 12/01/2014] [Indexed: 02/05/2023] Open
Abstract
Type 2 diabetes (T2DM) is characterized by insulin resistance and β-cell dysfunction. Although, in contrast to type 1 diabetes, insulin resistance is assumed to be a major pathophysiological feature of T2DM, T2DM never develops unless β-cells fail to compensate insulin resistance. Recent studies have revealed that a deficit of β-cell functional mass is an essential component of the pathophysiology of T2DM, implying that β-cell deficit is a common feature of both type 1 and type 2 diabetes. β-cell dysfunction is present at the diagnosis of T2DM and progressively worsens with disease duration. β-cell dysfunction is associated with worsening of glycemic control and treatment failure; thus, it is important to preserve or recover β-cell functional mass in the management of T2DM. Since β-cell regenerative capacity appears somewhat limited in humans, reducing β-cell workload appears to be the most effective way to preserve β-cell functional mass to date, underpinning the importance of lifestyle modification and weight loss for the treatment and prevention of T2DM. This review summarizes the current knowledge on β-cell functional mass in T2DM and discusses the treatment strategy for T2DM.
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Jin SM, Kim TH, Oh S, Baek J, Joung JY, Park SM, Cho YY, Sohn SY, Hur KY, Lee MS, Lee MK, Kim JH. Association between the extent of urinary albumin excretion and glycaemic variability indices measured by continuous glucose monitoring. Diabet Med 2015; 32:274-9. [PMID: 25307609 DOI: 10.1111/dme.12607] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 08/02/2014] [Accepted: 10/06/2014] [Indexed: 11/27/2022]
Abstract
AIMS The contribution of glycaemic variability to the microvascular complication of diabetes has not been established. We examined whether there is an independent association between indices of glycaemic variability in continuous glucose monitoring and extent of albuminuria. METHODS A total of 173 patients with Type 2 diabetes (without insulin therapy, n = 96; with insulin therapy, n = 77) who had unexplained large fluctuations in blood glucose values underwent three-day continuous glucose monitoring. We used a multinomial logistic regression model to determine whether the indices of glycaemic variability independently affected the odds of having a spot urine albumin/creatinine ratio of 30-299 mg/g and ≥ 300 mg/g. RESULTS Higher standard deviation (P = 0.002), mean of daily differences (P = 0.023) and mean amplitude of glycaemic excursion (P = 0.043) significantly increased the odds of having a urine albumin/creatinine ratio of ≥ 300 mg/g. In multivariable analysis, only higher standard deviation, but not mean amplitude of glycaemic excursion and mean of daily differences, independently increased the odds of having a urine albumin/creatinine ratio of ≥ 300 mg/g (P = 0.025). Coefficient of variation (sd/mean) was not associated with the odds of having a urine albumin/creatinine ratio of 30-299 or ≥ 300 mg/g. CONCLUSIONS The independent association between standard deviation and the extent of albuminuria was lost when the measures were normalized by mean glucose level. At least in terms of relative measures of glycaemic variability, we failed to demonstrate an independent association between glycaemic variability and albuminuria extent in patients with inadequately controlled Type 2 diabetes.
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Affiliation(s)
- S-M Jin
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Skriver MV, Sandbæk A, Kristensen JK, Støvring H. Relationship of HbA1c variability, absolute changes in HbA1c, and all-cause mortality in type 2 diabetes: a Danish population-based prospective observational study. BMJ Open Diabetes Res Care 2015; 3:e000060. [PMID: 25664182 PMCID: PMC4317527 DOI: 10.1136/bmjdrc-2014-000060] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/18/2014] [Accepted: 12/29/2014] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE We assessed the relationship of mortality with glycated hemoglobin (HbA1c) variability and with absolute change in HbA1c. DESIGN A population-based prospective observational study with a median follow-up time of 6 years. METHODS Based on a validated algorithm, 11 205 Danish individuals with type 2 diabetes during 2001-2006 were identified from public data files, with at least three HbA1c measurements: one index measure, one closing measure 22-26 months later, and one measurement in-between. Medium index HbA1c was 7.3%, median age was 63.9 years, and 48% were women. HbA1c variability was defined as the mean absolute residual around the line connecting index value with closing value. Cox proportional hazard models with restricted cubic splines were used, with all-cause mortality as the outcome. RESULTS Variability between 0 and 0.5 HbA1c percentage point was not associated with mortality, but for index HbA1c ≤8% (64 mmol/mol), a variability above 0.5 was associated with increased mortality (HR of 1 HbA1c percentage point variability was 1.3 (95% CI 1.1 to 1.5) for index HbA1c 6.6-7.4%). For index HbA1c≤8%, mortality increased when HbA1c declined, but was stable when HbA1c rose. For index HbA1c>8%, change in HbA1c was associated with mortality, with the lowest mortality for greatest decline (HR=0.9 (95% CI 0.80 to 0.98) for a 2-percentage point decrease). CONCLUSIONS For individuals with an index HbA1c below 8%, both high HbA1c variability and a decline in HbA1c were associated with increased mortality. For individuals with index HbA1c above 8%, change in HbA1c was associated with mortality, whereas variability was not.
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Affiliation(s)
- Mette V Skriver
- Department of Public Health , Health, Aarhus University , Aarhus C , Denmark
| | - Annelli Sandbæk
- Department of Public Health , Health, Aarhus University , Aarhus C , Denmark
| | - Jette K Kristensen
- Department of Public Health , Health, Aarhus University , Aarhus C , Denmark
| | - Henrik Støvring
- Department of Public Health , Health, Aarhus University , Aarhus C , Denmark
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Cheng D, Fei Y, Liu Y, Li J, Xue Q, Wang X, Wang N. HbA1C variability and the risk of renal status progression in Diabetes Mellitus: a meta-analysis. PLoS One 2014; 9:e115509. [PMID: 25521346 PMCID: PMC4270779 DOI: 10.1371/journal.pone.0115509] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 11/23/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To explore the association between glycated hemoglobin (A1C) variability and renal disease progression in patients with diabetes mellitus. METHODS A comprehensive search was performed using the PubMed and Embase databases (up to April 26, 2014). The hazard ratio (HR) was pooled per unit increase in the standard deviation of A1C (A1C-SD) to evaluate the dose-response relationship between A1C-SD and the risk of nephropathy. RESULTS Eight studies with a total of 17,758 subjects provided the HR for A1C-SD and were included in the final meta-analysis. The pooled HR results demonstrated that A1C-SD was significantly associated with the progression of renal status (HR for both T1DM and T2DM 1.43, 95% confidence interval [CI] 1.24-1.64; HR for T1DM 1.70, 95%CI 1.41-2.05; HR for T2DM 1.20, 95%CI 1.12-1.28). A1C-SD was significantly correlated with new-onset microalbuminuria (HR for T1DM 1.63, 95%CI 1.28-2.07; HR for T2DM 1.23, 95%CI 1.08-1.39). These outcomes were also supported in subgroup analyses. Furthermore, sensitivity analyses demonstrated that the results were robust. CONCLUSIONS A1C variability is independently associated with the development of microalbuminuria and the progression of renal status in both type 1 and 2 diabetes patients. A standard method for measuring A1C variability is essential for further and deeper analyses. In addition, future studies should assess the effect of reducing A1C variability on nephropathy complication.
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Affiliation(s)
- Dongsheng Cheng
- Department of Nephrology and Rheumatology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, P.R. China, 200233
| | - Yang Fei
- Department of Nephrology and Rheumatology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, P.R. China, 200233
| | - Yumei Liu
- Department of Nephrology and Rheumatology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, P.R. China, 200233
| | - Junhui Li
- Department of Nephrology and Rheumatology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, P.R. China, 200233
| | - Qin Xue
- Department of Nephrology and Rheumatology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, P.R. China, 200233
| | - Xiaoxia Wang
- Department of Nephrology and Rheumatology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, P.R. China, 200233
| | - Niansong Wang
- Department of Nephrology and Rheumatology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, P.R. China, 200233
- * E-mail:
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61
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Jia W. Glycated hemoglobin variability: A potential new risk marker for diabetes complications? J Diabetes Investig 2014; 5:635-6. [PMID: 25422761 PMCID: PMC4234224 DOI: 10.1111/jdi.12227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 02/19/2014] [Accepted: 02/20/2014] [Indexed: 11/28/2022] Open
Affiliation(s)
- Weiping Jia
- Department of Endocrinology and Metabolism Shanghai Jiaotong University Affiliated Sixth People's Hospital Shanghai Clinical Center for Diabetes Shanghai Key Laboratory of Diabetes Mellitus, and Shanghai Diabetes Institute Shanghai China
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62
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Saisho Y. Glycemic variability and oxidative stress: a link between diabetes and cardiovascular disease? Int J Mol Sci 2014; 15:18381-406. [PMID: 25314300 PMCID: PMC4227221 DOI: 10.3390/ijms151018381] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 09/16/2014] [Accepted: 09/28/2014] [Indexed: 02/06/2023] Open
Abstract
Diabetes is associated with a two to three-fold increase in risk of cardiovascular disease. However, intensive glucose-lowering therapy aiming at reducing HbA1c to a near-normal level failed to suppress cardiovascular events in recent randomized controlled trials. HbA1c reflects average glucose level rather than glycemic variability. In in vivo and in vitro studies, glycemic variability has been shown to be associated with greater reactive oxygen species production and vascular damage, compared to chronic hyperglycemia. These findings suggest that management of glycemic variability may reduce cardiovascular disease in patients with diabetes; however, clinical studies have shown conflicting results. This review summarizes the current knowledge on glycemic variability and oxidative stress, and discusses the clinical implications.
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Affiliation(s)
- Yoshifumi Saisho
- Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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63
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Smith-Palmer J, Brändle M, Trevisan R, Orsini Federici M, Liabat S, Valentine W. Assessment of the association between glycemic variability and diabetes-related complications in type 1 and type 2 diabetes. Diabetes Res Clin Pract 2014; 105:273-84. [PMID: 25023992 DOI: 10.1016/j.diabres.2014.06.007] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 04/28/2014] [Accepted: 06/15/2014] [Indexed: 12/21/2022]
Abstract
Chronic hyperglycemia is the main risk factor for the development of diabetes-related complications in both type 1 and type 2 diabetes, but it is thought that frequent or large glucose fluctuations may contribute independently to diabetes-related complications. A systematic literature review was performed using the PubMed, EMBASE and Cochrane Library databases with searches limited to studies published from June 2002 to March 2014, in English and including ≥50 patients. Twenty eight articles were included in the final review. Eighteen studies reported the association between glucose variability and diabetes-related complications exclusively in type 2 diabetes. A positive association between increased variability and microvascular complications and coronary artery disease was consistently reported. Associations between glucose variability and other macrovascular complications were inconsistent in type 2 diabetes. Seven studies examined the association between glucose variability and complications exclusively in type 1 diabetes. Increased glucose variability appears to play a minimal role in the development of micro- and macrovascular complications in type 1 diabetes. Consistent findings suggest that in type 2 diabetes glucose variability is associated with development of microvascular complications. The role of increased glucose variability in terms of microvascular and macrovascular complications in type 1 diabetes is less clear; more data in are needed.
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Affiliation(s)
- J Smith-Palmer
- Ossian Health Economics and Communications, Basel, Switzerland.
| | - M Brändle
- Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - R Trevisan
- Ospedali Riuniti di Bergamo, Bergamo, Italy
| | | | - S Liabat
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | - W Valentine
- Ossian Health Economics and Communications, Basel, Switzerland
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64
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Pugliese G, Solini A, Bonora E, Fondelli C, Orsi E, Nicolucci A, Penno G. Chronic kidney disease in type 2 diabetes: lessons from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study. Nutr Metab Cardiovasc Dis 2014; 24:815-822. [PMID: 24780515 DOI: 10.1016/j.numecd.2014.02.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 02/17/2014] [Accepted: 02/18/2014] [Indexed: 11/25/2022]
Abstract
The Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study is an ongoing observational survey that examines the role of estimated glomerular filtration rate (eGFR) as an independent predictor of cardiovascular and renal outcomes in 15,773 Italian subjects with type 2 diabetes. The analysis of data collected at the enrollment visit provided a picture of chronic kidney disease (CKD) and its association with other complications, risk factors for cardiovascular disease (CVD) and treatments in a large contemporary cohort. Main results of this analysis were that (a) non-albuminuric renal impairment is the predominant clinical phenotype in patients, particularly women, with reduced eGFR; (b) concordance between CKD and diabetic retinopathy is low, with only a minority of patients with renal dysfunction presenting with any or advanced retinal lesions; (c) the non-albuminuric form is associated with a significant prevalence of CVD, especially at the level of the coronary vascular bed; (d) CKD is associated with hemoglobin (Hb) A1c variability more than with average HbA1c, whereas retinopathy and CVD are not; (e) in elderly individuals with moderate-to-severe eGFR reduction, use of agents which are not recommended, such as sulphonylureas and metformin, is still frequent; and (f) though complications are generally more prevalent in men (except non-albuminuric renal impairment) women show a less favorable CVD risk profile and achieve therapeutic targets to a lesser extent than men, despite the fact that treatment intensity is not lower. These data update existing information on the natural history of CKD in patients with type 2 diabetes.
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Affiliation(s)
- G Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189 Rome, Italy.
| | - A Solini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - E Bonora
- Division of Endocrinology and Metabolic Diseases, University of Verona, Verona, Italy
| | - C Fondelli
- Diabetes Unit, Department of Internal Medicine, Endocrine and Metabolic Sciences and Biochemistry, University of Siena, Siena, Italy
| | - E Orsi
- Endocrinology and Diabetes Unit, Department of Medical Sciences, Fondazione IRCCS "Cà Granda - Ospedale Maggiore Policlinico", Milan, Italy
| | - A Nicolucci
- Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, S. Maria Imbaro, Chieti, Italy
| | - G Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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65
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Hirakawa Y, Arima H, Zoungas S, Ninomiya T, Cooper M, Hamet P, Mancia G, Poulter N, Harrap S, Woodward M, Chalmers J. Impact of visit-to-visit glycemic variability on the risks of macrovascular and microvascular events and all-cause mortality in type 2 diabetes: the ADVANCE trial. Diabetes Care 2014; 37:2359-65. [PMID: 24812434 DOI: 10.2337/dc14-0199] [Citation(s) in RCA: 245] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE There is no consensus on the importance of visit-to-visit glycemic variability in diabetes. Therefore, we assessed the effects of visit-to-visit variability (VVV) in HbA1c and fasting glucose on major outcomes in the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation) trial. RESEARCH DESIGN AND METHODS ADVANCE was a factorial randomized controlled trial of intensive glucose control and blood pressure lowering in patients with type 2 diabetes. VVV in the intensive glucose treatment group was defined using the SD of five measurements of HbA1c and glucose taken 3-24 months after randomization. Outcomes were combined macro- and microvascular events and all-cause mortality occurring post 24 months. Sensitivity analyses were performed using other indices of variability and in the standard glucose treatment group. RESULTS Among 4,399 patients in the intensive group, an increase in VVV of HbA1c was associated with an increased risk of vascular events (P = 0.01) and with mortality (P < 0.001): highest versus lowest tenth hazard ratio (95% CI) 1.64 (1.05-2.55) and 3.31 (1.57-6.98), respectively, after multivariable adjustment. A clear association was also observed between VVV of fasting glucose and increased risk of vascular events (P < 0.001; 2.70 [1.65-4.42]). HbA1c variability was positively associated with the risk of macrovascular events (P = 0.02 for trend), whereas glucose variability was associated with both macro- and microvascular events (P = 0.005 and P < 0.001 for trend, respectively). Sensitivity analyses using other indices, and patients in the standard glucose treatment group, were broadly consistent with these results. CONCLUSIONS Consistency of glycemic control is important to reduce the risks of vascular events and death in type 2 diabetes.
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Affiliation(s)
- Yoichiro Hirakawa
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Hisatomi Arima
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Sophia Zoungas
- The George Institute for Global Health, University of Sydney, Sydney, AustraliaSchool of Public Health, Monash University, Melbourne, Australia
| | - Toshiharu Ninomiya
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Mark Cooper
- Baker Heart Research Institute, Melbourne, Australia
| | - Pavel Hamet
- Centre Hospitalier de l'Université de Montreal and Université de Montreal, Montreal, Canada
| | | | - Neil Poulter
- Imperial College and St. Mary's Hospital, London, U.K
| | - Stephen Harrap
- University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | - Mark Woodward
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - John Chalmers
- The George Institute for Global Health, University of Sydney, Sydney, Australia
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66
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Chen L, Chuang LM, Chang CH, Wang CS, Wang IC, Chung Y, Peng HY, Chen HC, Hsu YL, Lin YS, Chen HJ, Chang TC, Jiang YD, Lee HC, Tan CT, Chang HL, Lai F. Evaluating self-management behaviors of diabetic patients in a telehealthcare program: longitudinal study over 18 months. J Med Internet Res 2013; 15:e266. [PMID: 24323283 PMCID: PMC3869106 DOI: 10.2196/jmir.2699] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 07/13/2013] [Accepted: 11/10/2013] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Self-management is an important skill for patients with diabetes, and it involves frequent monitoring of glucose levels and behavior modification. Techniques to enhance the behavior changes of diabetic patients have been developed, such as diabetes self-management education and telehealthcare. Although the patients are engaged in self-management activities, barriers to behavior changes remain and additional work is necessary to address the impact of electronic media and telehealthcare on patient self-care behaviors. OBJECTIVE The aims of this study were to (1) explore the behaviors of diabetic patients interacting with online applications, (2) determine the impact of a telehealthcare program among 7 self-care behaviors of the patients, and (3) determine the changes in glycosylated hemoglobin (HbA1c) levels. METHODS A telehealthcare program was conducted to assist the patients with 7 self-care activities. The telehealthcare program lasted for 18 months and included the use of a third-generation mobile telecommunications glucometer, an online diabetes self-management system, and a teleconsultant service. We analyzed the data of 59 patients who participated in the telehealthcare program and 103 who did not. The behavioral assessments and the HbA1c data were collected and statistically analyzed to determine whether the telehealthcare services had an impact on the patients. We divided the 18-month period into 3 6-month intervals and analyzed the parameters of patients assisted by the telehealthcare service at different time points. We also compared the results of those who were assisted by the telehealthcare service with those who were not. RESULTS There was a significant difference in monitoring blood glucose between the beginning and the end of the patient participation (P=.046) and between the overall period and the end of patient participation (P<.001). Five behaviors were significantly different between the intervention and control patients: being active (P<.001), healthy eating (P<.001), taking medication (P<.001), healthy coping (P=.02), and problem solving (P<.001). Monitoring of blood glucose was significantly different (P=.02) during the 6-12 month stage of patient participation between the intervention and control patients. A significant difference between the beginning and the 6-12 month stage of patient participation was observed for the mean value of HbA1c level (P=.02), and the differences between the overall HbA1c variability and the variability of each 6-month interval was also significant. CONCLUSIONS Telehealthcare had a positive effect on diabetic patients. This study had enhanced blood glucose monitoring, and the patients in the program showed improvements in glycemic control. The self-care behaviors affect patient outcomes, and the changes of behavior require time to show the effects.
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Affiliation(s)
- Lichin Chen
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan.
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67
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Lee EJ, Kim MK. Response: a1c variability can predict coronary artery disease in patients with type 2 diabetes with mean a1c level greater than 7 (endocrinol metab 2013;28:125-32, eun ju lee et Al.). Endocrinol Metab (Seoul) 2013; 28:348-9. [PMID: 24396703 PMCID: PMC3871032 DOI: 10.3803/enm.2013.28.4.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Eun Ju Lee
- Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Mi-Kyung Kim
- Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
- Paik Inje Memorial Institute for Clinical Medicine Research, Inje University College of Medicine, Busan, Korea
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68
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Jung HS. Letter: a1c variability can predict coronary artery disease in patients with type 2 diabetes with mean a1c level greater than 7 (endocrinol metab 2013;28:125-32, eun ju lee et Al.). Endocrinol Metab (Seoul) 2013; 28:346-7. [PMID: 24396702 PMCID: PMC3871030 DOI: 10.3803/enm.2013.28.4.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hye Seung Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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69
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Hsu YH, Huang MC, Chang HY, Shin SJ, Wahlqvist ML, Chang YL, Hsu KC, Hsu CC. Association between serum ferritin and microalbuminuria in Type 2 diabetes in Taiwan. Diabet Med 2013; 30:1367-73. [PMID: 23756251 DOI: 10.1111/dme.12257] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2013] [Indexed: 12/01/2022]
Abstract
AIMS Serum ferritin has been found closely related with diabetes and glucose metabolism, but its impact on diabetic nephropathy remains unknown. This study aimed to explore the association between serum ferritin and microalbuminuria in Type 2 diabetes. METHODS Eight hundred and fifty-one subjects with Type 2 diabetes were selected from a cohort participating in a glycaemic control study in Taiwan in 2008. We used urine albumin:creatinine ratio to define microalbuminuria; serum ferritin was divided into quartiles for analysis. Logistic regression and trend tests were used to delineate the association between serum ferritin and microalbuminuria. RESULTS Subjects with diabetes with higher ferritin tended to have more metabolic disorders, higher high-sensitivity C-reactive protein and higher prevalence of microalbuminuria. Compared with those in the lowest quartile, subjects with diabetes in the highest ferritin quartile were 55% (P = 0.029) more likely to have microalbuminuria. After controlling for demographics, metabolic profiles and other inflammatory markers, the association between serum ferritin levels and microalbuminuria remained significant (P for trend < 0.001). This independent relationship was not changed either for those who had better glycaemic control or those who had not used an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. CONCLUSIONS The current study shows hyperferritinemia may be an independent risk factor of nephropathy in patients with Type 2 diabetes.
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Affiliation(s)
- Y H Hsu
- Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi; Department of Health Services Administration, China Medical University, Taichung; Department of Nursing, Min-Hwei College of Health Care Management, Tainan
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70
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Chen WZ, Hung CC, Wen YW, Ning HC, Gau BR, Huang YY. Effect of glycemic control on microalbuminuria development among type 2 diabetes with high-normal albuminuria. Ren Fail 2013; 36:171-5. [DOI: 10.3109/0886022x.2013.832312] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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71
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Cavalot F. Do data in the literature indicate that glycaemic variability is a clinical problem? Glycaemic variability and vascular complications of diabetes. Diabetes Obes Metab 2013; 15 Suppl 2:3-8. [PMID: 24034513 DOI: 10.1111/dom.12140] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 04/25/2013] [Indexed: 01/29/2023]
Abstract
In recent years glycaemic variability (GV) has emerged as a determinant of vascular complications of both type 1 and type 2 diabetes mellitus. In type 1 diabetes analysis of data of GV show conflicting results on both micro- and macro-vascular complications. In non-diabetic subjects blood glucose after loading is a stronger predictor of cardiovascular complications than fasting glucose. In type 2 diabetes both coefficient of variation of fasting blood glucose and postprandial blood glucose predict cardiovascular events. Also, long term variability of HbA1c has been associated predominantly with diabetic nephropathy, less frequently with retinopathy. Intervention trials to evaluate the effect of postprandial glucose have been conducted only in prediabetes or in type 2 diabetes and the data are not conclusive. In vitro and in vivo data have shown the mechanisms that are at the basis of the adverse cardiovascular effects of GV, mainly associated with oxidative stress; the atherogenic action of postprandial glucose also involves insulin sensitivity, postprandial increase in serum lipids and glycaemic index of food. Thus, correction of GV emerges as a target to be pursued in clinical practice in order to safely reduce mean blood glucose (and thus glycated haemoglobin) and for its direct effects on vascular complications of diabetes.
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Affiliation(s)
- F Cavalot
- Internal Medicine and Metabolic Diseases Unit, San Luigi Gonzaga University Hospital, Turin, Italy
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72
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Penno G, Solini A, Bonora E, Fondelli C, Orsi E, Zerbini G, Morano S, Cavalot F, Lamacchia O, Laviola L, Nicolucci A, Pugliese G. HbA1c variability as an independent correlate of nephropathy, but not retinopathy, in patients with type 2 diabetes: the Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicenter study. Diabetes Care 2013; 36:2301-10. [PMID: 23491522 PMCID: PMC3714498 DOI: 10.2337/dc12-2264] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the association of hemoglobin (Hb) A1c variability with microvascular complications in the large cohort of subjects with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study. RESEARCH DESIGN AND METHODS Serial (3-5) HbA1c values collected in a 2-year period before enrollment were available from 8,260 subjects from 9 centers (of 15,773 patients from 19 centers). HbA1c variability was measured as the intraindividual SD of 4.52 ± 0.76 values. Diabetic retinopathy (DR) was assessed by dilated funduscopy. Chronic kidney disease (CKD) was defined based on albuminuria, as measured by immunonephelometry or immunoturbidimetry, and estimated glomerular filtration rate (eGFR) was calculated from serum creatinine. RESULTS Median and interquartile range of average HbA1c (HbA1c-MEAN) and HbA1c-SD were 7.57% (6.86-8.38) and 0.46% (0.29-0.74), respectively. The highest prevalence of microalbuminuria, macroalbuminuria, reduced eGFR, albuminuric CKD phenotypes, and advanced DR was observed when both HbA1c parameters were above the median and the lowest when both were below the median. Logistic regression analyses showed that HbA1c-SD adds to HbA1c-MEAN as an independent correlate of microalbuminuria and stages 1-2 CKD and is an independent predictor of macroalbuminuria, reduced eGFR, and stages 3-5 albuminuric CKD, whereas HbA1c-MEAN is not. The opposite was found for DR, whereas neither HbA1c-MEAN nor HbA1c-SD affected nonalbuminuric CKD. CONCLUSIONS In patients with type 2 diabetes, HbA1c variability affects (albuminuric) CKD more than average HbA1c, whereas only the latter parameter affects DR, thus suggesting a variable effect of these measures on microvascular complications.
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Affiliation(s)
- Giuseppe Penno
- Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
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73
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Penno G, Solini A, Zoppini G, Orsi E, Fondelli C, Zerbini G, Morano S, Cavalot F, Lamacchia O, Trevisan R, Vedovato M, Pugliese G. Hemoglobin A1c variability as an independent correlate of cardiovascular disease in patients with type 2 diabetes: a cross-sectional analysis of the renal insufficiency and cardiovascular events (RIACE) Italian multicenter study. Cardiovasc Diabetol 2013; 12:98. [PMID: 23829205 PMCID: PMC3750360 DOI: 10.1186/1475-2840-12-98] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 06/21/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous reports have clearly indicated a significant relationship between hemoglobin (Hb) A1c change from one visit to the next and microvascular complications, especially nephropathy (albuminuria and albuminuric chronic kidney disease, CKD). In contrast, data on macrovascular disease are less clear. This study was aimed at examining the association of HbA1c variability with cardiovascular disease (CVD) in the large cohort of subjects with type 2 diabetes from the Renal Insufficiency and Cardiovascular Events (RIACE) Italian Multicenter Study. METHODS Serial (3-5) HbA1c values obtained during the 2-year period preceding recruitment, including that obtained at the enrolment, were available from 8,290 subjects from 9 centers (out of 15,773 patients from 19 centers). Average HbA1c and HbA1c variability were calculated as the intra-individual mean (HbA1c-MEAN) and standard deviation (HbA1c-SD), respectively, of 4.52 ± 0.76 values. Prevalent CVD, total and by vascular bed, was assessed from medical history by recording previous documented major acute events. Diabetic retinopathy (DR) was assessed by dilated fundoscopy. CKD was defined based on albuminuria, as measured by immunonephelometry or immunoturbidimetry, and estimated glomerular filtration rate, as calculated from serum creatinine. RESULTS HbA1c-MEAN, but not HbA1c-SD, was significantly higher (P<0.0001) in subjects with history of any CVD (n. 2,133, 25.7%) than in those without CVD (n. 6,157, 74.3%). Median and interquartile range were 7.78 (7.04-8.56) and 7.49 (6.81-8.31), respectively, for HbA1c-MEAN, and 0.47 (0.29-0.75) and 0.46 (0.28-0.73), respectively, for HbA1c-SD. Logistic regression analyses showed that HbA1c-MEAN, but not HbA1c-SD (and independent of it), was a significant correlate of any CVD. Similar findings were observed in subjects with versus those without any coronary or cerebrovascular event or myocardial infarction. Conversely, none of these measures were associated with stroke, whereas both correlated with any lower limb vascular event and HbA1c-SD alone with ulceration/gangrene. All these associations were independent of known CVD risk factors and microvascular complications (DR and CKD). CONCLUSIONS In patients with type 2 diabetes, HbA1c variability has not a major impact on macrovascular complications, at variance with average HbA1c, an opposite finding as compared with microvascular disease, and particularly nephropathy. TRIAL REGISTRATION ClinicalTrials.Gov NCT00715481.
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Affiliation(s)
- Giuseppe Penno
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy
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74
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Huang YY, Lin KD, Jiang YD, Chang CH, Chung CH, Chuang LM, Tai TY, Ho LT, Shin SJ. Diabetes-related kidney, eye, and foot disease in Taiwan: An analysis of the nationwide data for 2000–2009. J Formos Med Assoc 2012; 111:637-44. [DOI: 10.1016/j.jfma.2012.09.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 09/06/2012] [Accepted: 09/07/2012] [Indexed: 10/27/2022] Open
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