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Donaghue KC, Marcovecchio ML, Wadwa RP, Chew EY, Wong TY, Calliari LE, Zabeen B, Salem MA, Craig ME. ISPAD Clinical Practice Consensus Guidelines 2018: Microvascular and macrovascular complications in children and adolescents. Pediatr Diabetes 2018; 19 Suppl 27:262-274. [PMID: 30079595 PMCID: PMC8559793 DOI: 10.1111/pedi.12742] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/27/2018] [Indexed: 12/25/2022] Open
Affiliation(s)
- Kim C Donaghue
- The Children's Hospital at Westmead, Westmead, NSW, Australia
- Discipline of Child and Adolescent Health, University of Sydney, Camperdown, Australia
| | | | - R P Wadwa
- University of Colorado School of Medicine, Denver, Colorado
| | - Emily Y Chew
- Division of Epidemiology and Clinical Applications, the National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Center, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | | | - Bedowra Zabeen
- Department of Paediatrics and Changing Diabetes in Children Program, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka, Bangladesh
| | - Mona A Salem
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Maria E Craig
- The Children's Hospital at Westmead, Westmead, NSW, Australia
- Discipline of Child and Adolescent Health, University of Sydney, Camperdown, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
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52
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Marcovecchio ML, Chiesa ST, Armitage J, Daneman D, Donaghue KC, Jones TW, Mahmud FH, Marshall SM, Neil HAW, Dalton RN, Deanfield J, Dunger DB, Acerini C, Ackland F, Anand B, Barrett T, Birrell V, Campbell F, Charakida M, Cheetham T, Chiesa S, Cooper C, Doughty I, Dutta A, Edge J, Gray A, Hamilton-Shield J, Mann N, Marcovecchio ML, Rayman G, Robinson JM, Russell-Taylor M, Sankar V, Smith A, Thalange N, Yaliwal C, Benitez-Aguirre P, Cameron F, Cotterill A, Couper J, Craig M, Davis E, Donaghue K, Jones TW, Verge C, Bergman P, Rodda C, Clarson C, Curtis J, Daneman D, Mahmud F, Sochett E, Marshall S, Armitage J, Bingley P, Van’t Hoff W, Dunger D, Dalton N, Daneman D, Neil A, Deanfield J, Jones T, Donaghue K, Baigent C, Emberson J, Flather M, Bilous R. Renal and Cardiovascular Risk According to Tertiles of Urinary Albumin-to-Creatinine Ratio: The Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT). Diabetes Care 2018; 41:1963-1969. [PMID: 30026334 DOI: 10.2337/dc18-1125] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 06/17/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Baseline data from the Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT) indicated that tertiles of urinary albumin-to-creatinine ratios (ACRs) in the normal range at age 10-16 years are associated with risk markers for diabetic nephropathy (DN) and cardiovascular disease (CVD). We aimed to determine whether the top ACR tertile remained associated with DN and CVD risk over the 2-4-year AdDIT study. RESEARCH DESIGN AND METHODS One hundred fifty adolescents (mean age 14.1 years [SD 1.6]) with baseline ACR in the upper tertile (high-ACR group) recruited to the AdDIT trial, who remained untreated, and 396 (age 14.3 years [1.6]) with ACR in the middle and lower tertiles (low-ACR group), who completed the parallel AdDIT observational study, were evaluated prospectively with assessments of ACR and renal and CVD markers, combined with carotid intima-media thickness (cIMT) at baseline and end of study. RESULTS After a median follow-up of 3.9 years, the cumulative incidence of microalbuminuria was 16.3% in the high-ACR versus 5.5% in the low-ACR group (log-rank P < 0.001). Cox models showed independent contributions of the high-ACR group (hazard ratio 4.29 [95% CI 2.08-8.85]) and HbA1c (1.37 [1.10-1.72]) to microalbuminuria risk. cIMT change from baseline was significantly greater in the high- versus low-ACR group (mean difference 0.010 mm [0.079], P = 0.006). Changes in estimated glomerular filtration rate, systolic blood pressure, and hs-CRP were also significantly greater in the high-ACR group (P < 0.05). CONCLUSIONS ACR at the higher end of the normal range at the age of 10-16 years is associated with an increased risk of progression to microalbuminuria and future CVD risk, independently of HbA1c.
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Affiliation(s)
| | - Scott T. Chiesa
- National Centre for Cardiovascular Prevention and Outcomes, University College London, London, U.K
| | - Jane Armitage
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, U.K
| | - Denis Daneman
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kim C. Donaghue
- Institute of Endocrinology and Diabetes, The Children’s Hospital at Westmead, University of Sydney, Camperdown, New South Wales, Australia
| | - Timothy W. Jones
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Farid H. Mahmud
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sally M. Marshall
- Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne, U.K
| | - H. Andrew W. Neil
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
| | - R. Neil Dalton
- Guy’s and St Thomas’ National Health Service Foundation Trust, London, U.K
| | - John Deanfield
- National Centre for Cardiovascular Prevention and Outcomes, University College London, London, U.K
| | - David B. Dunger
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
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53
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He W, Zhu W, Liu Y, Ye M, Wang H, Li W, Lin H, Liu D, Yao F. Left atrial diameter is associated with target organ damage in patients with type 2 diabetes mellitus. Int J Diabetes Dev Ctries 2018. [DOI: 10.1007/s13410-018-0665-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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54
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Costacou T, Crandell J, Kahkoska AR, Liese AD, Dabelea D, Lawrence JM, Pettitt DJ, Reynolds K, Mayer-Davis EJ, Mottl AK. Dietary Patterns Over Time and Microalbuminuria in Youth and Young Adults With Type 1 Diabetes: The SEARCH Nutrition Ancillary Study. Diabetes Care 2018; 41:1615-1622. [PMID: 29903846 PMCID: PMC6054499 DOI: 10.2337/dc18-0319] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/14/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We assessed the association between diet quality and microalbuminuria in youth-onset type 1 diabetes using three indices: a modified Mediterranean diet score for children and adolescents (mKIDMED), the Dietary Approaches to Stop Hypertension (DASH), and the Healthy Eating Index-2010 (HEI). RESEARCH DESIGN AND METHODS Youth and young adults from the SEARCH (SEARCH for Diabetes in Youth) Nutrition Ancillary Study (SNAS) diagnosed with type 1 diabetes in 2002-2008, who had repeated dietary assessments at baseline and follow-up visits and urine albumin-to-creatinine ratio (UACR) measured at the outcome visit (2012-2015) (n = 461), were selected for study. Regression models estimated the association between each longitudinally assessed diet score and UACR and microalbuminuria (UACR ≥30 μg/mg). RESULTS The cohort was 43% female, and at follow-up, mean age was 20 years, disease duration was 108 months, and 7% had microalbuminuria. Adherence to a higher-quality diet was low for the mKIDMED (mean 3.7 of a possible range of -3 to 12) and the DASH (mean 42 of 80) and better, for the HEI (mean 56.3 of 100). A borderline inverse association was observed between the HEI score and microalbuminuria after adjustment for caloric and protein intake and demographic and disease factors (odds ratio [OR]HEI 0.83, P = 0.07), which lost significance with further adjustment for HbA1c and systolic blood pressure (ORHEI 0.86, P = 0.19). Results were similar for continuous UACR. No significant associations were observed for diet quality characterized by the mKIDMED or DASH indices. CONCLUSIONS Greater adherence to the HEI may be beneficial for kidney health in youth and young adults with type 1 diabetes. Low adherence to the mKIDMED and DASH diets may explain the lack of association with microalbuminuria.
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Affiliation(s)
- Tina Costacou
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Jamie Crandell
- Department of Biostatistics, University of North Carolina Chapel Hill School of Nursing, Chapel Hill, NC
| | - Anna R Kahkoska
- Department of Biostatistics, University of North Carolina Chapel Hill School of Nursing, Chapel Hill, NC
| | - Angela D Liese
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC
| | - Dana Dabelea
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jean M Lawrence
- Department of Research & Evaluation, Kaiser Permanente Southern California, Santa Barbara, CA
| | - David J Pettitt
- Department of Research & Evaluation, Kaiser Permanente Southern California, Santa Barbara, CA
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Santa Barbara, CA
| | - Elizabeth J Mayer-Davis
- Departments of Nutrition and Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Amy K Mottl
- UNC Kidney Center, Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC
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55
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Ahmadizar F, Maitland-van der Zee AH. AdDIT Editorial comment-challenges in medication treatment of renal and cardiovascular diseases and risk factors in adolescents with type 1 diabetes. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:193. [PMID: 29951515 DOI: 10.21037/atm.2018.03.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Fariba Ahmadizar
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anke H Maitland-van der Zee
- Department of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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56
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Garofolo M, Russo E, Miccoli R, Lucchesi D, Giusti L, Sancho-Bornez V, Daniele G, Del Prato S, Penno G. Albuminuric and non-albuminuric chronic kidney disease in type 1 diabetes: Association with major vascular outcomes risk and all-cause mortality. J Diabetes Complications 2018; 32:550-557. [PMID: 29705091 DOI: 10.1016/j.jdiacomp.2018.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/23/2018] [Accepted: 03/25/2018] [Indexed: 12/17/2022]
Abstract
AIMS Albuminuric and non-albuminuric phenotypes of chronic kidney disease (CKD) may have different cardiovascular risk and survival in type 1 diabetes (T1DM). Herein we estimated risk of major vascular outcomes by the EURODIAB PCS score and determined all-cause mortality rate in 774 T1DM according to CKD phenotypes. METHODS We evaluated the distribution of CKD phenotypes [no CKD, stages 1-2, non-albuminuric stage ≥3 (Alb-CKD), albuminuric stage ≥3 (Alb+CKD)], the EURODIAB risk score for major vascular outcomes [low- (LS), intermediate- (IS), and high- (HS) risk] and all-cause mortality over a follow-up of 8.25 ± 2.34 years. RESULTS Out of 774 subjects, 692 (89.4%) had no CKD, 53 (6.8%) CKD stages 1-2, 17 (2.2%) Alb-CKD and 12 (1.6%) Alb+CKD; 466 (60.2%) had LS, 205 (26.5%) IS and 103 (13.3%) HS. Distribution of HS was: no CKD, 9.1%; CKD stages 1-2, 34.0%; Alb-CKD, 64.7%; Alb+CKD, 91.7% (P < 0.0001). Mortality increased from no CKD, 3.0%; to stages 1-2, 15.1% (HR 4.504); Alb-CKD, 29.4% (8.573); Alb+CKD, 50.0% (20.683, P < 0.0001). Accounting for age and sex, HRs for mortality compared to no CKD were: CKD stages 1-2, 3.84 (P = 0.001); Alb-CKD, 2.97 (P = 0.046); Alb+CKD, 7.44 (P < 0.0001). Adjusting for sex and the EURODIAB score, HRs for mortality compared to no CKD were: CKD stages 1-2, 2.57 (P = 0.027); Alb-CKD, 2.77 (P = 0.058); Alb+CKD, 4.58 (P = 0.003). CONCLUSIONS In our T1DM cohort, one fifth of those with CKDs were non-albuminuric. This phenotype was associated with higher risk of major outcomes and similar rate of mortality as compared to CKD stages 1-2. The greatest risk and highest mortality occur in patients with Alb+CKD.
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Affiliation(s)
- Monia Garofolo
- Diabetes and Metabolic Disease Section, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 2 Via Paradisa, 56124 Pisa, Italy
| | - Eleonora Russo
- Diabetes and Metabolic Disease Section, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 2 Via Paradisa, 56124 Pisa, Italy
| | - Roberto Miccoli
- Diabetes and Metabolic Disease Section, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 2 Via Paradisa, 56124 Pisa, Italy
| | - Daniela Lucchesi
- Diabetes and Metabolic Disease Section, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 2 Via Paradisa, 56124 Pisa, Italy
| | - Laura Giusti
- Diabetes and Metabolic Disease Section, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 2 Via Paradisa, 56124 Pisa, Italy
| | - Veronica Sancho-Bornez
- Diabetes and Metabolic Disease Section, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 2 Via Paradisa, 56124 Pisa, Italy
| | - Giuseppe Daniele
- Diabetes and Metabolic Disease Section, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 2 Via Paradisa, 56124 Pisa, Italy
| | - Stefano Del Prato
- Diabetes and Metabolic Disease Section, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 2 Via Paradisa, 56124 Pisa, Italy.
| | - Giuseppe Penno
- Diabetes and Metabolic Disease Section, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 2 Via Paradisa, 56124 Pisa, Italy
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Carbonell M, Castelblanco E, Valldeperas X, Betriu À, Traveset A, Granado-Casas M, Hernández M, Vázquez F, Martín M, Rubinat E, Lecube A, Franch-Nadal J, Fernández E, Puig-Domingo M, Avogaro A, Alonso N, Mauricio D. Diabetic retinopathy is associated with the presence and burden of subclinical carotid atherosclerosis in type 1 diabetes. Cardiovasc Diabetol 2018; 17:66. [PMID: 29728117 PMCID: PMC5935933 DOI: 10.1186/s12933-018-0706-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 04/18/2018] [Indexed: 02/07/2023] Open
Abstract
Background Cardiovascular (CV) disease due to atherosclerosis is a major cause of morbidity and mortality in adult patients with diabetes, either type 1 or type 2 diabetes. The aim of the study was to assess the association of the frequency and the burden of subclinical carotid atherosclerotic disease in patients with type 1 diabetes according to the presence and severity of diabetic retinopathy (DR). Methods A cross-sectional study was conducted in 340 patients with type 1 diabetes (41.5% with DR), and in 304 non-diabetic individuals. All participants were free from previous CV disease and chronic kidney disease (CKD). B-mode carotid ultrasound imaging was performed in all the study subjects. Patients with type 1 diabetes underwent a full eye examination, and DR patients were divided into two groups: mild disease and advanced disease. Results In the group of patients with type 1 diabetes, the percentage of patients with carotid plaques was higher in those with DR compared with those without DR (44.7% vs. 24.1%, p < 0.001). Patients with DR also presented a higher incidence of ≥ 2 carotid plaques (25.5% vs. 11.1%, p < 0.001). Apart from other traditional cardiovascular risk factors, the presence of advanced stages of DR was independently associated with the presence (p = 0.044) and the burden (≥ 2 carotid plaques; p = 0.009) of subclinical carotid atherosclerosis. Conclusions In patients with type 1 diabetes without previous CV disease or established CKD, the presence of advanced stages of DR is associated with a higher atherosclerotic burden in the carotid arteries. The presence of DR identifies patients at risk for carotid atherosclerotic disease. Electronic supplementary material The online version of this article (10.1186/s12933-018-0706-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marc Carbonell
- Department of Ophthalmology, University Hospital Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Barcelona Autonomous University (UAB), Barcelona, Spain.,Department of Surgery, Barcelona Autonomous University (UAB), Barcelona, Spain
| | - Esmeralda Castelblanco
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain.,Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain
| | - Xavier Valldeperas
- Department of Ophthalmology, University Hospital Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Barcelona Autonomous University (UAB), Barcelona, Spain.,Department of Surgery, Barcelona Autonomous University (UAB), Barcelona, Spain
| | - Àngels Betriu
- Biomedical Research Institute of Lleida, Lleida, Spain
| | - Alícia Traveset
- Department of Ophthalmology, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Minerva Granado-Casas
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain.,Biomedical Research Institute of Lleida, Lleida, Spain
| | - Marta Hernández
- Biomedical Research Institute of Lleida, Lleida, Spain.,Department of Endocrinology and Nutrition, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Federico Vázquez
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain
| | - Mariona Martín
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain
| | | | - Albert Lecube
- Biomedical Research Institute of Lleida, Lleida, Spain.,Department of Endocrinology and Nutrition, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Josep Franch-Nadal
- Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain.,Primary Health Care Center Raval Sud, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
| | | | - Manel Puig-Domingo
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain.,Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain.,Department of Medicine, Barcelona Autonomous University (UAB), Barcelona, Spain
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padua, Italy
| | - Núria Alonso
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain. .,Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain. .,Biomedical Research Institute of Lleida, Lleida, Spain. .,Department of Medicine, Barcelona Autonomous University (UAB), Barcelona, Spain.
| | - Dídac Mauricio
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain. .,Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain. .,Biomedical Research Institute of Lleida, Lleida, Spain. .,Department of Medicine, Barcelona Autonomous University (UAB), Barcelona, Spain.
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Jansson FJ, Forsblom C, Harjutsalo V, Thorn LM, Wadén J, Elonen N, Ahola AJ, Saraheimo M, Groop PH. Regression of albuminuria and its association with incident cardiovascular outcomes and mortality in type 1 diabetes: the FinnDiane Study. Diabetologia 2018; 61:1203-1211. [PMID: 29423580 DOI: 10.1007/s00125-018-4564-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
Abstract
AIMS/HYPOTHESIS Our aim was to assess regression of albuminuria and its clinical consequences in type 1 diabetes. METHODS The analysis included 3642 participants from the Finnish Diabetic Nephropathy (FinnDiane) Study with a 24 h urine sample and a history of albuminuria available at baseline. A total of 2729 individuals had normal AER, 438 a history of microalbuminuria and 475 a history of macroalbuminuria. Regression was defined as a change from a higher category of albuminuria pre-baseline to a lower category in two out of the three most recent urine samples at baseline. The impact of regression on cardiovascular events (myocardial infarction, stroke, coronary procedure) and mortality was analysed over a follow-up of 14.0 years (interquartile range 11.9-15.9). RESULTS In total, 102 (23.3%) individuals with prior microalbuminuria and 111 (23.4%) with prior macroalbuminuria had regressed at baseline. For individuals with normal AER as a reference, the age-adjusted HRs (95% CI) for cardiovascular events were 1.42 (0.75, 2.68) in individuals with regression from microalbuminuria, 2.62 (1.95, 3.54) in individuals with sustained microalbuminuria, 3.15 (2.02, 4.92) in individuals with regression from macroalbuminuria and 5.49 (4.31, 7.00) in individuals with sustained macroalbuminuria. Furthermore, for all-cause and cardiovascular mortality rates, HRs in regressed individuals were comparable with those with sustained renal status at the achieved level (i.e. those who did not regress but remained at the most advanced level of albuminuria noted pre-baseline). CONCLUSIONS/INTERPRETATION Progression of diabetic nephropathy confers an increased risk for cardiovascular disease and premature death. Notably, regression reduces the risk to the same level as for those who did not progress.
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Affiliation(s)
- Fanny J Jansson
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Haartmaninkatu 8, FIN - 00290, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Carol Forsblom
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Haartmaninkatu 8, FIN - 00290, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Valma Harjutsalo
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Haartmaninkatu 8, FIN - 00290, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
- The Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Lena M Thorn
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Haartmaninkatu 8, FIN - 00290, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Johan Wadén
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Haartmaninkatu 8, FIN - 00290, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Nina Elonen
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Haartmaninkatu 8, FIN - 00290, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Aila J Ahola
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Haartmaninkatu 8, FIN - 00290, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Markku Saraheimo
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Haartmaninkatu 8, FIN - 00290, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Haartmaninkatu 8, FIN - 00290, Helsinki, Finland.
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.
- Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland.
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia.
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Yang L, Zhang Q, Wu Q, Wei Y, Yu J, Mu J, Zhang J, Zeng W, Feng B. Effect of TET2 on the pathogenesis of diabetic nephropathy through activation of transforming growth factor β1 expression via DNA demethylation. Life Sci 2018; 207:127-137. [PMID: 29705354 DOI: 10.1016/j.lfs.2018.04.044] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 12/13/2022]
Abstract
AIMS Transforming growth factor β1 (TGFβ1) plays a pivotal role in the pathogenesis of diabetic nephropathy (DN). However, the mechanism of its expression and activation induced by high glucose (HG) is still unclear. We mainly explored the role of ten-eleven translocation enzyme-2 (TET2) in regulating TGFβ1 expression in the process of DN. MAIN METHODS Human mesangial cells (HMCs) and db/db mice were used to analyze the biological effects of hyperglycemia both in vivo and in vitro. Gene expression levels, cell proliferation, protein recruitment levels to TGFβ1 regulatory region, DNA methylation statues and pathological changes in kidney were tested in different groups. Short hairpin RNA(shRNA) and oral inhibitor were used to knock down or inhibit TET2 expression. KEY FINDINGS Our study demonstrated that TET2 expression was increased in the renal cortex of db/db mice and in HMCs inducing by HG. We also found that TET2 binding was increased while DNA methylation of CpG islands was reduced in the TGFβ1 regulation region in HG, resulting in the increased expression level of TGFβ1 and cell phenotype transformation. More importantly, clinical research revealed that gradually decreased DNA methylation in the TGFβ1 regulatory region was also present in patients with diabetes and DN. SIGNIFICANCE Our work suggests that TET2 plays an important role in the pathogenesis of DN by activating TGFβ1 expression through demethylation of CpG islands in the TGFβ1 regulatory region. This may provide a potential new therapeutic target for DN.
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Affiliation(s)
- Liling Yang
- Department of Nephrology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, PR China; MianYang Central Hospital, MianYang, SiChuan 621000, PR China
| | - Qian Zhang
- Department of Nephrology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, PR China
| | - Qiong Wu
- Department of Nephrology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, PR China
| | - Yi Wei
- Department of Nephrology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, PR China
| | - Jiawei Yu
- Department of Nephrology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, PR China
| | - Jiao Mu
- Department of Nephrology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, PR China
| | - Jun Zhang
- Department of Nephrology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, PR China
| | - Wei Zeng
- Department of Nephrology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, PR China
| | - Bing Feng
- Department of Nephrology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, PR China.
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Yoldas T, Orun UA, Sağsak E, Aycan Z, Kaya Ö, Ozgur S, Karademir S. Reply. Echocardiography 2018; 35:580. [PMID: 29679448 DOI: 10.1111/echo.13889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Tamer Yoldas
- Pediatric Cardiology, Dr. Sami Ulus Maternity, Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Utku Arman Orun
- Pediatric Cardiology, Dr. Sami Ulus Maternity, Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Elif Sağsak
- Pediatric Endocrinology, Dr. Sami Ulus Maternity, Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Zehra Aycan
- Pediatric Endocrinology, Dr. Sami Ulus Maternity, Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Özkan Kaya
- Pediatric Cardiology, Dr. Sami Ulus Maternity, Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Senem Ozgur
- Pediatric Cardiology, Dr. Sami Ulus Maternity, Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Selmin Karademir
- Pediatric Cardiology, Dr. Sami Ulus Maternity, Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
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Chen NC, Chen CH, Lin TK, Chen SD, Tsai MH, Chang CC, Tsai WC, Chuang YC. Risk of Microangiopathy in Patients with Epilepsy under Long-term Antiepileptic Drug Therapy. Front Neurol 2018; 9:113. [PMID: 29593629 PMCID: PMC5857530 DOI: 10.3389/fneur.2018.00113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 02/14/2018] [Indexed: 01/04/2023] Open
Abstract
Background Long-term antiepileptic drug (AED) therapy is considered a risk factor of atherosclerosis. Furthermore, the duration of therapy contributes to acceleration of large-vessel atherosclerosis. Therefore, in this study, we tested the hypothesis that long-term AED therapy plays a crucial role in the pathogenesis of microangiopathy in patients with epilepsy. Methods We recruited 120 patients with epilepsy (age, 18–60 years) and 40 healthy controls. Optical coherence tomography (OCT) was used to measure the central macular thickness and diameters of the retinal artery and vein to evaluate atherosclerotic retinopathy; microalbumin and creatinine levels in urine were assessed to evaluate atherosclerotic nephropathy. In addition, high-sensitivity C-reactive protein (hs-CRP), lipid profiles, homocysteine, folate, uric acid, and body mass index were determined. Results The ratio of urine albumin to creatine and OCT findings showed that patients with epilepsy had higher abnormal microalbuminuria and narrowing retinal vein diameters, respectively. Multiple linear regression analysis showed that increased triglyceride and hs-CRP levels might contribute to microalbuminuria. In addition, serum creatinine, duration of AED therapy, enzyme-inducing AED therapy, and duration of enzyme-inducing AED therapy were candidate risk factors for retinal vein narrowing. Conclusion Patients with epilepsy are at a higher risk for microangiopathy presented as retinopathy and nephropathy. Long-term AED therapy, particularly with enzyme-inducing AEDs; high triglyceride levels, and inflammatory processes play an important role in the development of microangiopathy in patients with epilepsy.
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Affiliation(s)
- Nai-Ching Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Hsin Chen
- Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsu-Kung Lin
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shang-Der Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Meng-Han Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chiung-Chih Chang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wan-Chen Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao-Chung Chuang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Biological Science, National Sun Yat-sen University, Kaohsiung, Taiwan
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62
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Garlo KG, White WB, Bakris GL, Zannad F, Wilson CA, Kupfer S, Vaduganathan M, Morrow DA, Cannon CP, Charytan DM. Kidney Biomarkers and Decline in eGFR in Patients with Type 2 Diabetes. Clin J Am Soc Nephrol 2018; 13:398-405. [PMID: 29339356 PMCID: PMC5967667 DOI: 10.2215/cjn.05280517] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 12/04/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Biomarkers may improve identification of individuals at risk of eGFR decline who may benefit from intervention or dialysis planning. However, available biomarkers remain incompletely validated for risk stratification and prediction modeling. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined serum cystatin C, urinary kidney injury molecule-1 (uKIM-1), and urinary neutrophil gelatinase-associated lipocalin (UNGAL) in 5367 individuals with type 2 diabetes mellitus and recent acute coronary syndromes enrolled in the Examination of Cardiovascular Outcomes with Alogliptin versus Standard of Care (EXAMINE) trial. Baseline concentrations and 6-month changes in biomarkers were also evaluated. Cox proportional regression was used to assess associations with a 50% decrease in eGFR, stage 5 CKD (eGFR<15 ml/min per 1.73 m2), or dialysis. RESULTS eGFR decline occurred in 98 patients (1.8%) over a median of 1.5 years. All biomarkers individually were associated with higher risk of eGFR decline (P<0.001). However, when adjusting for baseline eGFR, proteinuria, and clinical factors, only baseline cystatin C (adjusted hazard ratio per 1 SD change, 1.66; 95% confidence interval, 1.41 to 1.96; P<0.001) and 6-month change in urinary neutrophil gelatinase-associated lipocalin (adjusted hazard ratio per 1 SD change, 1.07; 95% confidence interval, 1.02 to 1.12; P=0.004) independently associated with CKD progression. A base model for predicting kidney function decline with nine standard risk factors had strong discriminative ability (C-statistic 0.93). The addition of baseline cystatin C improved discrimination (C-statistic 0.94), but it failed to reclassify risk categories of individuals with and without eGFR decline. CONCLUSIONS The addition of cystatin C or biomarkers of tubular injury did not meaningfully improve the prediction of eGFR decline beyond common clinical factors and routine laboratory data in a large cohort of patients with type 2 diabetes and recent acute coronary syndrome. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_01_16_CJASNPodcast_18_3_G.mp3.
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Affiliation(s)
- Katherine G. Garlo
- Division of Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts
- Department of Medicine, Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - William B. White
- Division of Hypertension and Clinical Pharmacology, Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut
| | - George L. Bakris
- Department of Medicine and American Society of Hypertension Comprehensive Hypertension Center University of Chicago, University of Chicago School of Medicine, Chicago, Illinois
| | - Faiez Zannad
- Department of Medicine, Universite de Lorraine and Centre Hospitalier Universitaire, Nancy, France
| | - Craig A. Wilson
- Division of Cardiovascular and Metabolic Diseases, Takeda Development Center Americas, Inc., Deerfield, Illinois; and
| | - Stuart Kupfer
- Division of Cardiovascular and Metabolic Diseases, Takeda Development Center Americas, Inc., Deerfield, Illinois; and
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David A. Morrow
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher P. Cannon
- Division of Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David M. Charytan
- Division of Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts
- Department of Medicine, Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
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Subramanian S, Hirsch IB. Intensive Diabetes Treatment and Cardiovascular Outcomes in Type 1 Diabetes Mellitus: Implications of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study 30-Year Follow-up. Endocrinol Metab Clin North Am 2018; 47:65-79. [PMID: 29407057 DOI: 10.1016/j.ecl.2017.10.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Type 1 diabetes mellitus, an autoimmune disorder characterized by beta-cell destruction and absolute insulin deficiency, is associated with significantly increased cardiovascular disease risk but the mechanisms underlying this enhanced risk are unclear. Results of the pivotal Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications study have shown that compared to conventional therapy, intensive glycemic control results in decreased cardiovascular morbidity and mortality. Evidence from this study also revealed contributions of blood pressure, renal disease, body weight, and lipids to cardiovascular disease in type 1 diabetes mellitus. Extrapolating from existing evidence, this article addresses clinical strategies to mitigate cardiovascular risks.
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Affiliation(s)
- Savitha Subramanian
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, 4245 Roosevelt Way Northeast, Box 354691, Seattle, WA 98105, USA.
| | - Irl B Hirsch
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, 4245 Roosevelt Way Northeast, Box 354691, Seattle, WA 98105, USA
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Sun W, Yang J, Wang W, Hou J, Cheng Y, Fu Y, Xu Z, Cai L. The beneficial effects of Zn on Akt-mediated insulin and cell survival signaling pathways in diabetes. J Trace Elem Med Biol 2018; 46:117-127. [PMID: 29413101 DOI: 10.1016/j.jtemb.2017.12.005] [Citation(s) in RCA: 38] [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: 07/01/2017] [Revised: 12/06/2017] [Accepted: 12/21/2017] [Indexed: 12/11/2022]
Abstract
Zinc is one of the essential trace elements and participates in numerous physiological processes. Abnormalities in zinc homeostasis often result in the pathogenesis of various chronic metabolic disorders, such as diabetes and its complications. Zinc has insulin-mimetic and anti-diabetic effects and deficiency has been shown to aggravate diabetes-induced oxidative stress and tissue injury in diabetic rodent models and human subjects with diabetes. Akt signaling pathway plays a central role in insulin-stimulated glucose metabolism and cell survival. Anti-diabetic effects of zinc are largely dependent on the activation of Akt signaling. Zn is also an inducer of metallothionein that plays important role in anti-oxidative stress and damage. However, the exact molecular mechanisms underlying zinc-induced activation of Akt signaling pathway remains to be elucidated. This review summarizes the recent advances in deciphering the possible mechanisms of zinc on Akt-mediated insulin and cell survival signaling pathways in diabetes conditions. Insights into the effects of zinc on epigenetic regulation and autophagy in diabetic nephropathy are also discussed in the latter part of this review.
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Affiliation(s)
- Weixia Sun
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, 130021, China.
| | - Jiaxing Yang
- Department of Gastrointestinal Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Wanning Wang
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, 130021, China; Pediatric Research Institute, The Departments of Pediatrics, Radiation Oncology, Pharmacology and Toxicology, The University of Louisville, Louisville, KY 40202, USA
| | - Jie Hou
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Yanli Cheng
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Yaowen Fu
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Zhonggao Xu
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, 130021, China.
| | - Lu Cai
- Pediatric Research Institute, The Departments of Pediatrics, Radiation Oncology, Pharmacology and Toxicology, The University of Louisville, Louisville, KY 40202, USA
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Jun M, Ohkuma T, Zoungas S, Colagiuri S, Mancia G, Marre M, Matthews D, Poulter N, Williams B, Rodgers A, Perkovic V, Chalmers J, Woodward M. Changes in Albuminuria and the Risk of Major Clinical Outcomes in Diabetes: Results From ADVANCE-ON. Diabetes Care 2018; 41:163-170. [PMID: 29079715 DOI: 10.2337/dc17-1467] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 09/26/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the association between 2-year changes in urine albumin-to-creatinine ratio (UACR) and the risk of clinical outcomes in type 2 diabetes. RESEARCH DESIGN AND METHODS We analyzed data from 8,766 participants in the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation Post-Trial Observational Study (ADVANCE-ON). Change in UACR was calculated from UACR measurements 2 years apart, classified into three groups: decrease in UACR of ≥30%, minor change, and increase in UACR of ≥30%. By analyzing changes from baseline UACR groups, categorized into thirds, we repeated these analyses accounting for regression to the mean (RtM). The primary outcome was the composite of major macrovascular events, renal events, and all-cause mortality; secondary outcomes were these components. Cox regression models were used to estimate hazard ratios (HRs). RESULTS Over a median follow-up of 7.7 years, 2,191 primary outcomes were observed. Increases in UACR over 2 years independently predicted a greater risk of the primary outcome (HR for ≥30% UACR increase vs. minor change: 1.26; 95% CI 1.13-1.41), whereas a decrease in UACR was not significantly associated with lower risk (HR 0.93; 95% CI 0.83-1.04). However, after allowing for RtM, the effect of "real" decrease in UACR on the primary outcome was found to be significant (HR 0.84; 95% CI 0.75-0.94), whereas the estimated effect on an increase was unchanged. CONCLUSIONS Changes in UACR predicted changes in the risk of major clinical outcomes and mortality in type 2 diabetes, supporting the prognostic utility of monitoring albuminuria change over time.
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Affiliation(s)
- Min Jun
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Toshiaki Ohkuma
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Sophia Zoungas
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stephen Colagiuri
- Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Giuseppe Mancia
- Istituto Auxologico Italiano, University of Milano-Bicocca, Milan, Italy
| | - Michel Marre
- INSERM, UMR S1138, Centre de Recherche des Cordeliers, Paris, France.,Department of Diabetology, Endocrinology and Nutrition, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, DHU FIRE, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France
| | - David Matthews
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
| | - Neil Poulter
- International Centre for Circulatory Health, Imperial College, London, U.K
| | - Bryan Williams
- Institute of Cardiovascular Sciences, University College London (UCL) and National Institute of Health Research UCL Hospitals Biomedical Research Centre, London, U.K
| | - Anthony Rodgers
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - John Chalmers
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Mark Woodward
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia.,The George Institute for Global Health, University of Oxford, Oxford, U.K.,Department of Epidemiology, Johns Hopkins University, Baltimore, MD
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Osama M, Mahmoud R, Said A. Microalbuminuria besides to urinary enzymatic protein levels increase in Diabetic kidney disease with type II diabetics. SANAMED 2018. [DOI: 10.24125/sanamed.v13i2.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Diabetic kidney disease (DKD) is a time progressive problem, give rise in uncontrolled Diabetics increasing risks for chronic kidney disease (CKD) and/or end-stage renal disease (ESRD). The vulnerability to renal dysfunction manifested with sudden glomerular hypofiltration associated with micro-to macroalbuminuria passing to renal failure. So that, screening of specific enzymes shifts, or urinary albumin may predict onset diabetic nephropathy. Objective: The assessment of urinary alkaline phosphatase (ALP), alanine aminopeptidase (AAP), acid phosphatase (ACP) and microalbuminuria (MAU) for type II diabetic patients. Patients and Methods: In this study,120 type II diabetic patients were compared to 90 healthy volunteers of matched age and sex in Al-Leith General Hospital, Al-Leith Kidney Unit (AKU), Al-Leith, Makkah area, KSA in which random urine samples were collected for testing of MAU, ALP, AAP, ACP and Cr. Results: Mean values of measured biomarkers in patient group for MAU, ALP, AAP, ACP and Cr were 51.92 mg/I, 41.55 U/L, 20.17 U/L, 570.10 U/L and 2.92 mg/dl VS in control group were 12.59 mg/I, 8.84 U/L, 6.94 U/L, 385.87U/L and 1.07 mg/dl respectively. Additionally, there were statistically positive correlation between AAP with MAU and ALP; ACP with MAU, ALP and AAP; Cr level with MAU, ALP, AAP and ACP; on the other hand, there were positive significant correlation between duration of diabetes with all studied markers. Conclusion: Using of MAU in addition to other urinary enzymes could be beneficial non-invasive indicators for renal deterioration in type II diabetics.
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Seferovic JP, Bentley-Lewis R, Claggett B, Diaz R, Gerstein HC, Køber LV, Lawson FC, Lewis EF, Maggioni AP, McMurray JJV, Probstfield JL, Riddle MC, Solomon SD, Tardif JC, Pfeffer MA. Retinopathy, Neuropathy, and Subsequent Cardiovascular Events in Patients with Type 2 Diabetes and Acute Coronary Syndrome in the ELIXA: The Importance of Disease Duration. J Diabetes Res 2018; 2018:1631263. [PMID: 30648112 PMCID: PMC6311850 DOI: 10.1155/2018/1631263] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 09/18/2018] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION We investigated the association of diabetic retinopathy and neuropathy with increased risk of recurrent cardiovascular (CV) events in 6068 patients with type 2 diabetes mellitus (T2DM) and recent acute coronary syndrome (ACS) enrolled in the Evaluation of Lixisenatide in Acute Coronary Syndrome (ELIXA). METHODS History of retinopathy and neuropathy as well as duration of T2DM were self-reported at screening. Proportional hazards regression models were used to assess relationships between retinopathy, neuropathy, and recurrent CV events. RESULTS At screening, retinopathy and neuropathy were reported in 10.7% and 17.5% of patients, respectively, while 5.7% reported both. When adjusted for randomized treatment only, both retinopathy and neuropathy were associated with a primary composite outcome (CV death, nonfatal MI, stroke, or hospitalization for unstable angina) (retinopathy: HR 1.44, 95% CI 1.19-1.75; neuropathy: HR 1.33, 95% CI 1.12-1.57), CV composite (CV death, nonfatal MI, stroke, hospitalization for heart failure (HF)) (retinopathy: HR 1.57, 95% CI 1.31-1.88; neuropathy: HR 1.38, 95% CI 1.19-1.62), myocardial infarction (retinopathy: HR 1.38, 95% CI 1.08-1.76; neuropathy: HR 1.26, 95% CI 1.02-1.54), HF hospitalization (retinopathy: HR 2.03, 95% CI 1.48-2.78; neuropathy: HR 1.71, 95% CI 1.30-2.27), and all-cause mortality (retinopathy: HR 1.65, 95% CI 1.28-2.12; neuropathy: HR 1.43, 95% CI 1.14-1.78). When included in the same model, and adjusted for T2DM duration, there were no independent associations of either with CV outcomes, while T2DM duration remained strongly associated with all outcomes. Addition of demographic characteristics and CV risk factors did not further alter these relationships. CONCLUSIONS In patients with T2DM and recent ACS, a history of retinopathy and/or neuropathy and longer T2DM duration could be considered clinical markers for high risk of recurrent CV events. This trial is registered with the ELIXA (Evaluation of Lixisenatide in Acute Coronary Syndrome), ClinicalTrials.gov registration number NCT01147250.
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Affiliation(s)
- Jelena P. Seferovic
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Rosario, Argentina
| | | | - Lars V. Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Eldrin F. Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo P. Maggioni
- Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy
| | - John J. V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | | | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
Approximately 20% to 40% of patients with type 1 or type 2 diabetes mellitus develop diabetic kidney disease. This is a clinical syndrome characterized by persistent albuminuria (> 300 mg/24 h, or > 300 mg/g creatinine), a relentless decline in glomerular filtration rate (GFR), raised arterial blood pressure, and enhanced cardiovascular morbidity and mortality. There is a characteristic histopathology. In classical diabetic nephropathy, the first clinical sign is moderately increased urine albumin excretion (microalbuminuria: 30-300 mg/24 h, or 30-300 mg/g creatinine; albuminuria grade A2). Untreated microalbuminuria will gradually worsen, reaching clinical proteinuria or severely increased albuminuria (albuminuria grade A3) over 5 to 15 years. The GFR then begins to decline, and without treatment, end-stage renal failure is likely to result in 5 to 7 years. Although albuminuria is the first sign of diabetic nephropathy, the first symptom is usually peripheral edema, which occurs at a very late stage. Regular, systematic screening for diabetic kidney disease is needed in order to identify patients at risk of or with presymptomatic diabetic kidney disease. Annual monitoring of urinary albumin-to-creatinine ratio, estimated GFR, and blood pressure is recommended. Several new biomarkers or profiles of biomarkers have been investigated to improve prognostic and diagnostic precision, but none have yet been implemented in routine clinical care. In the future such techniques may pave the way for personalized treatment.
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Sumida K, Molnar MZ, Potukuchi PK, George K, Thomas F, Lu JL, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Changes in Albuminuria and Subsequent Risk of Incident Kidney Disease. Clin J Am Soc Nephrol 2017; 12:1941-1949. [PMID: 28893924 PMCID: PMC5718265 DOI: 10.2215/cjn.02720317] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 08/02/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Albuminuria is a robust predictor of CKD progression. However, little is known about the associations of changes in albuminuria with the risk of kidney events outside the settings of clinical trials. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a nationwide cohort of 56,946 United States veterans with an eGFR≥60 ml/min per 1.73 m2, we examined the associations of 1-year fold changes in albuminuria with subsequent incident CKD (>25% decrease in eGFR reaching <60 ml/min per 1.73 m2) and rapid eGFR decline (eGFR slope <-5 ml/min per 1.73 m2 per year) assessed using Cox models and logistic regression, respectively, with adjustment for confounders. RESULTS The mean age was 64 (SD, 10) years old; 97% were men, and 91% were diabetic. There was a nearly linear association between 1-year fold changes in albuminuria and incident CKD. The multivariable-adjusted hazard ratios (95% confidence intervals) of incident CKD associated with more than twofold decrease, 1.25- to twofold decrease, 1.25- to twofold increase, and more than twofold increase (versus <1.25-fold decrease to <1.25-fold increase) in albuminuria were 0.82 (95% confidence interval, 0.77 to 0.89), 0.93 (95% confidence interval, 0.86 to 1.00), 1.12 (95% confidence interval, 1.05 to 1.20), and 1.29 (95% confidence interval, 1.21 to 1.38), respectively. Qualitatively similar associations were present for rapid eGFR decline (adjusted odds ratios; 95% confidence intervals for corresponding albuminuria changes: adjusted odds ratio, 0.86; 95% confidence interval, 0.78 to 0.94; adjusted odds ratio, 0.98; 95% confidence interval, 0.89 to 1.07; adjusted odds ratio, 1.18; 95% confidence interval, 1.08 to 1.29; and adjusted odds ratio, 1.67; 95% confidence interval, 1.54 and 1.81, respectively). CONCLUSIONS Relative changes in albuminuria over a 1-year interval were linearly associated with subsequent risk of kidney outcomes. Additional studies are warranted to elucidate the underlying mechanisms of the observed associations and test whether active interventions to lower elevated albuminuria can improve kidney outcomes.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine and
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z. Molnar
- Division of Nephrology, Department of Medicine and
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | | | - Koshy George
- Division of Nephrology, Department of Medicine and
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine and
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California; and
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine and
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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Leong A, Ekinci EI, Nguyen C, Milne M, Hachem M, Dobson M, MacIsaac RJ, Jerums G. Long-term intra-individual variability of albuminuria in type 2 diabetes mellitus: implications for categorization of albumin excretion rate. BMC Nephrol 2017; 18:355. [PMID: 29207965 PMCID: PMC5717840 DOI: 10.1186/s12882-017-0767-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 11/20/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease in the Western world. Early and accurate identification of DKD offers the best chance of slowing the progression of kidney disease. An important method for evaluating risk of progressive DKD is abnormal albumin excretion rate (AER). Due to the high variability in AER, most guidelines recommend the use of more than or equal to two out of three AER measurements within a 3- to 6-month period to categorise AER. There are recognised limitations of using AER as a marker of DKD because one quarter of patients with type 2 diabetes may develop kidney disease without an increase in albuminuria and spontaneous regression of albuminuria occurs frequently. Nevertheless, it is important to investigate the long-term intra-individual variability of AER in participants with type 2 diabetes. METHODS Consecutive AER measurements (median 19 per subject) were performed in 497 participants with type 2 diabetes from 1999 to 2012 (mean follow-up 7.9 ± 3 years). Baseline clinical characteristics were collected to determine associations with AER variability. Participants were categorised as having normo-, micro- or macroalbuminuria according to their initial three AER measurements. Participants were then categorised into four patterns of AER trajectories: persistent, intermittent, progressing and regressing. Coefficients of variation were used to measure intra-individual AER variability. RESULTS The median coefficient of variation of AER was 53.3%, 76.0% and 67.0% for subjects with normo-, micro- or macroalbuminuria at baseline. The coefficient of variation of AER was 37.7%, 66% and 94.8% for subjects with persistent, intermittent and progressing normoalbuminuria; 43%, 70.6%, 86.1% and 82.3% for subjects with persistent, intermittent, progressing and regressing microalbuminuria; and 55.2%, 67% and 82.4% for subjects with persistent, intermittent and regressing macroalbuminuria, respectively. CONCLUSION High long-term variability of AER suggests that two out of three AER measurements may not always be adequate for the optimal categorisation and prediction of AER.
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Affiliation(s)
- Amanda Leong
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
| | - Elif Ilhan Ekinci
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia.
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
- Menzies School of Health Research, Red 9, Casuarina Campus, University Drive North, Casuarina, Northern Territory, 0811, Australia.
| | - Cattram Nguyen
- Murdoch Children's Research Institute, Flemington Road, Melbourne, Victoria, 3052, Australia
| | - Michele Milne
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
| | - Mariam Hachem
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew Dobson
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, 41 Victoria Parade, Melbourne, Victoria, 3065, Australia
| | - George Jerums
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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71
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Predictors for the development of microalbuminuria and interaction with renal function. J Hypertens 2017; 35:2501-2509. [DOI: 10.1097/hjh.0000000000001491] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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72
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Marcovecchio ML, Chiesa ST, Bond S, Daneman D, Dawson S, Donaghue KC, Jones TW, Mahmud FH, Marshall SM, Neil HAW, Dalton RN, Deanfield J, Dunger DB. ACE Inhibitors and Statins in Adolescents with Type 1 Diabetes. N Engl J Med 2017; 377:1733-1745. [PMID: 29091568 DOI: 10.1056/nejmoa1703518] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Among adolescents with type 1 diabetes, rapid increases in albumin excretion during puberty precede the development of microalbuminuria and macroalbuminuria, long-term risk factors for renal and cardiovascular disease. We hypothesized that adolescents with high levels of albumin excretion might benefit from angiotensin-converting-enzyme (ACE) inhibitors and statins, drugs that have not been fully evaluated in adolescents. METHODS We screened 4407 adolescents with type 1 diabetes between the ages of 10 and 16 years of age and identified 1287 with values in the upper third of the albumin-to-creatinine ratios; 443 were randomly assigned in a placebo-controlled trial of an ACE inhibitor and a statin with the use of a 2-by-2 factorial design minimizing differences in baseline characteristics such as age, sex, and duration of diabetes. The primary outcome for both interventions was the change in albumin excretion, assessed according to the albumin-to-creatinine ratio calculated from three early-morning urine samples obtained every 6 months over 2 to 4 years, and expressed as the area under the curve. Key secondary outcomes included the development of microalbuminuria, progression of retinopathy, changes in the glomerular filtration rate, lipid levels, and measures of cardiovascular risk (carotid intima-media thickness and levels of high-sensitivity C-reactive protein and asymmetric dimethylarginine). RESULTS The primary outcome was not affected by ACE inhibitor therapy, statin therapy, or the combination of the two. The use of an ACE inhibitor was associated with a lower incidence of microalbuminuria than the use of placebo; in the context of negative findings for the primary outcome and statistical analysis plan, this lower incidence was not considered significant (hazard ratio, 0.57; 95% confidence interval, 0.35 to 0.94). Statin use resulted in significant reductions in total, low-density lipoprotein, and non-high-density lipoprotein cholesterol levels, in triglyceride levels, and in the ratio of apolipoprotein B to apolipoprotein A1, whereas neither drug had significant effects on carotid intima-media thickness, other cardiovascular markers, the glomerular filtration rate, or progression of retinopathy. Overall adherence to the drug regimen was 75%, and serious adverse events were similar across the groups. CONCLUSIONS The use of an ACE inhibitor and a statin did not change the albumin-to-creatinine ratio over time. (Funded by the Juvenile Diabetes Research Foundation and others; AdDIT ClinicalTrials.gov number, NCT01581476 .).
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Affiliation(s)
- M Loredana Marcovecchio
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - Scott T Chiesa
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - Simon Bond
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - Denis Daneman
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - Sarah Dawson
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - Kim C Donaghue
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - Timothy W Jones
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - Farid H Mahmud
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - Sally M Marshall
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - H Andrew W Neil
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - R Neil Dalton
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - John Deanfield
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
| | - David B Dunger
- From the Department of Paediatrics (M.L.M., D.B.D.) and the Wellcome Trust-Medical Research Council Institute of Metabolic Science (D.B.D.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital (S.B., S.D.), Cambridge, the National Centre for Cardiovascular Prevention and Outcomes, University College London (S.T.C., J.D.), and the WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital (R.N.D.), London, the Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne (S.M.M.), and the Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford (H.A.W.N.) - all in the United Kingdom; the Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto (D.D., F.H.M.); and the Institute of Endocrinology and Diabetes, Children's Hospital at Westmead and University of Sydney, Sydney (K.C.D.), and the Telethon Kids Institute, University of Western Australia, Perth (T.W.J.) - both in Australia
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Wang J, Li J, Wang A, Wang J, Yang Y, Chen S, Wu S, Zhao M, Guo X, Zhang L. Dipstick proteinuria and risk of myocardial infarction and all-cause mortality in diabetes or pre-diabetes: a population-based cohort study. Sci Rep 2017; 7:11986. [PMID: 28931849 PMCID: PMC5607308 DOI: 10.1038/s41598-017-12057-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 08/25/2017] [Indexed: 01/27/2023] Open
Abstract
To evaluate the association between dipstick proteinuria and myocardial infarction (MI) or all-cause mortality, a cohort study was conducted among 16,573 general Chinese population with diabetes or pre-diabetes, which were defined as self-reported history of diabetes or fasting blood glucose ≥5.6 mmol/L or under blood glucose lowering therapy. Proteinuria was detected biennially during 2006–2013 by dipstick test. MI and all-cause mortality were recorded through the end of 2014. Mean age (standard deviation) of study participants was 51.16 (10.63) years, with 82.24% of male. During a median follow-up of 8.03 years, 211 MI and 403 all-cause mortality occurred. Multivariable Cox regression revealed occasional or persistent detection of trace or higher in proteinuria increased the risk of all-cause mortality, with hazard ratios (HRs) of 1.42 (95% confidence intervals [CI]: 1.10, 1.83) and 2.23 (95% CI: 1.66, 3.01), respectively, compared to sustained negative in proteinuria. A time-dependent analysis also revealed the association between degree of proteinuria and all-cause mortality, with HRs of 1.80 (95% CI: 1.31, 2.48) for trace and 3.34 (95% CI: 2.40, 4.65) for one plus or higher in proteinuria, compared to negative. The associations regarding MI lost statistical significance after multivariable adjustment. In conclusion, dipstick proteinuria was associated with an increased risk of MI and all-cause mortality among a general population with diabetes or pre-diabetes.
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Affiliation(s)
- Jinwei Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, National Health and Family Planning Commission, Beijing, 100034, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, 100034, China
| | - Junjuan Li
- Department of Nephrology, Kailuan General Hospital Affiliated to North China University of science and technology, Tangshan, 063000, China
| | - Anxin Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University; Municipal Key Laboratory of Clinical Epidemiology, Beijing, 100069, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Jianli Wang
- Department of Nephrology, Kailuan General Hospital Affiliated to North China University of science and technology, Tangshan, 063000, China
| | - Yaozheng Yang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, National Health and Family Planning Commission, Beijing, 100034, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, 100034, China
| | - Shuohua Chen
- Department of Cardiology, Kailuan General Hospital Affiliated to North China University of science and technology, Tangshan, 063000, China
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital Affiliated to North China University of science and technology, Tangshan, 063000, China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, National Health and Family Planning Commission, Beijing, 100034, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, 100034, China
| | - Xiuhua Guo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University; Municipal Key Laboratory of Clinical Epidemiology, Beijing, 100069, China
| | - Luxia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, National Health and Family Planning Commission, Beijing, 100034, China. .,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, 100034, China.
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74
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Pena MJ, Stenvinkel P, Kretzler M, Adu D, Agarwal SK, Coresh J, Feldman HI, Fogo AB, Gansevoort RT, Harris DC, Jha V, Liu ZH, Luyckx VA, Massy ZA, Mehta R, Nelson RG, O'Donoghue DJ, Obrador GT, Roberts CJ, Sola L, Sumaili EK, Tatiyanupanwong S, Thomas B, Wiecek A, Parikh CR, Heerspink HJL. Strategies to improve monitoring disease progression, assessing cardiovascular risk, and defining prognostic biomarkers in chronic kidney disease. Kidney Int Suppl (2011) 2017; 7:107-113. [PMID: 30675424 DOI: 10.1016/j.kisu.2017.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Chronic kidney disease (CKD) is a major global public health problem with significant gaps in research, care, and policy. In order to mitigate the risks and adverse effects of CKD, the International Society of Nephrology has created a cohesive set of activities to improve the global outcomes of people living with CKD. Improving monitoring of renal disease progression can be done by screening and monitoring albuminuria and estimated glomerular filtration rate in primary care. Consensus on how many times and how often albuminuria and estimated glomerular filtration rate are measured should be defined. Meaningful changes in both renal biomarkers should be determined in order to ascertain what is clinically relevant. Increasing social awareness of CKD and partnering with the technological community may be ways to engage patients. Furthermore, improving the prediction of cardiovascular events in patients with CKD can be achieved by including the renal risk markers albuminuria and estimated glomerular filtration rate in cardiovascular risk algorithms and by encouraging uptake of assessing cardiovascular risk by general practitioners and nephrologists. Finally, examining ways to further validate and implement novel biomarkers for CKD will help mitigate the global problem of CKD. The more frequent use of renal biopsy will facilitate further knowledge into the underlying etiologies of CKD and help put new biomarkers into biological context. Real-world assessments of these biomarkers in existing cohorts is important, as well as obtaining regulatory approval to use these biomarkers in clinical practice. Collaborations among academia, physician and patient groups, industry, payer organizations, and regulatory authorities will help improve the global outcomes of people living with CKD.
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Affiliation(s)
- Michelle J Pena
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Matthias Kretzler
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Dwomoa Adu
- Department of Medicine and Therapeutics, School of Medicine and Dentistry, University of Ghana, Accra, Ghana
| | - Sanjay Kumar Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Josef Coresh
- Johns Hopkins University Bloomberg School of Public Health, George W. Comstock Center for Public Health Research and Prevention, Baltimore, Maryland, USA.,Johns Hopkins University School of Medicine, Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, Maryland, USA
| | - Harold I Feldman
- Department of Biostatistics, Epidemiology, and Informatics, and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ron T Gansevoort
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - David C Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Vivekanand Jha
- George Institute for Global Health India, New Delhi, India.,University of Oxford, Oxford, UK
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Valerie A Luyckx
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland.,Klinik für Nephrologie, Universitätsspital, Zurich, Switzerland
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré Hospital, APHP, Boulogne Billancourt/Paris, France.,French National Institute of Health and Medical Research (INSERM) U1018, Team5, Centre for Research in Epidemiology and Population Health (CESP), Paris-Ile-de-France-West, Versailles-Saint-Quentin-en-Yvelines University, Villejuif, France
| | - Ravindra Mehta
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Robert G Nelson
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona, USA
| | - Donal J O'Donoghue
- Department of Renal Medicine, Salford Royal National Health Service (NHS) Foundation Trust, Salford, UK.,Department of Renal Medicine, University of Manchester, Manchester, UK
| | - Gregorio T Obrador
- Faculty of Health Sciences & Universidad Panamericana, Mexico City, Mexico
| | - Charlotte J Roberts
- Standardisation, International Consortium for Health Outcomes Measurement, London, UK
| | - Laura Sola
- Division Epidemiologia, Dirección General de Salud (DIGESA)-Ministerio Salud Publica, Montevideo, Uruguay
| | - Ernest K Sumaili
- Renal Unit, Kinshasa University Hospital, University of Kinshasa, Kinshasa, DR Congo
| | | | - Bernadette Thomas
- Department of Global Health, The University of Washington, Seattle, Washington, USA
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Chirag R Parikh
- Program of Applied Translational Research, Department of Medicine, Yale University, New Haven, Connecticut, USA.,Veterans Affairs Medical Center, West Haven, Connecticut, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Cherney DZI, Zinman B, Inzucchi SE, Koitka-Weber A, Mattheus M, von Eynatten M, Wanner C. Effects of empagliflozin on the urinary albumin-to-creatinine ratio in patients with type 2 diabetes and established cardiovascular disease: an exploratory analysis from the EMPA-REG OUTCOME randomised, placebo-controlled trial. Lancet Diabetes Endocrinol 2017; 5:610-621. [PMID: 28666775 DOI: 10.1016/s2213-8587(17)30182-1] [Citation(s) in RCA: 262] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/08/2017] [Accepted: 05/09/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND In a pooled analysis of short-term trials, short-term treatment with the sodium-glucose co-transporter-2 (SGLT2) inhibitor empagliflozin reduced albuminuria in patients with type 2 diabetes and prevalent albuminuria. In this exploratory analysis of the EMPA-REG OUTCOME trial, we report the short-term and long-term effects of empagliflozin on albuminuria in patients with type 2 diabetes and established cardiovascular disease, according to patients' baseline albuminuria status. METHODS In this randomised, double-blind, placebo-controlled trial at 590 sites in 42 countries, we randomly assigned patients aged 18 years and older with type 2 diabetes and established cardiovascular disease (1:1:1) to empagliflozin 10 mg, empagliflozin 25 mg, or placebo in addition to standard of care until at least 691 patients experienced an adjudicated event included in the primary outcome. We did the randomisation with a computer-generated random-sequence and interactive voice-response and web-response system, stratified by HbA1c, BMI, region, and estimated glomerular filtration rate. Patients, investigators, and individuals involved in analysis of trial data were masked to treatment assignment. The primary and secondary efficacy and safety endpoints of this trial have been reported previously. Here, we report urinary albumin-to-creatinine ratio (UACR) data for the pooled empagliflozin group versus placebo according to albuminuria status at baseline (normoalbuminuria: UACR <30 mg/g; microalbuminuria: UACR ≥30 to ≤300 mg/g; and macroalbuminuria: UACR >300 mg/g). We did the analysis with mixed-model repeated measures including prespecified and post-hoc tests. This study is completed and registered with ClinicalTrials.gov, number NCT01131676. FINDINGS Between Sept 1, 2010, and April 22, 2013, we randomly assigned 7028 patients to treatment groups and 7020 patients received treatment. At baseline, we had UACR data for 6953 patients: 4171 (59% of treated patients; 1382 assigned to placebo and 2789 assigned to empagliflozin) had normoalbuminuria, 2013 (29%; 675 assigned to placebo and 1338 assigned to empagliflozin) had microalbuminuria, and 769 (11%; 260 assigned to placebo and 509 assigned to empagliflozin) had macroalbuminuria. Median treatment duration was 2·6 years (IQR 2·0-3·4; 136 weeks) and median observation time was 3·1 years (2·2-3·6; 164 weeks). After short-term treatment at week 12, the placebo-adjusted geometric mean ratio of UACR change from baseline with empagliflozin was -7% (95% CI -12 to -2; p=0·013) in patients with normoalbuminuria, -25% (-31 to -19; p<0·0001) in patients with microalbuminuria, and -32% (-41 to -23; p<0·0001) in patients with macroalbuminuria. The reductions in UACR were maintained with empagliflozin in all three groups compared with placebo during long-term treatment when measured at 164 weeks. At follow-up, after cessation of treatment for a median of 34 or 35 days, UACR was lower in the empagliflozin versus placebo group in those with baseline microalbuminuria (placebo-corrected adjusted geometric mean ratio of relative change from baseline with empagliflozin: -22%, 95% CI -32 to -11; p=0·0003) or macroalbuminuria (-29%, -44 to -10; p=0·0048), but not for patients with baseline normoalbuminuria (1%, -8 to 10; p=0·8911). Patients treated with empagliflozin were more likely to experience a sustained improvement from microalbuminuria to normoalbuminuria (hazard ratio [HR] 1·43, 95% CI 1·22 to 1·67; p<0·0001) or from macroalbuminuria to microalbuminuria or normoalbuminuria (HR 1·82, 1·40 to 2·37; p<0·0001), and less likely to experience a sustained deterioration from normoalbuminuria to microalbuminuria or macroalbuminuria (HR 0·84, 0·74 to 0·95; p=0·0077). The proportions of patients with any adverse events, serious adverse events, and adverse events leading to discontinuation increased with worsening UACR status at baseline, but were similar between treatment groups. The proportion of patients with genital infections was greater with empagliflozin than placebo in all subgroups by UACR status. INTERPRETATION These results support short-term and long-term benefits of empagliflozin on urinary albumin excretion, irrespective of patients' albuminuria status at baseline. FUNDING Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance.
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Affiliation(s)
- David Z I Cherney
- Department of Medicine and Department of Physiology, Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada.
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Christoph Wanner
- Division of Nephrology, Würzburg University Clinic, Würzburg, Germany
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Ahmed-Sarwar N, Nagel AK, Leistman S, Heacock K. SGLT-2 Inhibitors: Is There a Role in Type 1 Diabetes Mellitus Management? Ann Pharmacother 2017; 51:791-796. [DOI: 10.1177/1060028017710481] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: The purpose of this review is to identify and evaluate disease management of patients with type 1 diabetes mellitus (T1DM) who were treated with a sodium-glucose cotransporter 2 (SGLT-2) inhibitor as an adjunct to insulin therapy. Data Sources: A PubMed (1969 to March 2017) and Ovid (1946 to March 2017) search was performed for articles published utilizing the following MESH terms: canagliflozin, empagliflozin, dapagliflozin, type 1 diabetes mellitus, insulin dependent diabetes, insulin, sodium-glucose transporter 2. There were no limitations placed on publication type. Study Selection and Data Extraction: All English-language articles were evaluated for association of SGLT-2 inhibitors and type 1 diabetes. Further studies were identified by review of pertinent manuscript bibliographies. Data Synthesis: All 3 SGLT-2 inhibitors, when combined with insulin, resulted in an overall reduction of hemoglobin A1C (up to 0.49%), lower total daily insulin doses, and a reduction in weight (up to 2.7 kg). The combination therapy of insulin and SGLT-2 inhibitors also resulted in a lower incidence of hypoglycemia. Study duration varied from 2 to 18 weeks. Conclusion: A review of the identified literature indicated that there is a potential role for the combination of SGLT-2 inhibitors with insulin in T1DM for improving glycemic control without increasing the risk of hypoglycemia. The short duration and small sample sizes limit the ability to fully evaluate the incidences of diabetic ketoacidosis and urogenital infections. The risks associated with this combination of medications require further evaluation.
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Affiliation(s)
| | - Angela K. Nagel
- St John Fisher College, Rochester, NY, USA
- UR Medicine, Rochester, NY, USA
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77
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Orchard TJ, Costacou T. Cardiovascular complications of type 1 diabetes: update on the renal link. Acta Diabetol 2017; 54:325-334. [PMID: 27995339 DOI: 10.1007/s00592-016-0949-7] [Citation(s) in RCA: 11] [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: 10/05/2016] [Accepted: 11/25/2016] [Indexed: 12/22/2022]
Abstract
AIMS Despite recent findings of increased life expectancy among individuals with type 1 diabetes, mortality remains greatly increased compared to the general population. As this is largely the result of cardiovascular and renal complications, we aimed to review recent findings surrounding these diseases in type 1 diabetes. METHODS We reviewed published findings concerning the cardiovascular complications of type 1 diabetes, with a particular focus on links with renal disease. RESULTS The cardiovascular and renal complications of type 1 diabetes share many features including insulin resistance, oxidative damage, and genetic associations with the Haptoglobin genotype, and both are strongly affected by glycemic control. CONCLUSIONS Although current knowledge on predictors of type 1 diabetes cardiovascular and renal complications has increased, further investigation is required to understand the mechanisms leading to cardio-renal complications in this population.
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Affiliation(s)
- Trevor J Orchard
- Department of Epidemiology, Diabetes and Lipid Research Clinic, University of Pittsburgh, 3512 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Tina Costacou
- Department of Epidemiology, Diabetes and Lipid Research Clinic, University of Pittsburgh, 3512 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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78
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Comparison of HbA1c detection in whole blood and dried blood spots using an automated ion-exchange HPLC system. Bioanalysis 2017; 9:427-434. [PMID: 28220711 DOI: 10.4155/bio-2016-0278] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
AIM Hemoglobin A1c (HbA1c) is a widely recognized analyte for diagnosing and monitoring diabetes. Dried blood spot (DBS) constitutes a useful alternative to blood collection by venipuncture. Analytical and clinical validation of DBS use is, however, necessary before implementation. Results/methodology: HbA1c levels from whole blood or DBS from a cohort patients with diabetes were compared. DBS specimens were stable at ambient temperature. HbA1c detection on DBS was accurate, robust, and the correlation and agreement with whole blood values was excellent. CONCLUSION This study provides for the first time a complete method comparison and validation under the ISO15189 guideline using an automated HPLC system. This approach constitutes, therefore, a useful tool for diagnosing diabetes.
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80
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Dixon BS. Is Change in Albuminuria a Surrogate Marker for Cardiovascular and Renal Outcomes in Type 1 Diabetes? Clin J Am Soc Nephrol 2016; 11:1921-1923. [PMID: 27797905 PMCID: PMC5108209 DOI: 10.2215/cjn.09540916] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Bradley S Dixon
- Medicine Service, Veterans Administration Medical Center, Iowa City, Iowa; and
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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