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Mouzaki M, Yates KP, Arce-Clachar AC, Behling C, Blondet NM, Fishbein MH, Flores F, Adams KH, Hertel P, Jain AK, Molleston JP, Schwimmer JB, Vos MB, Xanthakos SA. Renal impairment is prevalent in pediatric NAFLD/MASLD and associated with disease severity. J Pediatr Gastroenterol Nutr 2024. [PMID: 38828720 DOI: 10.1002/jpn3.12272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/18/2024] [Accepted: 04/10/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES Renal impairment is prevalent in adults with nonalcoholic fatty liver disease (NAFLD/metabolic dysfunction associated steatotic liver disease [MASLD]) and is associated with increased mortality. Pediatric data are limited. Our objective was to determine the prevalence of hyperfiltration or chronic kidney disease (CKD) in children with NAFLD/MASLD and determine links with liver disease severity. METHODS Data from children who had previously participated in prospective, multicenter, pediatric studies by the Nonalcoholic Steatohepatitis Clinical Research Network (NASH-CRN) were collected. Renal function was determined using the calculated glomerular filtration rate (cGFR). Hyperfiltration was defined as cGFR > 135 mL/min/1.73m2, while CKD stage 2 or higher as cGFR < 90 mL/min/1.73 m2. Renal dysfunction progression was defined as transition from normal to hyperfiltration or to CKD stage ≥ 2, or change in CKD by ≥1 stage. Multinomial logistic regression models were used to determine the prevalence of CKD and independent associations between CKD and liver disease severity. RESULTS The study included 1164 children (age 13 ± 3 years, 72% male, 71% Hispanic). The median cGFR was 121 mL/min/1.73 m2; 12% had CKD stage 2-5, while 27% had hyperfiltration. Hyperfiltration was independently associated with significant liver fibrosis (odds ratio: 1.45). Baseline renal function was not associated with progression in liver disease over a 2-year period (n = 145). Renal dysfunction worsened in 19% independently of other clinical risk factors. Progression of renal impairment was not associated with change in liver disease severity. CONCLUSIONS Renal impairment is prevalent in children with NAFLD/MASLD and hyperfiltration is independently associated with significant liver fibrosis. Almost 1/5 children have evidence of progression in renal dysfunction over 2 years, not associated with change in liver disease severity. Future assessments including additional renal impairment biomarkers are needed.
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Affiliation(s)
- Marialena Mouzaki
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Katherine P Yates
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ana Catalina Arce-Clachar
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Cindy Behling
- Rady Children's Hospital, University of California San Diego School of Medicine, San Diego, California, USA
| | - Niviann M Blondet
- Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Mark H Fishbein
- Lurie Children's Hospital, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Francisco Flores
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kathryn Harlow Adams
- Riley Hospital for Children, Indiana University School of Medicine, Riley, Indiana, USA
| | - Paula Hertel
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Ajay K Jain
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Saint Louis University, Saint Louis, Missouri, USA
| | - Jean P Molleston
- Riley Hospital for Children, Indiana University School of Medicine, Riley, Indiana, USA
| | - Jeffrey B Schwimmer
- Rady Children's Hospital, University of California San Diego School of Medicine, San Diego, California, USA
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Miriam B Vos
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Stavra A Xanthakos
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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McGee AC, Reinicke T, Carrasco D, Goodrich J, Pavkov ME, van Raalte DH, Birznieks C, Nelson RG, Nadeau KJ, Choi YJ, Vigers T, Pyle L, de Boer I, Bjornstad P, Tommerdahl KL. Glycoprotein Acetyls Associate With Intraglomerular Hemodynamic Dysfunction, Albuminuria, Central Adiposity, and Insulin Resistance in Youth With Type 1 Diabetes. Can J Diabetes 2024; 48:244-249.e1. [PMID: 38341135 DOI: 10.1016/j.jcjd.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/18/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVES Glycoprotein acetyls (GlycA's) are biomarkers of systemic inflammation and cardiovascular disease, yet little is known about their role in type 1 diabetes (T1D). In this study we examined the associations among GlycA's, central adiposity, insulin resistance, and early kidney injury in youth with T1D. METHODS Glomerular filtration rate and renal plasma flow by iohexol and p-aminohippurate clearance, urine albumin-to-creatinine ratio (UACR), central adiposity by dual-energy x-ray absorptiometry, and estimated insulin sensitivity were assessed in 50 youth with T1D (16±3.0 years of age, 50% female, glycated hemoglobin 8.7%±1.3%, T1D duration 5.7±2.6 years). Concentrations of GlycA were quantified by targeted nuclear magnetic resonance spectroscopy. Correlation and multivariable linear regression analyses were performed. RESULTS GlycA's were higher in girls vs boys (1.05±0.26 vs 0.84±0.15 mmol/L, p=0.001) and in participants living with overweight/obesity vs normal weight (1.12±0.23 vs 0.87±0.20 mmol/L, p=0.0004). GlycA's correlated positively with estimated intraglomerular pressure (r=0.52, p=0.001), UACR (r=0.53, p<0.0001), and trunk mass (r=0.45, p=0.001), and inversely with estimated insulin sensitivity (r=-0.36, p=0.01). All relationships remained significant after adjustment for age, sex, and glycated hemoglobin. CONCLUSIONS As biomarkers of inflammation, GlycA's were higher in girls and those with overweight or obese body habitus in T1D. GlycA's associated with parameters of early kidney dysfunction, central adiposity, and insulin resistance.
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Affiliation(s)
- Alyssa Caldwell McGee
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Trenton Reinicke
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Diego Carrasco
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Jesse Goodrich
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, United States
| | - Meda E Pavkov
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, VUMC, Amsterdam, The Netherlands
| | - Carissa Birznieks
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Robert G Nelson
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, Arizona, United States
| | - Kristen J Nadeau
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Ye Ji Choi
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, United States
| | - Tim Vigers
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, United States
| | - Laura Pyle
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, United States
| | - Ian de Boer
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington, United States
| | - Petter Bjornstad
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States; Ludeman Family Center for Women's Health Research, University of Colorado School of Medicine, Aurora, Colorado, United States; Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Kalie L Tommerdahl
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States; Ludeman Family Center for Women's Health Research, University of Colorado School of Medicine, Aurora, Colorado, United States; Barbara Davis Center for Diabetes, Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States.
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3
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White B, Ng SM, Agwu JC, Barrett TG, Birchmore N, Kershaw M, Drew J, Kavvoura F, Law J, Moudiotis C, Procter E, Paul P, Regan F, Reilly P, Sachdev P, Sakremath R, Semple C, Sharples K, Skae M, Timmis A, Williams E, Wright N, Soni A. A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus. BMC Med 2024; 22:144. [PMID: 38561783 PMCID: PMC10986054 DOI: 10.1186/s12916-024-03349-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 03/11/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes. METHODS Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. RESULTS AND DISCUSSION Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events. CONCLUSIONS This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.
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Affiliation(s)
- Billy White
- University College London Hospitals NHS Foundation Trust, London, UK
| | - S M Ng
- Mersey And West Lancashire Teaching Hospitals NHS Trust, Ormskirk, UK
| | - J C Agwu
- Wye Valley NHS Trust, Hereford, UK
| | - T G Barrett
- Birmingham Women's And Children NHS Foundation Trust, Birmingham, UK
| | - N Birchmore
- Great Ormond Street Hospital For Children, NHS Foundation Trust, London, UK
| | - M Kershaw
- Birmingham Women's And Children NHS Foundation Trust, Birmingham, UK
| | - J Drew
- Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - F Kavvoura
- Royal Berkshire NHS Foundation Trust, Reading, UK
| | - J Law
- Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - C Moudiotis
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - E Procter
- Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - P Paul
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - F Regan
- Guy's and St Thomas's NHS Foundation Trust, London, UK
| | - P Reilly
- Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - P Sachdev
- Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - R Sakremath
- Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - C Semple
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - M Skae
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - A Timmis
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - E Williams
- Hampshire Hospitals NHS Foundation Trust, Winchester, UK
| | - N Wright
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, S102TH, UK
| | - A Soni
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, S102TH, UK.
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Kumar M, Dev S, Khalid MU, Siddenthi SM, Noman M, John C, Akubuiro C, Haider A, Rani R, Kashif M, Varrassi G, Khatri M, Kumar S, Mohamad T. The Bidirectional Link Between Diabetes and Kidney Disease: Mechanisms and Management. Cureus 2023; 15:e45615. [PMID: 37868469 PMCID: PMC10588295 DOI: 10.7759/cureus.45615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
The complex and mutually influential connection between diabetes mellitus and chronic kidney disease (CKD) is a significant focal point in the current healthcare landscape. Diabetes, a medical condition characterized by elevated blood glucose levels resulting from impaired insulin action or secretion, has become a significant global epidemic. It poses considerable challenges to healthcare systems and affects millions of individuals worldwide. Concurrently, CKD, characterized by the gradual decline of kidney function, has become a persistent health challenge. This narrative review explores the complex relationship between these two conditions, shedding light on their significant implications for public health, clinical practice, and biomedical research. The correlation between diabetes and kidney disease is not merely coincidental. Diabetes is recognized as a significant risk factor for CKD, as individuals with diabetes are considerably more vulnerable to developing renal complications. Diabetic nephropathy, a distinct type of kidney disease closely associated with diabetes, is a significant factor in developing end-stage renal disease. It is imperative to implement efficient diabetes management strategies to regulate blood sugar levels and prevent potential kidney damage. On the other hand, kidney disease may contribute to the development of diabetes. The kidneys regulate glucose levels by filtering the blood and selectively reabsorbing glucose as necessary. In compromised kidney function, such as CKD, impaired glucose metabolism can give rise to insulin resistance and diabetes. As a result, the management of kidney disease plays a dual role in both preserving renal function and preventing diabetes in individuals who are at risk. The coexistence of diabetes and kidney disease in a patient presents complex clinical challenges. Achieving effective management requires a meticulous balance between glycemic control and preservation of renal function. Failing to maintain this delicate equilibrium can lead to cardiovascular complications and subsequent hospitalizations. This comprehensive narrative review aims to thoroughly examine the pathophysiological mechanisms that connect diabetes and kidney disease. It will provide insights into the clinical manifestations and diagnostic methods, explore various approaches to managing the condition, discuss the crucial role of nutrition, delve into pharmacological interventions, emphasize the importance of patient education and self-care, and shed light on emerging research areas. In addition to impacting individual health outcomes, this reciprocal relationship has significant implications for healthcare systems, socioeconomic landscapes, and public health policy. Comprehending this complex interaction is crucial for making well-informed clinical judgments, improving patient care, and developing a more efficient public health approach to address the interconnected issues of diabetes and kidney disease.
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Affiliation(s)
| | - Shah Dev
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | | | | | | | - Chris John
- Internal Medicine, University College Dublin, Dublin, IRL
| | | | - Anum Haider
- Internal Medicine, Bahria University Medical and Dental College, Karachi, PAK
| | - Riya Rani
- Internal Medicine, Peoples University of Medical and Health Sciences for Women, Nawabshah, PAK
| | - Maham Kashif
- Medicine, Khawaja Muhammad Safdar Medical College, Sialkot, PAK
| | | | - Mahima Khatri
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Satesh Kumar
- Medicine and Surgery, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, PAK
| | - Tamam Mohamad
- Cardiovascular Medicine, Wayne State University, Detroit, USA
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5
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Impact of type 1 diabetes and its duration on wall-to-lumen ratio and blood flow in retinal arterioles. Microvasc Res 2023; 147:104499. [PMID: 36753823 DOI: 10.1016/j.mvr.2023.104499] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Subclinical damage to both the small and large vessels may contribute to the development and progression of cardiovascular disease. Scanning laser Doppler flowmetry (SLDF), an established method used to measure retinal microcirculation, has been successfully applied in hypertensive and post-stroke patients. METHODS Retinal microcirculation was assessed in 158 patients with type 1 diabetes and 38 age-matched healthy controls. The diabetics were divided into 3 groups: group A with diabetes duration <12 months, group B with diabetes with 1-10 years, and group C >10 years of diabetes. Retinal capillary structure and perfusion were evaluated using a Heidelberg retina flowmeter and automatically analyzed with full-field perfusion imaging. RESULTS Age and BMI were comparable in all the diabetic patients and the controls (mean age 24.8 ± 4.7 years, mean BMI 22.9 ± 4.1). In the univariate analyses, RCF (retinal capillary flow) was significantly higher in group A (297 ± 121 arbitrary units [AU]) vs group B (236 ± 52 AU; p = 0.007) and group C (236 ± 70 AU; p = 0.008) and comparable to that of the controls (p = 0.46). Additionally, the WLR (Wall-to-Lumen Ratio) was highest in group C compared to the other diabetic subgroups and controls (p = 0.001). Multivariate regression analyses including age, BMI, sex, HbA1c, smoking, systolic blood pressure, and diabetes duration as covariates, showed, that only diabetes duration was significantly associated with WLR variations, whereas HbA1c was significantly linked to retinal capillary flow levels. CONCLUSIONS New-onset diabetes is associated with an increase in RCF, which then gradually decreased with the duration of the disease. Structural changes of the retinal arterioles estimated via WLR are evident later in the course of diabetes, especially when the disease duration exceeded 10 years.
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Adebayo OC, Nkoy AB, van den Heuvel LP, Labarque V, Levtchenko E, Delanaye P, Pottel H. Glomerular hyperfiltration: part 2-clinical significance in children. Pediatr Nephrol 2022:10.1007/s00467-022-05826-5. [PMID: 36472656 DOI: 10.1007/s00467-022-05826-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/27/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022]
Abstract
Glomerular hyperfiltration (GHF) is a phenomenon that can occur in various clinical conditions affecting the kidneys such as sickle cell disease, diabetes mellitus, autosomal dominant polycystic kidney disease, and solitary functioning kidney. Yet, the pathophysiological mechanisms vary from one disease to another and are not well understood. More so, it has been demonstrated that GHF may occur at the single-nephron in some clinical conditions while in others at the whole-kidney level. In this review, we explore the pathophysiological mechanisms of GHF in relation to various clinical conditions in the pediatric population. In addition, we discuss the role and mechanism of action of important factors such as gender, low birth weight, and race in the pathogenesis of GHF. Finally, in this current review, we further highlight the consequences of GHF in the progression of kidney disease.
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Affiliation(s)
- Oyindamola C Adebayo
- Center of Vascular and Molecular Biology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Campus Gasthiusberg, 3000 Leuven, Belgium
- Laboratory of Pediatric Nephrology, Department of Development and Regeneration, Katholieke Universiteit Leuven, Campus Gasthiusberg, 3000 Leuven, Belgium
| | - Agathe B Nkoy
- Laboratory of Pediatric Nephrology, Department of Development and Regeneration, Katholieke Universiteit Leuven, Campus Gasthiusberg, 3000 Leuven, Belgium
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, University Hospital of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Lambertus P van den Heuvel
- Laboratory of Pediatric Nephrology, Department of Development and Regeneration, Katholieke Universiteit Leuven, Campus Gasthiusberg, 3000 Leuven, Belgium
- Department of Pediatric Nephrology, Radboud University Medical Centre, 6500 Nijmegen, The Netherlands
| | - Veerle Labarque
- Center of Vascular and Molecular Biology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Campus Gasthiusberg, 3000 Leuven, Belgium
- Department of Pediatric Hematology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Elena Levtchenko
- Laboratory of Pediatric Nephrology, Department of Development and Regeneration, Katholieke Universiteit Leuven, Campus Gasthiusberg, 3000 Leuven, Belgium
- Department of Pediatric Nephrology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
- Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
| | - Hans Pottel
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Campus Kulak, 8500 Kortrijk, Belgium.
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Evaluation of the clinical utility of the PromarkerD in-vitro test in predicting diabetic kidney disease and rapid renal decline through a conjoint analysis. PLoS One 2022; 17:e0271740. [PMID: 35913946 PMCID: PMC9342737 DOI: 10.1371/journal.pone.0271740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/06/2022] [Indexed: 11/19/2022] Open
Abstract
Background Early identification of patients at risk of developing diabetic kidney disease or rapid renal decline is imperative for appropriate patient management, but traditional methods of predicting renal decline are limited. Objective This study evaluated the impact of PromarkerD, a biomarker-based blood test predicting the risk of diabetic kidney disease (DKD) and rapid renal decline. Methods Conjoint analysis clarified the importance of PromarkerD and other patient attributes to physician decisions for type 2 diabetes patients. Forty-two patient profiles were generated, with varying levels of albuminuria, estimated glomerular filtration rate (eGFR), blood pressure, hemoglobin A1c (HbA1c), age, and PromarkerD result. A web-based survey asked each physician to make monitoring/treatment decisions about eight randomly selected profiles. Data were analyzed using multivariable logit models. Results Two hundred three primary care physicians and 197 endocrinologists completed the survey. PromarkerD result was most important for increasing the frequency of risk factor monitoring. PromarkerD was second to HbA1c in importance for deciding to prescribe sodium/glucose cotransporter-2 inhibitors (SGLT2s) with a DKD indication, second to blood pressure for increasing the dose of lisinopril, and second to eGFR for replacing ibuprofen with a non-nephrotoxic medication. Compared with no PromarkerD results, a high-risk PromarkerD result was associated with significantly higher odds of increasing monitoring frequency (odds ratio [OR]: 2.56, 95% confidence interval: 1.90–3.45), prescribing SGLT2s (OR: 1.98 [1.56–2.52]), increasing lisinopril dose (OR: 1.48 [1.17–1.87]), and replacing ibuprofen (OR: 1.78 [1.32–2.40]). A low-risk PromarkerD result was associated with significantly lower odds of increasing monitoring frequency (OR: 0.48 [0.37–0.64]), prescribing SGLT2s (OR: 0.70 [0.56–0.88]), and replacing ibuprofen (OR: 0.75 [0.57–0.99]). Conclusion PromarkerD could increase adoption of renoprotective interventions in patients at high risk for renal decline and lower the likelihood of aggressive treatment in those at low risk. Further studies are needed to assess patient outcomes with PromarkerD in real-world practice.
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Amatruda M, Gembillo G, Giuffrida AE, Santoro D, Conti G. The Aggressive Diabetic Kidney Disease in Youth-Onset Type 2 Diabetes: Pathogenetic Mechanisms and Potential Therapies. ACTA ACUST UNITED AC 2021; 57:medicina57090868. [PMID: 34577791 PMCID: PMC8467670 DOI: 10.3390/medicina57090868] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/21/2021] [Accepted: 08/22/2021] [Indexed: 02/07/2023]
Abstract
Youth-onset Type 2 Diabetes Mellitus (T2DM) represents a major burden worldwide. In the last decades, the prevalence of T2DM became higher than that of Type 1 Diabetes Mellitus (T1DM), helped by the increasing rate of childhood obesity. The highest prevalence rates of youth-onset T2DM are recorded in China (520 cases/100,000) and in the United States (212 cases/100,000), and the numbers are still increasing. T2DM young people present a strong hereditary component, often unmasked by social and environmental risk factors. These patients are affected by multiple coexisting risk factors, including obesity, hyperglycemia, dyslipidemia, insulin resistance, hypertension, and inflammation. Juvenile T2DM nephropathy occurs earlier in life compared to T1DM-related nephropathy in children or T2DM-related nephropathy in adult. Diabetic kidney disease (DKD) is T2DM major long term microvascular complication. This review summarizes the main mechanisms involved in the pathogenesis of the DKD in young population and the recent evolution of treatment, in order to reduce the risk of DKD progression.
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Affiliation(s)
- Michela Amatruda
- Unit of Pediatric Nephrology with Dialysis, AOU Policlinic G Martino, University of Messina, 98125 Messina, Italy;
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (G.G.); (A.E.G.); (D.S.)
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, 98125 Messina, Italy
| | - Alfio Edoardo Giuffrida
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (G.G.); (A.E.G.); (D.S.)
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (G.G.); (A.E.G.); (D.S.)
| | - Giovanni Conti
- Unit of Pediatric Nephrology with Dialysis, AOU Policlinic G Martino, University of Messina, 98125 Messina, Italy;
- Correspondence:
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Abstract
PURPOSE OF REVIEW Sodium-glucose cotransporter 2 (SGLT2) inhibitors have proven cardiorenal protection in patients with diabetes and chronic kidney disease (CKD) as seen in cardiovascular outcome trials (CVOTs) and CREDENCE. In this review, we aim to discuss the mechanisms of kidney protection with SGLT2 inhibition as well as review the results of multiple translational studies and clinical trials of SGLT2 inhibition in the nondiabetic kidney disease (non-DKD) population. RECENT FINDINGS The application of SGLT2 inhibitors as dedicated kidney-protective agents continues to evolve with the publication of the dapagliflozin in patients with chronic kidney disease (DAPA CKD) trial, which extends their cardiorenal protection to patients with nondiabetic CKD. This trial was preceded by CREDENCE, a dedicated kidney outcome study in participants with DKD that demonstrated a 30% reduction in the risk of the composite kidney outcome. From a physiological perspective, mechanistic benefits of SGLT2 inhibitors are independent of their glucose-lowering effects as demonstrated in preclinical studies and post hoc analyses of dedicated CVOTs in participants with type 2 diabetes. From a clinical perspective, there is a growing body of evidence for kidney protection in nondiabetes mellitus patients. SUMMARY There exists strong rationale for SGLT2 inhibition to be incorporated into standard of care for appropriate groups of patients with nondiabetic kidney disease.
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10
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Khoury M, Kavey REW, St Pierre J, McCrindle BW. Incorporating Risk Stratification Into the Practice of Pediatric Preventive Cardiology. Can J Cardiol 2020; 36:1417-1428. [PMID: 32679170 PMCID: PMC7358764 DOI: 10.1016/j.cjca.2020.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/19/2020] [Accepted: 06/19/2020] [Indexed: 12/17/2022] Open
Abstract
Atherosclerosis in its earliest stages is associated with the same traditional cardiovascular disease (CVD) risk factors as are associated with manifest CVD events in adulthood. Clustering of risk factors is associated with exponential increases in atherosclerotic burden from a young age. Some medical conditions and risk behaviours occurring in children can either increase the likelihood of higher levels of risk factors (such as chronic kidney disease) or the presence of risk factor clustering (such as obesity and cardiometabolic syndrome) or are associated with acquired coronary artery pathology (such as Kawasaki disease). This creates a milieu for-or increases the impact of-accelerated atherosclerosis that, in turn, increases the likelihood of premature CVD. This review highlights the importance of considering the total risk factor and risk-condition profile of pediatric patients. An algorithm is provided for stratifying patients into high-, moderate-, and at-risk categories, and practical examples are provided as to how the evaluation and management of 1 risk factor or risk condition might need to be intensified in the context of additional risk factors or risk conditions. For example, for treatment of an adolescent with familial hypercholesterolemia, the target low-density lipoprotein cholesterol level might be lowered by the concomitant presence of low high-density lipoprotein cholesterol or elevated lipoprotein(a) levels. As awareness of cardiovascular risk and atherosclerosis in pediatric patients increases, new at-risk conditions that warrant consideration are emerging. The identification and management of high-risk individuals is an important part of the overall practice of pediatric preventive cardiology.
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Affiliation(s)
- Michael Khoury
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - Rae-Ellen W. Kavey
- Preventive Cardiology–Lipid Clinic, Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Julie St Pierre
- Department of Pediatrics, McGill University, Clinique 180, Montréal, Québec, Canada
| | - Brian W. McCrindle
- Department of Pediatrics, University of Toronto, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
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11
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Ichikawa S, Gohda T, Murakoshi M, Li Z, Adachi E, Koshida T, Suzuki Y. Aspartic acid supplementation ameliorates symptoms of diabetic kidney disease in mice. FEBS Open Bio 2020; 10:1122-1134. [PMID: 32301275 PMCID: PMC7262904 DOI: 10.1002/2211-5463.12862] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 03/31/2020] [Accepted: 04/13/2020] [Indexed: 12/23/2022] Open
Abstract
Diabetic kidney disease (DKD) is among the most common and serious complications of both type 1 and type 2 diabetes. In this study, we used KK/Ta‐Ins2Akita (KK‐Akita) mice as a model of DKD and KK/Ta (KK) mice as controls to identify novel factors related to the development/progression of DKD. Capillary electrophoresis coupled with mass spectrometry analysis revealed that circulating Asp (l‐aspartic acid) levels in diabetic KK‐Akita mice tend to be lower than those in control KK mice. Therefore, we evaluated the effect of Asp supplementation to prevent the progression of DKD in KK‐Akita mice. Mice were divided into three groups: (a) untreated KK mice (Control group), (b) untreated KK‐Akita mice (DKD group), and (c) treated (double‐volume Asp diet) KK‐Akita mice (Tx group). Kidney sections were stained with fluorescein isothiocyanate‐labeled lectins, wheat germ agglutinin (WGA), and anti‐endothelial nitric oxide synthase (eNOS) antibody for evaluation of endothelial surface layer (ESL) and NO synthesis. The mesangial area and glomerular size in the DKD group were significantly larger than those in the Control group; however, there was no significant difference in those between the DKD and Tx groups. Albuminuria, the ratio of foot process effacement, and thickness of glomerular basement membrane in the Tx group were significantly lower than those in the DKD group. Furthermore, the expression levels of glomerular WGA and microvascular eNOS in the Tx group improved significantly and approached the level in the Control group. In conclusion, the improvement of albuminuria in the Tx group may be caused by the reduction of oxidative stress in the kidneys, which may lead to the subsequent improvement of glomerular ESL.
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Affiliation(s)
- Saki Ichikawa
- Department of Nephrology, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Tomohito Gohda
- Department of Nephrology, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Maki Murakoshi
- Department of Nephrology, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Zi Li
- Department of Nephrology, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Eri Adachi
- Department of Nephrology, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Takeo Koshida
- Department of Nephrology, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
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12
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Lytvyn Y, Bjornstad P, van Raalte DH, Heerspink HL, Cherney DZI. The New Biology of Diabetic Kidney Disease-Mechanisms and Therapeutic Implications. Endocr Rev 2020; 41:5601424. [PMID: 31633153 PMCID: PMC7156849 DOI: 10.1210/endrev/bnz010] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
Diabetic kidney disease remains the most common cause of end-stage kidney disease in the world. Despite reductions in incidence rates of myocardial infarction and stroke in people with diabetes over the past 3 decades, the risk of diabetic kidney disease has remained unchanged, and may even be increasing in younger individuals afflicted with this disease. Accordingly, changes in public health policy have to be implemented to address the root causes of diabetic kidney disease, including the rise of obesity and diabetes, in addition to the use of safe and effective pharmacological agents to prevent cardiorenal complications in people with diabetes. The aim of this article is to review the mechanisms of pathogenesis and therapies that are either in clinical practice or that are emerging in clinical development programs for potential use to treat diabetic kidney disease.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Petter Bjornstad
- Department of Medicine, Division of Nephrology, Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Netherlands
| | - Hiddo L Heerspink
- The George Institute for Global Health, Sydney, Australia.,Department of Clinical Pharmacology, University of Groningen, Groningen, Netherlands
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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13
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Sridhar VS, Rahman HU, Cherney DZI. What have we learned about renal protection from the cardiovascular outcome trials and observational analyses with SGLT2 inhibitors? Diabetes Obes Metab 2020; 22 Suppl 1:55-68. [PMID: 32267075 DOI: 10.1111/dom.13965] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 12/21/2022]
Abstract
Over the past 5 years, sodium-glucose cotransport 2 (SGLT2) inhibitors have been increasingly regarded as glycaemic agents with cardiovascular (CV) and renal protective effects. The CV benefits of SGLT2 inhibitors have been well established in patients with type 2 diabetes (T2D) and a range of CV comorbidities at baseline. Subsequently, the renal benefits of SGLT2 inhibitors were established in the CREDENCE trial, a dedicated renal outcome trial where canagliflozin reduced the primary composite renal outcome by 30%. In light of these trials, clinical practice guidelines have rapidly evolved, recommending the use of SGLT2 inhibitors as renal and cardioprotective agents in appropriate patient populations. Accordingly, it is important to have an in-depth understanding of the evidence underlying the use of SGLT2 inhibitors in patients with T2D based on published clinical trials and real-world evidence (RWE) studies, as well as information related to potential safety concerns. To accomplish this, we reviewed the evidence for renal protection and safety with SGLT2 inhibitors in the EMPA-REG OUTCOME, CANVAS Program and DECLARE-TIMI 58 CV safety trials, and in the growing body of evidence emerging from real-world studies. This body of work has shown that SGLT2 inhibitors reduce the risk of surrogate renal endpoints such as albuminuria and mitigate the risk of hard renal endpoints including doubling of serum creatinine and end-stage kidney disease in patients with T2D.
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Affiliation(s)
- Vikas S Sridhar
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Habib U Rahman
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
- Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology and Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada
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14
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Savelieff MG, Callaghan BC, Feldman EL. The emerging role of dyslipidemia in diabetic microvascular complications. Curr Opin Endocrinol Diabetes Obes 2020; 27:115-123. [PMID: 32073426 DOI: 10.1097/med.0000000000000533] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW To summarize recent advancements in our understanding of the impact of dyslipidemia on microvascular complications in type 2 diabetes (T2D), with an emphasis on peripheral neuropathy and nephropathy. RECENT FINDINGS Mounting evidence suggests that rigorous glycemic control only mitigates certain microvascular complications in T2D patients. Particularly, well regulated blood glucose levels only marginally improve peripheral neuropathy in the T2D setting. Dyslipidemia, an abnormal lipid profile, is emerging as a key factor in peripheral neuropathy. Furthermore, although glycemic control may prevent or slow nephropathy, recent developments demonstrate that dyslipidemia can also affect kidney outcomes in normoglycemic patients. Transcriptomic, epigenomic, and lipidomic investigations, as well as integrative approaches, are shedding light on potential pathomechanisms. These molecular studies are identifying possible targets for therapeutic intervention. Complementing molecular research, lifestyle interventions are on-going to assess whether dietary choices and/or exercise, weight-loss, or surgical interventions, such as bariatric surgery, can ameliorate peripheral neuropathy and nephropathy in T2D patients. SUMMARY Dyslipidemia is an emerging mechanism in microvascular complications in T2D. Elucidating the molecular pathomechanisms may pinpoint potential lipid-centric treatments. Interventional studies of dietary changes, exercise, or weight-loss surgery may also positively impact these highly prevalent and morbid complications.
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Affiliation(s)
- Masha G Savelieff
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
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15
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Five-year kidney outcomes of bariatric surgery differ in severely obese adolescents and adults with and without type 2 diabetes. Kidney Int 2020; 97:995-1005. [PMID: 32229096 DOI: 10.1016/j.kint.2020.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/09/2019] [Accepted: 01/02/2020] [Indexed: 12/17/2022]
Abstract
Bariatric surgery improves markers of kidney health in severe obesity, yet it is unclear if kidney disease outcomes differ according to age at surgery. Therefore, we examined health effects of Roux-en-Y gastric bypass between 161 adolescents and 396 adults participating in two related but distinct studies. Primary outcomes were elevated urine albumin-to-creatinine ratio (UACR) of 30 mg/g or more and hyperfiltration (an estimated glomerular filtration rate of 135 ml/min/1.73m2 or more). Analyses were stratified by the presence of pre-operative type 2 diabetes. Adolescents with pre-operative type 2 diabetes had a significantly increased prevalence of elevated UACR prior to surgery compared to adults (22.5 vs. 9.0%). Resolution of elevated UACR following surgery differed between adolescents and adults with type 2 diabetes, with adolescents experiencing a significantly earlier improvement following surgery. Adolescents without pre-operative type 2 diabetes demonstrated a significantly increased prevalence of UACR prior to surgery compared to adults (9.4 vs. 4.5%), with no improvement occurring in either group post-operatively. Adolescents with pre-operative type 2 diabetes had a significantly increased prevalence of hyperfiltration that remained throughout the study period, whereas hyperfiltration prevalence was similar among those without type 2 diabetes. Thus, adolescents with pre-operative type 2 diabetes experienced earlier attenuation of elevated UACR compared to adults with pre-operative type 2 diabetes in response to gastric bypass.
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16
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Khanolkar AR, Amin R, Taylor-Robinson D, Viner RM, Warner J, Stephenson T. Inequalities in glycemic control in childhood onset type 2 diabetes in England and Wales-A national population-based longitudinal study. Pediatr Diabetes 2019; 20:821-831. [PMID: 31329349 DOI: 10.1111/pedi.12897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 04/10/2019] [Accepted: 06/26/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Not much is known about glycaemic-control trajectories in childhood-onset type 2 diabetes (T2D). We investigated characteristics of children and young people (CYP) with T2D and inequalities in glycemic control. METHODS We studied 747 CYP with T2D, <19 years of age in 2009-2016 (from the total population-based National Pediatric Diabetes Audit [>95% diabetes cases in England/Wales]). Linear mixed-effects modeling was used to assess socioeconomic and ethnic differences in longitudinal glycated hemoglobin (HbA1c ) trajectories during 4 years post-diagnosis (3326 HbA1c data points, mean 4.5 data points/subject). Self-identified ethnicity was grouped into six categories. Index of Multiple Deprivation (a small geographical area-level deprivation measure) was grouped into SES quintiles for analysis. RESULTS Fifty-eight percent were non-White, 66% were female, and 41% were in the most disadvantaged SES quintile. Mean age and HbA1c at diagnosis were 13.4 years and 68 mmol/mol, respectively. Following an initial decrease between diagnosis and end of year 1 (-15.2 mmol/mol 95%CI, -19.2, -11.2), HbA1c trajectories increased between years 1 and 3 (10 mmol/mol, 7.6, 12.4), followed by slight gradual decrease subsequently (-1.6 mmol/mol, -2, -1.1). Compared to White CYP, Pakistani children had higher HbA1c at diagnosis (13.2 mmol/mol, 5.6-20.9). During follow-up, mixed-ethnicity and Pakistani CYP had poorer glycemic control. Compared to children in the most disadvantaged quintile, those in the most advantaged had lower HbA1c at diagnosis (-6.3 mmol, -12.6, -0.1). Differences by SES remained during follow-up. Mutual adjustment for SES and ethnicity did not substantially alter the above estimates. CONCLUSIONS About two-thirds of children with childhood-onset T2D were non-White, female adolescents, just under half of whom live in the most disadvantaged areas of England and Wales. Additionally, there are substantial socioeconomic and ethnic inequalities in diabetes control.
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Affiliation(s)
- Amal R Khanolkar
- GOS Institute of Child Health, University College London (UCL), London, UK.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Rakesh Amin
- GOS Institute of Child Health, University College London (UCL), London, UK
| | | | - Russell M Viner
- GOS Institute of Child Health, University College London (UCL), London, UK
| | - Justin Warner
- Department of Paediatrics, Noah's Ark Children's Hospital for Wales, Cardiff, UK
| | - Terence Stephenson
- GOS Institute of Child Health, University College London (UCL), London, UK
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17
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Progress in understanding youth-onset type 2 diabetes in the United States: recent lessons from clinical trials. World J Pediatr 2019; 15:315-321. [PMID: 31077083 DOI: 10.1007/s12519-019-00247-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/20/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Due to the dramatic increase in the rates of childhood obesity and youth-onset type 2 diabetes (T2D) in the late 1990s in the United States, the US government, through the National Institute of Diabetes, Digestive Disease, and Kidney (NIDDK) and the Centers for Disease Control, funded a series of large studies and trials which, together, have formed the basis for much of what we currently understand about youth-onset T2D. DATA SOURCES The review focus on the recent results and implications of the treatment options for Type 2 Diabetes in Adolescents and Youth (TODAY) study and the Restoring Insulin Secretion (RISE) study. RESULTS AND CONCLUSIONS Both TODAY and RISE studies have provided critical insight into the unique aspects of the pathophysiology of youth-onset type 2 diabetes and also provided the evidence base for our current approach to the management of this disorder.
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18
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Metformin monotherapy in children and adolescents with type 2 diabetes mellitus in Japan. Diabetol Int 2018; 10:51-57. [PMID: 30800563 DOI: 10.1007/s13340-018-0361-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/17/2018] [Indexed: 01/07/2023]
Abstract
Objective To evaluate the safety and effectiveness of metformin monotherapy for 52 weeks, including 24 weeks of treatment and a 28-week extension period for evaluation of long-term safety, in 37 Japanese pediatric patients with type 2 diabetes mellitus. Research design and methods This study design was an open-label, non-randomized, multicenter trial. The primary effectiveness endpoint was the changes from baseline to the final visit at 24 weeks in HbA1c. The secondary endpoints were the rate for achieving the treatment goal, and the changes in glycated albumin, fasting blood glucose, fasting insulin, HOMA-IR, and fasting serum lipids. Metformin was administrated at the dose of 500 mg/day up to a maximum of 2000 mg/day taken in two or three divided doses. Results The mean change of HbA1c at the final visit at 24 weeks for 20 metformin-naïve patients (Group A) was - 0.66 ± 0.95% and that of 17 already-on metformin patients (Group B) was - 0.98 ± 1.62%. These figures proved the effectiveness of metformin as defined before the study. Secondary effectiveness endpoints were also improved. The improvement of blood glucose, fasting insulin and serum lipid levels proved the effectiveness of metformin without increasing body weight. Adverse effects such as nausea and diarrhea were observed in 35 of the 37 subjects and drug-related adverse events were observed in 19 patients. However, these events were not serious and did not increase with long-term treatment. Conclusions Metformin is safe and effective for Japanese pediatric patients with T2DM.
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Lake AJ, Rees G, Speight J. Clinical and Psychosocial Factors Influencing Retinal Screening Uptake Among Young Adults with Type 2 Diabetes. Curr Diab Rep 2018; 18:41. [PMID: 29797076 DOI: 10.1007/s11892-018-1007-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW Young adults with type 2 diabetes (T2D, 18-39 years) experience early-onset and rapid progression of diabetic retinopathy (DR), the leading cause of vision loss for working age adults. Despite this, uptake of retinal screening, the crucial first step in preventing vision loss from DR, is low. The aim of this review is to summarize the clinical and psychosocial factors affecting uptake of retinal screening. RECENT FINDINGS Barriers include lack of diabetes-related symptoms, low personal DR risk perception, high rates of depression and diabetes-related distress, fatalism about inevitability of complications, time and financial constraints, disengagement with existing diabetes self-management services, and perceived stigma due to having a condition associated with older adults. Young adults with T2D are an under-researched population who face an accumulation of barriers to retinal screening. Tailored interventions that address the needs, characteristics, and priorities of young adults with T2D are warranted.
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Affiliation(s)
- A J Lake
- School of Psychology, Deakin University, Geelong, VIC, 3220, Australia.
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, c/- 570 Elizabeth Street, Melbourne, VIC, 3000, Australia.
| | - G Rees
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, 3002, Australia
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, 3010, Australia
| | - J Speight
- School of Psychology, Deakin University, Geelong, VIC, 3220, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, c/- 570 Elizabeth Street, Melbourne, VIC, 3000, Australia
- AHP Research, Hornchurch, UK
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Lovshin JA, Škrtić M, Bjornstad P, Moineddin R, Daneman D, Dunger D, Reich HN, Mahmud F, Scholey J, Cherney DZI, Sochett E. Hyperfiltration, urinary albumin excretion, and ambulatory blood pressure in adolescents with Type 1 diabetes mellitus. Am J Physiol Renal Physiol 2018; 314:F667-F674. [PMID: 29357443 PMCID: PMC5966760 DOI: 10.1152/ajprenal.00400.2017] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/10/2017] [Accepted: 12/07/2017] [Indexed: 12/15/2022] Open
Abstract
Adolescents with Type 1 diabetes mellitus (T1DM) are at risk for hyperfiltration and elevated urinary albumin-to-creatinine ratio (ACR), which are early indicators of diabetic nephropathy. Adolescents with T1DM also develop early changes in blood pressure, cardiovascular structure, and function. Our aims were to define the relationships between hyperfiltration, ACR, and 24-h ambulatory blood pressure over time in adolescents with T1DM. Normotensive, normoalbuminuric adolescents ( n = 98) with T1DM underwent baseline and 2-yr 24-h ambulatory blood pressure monitoring, glomerular filtration rate (eGFR) estimated by cystatin C (Larsson equation), and ACR measurements. Linear regression models adjusted for diabetes duration, sex, and HbA1c were used to determine associations. Hyperfiltration (eGFR ≥ 133 ml/min) was present in 31% at baseline and 21% at 2-yr follow-up. Hyperfiltration was associated with greater odds of rapid GFR decline (>3 ml·min-1·yr-1) [OR: 5.33, 95%; CI: 1.87-15.17; P = 0.002] over 2 yr. Natural log of ACR at baseline was associated with greater odds of hyperfiltration (OR: 1.71, 95% CI: 1.00-2.92; P = 0.049) and 2-yr follow-up (OR: 2.14, 95%; CI: 1.09-4.19; P = 0.03). One SD increase in eGFR, but not ln ACR, at 2-yr follow-up conferred greater odds of nighttime nondipping pattern (OR: 1.96, 95% CI: 1.06-3.63; P = 0.03). Hyperfiltration was prevalent at baseline and at 2-yr follow-up, predicted rapid decline in GFR, and was related to ACR. Elevated GFR at 2-yr follow-up was associated with nighttime nondipping pattern. More work is needed to better understand early relationships between renal hemodynamic and systemic hemodynamic changes in adolescents with T1DM to reduce future cardiorenal complications.
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Affiliation(s)
- Julie A Lovshin
- Division of Endocrinology and Metabolism, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronoto , Toronto, Ontario , Canada
| | - Marko Škrtić
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Petter Bjornstad
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto , Toronto, Ontario , Canada
- Division of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine , Aurora, Colorado
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto , Toronto, Ontario , Canada
| | - Denis Daneman
- Division of Endocrinology and Metabolism, Department of Pediatrics, Hospital for Sick Children, University of Toronto , Toronto, Ontario , Canada
| | - David Dunger
- Department of Pediatrics, University of Cambridge , Cambridge , United Kingdom
| | - Heather N Reich
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Farid Mahmud
- Division of Endocrinology and Metabolism, Department of Pediatrics, Hospital for Sick Children, University of Toronto , Toronto, Ontario , Canada
| | - James Scholey
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Etienne Sochett
- Division of Endocrinology and Metabolism, Department of Pediatrics, Hospital for Sick Children, University of Toronto , Toronto, Ontario , Canada
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Bjornstad P, Cherney DZ. Renal Hyperfiltration in Adolescents with Type 2 Diabetes: Physiology, Sex Differences, and Implications for Diabetic Kidney Disease. Curr Diab Rep 2018; 18:22. [PMID: 29557063 PMCID: PMC6344350 DOI: 10.1007/s11892-018-0996-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Compared to adult-onset type 2 diabetes (T2D), youth with T2D have a more aggressive phenotype with greater insulin resistance (IR), more rapid β cell decline, and higher prevalence of diabetic kidney disease (DKD). RECENT FINDINGS Hyperfiltration is common in youth with T2D and predicts progressive DKD. Hyperfiltration is a consequence of early changes in intrarenal hemodynamic function, including increased renal plasma flow (RPF) and glomerular pressure. Girls with T2D are disproportionally affected by DKD, with a 3-fold greater risk of developing hyperfiltration over 5 years compared to boys. Despite the high prevalence and gravity of DKD in youth-onset T2D, widely effective therapeutic options are lacking. In this review, we focus on pathophysiology underlying early DKD in T2D and sex differences and summarize promising novel medical therapies and bariatric surgery.
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Affiliation(s)
- Petter Bjornstad
- Department of Pediatric Endocrinology, University of Colorado School of Medicine, 13123 East 16th Ave, Box B265, Aurora, CO, 80045, USA.
| | - David Z Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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22
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Bjornstad P, Nehus E, El Ghormli L, Bacha F, Libman IM, McKay S, Willi SM, Laffel L, Arslanian S, Nadeau KJ. Insulin Sensitivity and Diabetic Kidney Disease in Children and Adolescents With Type 2 Diabetes: An Observational Analysis of Data From the TODAY Clinical Trial. Am J Kidney Dis 2017; 71:65-74. [PMID: 29157731 DOI: 10.1053/j.ajkd.2017.07.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 07/25/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Diabetic kidney disease is a major cause of premature mortality in type 2 diabetes mellitus (T2DM). Worsening insulin sensitivity independent of glycemic control may contribute to the development of diabetic kidney disease. We investigated the longitudinal association of insulin sensitivity with hyperfiltration and increased albumin excretion in adolescents with T2DM. STUDY DESIGN Observational prospective cohort study. SETTING & PARTICIPANTS 532 TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) participants aged 12 to 17 years with T2DM duration less than 2 years at baseline. The TODAY Study was a multicenter randomized clinical trial that examined the efficacy of 3 treatment regimens (metformin monotherapy, metformin plus rosiglitazone, or metformin plus an intensive lifestyle intervention program) to achieve durable glycemic control. PREDICTORS Natural log-transformed estimated insulin sensitivity (reciprocal of fasting insulin), hemoglobin A1c concentration, age, race-ethnicity, treatment group, body mass index, loss of glycemic control, and hypertension. OUTCOMES Hyperfiltration was defined as 99th percentile or higher of estimated glomerular filtration rate (≥140mL/min/1.73m2) when referenced to healthy adolescents (NHANES 1999-2002) and albumin-creatinine ratio ≥ 30μg/mg at 3 consecutive annual visits. RESULTS Hyperfiltration was observed in 7.0% of participants at baseline and in 13.3% by 5 years, with a cumulative incidence of 5.0% over 5 years. The prevalence of increased albumin excretion was 6% at baseline and 18% by 5 years, with a cumulative incidence of 13.4%. There was an 8% increase in risk for hyperfiltration per 10% lower estimated insulin sensitivity in unadjusted and adjusted models (P=0.01). Increased albumin excretion was associated with hemoglobin A1c concentration, but not estimated insulin sensitivity. LIMITATIONS Longer follow-up is needed to capture the transition from hyperfiltration to rapid glomerular filtration rate decline in youth-onset T2DM. CONCLUSIONS Lower estimated insulin sensitivity was associated with risk for hyperfiltration over time, whereas increased albumin excretion was associated with hyperglycemia in youth-onset T2DM.
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Affiliation(s)
- Petter Bjornstad
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO
| | - Edward Nehus
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Laure El Ghormli
- George Washington University Biostatistics Center, Rockville, MD.
| | - Fida Bacha
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ingrid M Libman
- Children's Hospital University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Steven M Willi
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Silva Arslanian
- Children's Hospital University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kristen J Nadeau
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO
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Peters KE, Davis WA, Ito J, Winfield K, Stoll T, Bringans SD, Lipscombe RJ, Davis TME. Identification of Novel Circulating Biomarkers Predicting Rapid Decline in Renal Function in Type 2 Diabetes: The Fremantle Diabetes Study Phase II. Diabetes Care 2017; 40:1548-1555. [PMID: 28851702 DOI: 10.2337/dc17-0911] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/03/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the ability of plasma apolipoprotein (apo) A-IV (apoA4), apo C-III, CD5 antigen-like (CD5L), complement C1q subcomponent subunit B (C1QB), complement factor H-related protein 2, and insulin-like growth factor binding protein 3 (IBP3) to predict rapid decline in estimated glomerular filtration rate (eGFR) in type 2 diabetes. RESEARCH DESIGN AND METHODS Mass spectrometry was used to measure baseline biomarkers in 345 community-based patients (mean age 67.0 years, 51.9% males) from the Fremantle Diabetes Study Phase II (FDS2). Multiple logistic regression was used to determine clinical predictors of rapid eGFR decline trajectory defined by semiparametric group-based modeling over a 4-year follow-up period. The incremental benefit of each biomarker was then assessed. Similar analyses were performed for a ≥30% eGFR fall, incident chronic kidney disease (eGFR <60 mL/min/1.73 m2), and eGFR decline of ≥5 mL/min/1.73 m2/year. RESULTS Based on eGFR trajectory analysis, 35 participants (10.1%) were defined as "rapid decliners" (mean decrease 2.9 mL/min/1.73 m2/year). After adjustment for clinical predictors, apoA4, CD5L, and C1QB independently predicted rapid decline (odds ratio 2.40 [95% CI 1.24-4.61], 0.52 [0.29-0.93], and 2.41 [1.14-5.11], respectively) and improved model performance and fit (P < 0.001), discrimination (area under the curve 0.75-0.82, P = 0.039), and reclassification (net reclassification index 0.76 [0.63-0.89]; integrated discrimination improvement 6.3% [2.1-10.4%]). These biomarkers and IBP3 contributed to improved model performance in predicting other indices of rapid eGFR decline. CONCLUSIONS The current study has identified novel plasma biomarkers (apoA4, CD5L, C1QB, and IBP3) that may improve the prediction of rapid decline in renal function independently of recognized clinical risk factors in type 2 diabetes.
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Affiliation(s)
- Kirsten E Peters
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Fremantle, Western Australia, Australia.,Proteomics International, Perth, Western Australia, Australia
| | - Wendy A Davis
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Fremantle, Western Australia, Australia
| | - Jun Ito
- Proteomics International, Perth, Western Australia, Australia
| | - Kaye Winfield
- Proteomics International, Perth, Western Australia, Australia
| | - Thomas Stoll
- Proteomics International, Perth, Western Australia, Australia
| | | | | | - Timothy M E Davis
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Fremantle, Western Australia, Australia
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24
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Viner R, White B, Christie D. Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden. Lancet 2017; 389:2252-2260. [PMID: 28589895 DOI: 10.1016/s0140-6736(17)31371-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/27/2017] [Accepted: 05/10/2017] [Indexed: 01/14/2023]
Abstract
Type 2 diabetes in adolescence manifests as a severe progressive form of diabetes that frequently presents with complications, responds poorly to treatment, and results in rapid progression of microvascular and macrovascular complications. Although overall still a rare disease, adolescent type 2 diabetes now poses major challenges to paediatric and adult diabetes services in many countries. Therapeutic options are heavily curtailed by a dearth of knowledge about the condition, with low numbers of participants and poor trial recruitment impeding research. Together with lifestyle modification, metformin remains the first-line therapy for adolescents with type 2 diabetes, although the majority rapidly progress to treatment failure and insulin therapy. Early bariatric surgery is controversial but has great potential to transform outcomes. Health systems must respond by both concentrating patients in specialist clinical services integrated with translational research programmes, but also by joining up with local health and social care services to improve engagement and uptake of services.
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Affiliation(s)
- Russell Viner
- UCL Great Ormond Street Institute of Child Health, London, UK; Child and Adolescent Diabetes Service, UCL Hospitals NHS Foundation Trust, London, UK.
| | - Billy White
- UCL Great Ormond Street Institute of Child Health, London, UK; Child and Adolescent Diabetes Service, UCL Hospitals NHS Foundation Trust, London, UK
| | - Deborah Christie
- Child and Adolescent Diabetes Service, UCL Hospitals NHS Foundation Trust, London, UK; UCL Institute of Epidemiology and Healthcare, London, UK
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25
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Razek AAKA, Al-Adlany MAAA, Alhadidy AM, Atwa MA, Abdou NEA. Diffusion tensor imaging of the renal cortex in diabetic patients: correlation with urinary and serum biomarkers. Abdom Radiol (NY) 2017; 42:1493-1500. [PMID: 28044190 DOI: 10.1007/s00261-016-1021-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE To demonstrate role of diffusion tensor imaging of the kidney in diabetic patients and to correlate renal fractional anisotropy (FA) and apparent diffusion coefficient (ADC) of the renal cortex with urinary and serum biomarkers of diabetes. MATERIAL AND METHODS Prospective study was conducted upon 42 diabetic patients (28 males, 14 females; mean age = 33 years) and 17 age- and sex-matched volunteers. Diabetic patients were micro-normoalbuminuric (n = 27) and macroalbuminuric (n = 15). Patients and volunteers underwent diffusion tensor imaging of the kidney. The FA and ADC of the renal cortex were calculated from 3 regions of interests of both kidneys. RESULTS The mean FA and ADC of the renal cortex in diabetic patients (0.36 ± 0.10 and 1.74 ± 0.16 × 10-3 mm2/s) was significantly different (p = 0.001) from that of volunteers (0.26 ± 0.02 and 1.88 ± 0.03 × 10-3 mm2/s). The cut-off renal FA and ADC used to differentiate diabetic patients from volunteers were 0.28 and 1.89 × 10-3 mm2/s with AUC of 0.791 and 0.773 and accuracy of 71% and 76%. The FA and ADC calculated in the renal cortex in patients with macroalbuminuria (0.43 ± 0.10 and 1.63 ± 0.19 × 10-3 mm2/s) was significantly different (p = 0.001) from that of patients with micro-normoalbuminuria (0.35 ± 0.12 and 1.80 ± 0.18 × 10-3 mm2/s). The FA and ADC of the renal cortex in diabetic patients correlated with urinary albumin (r = 0.530; p = 0.001, r = -0.421; p = 0.006), urinary NAG (r = 0.376; p = 0.014, r = -0.245; p = 0.01), urinary TGF-β1 (r = 0.287; p = 0.065, r = -0.214; p = 0.175), and serum creatinine (r = 0.381; p = 0.013, r = -0.349; p = 0.023). CONCLUSION The FA and ADC of the renal cortex may help in differentiation of diabetic kidney from volunteers and prediction of the presence of macroalbuminuria in diabetic patients and correlated with some of the urinary and serum biomarkers of diabetes.
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Affiliation(s)
| | | | | | - Mohammed Ali Atwa
- Department of Clinical Pathology, Mansoura Faculty of Medicine, Mansoura, Egypt
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