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Morita R, Tsukamoto S, Obata S, Yamada T, Uneda K, Uehara T, Rehman ME, Azushima K, Wakui H, Tamura K. Effects of sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists, and their combination on albuminuria in diabetic patients. Diabetes Obes Metab 2023; 25:1271-1279. [PMID: 36633511 DOI: 10.1111/dom.14976] [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: 12/13/2022] [Accepted: 01/08/2023] [Indexed: 01/13/2023]
Abstract
AIMS Diabetes mellitus (DM) is the leading cause of chronic kidney disease. Albuminuria is associated with an increased risk of cardiovascular mortality. Sodium-glucose cotransporter 2 inhibitors (SGLT2-Is) and mineralocorticoid receptor antagonists (MRAs) protect against albuminuria; however, their combined effects on albuminuria are unclear. We performed a network meta-analysis to investigate the effects of SGLT2-Is, MRAs and their combination on albuminuria in type 2 DM. METHODS We systematically searched PubMed, Medline, EMBASE and the Cochrane Library from inception up to 20 November 2022. We selected randomized control and crossover trials that compared MRAs, SGLT2-Is, MRAs + SGLT2-Is, or a placebo in patients with type 2 DM with a urinary albumin-creatinine ratio (UACR) ≥30 mg/g creatinine. The primary outcome was the change in the UACR. RESULTS This meta-analysis analysed 17 studies with 34 412 patients. The use of combination treatment with SGLT2-Is and MRAs was associated with lower albuminuria compared with the use of SGLT2-Is, MRAs, or the placebo alone [mean difference (95% CI): -34.19 (-27.30; -41.08), -32.25 (-24.53; -39.97) and -65.22 (-57.97; -72.47), respectively]. Treatment with SGLT2-Is or MRAs alone caused a significant reduction in UACR compared with the placebo [mean difference (95% CI): -31.03 (-28.35; -33.72) and -32.97 (-29.68; -36.27), respectively]. The effects of MRAs on the UACR are comparable with those of SGLT2-Is. Sensitivity analyses showed similar results. CONCLUSION Combination therapy with SGLT2-Is and MRAs was associated with lower albuminuria in patients with type 2 DM compared with monotherapy with SGLT2-Is or MRAs alone.
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Affiliation(s)
- Ryutaro Morita
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shunichiro Tsukamoto
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shota Obata
- Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Takayuki Yamada
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kazushi Uneda
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Kampo Medicine, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Tatsuki Uehara
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Muhammad Ebad Rehman
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kengo Azushima
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiromichi Wakui
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Bartziokas K, Kyriakopoulos C, Dounousi E, Kostikas K. Microalbuminuria on admission for acute exacerbation of COPD as a predictor of all-cause mortality and future exacerbations. Postgrad Med J 2021; 99:postgradmedj-2021-141206. [PMID: 34876486 DOI: 10.1136/postgradmedj-2021-141206] [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: 09/21/2021] [Accepted: 11/13/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Microalbuminuria (MAB) is a sensitive biomarker of cardiovascular risk that is directly associated with cardiovascular events and mortality. Recent studies have evaluated the presence of MAB in patients with stable chronic obstructive pulmonary disease (COPD) or hospitalised for acute exacerbation of COPD (AECOPD). METHODS We evaluated 320 patients admitted for AECOPD in respiratory medicine departments of two tertiary hospitals. On admission, demographic, clinical and laboratory values and COPD severity were assessed. Patients were evaluated monthly for 1 year, recording new AECOPD and death from any cause. RESULTS Patients with documented MAB (urinary albumin excretion of 30-300 mg/24 hours) on admission had worse lung function (forced expiratory volume in 1 s, %) (mean (SD) 34.2 (13.6)% vs 61.5 (16.7)%), higher modified Medical Research Council (3.6 (1.2) vs 2.1 (0.8)), lower 6 min walk test (171 (63) vs 366 (104)) and more hospitalisation days (9 (2.8) vs 4.7 (1.9)) (p<0.001 for all comparisons). MAB was also correlated with Global Initiative for Chronic Obstructive Lung Disease 2020 COPD stages (p<0.001). In multivariate regression analysis, MAB was a significant predictor of longer hospitalisation duration (OR 6.847, 95% CI 3.050 to 15.370, p<0.0001). Twelve-month follow-up revealed that patients with MAB experienced more AECOPDs (4.6 (3.6) vs 2.2 (3.5), p<0.0001) and deaths, n (%) (52 (36.6) vs 14 (7.8), p<0.001). Kaplan-Meier survival curves demonstrated that patients with MAB presented with increased mortality, AECOPD and hospitalisation for AECOPD risk at 1 year (p<0.001 for all comparisons). CONCLUSIONS The presence of MAB on admission for AECOPD was associated with more severe COPD and prolonged hospitalisation, as well as with higher rates of AECOPD and mortality risk at 1-year follow-up.
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Affiliation(s)
- Konstantinos Bartziokas
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Epirus, Greece
| | - Christos Kyriakopoulos
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Epirus, Greece
| | - Evangelia Dounousi
- Nephrology Department, University of Ioannina Faculty of Medicine, Ioannina, Epirus, Greece
| | - Konstantinos Kostikas
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Epirus, Greece
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Schick V, Boensch M, van Edig M, Alfitian J, Pola T, Ecker H, Lindacher F, Shah-Hosseini K, Wetsch WA, Riedel B, Schier R. Impaired vascular endothelial function as a perioperative risk predictor - a prospective observational trial. BMC Anesthesiol 2021; 21:190. [PMID: 34266384 PMCID: PMC8281450 DOI: 10.1186/s12871-021-01400-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/14/2021] [Indexed: 11/18/2022] Open
Abstract
Background In the recent years, an increasing number of patients with multiple comorbidities (e.g. coronary artery disease, diabetes, hypertension) presents to the operating room. The clinical risk factors are accompanied by underlying vascular-endothelial dysfunction, which impairs microcirculation and may predispose to end-organ dysfunction and impaired postoperative outcome. Whether preoperative endothelial dysfunction identifies patients at risk of postoperative complications remains unclear. In this prospective observational study, we tested the hypothesis that impaired flow-mediated dilation (FMD), a non-invasive surrogate marker of endothelial function, correlates with Days at Home within 30 days after surgery (DAH30). DAH30 is a patient-centric metric that captures postoperative complications and importantly also hospital re-admissions. Methods Seventy-one patients scheduled for major abdominal surgery were enrolled. FMD was performed pre-operatively prior to major abdominal surgery and patients were dichotomised at a threshold value of 10%. FMD was then correlated with DAH30 (primary endpoint) and postoperative complications (secondary endpoints). Results DAH30 did not differ between patients with reduced FMD and normal FMD (14 (4) (median (IQR)) vs. 15 (8), P = 0.8). Similary, no differences between both groups were found for CCI (normal FMD: 21 (30) (median (IQR)), reduced FMD: 26 (38), P = 0.4) or frequency of major complications (normal FMD: 7 (19%) (n (%)), reduced FMD: 12 (35%), P = 0.12). The regression analyses revealed that FMD in combination with ASA status and surgery duration had no additional significant predictive effect for DAH30, CCI or Clavien-Dindo score. Conclusion FMD does not add predictive value with regards to DAH30, CCI or Clavien-Dindo score within our study cohort of patients undergoing abdominal surgery. Trial registration The study was registered in the German Clinical Trials Register (DRKS00005472), prospectively registered on 25/11/2013.
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Affiliation(s)
- Volker Schick
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - Marc Boensch
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Milan van Edig
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Jonas Alfitian
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Tülay Pola
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Hannes Ecker
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Falko Lindacher
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Kija Shah-Hosseini
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Wolfgang A Wetsch
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and The University of Melbourne, Melbourne, Australia
| | - Robert Schier
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
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Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology. Arch Cardiovasc Dis 2020; 114:150-172. [PMID: 33309203 DOI: 10.1016/j.acvd.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/09/2023]
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Kakutani Y, Morioka T, Mori K, Yamazaki Y, Ochi A, Kurajoh M, Fukumoto S, Shioi A, Shoji T, Inaba M, Emoto M. Albuminuria rather than glomerular filtration rate is associated with vascular endothelial function in patients with type 2 diabetes. J Diabetes Complications 2020; 34:107702. [PMID: 32888790 DOI: 10.1016/j.jdiacomp.2020.107702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/11/2020] [Accepted: 07/25/2020] [Indexed: 11/20/2022]
Abstract
AIMS Albuminuria and reduced glomerular filtration rate (GFR) are manifestations of diabetic kidney disease and are both shown to be associated with cardiovascular outcomes. However, the differential association of albuminuria and reduced GFR with endothelial dysfunction, an early feature of atherosclerotic vascular damage, remains unclear. In this study, we investigated the association between albuminuria or estimated GFR (eGFR) and flow-mediated dilatation (FMD), a marker of endothelial function, in patients with type 2 diabetes. METHODS This study included 633 patients with type 2 diabetes. The FMD of the brachial artery was measured by ultrasonography. Albuminuria was evaluated by urinary albumin-to-creatinine ratio (ACR). RESULTS The mean FMD and eGFR, and the median value of ACR were 6.7%, 66.5 mL/min/1.73m2 and 12.5 mg/g creatinine, respectively. Impaired FMD was found in patients with advanced stages of chronic kidney disease based on both GFR and albuminuria categories. Multivariate analysis after adjusting for potential confounders revealed that ACR, but not eGFR, was significantly and inversely associated with FMD. CONCLUSIONS Albuminuria is associated with FMD, independently of traditional cardiovascular risk factors in patients with type 2 diabetes. This study suggests a close relationship between albuminuria, rather than reduced GFR, and endothelial dysfunction in type 2 diabetes.
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Affiliation(s)
- Yoshinori Kakutani
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine. 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Tomoaki Morioka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine. 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan.
| | - Katsuhito Mori
- Department of Nephrology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Yuko Yamazaki
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine. 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Akinobu Ochi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine. 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Masafumi Kurajoh
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine. 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Shinya Fukumoto
- Department of Premier Preventive Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Atsushi Shioi
- Department of Vascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan; Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Tetsuo Shoji
- Department of Vascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan; Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine. 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan; Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine. 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
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Valensi P, Henry P, Boccara F, Cosson E, Prevost G, Emmerich J, Ernande L, Marcadet D, Mousseaux E, Rouzet F, Sultan A, Ferrières J, Vergès B, Van Belle E. Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology. DIABETES & METABOLISM 2020; 47:101185. [PMID: 32846201 DOI: 10.1016/j.diabet.2020.08.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Paul Valensi
- Unit of Endocrinology Diabetology Nutrition, AP-HP, Jean Verdier hospital, CINFO, CRNH-IdF, Paris 13 University, Sorbonne Paris Cité, Bondy, France
| | - Patrick Henry
- Department of Cardiology, Inserm U942, Lariboisiere Hospital, Assistance Publique - Hôpitaux de Paris, University of Paris, Paris, France.
| | - Franck Boccara
- AP-HP, Hôpitaux de l'Est Parisien, Hôpital Saint-Antoine, Department of Cardiology, Sorbonne Université-Inserm UMR S_938, Centre de Recherche Saint-Antoine, Paris, France
| | - Emmanuel Cosson
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France; Paris 13 University, Sorbonne Paris Cité, UMR U557 Inserm/U11125 INRAE/CNAM/Université Paris13, Unité de Recherche Epidémiologique Nutritionnelle, Bobigny, France
| | - Gaetan Prevost
- Department of Endocrinology, Diabetes and Metabolic Diseases, Normandie Univ, UNIROUEN, Rouen University Hospital, Centre d'Investigation Clinique (CIC-CRB)-Inserm 1404, Rouen University Hospital, 76000 Rouen, France
| | - Joseph Emmerich
- Service de Médecine Vasculaire, Groupe Hospitalier Paris Saint-Joseph, Université de Paris, Inserm UMR1153-CRESS, 75674 Paris cedex 14, France
| | - Laura Ernande
- Service des explorations fonctionnelles, Hôpital Henri Mondor, AP-HP et Inserm U955, Université Paris-Est Créteil, France
| | - Dany Marcadet
- Centre Coeur et Santé Bernoulli - Cardiologie du sport et Réadaptation Cardiaque, 3, rue Bernoulli, 75008 Paris, France
| | - Elie Mousseaux
- Radiology Department, Hôpital Européen Georges Pompidou & Inserm U 970; Assistance Publique - Hôpitaux de Paris, University of Paris, French Society of Cardiovascular Imaging (SFICV), Paris, France
| | - François Rouzet
- Nuclear Medicine Department, Bichat Hospital, AP-HP Paris - Université de Paris, Laboratory for Vascular Translational Science, Inserm, UMR 1148, 75018 Paris, France
| | - Ariane Sultan
- Physiologie et Médecine Expérimentale du Coeur et des Muscles (PHYMEDEX), U1046 Inserm, UMR9214 CNRS, Université de Montpellier, 34295 Montpellier; Département Endocrinologie, Nutrition, Diabète, Equipe Nutrition, Diabète, CHRU Montpellier, 34090 Montpellier, France
| | - Jean Ferrières
- Department of Cardiology and UMR Inserm 1027, Toulouse Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France
| | - Bruno Vergès
- Service Endocrinologie-Diabétologie, CHU Dijon - Inserm LNC-UMR 1231, Dijon, France
| | - Eric Van Belle
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France; Inserm, U1011, Institut Pasteur de Lille, EGID, Lille, France; Department of Medicine, Université de Lille, Lille, France
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Ishigami J, Matsushita K. Clinical epidemiology of infectious disease among patients with chronic kidney disease. Clin Exp Nephrol 2018; 23:437-447. [PMID: 30178234 PMCID: PMC6435626 DOI: 10.1007/s10157-018-1641-8] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 08/24/2018] [Indexed: 12/20/2022]
Abstract
Infectious disease is recognized as an important complication among patients with end-stage renal disease, contributing to excess morbidity and health care costs. However, recent epidemiological studies have revealed that even mild to moderate stages of chronic kidney disease (CKD) substantially increase risk of infection. Regarding underlying mechanisms, evidence suggests various aspects of altered immune response in patients with CKD including impaired function of T cells, B cells and neutrophil. Multiple conditions surrounding CKD, such as older age, diabetes, and cardiovascular disease are important contributors in the increased susceptibility to infection in this population. In addition, several mechanisms impairing immune function have been hypothesized including accumulated uremic toxins, increased oxidative stress, endothelial dysfunction, low-grade inflammation, and mineral and bone disorders. In terms of prevention strategies, influenza and pneumococcal vaccines are most feasible and important. Nevertheless, the extent of vaccine utilization in CKD has not been well documented. In addition, antibody response to vaccination may be reduced in CKD patients, and thus a vaccine delivery strategy (e.g., dose and frequency) may need to be optimized among patients with CKD. Through this review, we demonstrate that infection is a major but underrecognized complication of CKD. As CKD is recognized as a serious public health issue, dedicated research is needed to better characterize the burden of infectious disease associated with CKD, understand the pathophysiology of infection in patients with CKD, and develop effective strategies to prevent infection and its sequela in this high risk population.
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Affiliation(s)
- Junichi Ishigami
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument St., Suite 2-600, Baltimore, MD, 21287, USA.
| | - Kunihiro Matsushita
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument St., Suite 2-600, Baltimore, MD, 21287, USA
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Shi R, Guo Z, Wang F, Li R, Zhao L, Lin R. Alterations in retinal nerve fiber layer thickness in early stages of diabetic retinopathy and potential risk factors. Curr Eye Res 2017; 43:244-253. [PMID: 29111833 DOI: 10.1080/02713683.2017.1387669] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIMS To investigate the loss of retinal nerve fiber layer (RNFL) in type-2 diabetic patients with early-stage diabetic retinopathy (DR) and to identify potential risk factors accounting for these alterations. METHODS In this cross-sectional study, 158 type-2 diabetic patients were divided into three groups based on their DR status. RNFL thickness and other optic disc parameters were obtained by optical coherence tomography (OCT) and then compared among different groups. We investigated the potential association between RNFL loss and systemic risk factors for DR, including diabetes duration, body mass index (BMI), serum lipids, hemoglobin A1c (HbA1c) and albumin-creatinine ratio (ACR). One-way ANOVA was carried out to compare RNFL thickness among different groups, Pearson correlation and multivariate linear regression analysis were performed to determine potential risk factors related to RNFL thickness in these patients. RESULTS There were significant differences in the average (F = 8.872, P = 0.003), superior (F = 8.769, P = 0.004), and inferior (F = 8.857, P = 0.003) RNFL thickness of both eyes among the groups, but no obvious difference in optic disc parameters was found. Diabetic duration, BMI, TG, High density lipoprotein cholesterol (HDL), HbA1c, and ACR were found negatively related to the RNFL thickness in both or single eye according to Pearson correlation analysis. After controlling for age, gender, and axis length (AL) in multivariate linear regression analysis, the diabetic duration was associated significantly with RNFL thickness of superior in both eye (right eye: p = 0.016, left eye: p = 0.024), BMI was related to the nasal quadrant of the right eye (p = 0.034), and TG was related to the inferior of the right eye (p = 0.037), HbA1c (p = 0.026) was associated significantly with the average RNFL thickness of the right eye. In addition, ACR was found negatively related to average (p = 0.042) and inferior quadrant (p = 0.014) of the left eye, respectively. CONCLUSIONS RNFL loss might be the earliest structural change of retina in diabetic patients, and associated with diabetic duration, BMI, TG, HbA1c, and ACR. The conclusions of this study need to be proved by other well-matched and large-scale prospective clinical trials in the future, because the correlations discovered in our study were weak.
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Affiliation(s)
- Rui Shi
- a Department of Pharmacology , School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center , Xi'an , Shaanxi , P.R. China.,b Department of Ophthalmology , Shaanxi Provincial People's Hospital , Xi'an , China
| | - Zhonglan Guo
- b Department of Ophthalmology , Shaanxi Provincial People's Hospital , Xi'an , China
| | - Feng Wang
- c Department of Ophthalmology , the Second Affiliated Hospital of Xi'an Jiaotong University (Xibei hospital) , Xi'an , China
| | - Rong Li
- d the First Affiliated Hospital , Xi'an Medical University , Xi'an , China
| | - Lei Zhao
- e Department of Molecular Physiology and Biophysics, Holden Comprehensive Cancer Center , University of Iowa Carver College of Medicine , Iowa City , USA
| | - Rong Lin
- f Department of Pharmacology , School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center , Xi'an , P. R. China
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9
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Martens RJH, Henry RMA, Houben AJHM, van der Kallen CJH, Kroon AA, Schalkwijk CG, Schram MT, Sep SJS, Schaper NC, Dagnelie PC, Muris DMJ, Gronenschild EHBM, van der Sande FM, Leunissen KML, Kooman JP, Stehouwer CDA. Capillary Rarefaction Associates with Albuminuria: The Maastricht Study. J Am Soc Nephrol 2016; 27:3748-3757. [PMID: 27160406 DOI: 10.1681/asn.2015111219] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 04/07/2016] [Indexed: 11/03/2022] Open
Abstract
Albuminuria may be a biomarker of generalized (i.e., microvascular and macrovascular) endothelial dysfunction. According to this concept, endothelial dysfunction of the renal microcirculation causes albuminuria by increasing glomerular capillary wall permeability and intraglomerular pressure, the latter eventually leading to glomerular capillary dropout (rarefaction) and further increases in intraglomerular pressure. However, direct evidence for an association between capillary rarefaction and albuminuria is lacking. Therefore, we examined the cross-sectional association between the recruitment of capillaries after arterial occlusion (capillary density during postocclusive peak reactive hyperemia) and during venous occlusion (venous congestion), as assessed with skin capillaroscopy, and albuminuria in 741 participants of the Maastricht Study, including 211 participants with type 2 diabetes. Overall, 57 participants had albuminuria, which was defined as a urinary albumin excretion ≥30 mg/24 h. After adjustment for potential confounders, participants in the lowest tertile of skin capillary recruitment during postocclusive peak reactive hyperemia had an odds ratio for albuminuria of 2.27 (95% confidence interval, 1.07 to 4.80) compared with those in the highest tertile. Similarly, a comparison between the lowest and the highest tertiles of capillary recruitment during venous congestion yielded an odds ratio of 2.89 (95% confidence interval, 1.27 to 6.61) for participants in the lowest tertile. In conclusion, lower capillary density of the skin microcirculation independently associated with albuminuria, providing direct support for a role of capillary rarefaction in the pathogenesis of albuminuria.
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Affiliation(s)
- Remy J H Martens
- Department of Internal Medicine, Division of Nephrology and.,School of Nutrition and Translational Research in Metabolism
| | - Ronald M A Henry
- Departments of Internal Medicine and.,Cardiovascular Research Institute Maastricht
| | - Alfons J H M Houben
- Departments of Internal Medicine and.,Cardiovascular Research Institute Maastricht
| | | | - Abraham A Kroon
- Departments of Internal Medicine and.,Cardiovascular Research Institute Maastricht
| | - Casper G Schalkwijk
- Departments of Internal Medicine and.,Cardiovascular Research Institute Maastricht
| | - Miranda T Schram
- Departments of Internal Medicine and.,Cardiovascular Research Institute Maastricht
| | - Simone J S Sep
- Departments of Internal Medicine and.,Cardiovascular Research Institute Maastricht
| | - Nicolaas C Schaper
- Departments of Internal Medicine and.,Cardiovascular Research Institute Maastricht.,School for Public Health and Primary Care
| | - Pieter C Dagnelie
- Cardiovascular Research Institute Maastricht.,School for Public Health and Primary Care.,Department of Epidemiology, and
| | - Dennis M J Muris
- Departments of Internal Medicine and.,Cardiovascular Research Institute Maastricht
| | - Ed H B M Gronenschild
- Psychiatry and Neuropsychology, Maastricht University Medical Center, Maastricht, The Netherlands; and.,School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | | | - Karel M L Leunissen
- Department of Internal Medicine, Division of Nephrology and.,School of Nutrition and Translational Research in Metabolism
| | - Jeroen P Kooman
- Department of Internal Medicine, Division of Nephrology and.,School of Nutrition and Translational Research in Metabolism
| | - Coen D A Stehouwer
- Departments of Internal Medicine and .,Cardiovascular Research Institute Maastricht
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10
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Tuna MM, Doğan BA, Arduç A, Imga NN, Tütüncü Y, Berker D, Güler S. Impaired endothelial function in patients with mild primary hyperparathyroidism improves after parathyroidectomy. Clin Endocrinol (Oxf) 2015; 83:951-6. [PMID: 25393455 DOI: 10.1111/cen.12666] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 10/03/2014] [Accepted: 11/10/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) is associated with cardiovascular morbidity; however, data on the reversibility of cardiovascular disease in mild primary hyperparathyroidism are conflicting. The aim of this study was to assess endothelial function in patients with mild PHPT before and after parathyroidectomy (Ptx). METHODS We prospectively evaluated 53 patients with mild PHPT (Group 1; 45 women, eight men; aged 52 ± 3·1 years) and 46 healthy control subjects (Group 2; 38 women, eight men; aged 46 ± 9·5 years). Endothelial function was measured as flow-mediated dilation (FMD) and carotid intima-media thickness (CIMT) using Doppler ultrasonography. Patients with diabetes mellitus, coronary heart disease, impaired renal function, hyperthyroidism, hypothyroidism and a history of smoking were excluded from the study. Patients were studied at baseline and 6-12 months after the first evaluation. RESULTS There were no differences with respect to age, gender and BMI between the two groups. Hypertension prevalence was three times higher in group 1 than in controls. % FMD was lower in group 1 than in group 2 (2·6 ± 1·2 vs 14·8 ± 9·6, P < 0·001). CIMT was higher in patients with PHPT than controls (0·69 ± 0·18 vs 0·61 ± 0·12, P = 0·045). This significance remained when hypertensive patients were excluded from the analysis. While FMD and CIMT improved significantly after Ptx, there were no differences in mild PHPT patients who followed without parathyroidectomy. CONCLUSION FMD and CIMT are impaired in patients with mild PHPT compared to controls and improved significantly after a successful Ptx. Ptx improves endothelial function in patients with mild PHPT that may lead to decreased cardiovascular morbidity and mortality.
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Affiliation(s)
- Mazhar M Tuna
- Department of Metabolism, Medical Faculty of Endocrinology, Dicle University, Diyarbakir, Turkey
| | - Berçem A Doğan
- Department of Endocrinology and Metabolism, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Ayşe Arduç
- Diabetes, Endocrine and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Washington, DC, USA
| | - Narin Nasiroğlu Imga
- Department of Endocrinology and Metabolism, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Yasemin Tütüncü
- Department of Endocrinology and Metabolism, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Dilek Berker
- Department of Endocrinology and Metabolism, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Serdar Güler
- Department of Metabolism, Medical Faculty of Endocrinology, Hitit University, Çorum, Turkey
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11
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Choi JA, Ko SH, Park YR, Jee DH, Ko SH, Park CK. Retinal nerve fiber layer loss is associated with urinary albumin excretion in patients with type 2 diabetes. Ophthalmology 2015; 122:976-81. [PMID: 25666831 DOI: 10.1016/j.ophtha.2015.01.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 12/30/2014] [Accepted: 01/02/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To identify the factors associated with retinal nerve fiber layer (RNFL) loss in patients with type 2 diabetes. DESIGN Cross-sectional study. PARTICIPANTS Ninety-six nonglaucomatous patients with type 2 diabetes without renal impairment (estimated glomerular filtration rate, ≥60 ml/minute per 1.73 m(2)). METHODS Eyes were divided into 2 groups based on the presence or absence of RNFL defects detected by red-free retinal fundus photography. All participants underwent an eye fundus examination, and the urinary albumin-to-creatinine ratio (ACR) was determined. A cardiovascular autonomic function test was performed using the following heart rate variability parameters: expiration-to-inspiration ratio, response to the Valsalva maneuver, and standing. Multiple logistic regression analyses were performed to determine potential risk factors related to the presence of RNFL defects in these patients. MAIN OUTCOMES AND MEASURES The association between RNFL defects and diabetic complications. RESULTS Among the patients, 43 (44.8%) had localized RNFL defects (group 1), whereas the others (55.2%) did not (group 2). The RNFL defects occurred more frequently on the superior side (75.6% and 71.0% in right and left eyes, respectively) compared with the inferior side (13.8% and 0.0% in right and left eyes, respectively). Patients with RNFL defects (group 1) had significantly higher rates of diabetic retinopathy (60.5%) compared with those without RNFL defects (group 2; 32.1%; P = 0.007). The urinary ACR was significantly higher in patients with RNFL defects than in those without defects (45.3±72.1 μg/mg vs. 15.4±17.3 μg/mg creatinine, respectively; P = 0.015), whereas autonomic function test grading was similar between the groups. The urinary ACR was the only factor related to visual field defect location in both univariate (P = 0.021) and multivariate (P = 0.036) logistic regression analyses after adjusting for age; gender; presence of diabetic retinopathy; diabetes duration; smoking; statin use; and antiplatelet, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker treatment. CONCLUSIONS Urinary albumin excretion was associated with nerve fiber layer loss in patients with type 2 diabetes. Careful examination of the optic nerve head may be necessary, particularly in patients with type 2 diabetes exhibiting albuminuria.
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Affiliation(s)
- Jin A Choi
- Department of Ophthalmology, St. Vincent's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sun-Hee Ko
- Division of Endocrinology and Metabolism, Cheonan Chungmu Hospital, Cheonan, Republic of Korea
| | - Yi Ryeung Park
- Department of Ophthalmology, St. Vincent's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Hyun Jee
- Department of Ophthalmology, St. Vincent's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung-Hyun Ko
- Division of Endocrinology and Metabolism, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chan Kee Park
- Department of Ophthalmology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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12
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Harmer JA, Keech AC, Veillard AS, Skilton MR, Marwick TH, Watts GF, Meredith IT, Celermajer DS. Cigarette smoking and albuminuria are associated with impaired arterial smooth muscle function in patients with type 2 diabetes mellitus: a FIELD substudy. Diabetes Res Clin Pract 2014; 106:328-36. [PMID: 25301035 DOI: 10.1016/j.diabres.2014.08.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 06/13/2014] [Accepted: 08/30/2014] [Indexed: 11/16/2022]
Abstract
AIM Impaired arterial function has been implicated in diabetes-related atherosclerosis, but its determinants in high-risk adults have not been well characterised. We investigated factors associated with impaired arterial function in adults with type 2 diabetes. METHODS Flow-mediated dilatation (a marker of endothelial function) and dilator response to glyceryl trinitrate (to assess smooth muscle function) of the brachial artery were assessed at baseline in 193 patients with type 2 diabetes from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. Traditional risk factors were assessed and a multivariable model was constructed to identify factors independently associated with impaired arterial function. RESULTS Median age was 64 years (interquartile range, 58-69; 61% male) and duration of diabetes was 4 years (interquartile range, 2-9). Flow-mediated dilatation (3.06 ± 0.25%, mean ± SEM) was severely impaired but not significantly associated with other risk factors. Dilator responses to glyceryl trinitrate (10.56 ± 0.52%) were significantly and independently impaired in past and present cigarette smokers (P = 0.005) and in subjects with increased urinary albumin/creatinine ratio (P = 0.01). CONCLUSIONS In adults with type 2 diabetes and known or suspected atherosclerosis, arterial smooth muscle-dependent dilatation was shown to be significantly impaired in cigarette smokers and those with elevated urinary albumin levels.
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Affiliation(s)
- Jason A Harmer
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia.
| | - Anthony C Keech
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | | | - Michael R Skilton
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | - Gerald F Watts
- Department of Medicine, University of Western Australia, Perth, WA, Australia
| | - Ian T Meredith
- Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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13
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Choi JA, Han K, Kwon HS. Association between urinary albumin excretion and intraocular pressure in type 2 diabetic patients without renal impairment. PLoS One 2014; 9:e96335. [PMID: 24788677 PMCID: PMC4008590 DOI: 10.1371/journal.pone.0096335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 04/07/2014] [Indexed: 11/29/2022] Open
Abstract
Background To assess the relationship between urinary albumin excretion and intraocular pressure (IOP) in type 2 diabetes patients without renal impairment. Methods We explored the effects of albuminuria on high IOP in 402 non-glaucomatous type 2 diabetes without renal impairment who participated in the 2011 Korean National Health and Nutrition Examination Survey (KNHANES). Multiple logistic regression analysis was used to assess the relationship between log-transformed albumin/creatinine ratio (ACR) tertiles and an IOP of ≥18 mmHg after adjusting for age, gender, hypertension, body mass index, triglycerides, area of residence, and education level. Results Subjects with a high IOP ≥18 mmHg were more likely to be current smokers (P = 0.038), heavy drinkers (P = 0.006), and to have high systolic blood pressure (P = 0.016), triglycerides (P = 0.008), and a higher log-transformed ACR (P = 0.022).In multivariate regression analysis, ACR tertile was associated with the prevalence of high IOP significantly (P = 0.022). The associations between ACR tertiles and high IOP were significant in overweight patients and those with abdominal obesity (P = 0.003 and 0.003, respectively). In contrast, there were no associations in the subgroup of patients who were not overweight and those without abdominal obesity (P = 0.291 and 0.561, respectively). Conclusions Urinary albumin excretion is associated with high IOP in the type 2 diabetes population without renal insufficiency. The effect of the albuminuria on IOP was evident in a subgroup of patients with components of metabolic syndrome.
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Affiliation(s)
- Jin A. Choi
- St. Vincent Hospital, Department of Ophthalmology, Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyungdo Han
- St. Vincent Hospital, Department of Biostatistics, Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyuk-Sang Kwon
- Yeouido St. Mary's Hospital, Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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Flow-mediated-paradoxical vasoconstriction is independently associated with asymptomatic myocardial ischemia and coronary artery disease in type 2 diabetic patients. Cardiovasc Diabetol 2014; 13:20. [PMID: 24428877 PMCID: PMC3901336 DOI: 10.1186/1475-2840-13-20] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/31/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To investigate whether flow-mediated dilation (FMD) impairment, which precedes overt atherosclerosis, is associated with silent myocardial ischemia (SMI) and asymptomatic coronary artery disease (CAD) in type 2 diabetes. METHODS Forearm FMD was measured by ultrasonography in 25 healthy control, 30 non-diabetic overweight or obese patients and 118 asymptomatic type 2 diabetic patients with a high cardiovascular risk profile. SMI (abnormal stress myocardial scintiscan and/or stress dobutamine echocardiogram) and CAD (coronary angiography in the patients with SMI) were assessed in the diabetic cohort. RESULTS FMD was lower in diabetic patients (median 0.61% (upper limits of first and third quartiles -1.22;3.2)) than in healthy controls (3.95% (1.43;5.25), p < 0.01) and overweight/obese patients (4.25% (1.74;5.56), p < 0.01). SMI was present in 60 diabetic patients, including 21 subjects with CAD. FMD was lower in patients with SMI than in those without (0.12% (-2.3;1.58) vs 1.64% (0;3.69), p < 0.01), with a higher prevalence of paradoxical vasoconstriction (50.0% vs 29.3%, p < 0.05). FMD was also lower in patients with than without CAD (-1.22% (-2.5;1) vs 1.13% (-0.4;3.28), p < 0.01; paradoxical vasoconstriction 61.9% vs 34.4%, p < 0.05). Logistic regression analyses considering the parameters predicting SMI or CAD in univariate analyses with a p value <0.10 showed that paradoxical vasoconstriction (odds ratio 2.7 [95% confidence interval 1.2-5.9], p < 0.05) and nephropathy (OR 2.6 [1.2-5.7], p < 0.05) were independently associated with SMI; and only paradoxical vasoconstriction (OR 3.1 [1.2-8.2], p < 0.05) with CAD. The negative predictive value of paradoxical vasoconstriction to detect CAD was 88.7%. CONCLUSIONS In diabetic patients, FMD was independently associated with SMI and asymptomatic CAD. TRIAL REGISTRATION Trial registration number NCT00685984.
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15
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May A, Wang TJ. Evaluating the role of biomarkers for cardiovascular risk prediction: focus on CRP, BNP and urinary microalbumin. Expert Rev Mol Diagn 2014; 7:793-804. [DOI: 10.1586/14737159.7.6.793] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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16
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Gutiérrez E, Flammer AJ, Lerman LO, Elízaga J, Lerman A, Fernández-Avilés F. Endothelial dysfunction over the course of coronary artery disease. Eur Heart J 2013; 34:3175-81. [PMID: 24014385 DOI: 10.1093/eurheartj/eht351] [Citation(s) in RCA: 210] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The vascular endothelium regulates blood flow in response to physiological needs. Endothelial dysfunction is closely related to atherosclerosis and its risk factors, and it constitutes an intermediate step on the progression to adverse events throughout the natural history of coronary artery disease (CAD), often affecting clinical outcomes. Understanding the relation of endothelial function with CAD provides an important pathophysiological insight, which can be useful both in clinical and research management. In this review, we summarize the current knowledge on endothelial dysfunction and its prognostic influence throughout the natural history of CAD, from early atherosclerosis to post-transplant management.
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Affiliation(s)
- Enrique Gutiérrez
- Servicio de Cardiología, Instituto de Investigación Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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17
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Kattah AG, Asad R, Scantlebury DC, Bailey KR, Wiste HJ, Hunt SC, Mosley TH, Kardia SLR, Turner ST, Garovic VD. Hypertension in pregnancy is a risk factor for microalbuminuria later in life. J Clin Hypertens (Greenwich) 2013; 15:617-23. [PMID: 24034653 PMCID: PMC3775278 DOI: 10.1111/jch.12116] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 03/20/2013] [Accepted: 03/20/2013] [Indexed: 01/14/2023]
Abstract
The authors aimed to compare renal function by estimated glomerular filtration rate and albuminuria in 3 groups of women: nulliparous women, women with a history of normotensive pregnancies, and women with a history of at least one hypertensive pregnancy. Women who participated in the second Family Blood Pressure Program Study visit (2000-2004) and had serum creatinine and urine albumin measurements (n=3015) were categorized as having had no pregnancy lasting >6 months (n=341), having had only normotensive pregnancies (n=2199), or having had at least 1 pregnancy with hypertension (n=475) based on a standardized questionnaire. Women who reported having had at least one pregnancy with hypertension were significantly more likely to be hypertensive (75.6% vs 59.4%, P<.001), diabetic (34.2% vs 27.3%, P≤.001), and have higher body mass index (32.8 vs 30.5, P<.001) than those who reported normotensive pregnancies. There was a significantly greater risk of microalbuminuria (urine albumin-creatinine ratio >25 mg/g) in those who reported at least one pregnancy with hypertension (odds ratio, 1.37; confidence interval, 1.02-1.85; P=.04) than in those with normotensive pregnancies, after adjusting for risk factors for chronic kidney and cardiovascular disease. Hypertension in pregnancy is associated with an increased risk of future microalbuminuria.
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Affiliation(s)
| | - Reem Asad
- Division of Nephrology and HypertensionMayo ClinicRochesterMN
| | | | - Kent R. Bailey
- Division of Biomedical Statistics and InformaticsMayo ClinicRochesterMN
| | - Heather J. Wiste
- Division of Biomedical Statistics and InformaticsMayo ClinicRochesterMN
| | - Steven C. Hunt
- Department of Internal MedicineUniversity of UtahSalt Lake CityUT
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Hamilton SJ, Watts GF. Endothelial dysfunction in diabetes: pathogenesis, significance, and treatment. Rev Diabet Stud 2013; 10:133-56. [PMID: 24380089 DOI: 10.1900/rds.2013.10.133] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Type 2 diabetes (T2D) markedly increases the risk of cardiovascular disease. Endothelial dysfunction (ED), an early indicator of diabetic vascular disease, is common in T2D and independently predicts cardiovascular risk. Although the precise pathogenic mechanisms for ED in T2D remain unclear, at inception they probably involve uncoupling of both endothelial nitric oxide synthase activity and mitochondrial oxidative phosphorylation, as well as the activation of vascular nicotinamide adenine dinucleotide phosphate oxidase. The major contributing factors include dyslipoproteinemia, oxidative stress, and inflammation. Therapeutic interventions are designed to target these pathophysiological factors that underlie ED. Therapeutic interventions, including lifestyle changes, antiglycemic agents and lipid-regulating therapies, aim to correct hyperglycemia and atherogenic dyslipidemia and to improve ED. However, high residual cardiovascular risk is seen in both research and clinical practice settings. Well-designed studies of endothelial function in appropriately selected volunteers afford a good opportunity to test new therapeutic interventions, paving the way for clinical trials and utilization in the care of the diabetic patient. However, based on the results from a recent clinical trial, niacin should not be added to a statin in individuals with low high-density lipoprotein cholesterol and very well controlled low-density lipoprotein cholesterol.
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Affiliation(s)
- Sandra J Hamilton
- Combined Universities Centre for Rural Health, University of Western Australia, Geraldton, Australia
| | - Gerald F Watts
- School of Medicine and Pharmacology, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
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Hamilton SJ, Chew GT, Davis TME, Watts GF. Prevalence and predictors of abnormal arterial function in statin-treated type 2 diabetes mellitus patients. Metabolism 2012; 61:349-57. [PMID: 21944268 DOI: 10.1016/j.metabol.2011.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 06/26/2011] [Accepted: 07/18/2011] [Indexed: 11/18/2022]
Abstract
Arterial dysfunction (AD) in type 2 diabetes mellitus (T2DM) predicts cardiovascular events. The objective was to investigate the prevalence and predictors of AD in statin-treated T2DM patients. We measured flow-mediated (FMD) and nitrate-mediated (NMD) brachial artery dilatation in 86 statin-treated T2DM patients. Patients were classified into 2 groups: normal arterial function (FMD ≥3.7% with NMD ≥11.9%) or AD (FMD <3.7% with or without NMD <11.9%). Endothelial dysfunction without smooth muscle cell dysfunction (ED) was defined as FMD less than 3.7% with NMD of at least 11.9%, and endothelial dysfunction with smooth muscle cell dysfunction (ED/SMD) was defined as FMD less than 3.7% with NMD less than 11.9%. Predictors of arterial function were investigated using linear and logistic regression methods. The prevalence of AD was 33.7% (23.2% with ED and 10.5% with ED/SMD). In multivariate linear regression, history of hypertension (P < .01), statin dose (P < .05), and estimated glomerular filtration rate (eGFR) (P = .02) were significant predictors of FMD. Sex (P < .01) and creatinine (P = .03) or eGFR (P = .02) predicted NMD. In multivariate logistic regression, the independent predictors of AD were history of hypertension (odds ratio [OR], 8.79; 95% confidence interval, 2.14-36.12; P < .01), age (OR, 1.08; 1.01-1.17; P = .03), and statin dose (OR, 0.33; 0.12-0.87; P = .02). A history of hypertension (OR, 8.99; 1.87-43.26; P < .01) was the sole independent predictor of ED; eGFR (OR, 0.01; 0.00-0.26; P < .01) independently predicted ED/SMD. Our data suggest that one third of statin-treated diabetic patients have residual AD, mainly due to ED alone. Earlier identification and treatment of hypertension and renal impairment may improve AD and further decrease cardiovascular risk in such patients.
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Affiliation(s)
- Sandra J Hamilton
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia 6847, Australia
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Davidson MB, Tareen N, Duran P, Aguilar V, Lee ML. Aggressive versus Low Dose Inhibition of the Renin-Angiotensin System for the Treatment of Microalbuminuria in Type 2 Diabetic Patients: A Pilot Study. ISRN ENDOCRINOLOGY 2012; 2011:696124. [PMID: 22363885 PMCID: PMC3262631 DOI: 10.5402/2011/696124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 08/15/2011] [Indexed: 11/23/2022]
Abstract
Objective. This study compares low dose versus aggressive inhibition of the renin angiotensin system (RAS) to treat microalbuminuria (MA). Methods. Patients with MA after a run-in period to control BP to <130/80 mm Hg with 10 mg benazepril plus other drugs and HbA1c levels to <8.0% were randomized to either continue 10 mg benazepril (N = 12) or to take maximal doses of benazepril plus losartan in monthly stepwise increases to achieve normoalbuminuria (N = 11). Because MA is associated with CVD and inflammation, carotid intima medial thickness (CIMT) and endothelial function by peripheral arterial tonometry (PAT) as surrogate indices of atherosclerosis and highly sensitive C-reactive protein (hs-CRP) to assess inflammation were measured every six months. Results. BP, HbA1c levels, albumin : creatinine ratios, CIMT, PAT, and hs-CRP did not differ over a mean of 12 months between the two groups. Conclusions. Aggressive inhibition of the RAS is unnecessary to treat MA.
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Affiliation(s)
- M B Davidson
- Department of Internal Medicine, Charles R. Drew University, Los Angeles, CA 90059, USA
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Littarru GP, Tiano L, Belardinelli R, Watts GF. Coenzyme Q(10) , endothelial function, and cardiovascular disease. Biofactors 2011; 37:366-73. [PMID: 21674640 DOI: 10.1002/biof.154] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 03/09/2011] [Indexed: 01/15/2023]
Abstract
Since the time a precise role of coenzyme Q(10) (CoQ(10) ) in myocardial bioenergetics was established, the involvement of CoQ in the pathophysiology of heart failure was hypothesized. This provided the rationale for numerous clinical trials of CoQ(10) as adjunctive treatment for heart failure. A mild hypotensive effect of CoQ was reported in the early years of clinical use of this compound. We review early human and animal studies on the vascular effects of CoQ. We then focus on endothelial dysfunction in type 2 diabetes and the possible impact on this condition of antioxidants and nutritional supplements, and in particular the therapeutic effects of CoQ. The effect of CoQ(10) on endothelial dysfunction in ischemic heart disease is also reviewed together with recent data highlighting that treatment with CoQ(10) increases extracellular SOD activity.
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Affiliation(s)
- Gian Paolo Littarru
- Department of Biochemistry, Biology & Genetics, Marche Polytechnic University, Ancona, Italy.
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Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, Foster E, Hlatky MA, Hodgson JM, Kushner FG, Lauer MS, Shaw LJ, Smith SC, Taylor AJ, Weintraub WS, Wenger NK, Jacobs AK, Smith SC, Anderson JL, Albert N, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Nishimura R, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 56:e50-103. [PMID: 21144964 DOI: 10.1016/j.jacc.2010.09.001] [Citation(s) in RCA: 1001] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, Foster E, Hlatky MA, Hodgson JM, Kushner FG, Lauer MS, Shaw LJ, Smith SC, Taylor AJ, Weintraub WS, Wenger NK, Jacobs AK. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2010; 122:e584-636. [PMID: 21098428 DOI: 10.1161/cir.0b013e3182051b4c] [Citation(s) in RCA: 402] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
The mechanisms that drive the development of diabetic nephropathy remain undetermined. Only 30-40% of patients with diabetes mellitus develop overt nephropathy, which suggests that other contributing factors besides the diabetic state are required for the progression of diabetic nephropathy. Endothelial dysfunction is associated with human diabetic nephropathy and retinopathy, and advanced diabetic glomerulopathy often exhibits thrombotic microangiopathy, including glomerular capillary microaneurysms and mesangiolysis, which are typical manifestations of endothelial dysfunction in the glomerulus. Likewise, diabetic mice with severe endothelial dysfunction owing to deficiency of endothelial nitric oxide synthase develop progressive nephropathy and retinopathy similar to the advanced lesions observed in humans with diabetes mellitus. Additionally, inhibitors of the renin-angiotensin system fail to be renoprotective in some individuals with diabetic nephropathy (due in part to aldosterone breakthrough) and in some mouse models of the disease. In this Review, we discuss the clinical and experimental evidence that supports a role for endothelial nitric oxide deficiency and subsequent endothelial dysfunction in the progression of diabetic nephropathy and retinopathy. If endothelial dysfunction is the key factor required for diabetic nephropathy, then agents that improve endothelial function or raise intraglomerular nitric oxide level could be beneficial in the treatment of diabetic nephropathy.
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Silva AMV, Schaan BD, Signori LU, Plentz RDM, Moreno H, Bertoluci MC, Irigoyen MC. Microalbuminuria is associated with impaired arterial and venous endothelium-dependent vasodilation in patients with Type 2 diabetes. J Endocrinol Invest 2010; 33:696-700. [PMID: 20354354 DOI: 10.1007/bf03346672] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Microalbuminuria in Type 2 diabetes is associated with arterial endothelial dysfunction, but the venous bed was never evaluated. AIM To study the endothelial function in the venous and arterial bed in patients with Type 2 diabetes with normoalbuminuria or microalbuminuria. MATERIAL AND METHODS We evaluated 28 patients with Type 2 diabetes, glycated hemoglobin (HbA(₁c)) <7.5%, who were classified as normo- (albuminuria <30 mg/24 h; no.=16) or microalbuminuric (albuminuria 30-300 mg/24 h; no.=12). Venous and arterial endothelial function were assessed by the dorsal hand vein technique (venodilation by acetylcholine) and brachial artery flow-mediated vasodilation, respectively. RESULTS Patients were normotensive (systolic arterial pressure: 131.1±10.6 mmHg) and on good metabolic control (HbA(₁c): 6.6±0.6%). Microalbuminuric patients presented impaired venous (32.9±17.4 vs 59.3±26.5%; p=0.004) and arterial vasodilation (1.8±0.9 vs 5.1±2.4; p<0.001), as compared to normoalbuminuric patients. There was a negative correlation between acetylcholine-induced venodilation and albuminuria (r=-0.62; p<0.001) and HbA(₁c) (r=-0.41; p=0.032). The same was observed between flow mediated arterial vasodilation and albuminuria (r=-0.49; p=0.007) and HbA(₁c) (r=-0.44; p=0.019). Venous and arterial vasodilation was positively correlated (r=0.50; p=0.007). CONCLUSIONS Both venous and arterial endothelial function are impaired in Type 2 microalbuminuric diabetics, in spite of good metabolic control, suggesting that other factors are involved in its pathogenesis.
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Affiliation(s)
- A M V Silva
- Department of Physiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Casanova C, de Torres JP, Navarro J, Aguirre-Jaíme A, Toledo P, Cordoba E, Baz R, Celli BR. Microalbuminuria and hypoxemia in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010; 182:1004-10. [PMID: 20558625 DOI: 10.1164/rccm.201003-0360oc] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Microalbuminuria (MAB), a marker of endovascular dysfunction, is a predictor of cardiovascular events and all-cause mortality in the general population. There is evidence of vascular dysfunction in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVES To assess the prevalence and relationship of MAB with clinical and physiological parameters in stable patients with COPD. METHODS We measured urinary albumin rate (urinary albumin to creatinine ratio: UACR), smoking history, arterial blood pressure, gas exchange, body mass index, lung function, BODE index (body mass index, airflow obstruction, dyspnea, exercise performance), and comorbidity index in 129 patients with stable COPD and 51 smokers with normal spirometry without known cardiovascular disease. MAB levels were compared between groups. A multivariate analysis was performed to determine the best determinants of MAB levels. MEASUREMENTS AND MAIN RESULTS MAB was higher in patients with COPD than in control smokers (8 [5th-95th percentile (P₅₋₉₅), 2.9-113] vs. 4.2 [P₅₋₉₅, 1.8-22.7] mg/g, P < 0.001]). The difference remained significant even after using the standard pathologic threshold (MAB, 30-299 mg/g in women and 20-299 mg/g in men; 24% in patients with COPD vs. 6% in control smokers; P = 0.005). In patients with COPD, there was a negative correlation between Pa(O₂) and MAB (r = -0.40, P < 0.001). Using multivariate analysis, MAB was only associated with the Pa(O₂) (relative risk, 0.934; 95% confidence interval, 0.880-0.992; P < 0.001) and with the systolic arterial blood pressure (relative risk, 1.034; 95% confidence interval, 1.011-1.057; P = 0.003). CONCLUSIONS MAB is frequent in patients with COPD and is associated with hypoxemia independent of other cardiovascular risk factors. Further studies are necessary to investigate whether MAB could be an early simple biomarker of cardiovascular compromise in patients with COPD.
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Affiliation(s)
- Ciro Casanova
- Respiratory Research Unit, Pulmonary Department, Hospital Universitario La Candelaria, 38010 Santa Cruz de Tenerife, Spain.
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Duran M, Kalay N, Ardic I, Yarlioglues M, Kayaaltı F, Yılmaz Y, Akpek M, Kaya MG, Topsakal R. Microalbuminuria is not associated with endothelial dysfunction and coronary atherosclerosis in patients with acute coronary syndromes. Ren Fail 2010; 32:659-65. [DOI: 10.3109/0886022x.2010.485288] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kosugi T, Heinig M, Nakayama T, Matsuo S, Nakagawa T. eNOS knockout mice with advanced diabetic nephropathy have less benefit from renin-angiotensin blockade than from aldosterone receptor antagonists. THE AMERICAN JOURNAL OF PATHOLOGY 2009; 176:619-29. [PMID: 20042665 DOI: 10.2353/ajpath.2010.090578] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
While blockade of the renin angiotensin system (RAS) is beneficial in treating many patients with diabetic nephropathy, some patients show a poor response. We hypothesized that the poor response of RAS blockade is attributed to inability to stimulate endothelial nitric oxide. Recently, we reported that diabetic eNOS knockout (KO) mice develop advanced diabetic nephropathy similar to human disease. Here, we tested the hypothesis that blockade of the RAS would be less beneficial in this model than in diabetic wild-type mice. Both enalapril and telmisartan were less effective at reducing renal injury in diabetic eNOSKO mice compared with diabetic wild-type mice. Blood pressure was only transiently reduced by these treatments in diabetic eNOSKO mice and later returned to levels similar to that of untreated diabetic eNOSKO mice. Serum aldosterone tended to be paradoxically higher with enalapril or telmisartan in diabetic eNOSKO mice, whereas these treatments tended to lower aldosterone in diabetic wild-type mice. The pathogenic role of aldosterone was demonstrated by the evidence that spironolactone significantly reduced blood pressure and prevented renal injury. In addition, a higher dose of enalapril also failed to prevent hypertension and renal injury in diabetic eNOSKO mice. In conclusion, an impaired endothelial NO response could lessen the benefit of RAS inhibition in diabetic renal disease. Aldosterone blockade may provide superior protection in this setting.
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Affiliation(s)
- Tomoki Kosugi
- Division of Nephrology, University of Florida, Gainesville, Florida, USA
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Angadi SS, Gaesser GA. Pre-exercise cardiology screening guidelines for asymptomatic patients with diabetes. Clin Sports Med 2009; 28:379-92. [PMID: 19505622 DOI: 10.1016/j.csm.2009.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Coronary heart disease is a major cause of morbidity and mortality in persons with diabetes mellitus. Exercise is an important cornerstone in the treatment and management of diabetes but is also associated with a heightened risk of sudden cardiac death in those with occult coronary heart disease. Before beginning a physical activity program that involves anything greater than moderate intensity exercise, consideration should be given to screening asymptomatic persons with diabetes for silent myocardial ischemia.
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Affiliation(s)
- Siddhartha S Angadi
- Department of Exercise and Wellness, Arizona State University, 7350 E. Unity Avenue, Mesa, AZ 85296, USA.
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Urbina EM, Williams RV, Alpert BS, Collins RT, Daniels SR, Hayman L, Jacobson M, Mahoney L, Mietus-Snyder M, Rocchini A, Steinberger J, McCrindle B. Noninvasive assessment of subclinical atherosclerosis in children and adolescents: recommendations for standard assessment for clinical research: a scientific statement from the American Heart Association. Hypertension 2009; 54:919-50. [PMID: 19729599 DOI: 10.1161/hypertensionaha.109.192639] [Citation(s) in RCA: 474] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Deterioration in endothelial function and arterial stiffness are early events in the development of cardiovascular diseases. In adults, noninvasive measures of atherosclerosis have become established as valid and reliable tools for refining cardiovascular risk to target individuals who need early intervention. With limited pediatric data, the use of these techniques in children and adolescents largely has been reserved for research purposes. Therefore, this scientific statement was written to (1) review the current literature on the noninvasive assessment of atherosclerosis in children and adolescents, (2) make recommendations for the standardization of these tools for research, and (3) stimulate further research with a goal of developing valid and reliable techniques with normative data for noninvasive clinical evaluation of atherosclerosis in pediatric patients. Precise and reliable noninvasive tests for atherosclerosis in youth will improve our ability to estimate future risk for heart attack and stroke. Currently, large longitudinal studies of cardiovascular risk factors in youth, such as the Bogalusa and Muscatine studies, lack sufficient adult subjects experiencing hard outcomes, such as heart attack and stroke, to produce meaningful risk scores like those developed from Framingham data.
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Boodhwani M, Sellke FW. Therapeutic angiogenesis in diabetes and hypercholesterolemia: influence of oxidative stress. Antioxid Redox Signal 2009; 11:1945-59. [PMID: 19187003 PMCID: PMC2848518 DOI: 10.1089/ars.2009.2439] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Despite significant improvements in the medical, percutaneous, and surgical management, numerous patients are first seen with non-revascularizable coronary artery disease (CAD). The growth of new blood vessels to improve myocardial perfusion (i.e., therapeutic angiogenesis) is an attractive treatment option for these patients. However, the successes of angiogenic therapy, observed in preclinical studies, have not been realized in clinical trials. Increasing evidence suggests that this discrepancy between animal and human studies may be due to the nature of the substrate, or the molecular and cellular environment within which the angiogenic agent acts. Antiangiogenic influences, including endothelial dysfunction, hypercholesterolemia, and diabetes, are present in virtually all patients with advanced CAD. Recent studies have better characterized the abnormalities associated with these disease states, providing novel targets for intervention. These substrate-modifying interventions can potentially enhance the response to protein-, gene-, or cell-based angiogenic therapy. In this review, we discuss key aspects of the angiogenic process and the pathophysiologic and molecular mechanisms that contribute to an impaired angiogenic response in the setting of endothelial dysfunction, hypercholesterolemia, and diabetes, with a focus on the role of oxidative stress. Last, we briefly explore substrate modifying agents that have been evaluated in preclinical and clinical studies to improve the angiogenic response.
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Affiliation(s)
- Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
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Gómez JM, Vila R, Catalina P, Soler J, Badimón L, Sahún M. The markers of inflammation and endothelial dysfunction in correlation with glycated haemoglobin are present in type 2 diabetes mellitus patients but not in their relatives. Glycoconj J 2008; 25:573-9. [PMID: 18347976 DOI: 10.1007/s10719-008-9118-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Revised: 02/13/2008] [Accepted: 02/14/2008] [Indexed: 10/22/2022]
Abstract
UNLABELLED The aim of this study is to test several biomarkers of inflammation, of endothelial dysfunction, glycated haemoglobin, and their reflection in arterial dilatation, in patients with type 2 diabetes mellitus and in their relatives, in order to demonstrate if relatives present markers as a form of precocious indicators of diabetes mellitus. Individuals between 30 and 55 years of age and without clinical arterial disease were divided in three groups: type 2 diabetes mellitus patients without complications (12 men and 18 women); first degree relatives of type 2 diabetes mellitus (14 men and 20 women); and control individuals (9 men and 16 women). Body composition was measured with a bioelectrical impedance analyzer and endothelial function with an eco-Doppler device. We determined glucose, insulin, C-peptide, glycated haemoglobin, fibrinogen, E-selectin, P-selectin, soluble intercellular cell adhesion molecule-1 (ICAM-1), soluble vascular cell adhesion molecule-1 (VCAM-1), interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), C-reactive protein (CRP) in plasma. We also studied endothelium independent dilatation and endothelium dependent dilatation. THE RESULTS ICAM-1 and VCAM-1 were significantly higher in the diabetic group (237.5+/-43.4 and 692.5+/-168.6 ng/l) than in controls (197.4+/-51.2 and 573.5+/-121.1 ng/l, p=0.011 and 0.013, respectively), but were not higher in the family group (224.5+/-45.2 and 599.8+/-150.4 ng/l). CRP was higher in the diabetic group (3.35+/-3.27 mg/l) than in the other groups (1.28+/-1.29 and 1.61+/-1.54 mg/l, p=0.002) and correlated with glycated haemoglobin. The non-endothelium mediated dilatation was lesser in the diabetic group than in the family group (17.3+/-6.1 vs. 24+/-8, p=0.029) and controls. In conclusion patients with uncomplicated type 2 diabetes, but not their relatives, have biochemical markers of sub-clinical inflammation in relationship with glycated haemoglobin and dysfunction of the endothelial cells markers. In these patients endothelium independent dilatation is more affected than endothelium dependent dilatation.
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Affiliation(s)
- José Manuel Gómez
- Department of Endocrinology and Nutrition, University Hospital of Bellvitge, Barcelona, Spain.
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Watanabe K, Suzuki T, Nakano H, Oba K. Relationship between diabetic retinopathy and vascular endothelial function in elderly type 2 diabetic Japanese patients without cardiovascular disease. Geriatr Gerontol Int 2007. [DOI: 10.1111/j.1447-0594.2007.00423.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Na+/H+ exchange inhibition with cariporide prevents alterations of coronary endothelial function in streptozotocin-induced diabetes. Mol Cell Biochem 2007; 310:93-102. [DOI: 10.1007/s11010-007-9669-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Accepted: 11/22/2007] [Indexed: 10/22/2022]
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Boodhwani M, Sodha NR, Mieno S, Xu SH, Feng J, Ramlawi B, Clements RT, Sellke FW. Functional, cellular, and molecular characterization of the angiogenic response to chronic myocardial ischemia in diabetes. Circulation 2007; 116:I31-7. [PMID: 17846323 PMCID: PMC2723770 DOI: 10.1161/circulationaha.106.680157] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ischemic heart disease is the most common cause of mortality in diabetic patients. Although therapeutic angiogenesis is an attractive option for these patients, they appear to have reduced collateral formation in response to myocardial ischemia. The aims of this study were to establish a large animal model of diabetes and chronic myocardial ischemia, evaluate the effects of diabetes on the angiogenic response, and elucidate the molecular pathways involved. METHODS AND RESULTS Diabetes was induced in male Yucatan miniswine using a pancreatic beta-cell specific toxin, alloxan (150 mg/kg; n=8). Age-matched swine served as controls (n=8). Eight weeks after induction, chronic ischemia was induced by ameroid constrictor placement around the circumflex coronary artery. Myocardial perfusion and function were assessed at 3 and 7 weeks after ameroid placement using isotope-labeled microspheres. Endothelial cell density and myocardial expression of angiogenic mediators was evaluated. Diabetic animals exhibited significant endothelial dysfunction. Collateral dependent perfusion and LV function were significantly impaired in diabetic animals. Diabetic animals also demonstrated reduced endothelial cell density (173+/-14 versus 234+/-23 cells/hpf, P=0.03). Expression of VEGF, Ang-1, and Tie-2 was reduced, whereas antiangiogenic proteins, angiostatin (4.4+/-0.9-fold increase, P<0.001), and endostatin (2.9+/-0.4-fold increase, P=0.03) were significantly elevated in the diabetic myocardium. CONCLUSIONS Diabetes results in a profound impairment in the myocardial angiogenic response to chronic ischemia. Pro- and antiangiogenic mediators identified in this study offer novel targets for the modulation of the angiogenic response in diabetes.
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Affiliation(s)
- Munir Boodhwani
- Beth Israel Deaconess Medical Center, 110 Francis Street, Boston, MA 02215, USA
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36
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Hamilton SJ, Chew GT, Watts GF. Therapeutic regulation of endothelial dysfunction in type 2 diabetes mellitus. Diab Vasc Dis Res 2007; 4:89-102. [PMID: 17654442 DOI: 10.3132/dvdr.2007.026] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Endothelial dysfunction is universal in diabetes, being intimately involved with the development of cardiovascular disease. The pathogenesis of endothelial dysfunction in diabetes is complex. It is initially related to the effects of fatty acids and insulin resistance on 'uncoupling' of both endothelial nitric oxide synthase activity and mitochondrial function. Oxidative stress activates protein kinase C (PKC), polyol, hexosamine and nuclear factor kappa B pathways, thereby aggravating endothelial dysfunction. Improvements in endothelial function in the peripheral circulation in diabetes have been demonstrated with monotherapies, including statins, fibrates, angiotensin-converting enzyme (ACE) inhibitors, metformin and fish oils. These observations are supported by large clinical end point trials. Other studies show benefits with certain antioxidants, L-arginine, folate, PKC-inhibitors, peroxisome proliferator activated receptor (PPAR)-alpha and -gamma agonists and phosphodiesterase (PDE-5) inhibitors. However, the benefits of these agents remain to be shown in clinical end point trials. Combination treatments, for example, statins plus ACE inhibitors and statins plus fibrates, have also been demonstrated to have additive benefits on endothelial function in diabetes, but there are no clinical outcome data to date. Measurement of endothelial dysfunction in cardiovascular research can provide fresh opportunities for exploring the mechanism of benefit of new therapeutic regimens and for planning and designing large clinical trials.
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Affiliation(s)
- Sandra J Hamilton
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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Suetsugu M, Takebayashi K, Aso Y. Association between diabetic microangiopathy and vascular endothelial function evaluated by flow-mediated vasodilatation in patients with type 2 diabetes. Int J Clin Pract 2007; 61:920-6. [PMID: 17343657 DOI: 10.1111/j.1742-1241.2006.01223.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The main purpose of the study was to investigate the association between vascular endothelial function and diabetic microangiopathy (nephropathy, retinopathy and neuropathy) in patients with type 2 diabetes. In addition, the association between endothelial function and macroangiopathy evaluated by intimal-medial complex thickness (IMT) was also investigated. Endothelial function was evaluated non-invasively by the measurement of flow-mediated vasodilatation (FMD) of the brachial artery. Diabetic nephropathy and neuropathy were assessed by urinary albumin excretion (UAE) and motor or sensory nerve conduction velocity (MCV, SCV), respectively, and retinopathy was evaluated by an ophthalmologist using the Davis classification. FMD was measured in 102 patients with type 2 diabetes and in 20 control subjects, and showed a tendency to be lower in the diabetic patients. There was a significant decrease in FMD in patients with proliferative diabetic retinopathy, compared with those in patients with no diabetic retinopathy. FMD showed significant positive correlations with MCV and SCV, and significant negative correlations with log UAE, systolic blood pressure and diabetic duration, but no correlation was obtained between FMD and IMT. In stepwise regression analysis, MCV alone showed a significant association with FMD. In conclusion, our results show that in patients with type 2 diabetes FMD is closely associated with all types of microangiopathy, with neuropathy being most strongly associated with FMD; however, FMD is not associated with macroangiopathy evaluated by IMT.
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Affiliation(s)
- M Suetsugu
- Department of Internal Medicine, Koshigaya Hospital, Dokkyo Medical University, Koshigaya Hospital, Koshigaya, Saitama, Japan
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Abstract
With the aging of the baby-boom generation, non-insulin-requiring diabetes mellitus (type 2) has become a worldwide pandemic. The causes of the disease are complex and multifactorial and include genetic disposition, lifestyle choices, abnormal aging processes, and alterations in metabolic processes. The impetus for diagnosing the preclinical effects of diabetes generally has been the individual patient's risk for cardiovascular diseases, heart attack, stroke, and peripheral vascular diseases. This review highlights the newer noninvasive imaging methods designed to provide the early prevention of preclinical atherosclerosis.
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Malik AR, Sultan S, Turner ST, Kullo IJ. Urinary albumin excretion is associated with impaired flow- and nitroglycerin-mediated brachial artery dilatation in hypertensive adults. J Hum Hypertens 2007; 21:231-8. [PMID: 17230233 DOI: 10.1038/sj.jhh.1002143] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We investigated whether the urinary albumin/creatinine ratio (UACR), a measure of albuminuria, is associated with non-invasive measures of arterial function in hypertensive adults without known coronary heart disease (CHD) or stroke. UACR was measured in the first voided morning urine sample in 469 non-Hispanic white hypertensive individuals (mean age 62.2+/-9.8 years, 41% men) belonging to hypertensive sibships. High-resolution ultrasonography of the brachial artery was used to assess flow-mediated dilatation (FMD)--an endothelium-dependent response--and nitroglycerin-mediated dilatation (NMD)--an endothelium-independent response. Because of skewed distribution, UACR was log transformed after addition of 0.1. The association of log (UACR+0.1) with FMD and NMD, before and after adjustment for CHD risk factors, serum creatinine, and hypertension medication and statin use was assessed using linear regression analyses. In univariable analyses, variables associated with lower FMD were greater age, male sex, history of smoking, lower high-density lipoprotein (HDL) cholesterol, higher serum creatinine and higher log (UACR+0.1); variables associated with lower NMD were greater age, male sex, higher systolic blood pressure, lower HDL cholesterol, higher serum creatinine and higher log (UACR+0.1). In separate stepwise multivariable regression analyses that adjusted for conventional CHD risk factors, serum creatinine and hypertension medication and statin use, higher log (UACR+0.1) was associated with lower brachial artery FMD (P=0.035) and NMD (P=0.0002). These findings highlight the association of increased urinary albumin excretion with impaired vascular reactivity in hypertensive individuals.
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Affiliation(s)
- A R Malik
- Division of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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Papaioannou GI, Kasapis C, Seip RL, Grey NJ, Katten D, Wackers FJT, Inzucchi SE, Engel S, Taylor A, Young LH, Chyun DA, Davey JA, Iskandrian AE, Ratner RE, Robinson EC, Carolan S, Heller GV. Value of peripheral vascular endothelial function in the detection of relative myocardial ischemia in asymptomatic type 2 diabetic patients who underwent myocardial perfusion imaging. J Nucl Cardiol 2007; 13:362-8. [PMID: 16750781 DOI: 10.1016/j.nuclcard.2006.01.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Accepted: 01/30/2006] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endothelial dysfunction precedes overt atherosclerosis and is present in patients with type 2 diabetes mellitus (T2DM). Myocardial perfusion imaging (MPI) is an effective method of detection of coronary artery disease (CAD); however, the relationship between endothelial function and MPI in asymptomatic patients with T2DM has not been examined. METHODS AND RESULTS This study used a subset of the population from the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study. Endothelium-dependent vasodilation (EDV) and endothelium-independent vasodilation (EIV) were measured by use of brachial artery ultrasonography in 75 asymptomatic patients with T2DM (56 men; mean age, 58.6 +/- 6.4 years; mean duration of diabetes, 8.4 +/- 7.5 years) who underwent adenosine MPI. Of the patients, 15 (20%) had evidence of relative ischemia (MPI(+)) whereas 60 (80%) had a normal study (MPI(-)). Both EDV (3.5% +/- 3.7% vs 4.5% +/- 6.6%, P = not significant) and EIV (15.1% +/- 7.5% vs 16.8% +/- 8.4%, P = not significant) were similar in the 2 groups. On the basis of a receiver-operator analysis, an EDV response of 8% was selected as a cut point, with a negative predictive value of 93% (13/14 subjects with EDV >or=8% were MPI(-)). CONCLUSIONS Endothelial function in asymptomatic patients with T2DM is not associated with the presence of relative myocardial ischemia by MPI; however, an EDV of 8% or greater has a high negative predictive value for the exclusion of CAD.
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Ochodnicky P, Henning RH, van Dokkum RPE, de Zeeuw D. Microalbuminuria and endothelial dysfunction: emerging targets for primary prevention of end-organ damage. J Cardiovasc Pharmacol 2006; 47 Suppl 2:S151-62; discussion S172-6. [PMID: 16794452 DOI: 10.1097/00005344-200606001-00009] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A minor increase in urinary albumin excretion (microalbuminuria) is known to predict adverse renal and cardiovascular events in diabetic and hypertensive patients. Recent intriguing findings show that microalbuminuria is an early and sensitive marker of future cardiovascular events even in healthy subjects. The mechanisms linking microalbuminuria with end-organ damage have not been fully explained yet; however, generalized endothelial dysfunction might play an important role. Prevailing experimental and clinical data suggest that generalized endothelial dysfunction, frequently characterized by decreased nitric oxide bioavailability, actually precedes the development of microalbuminuria. This review summarizes the current knowledge about the intricate relationship between microalbuminuria and endothelial dysfunction. On the basis of the current evidence, we propose that microalbuminuria and endothelial dysfunction are an emerging target for primary prevention strategies in cardiovascular disease. In near future, dietary components improving nitric oxide bioavailability, such as cocoa-derived flavanols may play important role in these preventive strategies.
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Affiliation(s)
- Peter Ochodnicky
- Department of Clinical Pharmacology, University Medical Center Groningen and Groningen Institute for Drug Exploration (GUIDE), University of Groningen, the Netherlands.
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Guo C, Martinez-Vasquez D, Mendez GP, Toniolo MF, Yao TM, Oestreicher EM, Kikuchi T, Lapointe N, Pojoga L, Williams GH, Ricchiuti V, Adler GK. Mineralocorticoid receptor antagonist reduces renal injury in rodent models of types 1 and 2 diabetes mellitus. Endocrinology 2006; 147:5363-73. [PMID: 16901964 DOI: 10.1210/en.2006-0944] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To determine whether mineralocorticoid receptor (MR) activation plays a role in diabetic renal injury and whether this role differs in types 1 and 2 diabetes mellitus, we examined the effect of a MR antagonist on renal injury in rodent models of type 1 (streptozotocin-treated rat) and type 2 (db/db mouse) diabetes. We studied three groups of 8-wk-old, uninephrectomized Wistar rats for 4 wk: diabetic streptozotocin- (55 mg/kg) treated rats (n = 11), diabetic streptozotocin-treated rats receiving the MR antagonist eplerenone (n = 15), and nondiabetic rats (n = 9). In addition, we studied three groups of 8-wk-old mice for 16 wk: diabetic db/db mice (n = 10), diabetic db/db mice treated with eplerenone (n = 8), and nondiabetic, db/+ littermates (n = 11). Diabetic rats and mice developed albuminuria and histopathological evidence of renal injury, including glomerular hypertrophy, mesangial expansion, and tubulointerstitial injury as well as increased renal cortical levels of MR protein, MR mRNA, TGFbeta mRNA, and osteopontin mRNA. All of these changes were significantly reduced by treatment with eplerenone except for the elevated MR levels. The beneficial effects of eplerenone were not attributable to changes in blood pressure or glycemia. In summary, MR expression was increased in kidneys of diabetic rodents, and MR antagonists effectively reduced diabetic renal injury irrespective of the species or specific cause of the diabetes. Thus, these data suggest that MR activation is a critical factor in the early pathogenesis of renal disease in both type 1 and type 2 diabetes mellitus.
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MESH Headings
- Albuminuria/prevention & control
- Animals
- Diabetes Mellitus, Experimental/complications
- Diabetes Mellitus, Experimental/metabolism
- Diabetes Mellitus, Experimental/pathology
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/metabolism
- Diabetes Mellitus, Type 1/pathology
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/pathology
- Diabetic Nephropathies/etiology
- Diabetic Nephropathies/prevention & control
- Eplerenone
- Hypertrophy
- Kidney/pathology
- Male
- Mice
- Mice, Inbred C57BL
- Mineralocorticoid Receptor Antagonists
- Osteopontin/analysis
- Osteopontin/genetics
- RNA, Messenger/analysis
- Rats
- Rats, Wistar
- Receptors, Mineralocorticoid/genetics
- Receptors, Mineralocorticoid/physiology
- Spironolactone/analogs & derivatives
- Spironolactone/pharmacology
- Spironolactone/therapeutic use
- Streptozocin
- Systole
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Affiliation(s)
- Christine Guo
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, Massachusetts 02115, USA
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43
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Al-Ozairi E, Middelbeek RJW, Horton ES. Cardiovascular risk assessment in type 2 diabetes mellitus. Curr Diab Rep 2006; 6:333-6. [PMID: 17076992 DOI: 10.1007/s11892-006-0001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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44
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Helaly MA, Sheashaa HA, Hatata ESZ, Youssef AB, Hegazi A, Abdel-Aal IA. Endothelial dysfunction in geriatric diabetic patients: the role of microalbuminuria in elderly type 2 diabetic patients? A randomized controlled study. Int Urol Nephrol 2006; 39:333-8. [PMID: 17031505 DOI: 10.1007/s11255-006-9103-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2006] [Accepted: 08/09/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUNDS/AIMS Microalbuminuria is considered a marker of extensive endothelial dysfunction and is associated with excess of other cardiovascular risk factors. Our aim is to assess the importance of the presence of microalbuminuria in elderly diabetic patients. METHODS A total of 40 normotensive elderly type 2 diabetic patients of both genders with mean age >65 years were randomly included and were further subdivided according to the presence of persistent microalbuminuria into microalbuminuric and normoalbuminuric groups. PATIENTS AND METHODS All patients in both groups were subjected to thorough clinical and laboratory investigations including the assay of serum thrombomodulin (TM) and glycosylated hemoglobin level. Early-morning midstream urine samples were evaluated for levels of beta 2 microglobulin, alpha 1 microglobulin, TM, and N-acetyl-beta-D-glucosaminidase (NAG). RESULTS There was no significant difference between both groups regarding the clinical demographic characteristics. There were statistically significant higher values for glycosylated hemoglobin percentage, serum triglycerides and serum TM and urinary B2 microglobulin, urinary alpha 1 microglobulin, urinary NAG and urinary thrombomodulin in microalbuminuric group in comparison to normoalbuminuric group (P < 0.05). CONCLUSION Microalbuminuria is associated with markers of endothelial dysfunction in elderly normotensive type 2 diabetic patients. We recommend incorporation of periodic testing for microalbuminuria in this sector of patients.
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Affiliation(s)
- Mohamed A Helaly
- Internal Medicine Department, Mansoura University, Mansoura, Egypt
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45
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Chan WB, Chan NN, Lai CWK, So WY, Lo MKW, Lee KF, Chow CC, Metreweli C, Chan JCN. Vascular defect beyond the endothelium in type II diabetic patients with overt nephropathy and moderate renal insufficiency. Kidney Int 2006; 70:711-6. [PMID: 16807539 DOI: 10.1038/sj.ki.5001652] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
There is a paucity of data on the effects of overt nephropathy and moderate renal impairment on endothelial function in diabetic patients. A total of 26 type II diabetic (DM) patients with nephropathy (DMN+) (mean +/- s.d. age: 63.7 +/- 6.3 years), 32 diabetic patients without nephropathy (DMN-) (59.4 +/- 10.1 years), and 52 non-diabetic subjects (54.9 +/- 8.2 years) were recruited. High-resolution ultrasound scan was used to measure carotid intima media thickness (IMT) and flow-mediated dilation (FMD) of the brachial artery. Endothelium-independent dilation was determined by maximal vascular dilation after sublingual nitroglycerine (glyceryl trinitrate (GTN)-induced dilation). The mean carotid IMT increased progressively from non-DM to DMN- to DMN+ groups (0.74 +/- 0.23 vs 0.80 +/- 0.25 vs 1.03 +/- 0.38 mm; P=0.001 for trend) whereas FMD- (4.3 +/- 2.5 vs 3.9 +/- 1.7 vs 1.9 +/- 2.0%, P<0.001 for trend) and GTN-induced dilation (14.7 +/- 4.0 vs 14.5 +/- 3.9 vs 10.3 +/- 3.2%; P<0.001 for trend) declined in an opposite manner. On multivariate analysis, age (beta=0.257, P=0.009), glomerular filtration rate (beta=-0.364, P<0.001), and smoking (beta=0.25, P=0.013) were independently associated with carotid IMT (F=15.76, R(2)=0.340, P<0.001). After adjustment for baseline brachial arterial diameter, history of smoking (beta=-0.039, P<0.001), fasting plasma glucose (beta=-0.033, P=0.002), and total cholesterol (beta=-0.023, P=0.024) were independently associated with vessel diameter after FMD (F=2446.5, R(2)=0.992, P<0.001); whereas age (beta=-0.069, P=0.001) and urinary albumin excretion (beta=-0.048, P=0.018) were independently associated with vessel diameter after GTN (F=851.6, R(2)=0.967, P<0.001). Type II diabetic patients with overt nephropathy and moderate renal impairment had both structural and functional vascular abnormalities beyond the endothelium.
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Affiliation(s)
- W B Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, The Prince of Wales Hospital, Shatin, Hong Kong.
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46
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Jay D, Hitomi H, Griendling KK. Oxidative stress and diabetic cardiovascular complications. Free Radic Biol Med 2006; 40:183-92. [PMID: 16413400 DOI: 10.1016/j.freeradbiomed.2005.06.018] [Citation(s) in RCA: 332] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Accepted: 06/15/2005] [Indexed: 02/07/2023]
Abstract
Diabetes diagnoses are increasing at an alarming rate worldwide. The majority of diabetes-related deaths arise from cardiovascular complications such as myocardial infarction, stroke, and peripheral vascular disease. Oxidative stress has been demonstrated to be present in animal models as well as in patients with diabetes and has been suggested as a possible contributor to the accelerated atherosclerosis seen in diabetics. The generation of reactive oxygen species in diabetes occurs via several mechanisms and is initiated not only by glucose, but also by other substances that are found at elevated levels in diabetic patients. The resulting oxidative stress leads to a number of proatherogenic events. The elucidation of the mechanisms of oxidative stress in diabetes and their relationship with atherosclerosis could potentially identify molecular targets of therapy for this condition and its cardiovascular consequences.
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Affiliation(s)
- Desmond Jay
- Department of Medicine, Division of Cardiology, Emory University, Atlanta, GA 30322, USA
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47
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Charvát J, Michalova K, Chlumský J, Valenta Z, Kvapil M. The association between left ventricle diastolic dysfunction and endothelial dysfunction and the results of stress myocardial SPECT in asymptomatic patients with type 2 diabetes. J Int Med Res 2005; 33:473-82. [PMID: 16222880 DOI: 10.1177/147323000503300501] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Diabetes mellitus is associated with a poor cardiovascular prognosis. Stress myocardial single-photon emission computed tomography (SPECT) reliably detects coronary ischaemia in asymptomatic patients. Our study aimed to evaluate the association between systolic and diastolic left ventricular function, left ventricular hypertrophy, endothelial function and the results of stress myocardial SPECT in 126 patients with type 2 diabetic patients with no cardiovascular symptoms. Thirty-three patients (26%) had abnormal SPECT results, 33 patients (26%) had intermediate (equivocal) results, and 60 patients (48%) had normal results. We found a significant association between an abnormal SPECT result, left ventricular diastolic dysfunction and impaired post-ischaemic dilatation of the brachial artery. No association was found between the SPECT result and systolic function and left ventricular hypertrophy, however. An abnormal SPECT result was significantly associated with left ventricular diastolic dysfunction and the deterioration of post-ischaemic dilatation of the brachial artery in asymptomatic patients with type 2 diabetes.
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Affiliation(s)
- J Charvát
- Medical Department, Second Medical Faculty, Charles University, Prague, Czech Republic.
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48
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Beishuizen ED, Tamsma JT, Jukema JW, van de Ree MA, van der Vijver JCM, Meinders AE, Huisman MV. The effect of statin therapy on endothelial function in type 2 diabetes without manifest cardiovascular disease. Diabetes Care 2005; 28:1668-74. [PMID: 15983318 DOI: 10.2337/diacare.28.7.1668] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Cardiovascular disease (CVD) is the most important cause of mortality in patients with type 2 diabetes and is preceded by endothelial dysfunction. Flow-mediated dilation (FMD) is a noninvasive technique for measuring endothelial dysfunction. We aimed to determine the effect of long-term statin therapy versus placebo on FMD in patients with type 2 diabetes without manifest CVD. RESEARCH DESIGN AND METHODS A randomized, placebo-controlled, double-blind trial was performed with 250 type 2 diabetic patients. Patients were given 0.4 mg cerivastatin or placebo daily. In August 2001, when cerivastatin was withdrawn from the market, the 0.4 mg cerivastatin was replaced by 20 mg simvastatin, without deblinding the study. The primary end point was the change in FMD, measured by B-mode ultrasound, after 2 years. RESULTS Determinants of baseline FMD were diabetes duration, common carotid intima-media thickness, and brachial artery diameter. FMD at baseline was 1.51% in the placebo group and 1.66% in the statin group and did not change significantly after 2 years. CONCLUSIONS The 2-year statin therapy had no effect on FMD in type 2 diabetes. Statin-induced improvement of cardiovascular risk in patients with type 2 diabetes may be mediated through mechanisms other than increased nitric oxide availability.
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Affiliation(s)
- Edith D Beishuizen
- Department of General Internal Medicine, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, Netherlands.
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Gulati R, Lerman A, Simari RD. Therapeutic uses of autologous endothelial cells for vascular disease. Clin Sci (Lond) 2005; 109:27-37. [PMID: 15966869 DOI: 10.1042/cs20050002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Endothelial cells play important structural and functional roles in vascular homoeostasis. Perturbations in endothelial cell number and function are directly involved with the initiation and progression of multiple cardiovascular diseases, including atherosclerosis, hypertension and congestive heart failure. Attempts to modify these disorders have included pharmacological strategies to improve vascular and thus endothelial function. A goal of biological approaches to these disorders is the delivery of endothelial cells that might act to provide beneficial endothelial-derived factors. However, this approach has generally been limited by the lack of readily available autologous endothelial cells for delivery. The isolation of circulation-derived endothelial progenitor cells allows for direct access to autologous endothelial cells for preclinical and clinical studies. Preclinical studies using autologous endothelial cells have demonstrated beneficial effects when delivered in animal models of vascular injury and grafting. These effects are related to the endothelial nature of the cells and may be paracrine in nature. Ongoing studies are aimed at defining the nature of these effects and optimizing delivery strategies cognizant of these mechanisms.
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Affiliation(s)
- Rajiv Gulati
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK
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50
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Woodman RJ, Chew GT, Watts GF. Mechanisms, Significance and Treatment of Vascular Dysfunction in Type 2 Diabetes Mellitus. Drugs 2005; 65:31-74. [PMID: 15610050 DOI: 10.2165/00003495-200565010-00003] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Endothelial dysfunction and increased arterial stiffness occur early in the pathogenesis of diabetic vasculopathy. They are both powerful independent predictors of cardiovascular risk. Advances in non-invasive methodologies have led to widespread clinical investigation of these abnormalities in diabetes mellitus, generating a wealth of new knowledge concerning the mechanisms of vascular dysfunction, risk factor associations and potential treatment targets. Endothelial dysfunction primarily reflects decreased availability of nitric oxide (NO), a critical endothelium-derived vasoactive factor with vasodilatory and anti-atherosclerotic properties. Techniques for assessing endothelial dysfunction include ultrasonographic measurement of flow-mediated vasodilatation of the brachial artery and plethysmography measurement of forearm blood flow responses to vasoactive agents. Arterial stiffness may be assessed using pulse wave analysis to generate measures of pulse wave velocity, arterial compliance and wave reflection. The pathogenesis of endothelial dysfunction in type 2 diabetes is multifactorial, with principal contributors being oxidative stress, dyslipidaemia and hyperglycaemia. Elevated blood glucose levels drive production of reactive oxidant species (ROS) via multiple pathways, resulting in uncoupling of mitochondrial oxidative phosphorylation and endothelial NO synthase (eNOS) activity, reducing NO availability and generating further ROS. Hyperglycaemia also contributes to accelerated arterial stiffening by increasing formation of advanced glycation end-products (AGEs), which alter vessel wall structure and function. Diabetic dyslipidaemia is characterised by accumulation of triglyceride-rich lipoproteins, small dense low-density lipoprotein (LDL) particles, reduced high-density lipoprotein (HDL)-cholesterol and increased postprandial free fatty acid flux. These lipid abnormalities contribute to increasing oxidative stress and may directly inhibit eNOS activity. Although lipid-regulating agents such as HMG-CoA reductase inhibitors (statins), fibric acid derivatives (fibrates) and fish oils are used to treat diabetic dyslipidaemia, their impact on vascular function is less clear. Studies in type 2 diabetes have yielded inconsistent results, but this may reflect sampling variation and the potential over-riding influence of oxidative stress, dysglycaemia and insulin resistance on endothelial dysfunction. Results of positive intervention trials suggest that improvement in vascular function is mediated by both lipid and non-lipid mechanisms, including anti-inflammatory, anti-oxidative and direct effects on the arterial wall. Other treatments, such as renin-angiotensin-aldosterone system antagonists, insulin sensitisers and lifestyle-based interventions, have shown beneficial effects on vascular function in type 2 diabetes. Novel approaches, targeting eNOS and AGEs, are under development, as are new lipid-regulating therapies that more effectively lower LDL-cholesterol and raise HDL-cholesterol. Combination therapy may potentially increase therapeutic efficacy and permit use of lower doses, thereby reducing the risk of adverse drug effects and interactions. Concomitant treatments that specifically target oxidative stress may also improve endothelial dysfunction in diabetes. Vascular function studies can be used to explore the therapeutic potential and mechanisms of action of new and established interventions, and provide useful surrogate measures for cardiovascular endpoints in clinical trials.
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Affiliation(s)
- Richard J Woodman
- School of Medicine and Pharmacology, University of Western Australia, and West Australian Heart Research Institute, Perth, Western Australia, Australia
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