Diabetic Nephropathy in the Elderly

Chronic Kidney Disease in the Older Adult Patient with Diabetes

Diabetes mellitus (DM) and chronic kidney disease (CKD) are common in middle aged and older adult individuals. DM may accelerate the aging process, and the age-related declines in the estimated glomerular filtration rate (eGFR) can pose a challenge to diagnosing diabetic kidney disease (DKD) using standard diagnostic criteria especially with the absence of severe albuminuria among older adults. In the presence of CKD and DM, older adult patients may need multidisciplinary care due to susceptibility to various health issues, e.g., cognitive decline, auditory or visual impairment, various comorbidities, complex medical regimens, and increased sensitivity to medication adverse effects. As a result, it can be challenging to apply recent therapeutic advancements for the general population to older adults. We review the evidence that the benefits from these newer therapies apply equally to older and younger patients with CKD and diabetes type 2 and propose a comprehensive management. This framework will address nonpharmacological measures and pharmacological management with renin angiotensin system inhibitors (RASi), sodium glucose co-transporter 2 inhibitors (SGLT2i), non-steroidal mineralocorticoids receptor antagonists (MRAs), and glucagon like peptide 1 receptor agonists (GLP1-RAs).

Circ_0068087 Promotes High Glucose-Induced Human Renal Tubular Cell Injury through Regulating miR-106a-5p/ROCK2 Pathway

<b><i>Background:</i></b> Many studies have confirmed that circular RNA (circRNA) is an important target for regulating human disease progression. This study aimed to explore the role of circ_0068087 in diabetic nephropathy (DN) progression. <b><i>Methods:</i></b> High glucose (HG)-induced renal tubular cells (HK2) were used to mimic DN cell models in vitro. The expression levels of circ_0068087, microRNA (miR)-106a-5p, and Rho-associated coiled-coil-containing kinase 2 (ROCK2) were detected by quantitative real-time PCR. Cell proliferation and apoptosis were examined by cell counting kit-8 assay, 5-ethynyl-2′-deoxyuridine assay, colony formation assay, and flow cytometry. The protein levels were examined by Western blot analysis. Cell oxidative stress was assessed by measuring MDA level and SOD activity, and cell inflammation was evaluated by detecting the concentrations of inflammatory factors. RNA interaction was verified by dual-luciferase reporter assay and RNA pull-down assay. <b><i>Results:</i></b> The present study showed that circ_0068087 was highly expressed in the serum of DN patients and HG-induced HK2 cells. Interference of circ_0068087 alleviated HG-induced apoptosis, oxidative stress, inflammation, and fibrosis in HK2 cells, while accelerated cell proliferation. miR-106a-5p could be sponged by circ_0068087, and its inhibitor eliminated the regulation of circ_0068087 knockdown on HG-induced HK2 cell injury. ROCK2 was a target of miR-106a-5p, and its expression was suppressed by circ_0068087 knockdown. miR-106a-5p overexpression suppressed HG-induced HK2 cell injury, and this effect was reversed by ROCK2 upregulation. <b><i>Conclusion:</i></b> Our data indicated that circ_0068087 downregulation mitigated HG-induced HK2 cell injury through the miR-106a-5p/ROCK2 axis, providing a potential circRNA-targeted therapy for DN.

Theabrownin-targeted regulation of intestinal microorganisms to improve glucose and lipid metabolism in Goto-Kakizaki rats

Diabetes is a disease that is characterized by a disturbance of glucose metabolism. Theabrownin (TB) is one of the most active and abundant pigments in Pu-erh tea, and it is a brown pigment with multiple aromatic rings and attached residues of polysaccharides and proteins. TB has been shown to be hypolipidemic and displays fasting blood glucose (FBG)-lowering properties in rats fed a high-fat diet, but the underlying mechanism has not been elucidated. This study aimed to determine the effect of TB in treating diabetes and explore the underlying mechanism of action of intestinal microbes by using Goto-Kakizaki (GK) rats. Diabetic GK rats were treated up to 8 weeks with TB (GK-TB). Following treatment, the body weight, triglyceride (TG) content, fasting blood glucose (FBG) content, and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) were significantly lower in the GK-TB group than in the GK control group (P < 0.05). Meanwhile, the circulating adiponectin (ADPN), leptin, and glucokinase levels in the serum of the GK-TB group were significantly higher than those in the GK group, while there was little difference in hepatic lipase (HL) and hormone-sensitive triglyceride lipase (HSL) enzyme activities (P > 0.05). Furthermore, with the extension of treatment time, the number of unique intestinal microorganisms in GK rats greatly increased and an interaction among intestinal microorganisms was observed. The Firmicutes/Bacteroides ratio was decreased significantly, and the composition of Actinobacteria and Proteobacteria was increased. The use of multiple omics technologies showed that TB is involved in the targeted regulation of the core characteristic intestinal flora including Bacteroides thetaiotaomicron (BT), Lactobacillus murinus (LM), Parabacteroides distasonis (PD), and Bacteroides_acidifaciens (BA) which improved the glucose and lipid metabolism of GK rats via the AMP-activated protein kinase signaling pathway, insulin signaling pathway, bile secretion and glycerophospholipid metabolism. Intragastric administration of BT, LM, PD, or BA led to a significantly reduced HOMA-IR in GK rats. Furthermore, BT significantly reduced serum lipid TG and total cholesterol (TC) and BA significantly reduced the serum lipid TC and low-density lipoprotein (LDL). PD significantly reduced serum LDL, while the effect of LM was not significant. However, LM and PD significantly increased the content of ADPN in serum. Taken together, our results indicated that the effect of TB on diabetic rats mainly depends on the targeted regulation of intestinal microorganisms and that TB is a functional food component with great potential to treat or prevent diabetes.

Multidisciplinary management of diabetic kidney disease: a systematic review and meta-analysis

BACKGROUND

The increasing prevalence of diabetes poses significant challenges to healthcare systems around the world. Diabetes is the leading cause of end-stage renal disease. Diabetic kidney disease (DKD) is becoming a global health concern because it is a progressive disease associated with major health complications and increased health costs. The treatment goals for DKD are to slow the progression of the renal disease and prevent cardiovascular events. Accordingly, patients are expected to adhere to prescribed treatments and manage a wide range of daily self-care activities. Multidisciplinary management of chronic diseases, like diabetes and kidney disease, has been suggested as a means to improve patients' adherence to treatment and enhance health-related outcomes. This systematic review of multidisciplinary management of DKD is an important step in evaluating if such a management approach is effective in delaying disease progression.

OBJECTIVES

The goal of this systematic review was to identify the best available evidence regarding multidisciplinary management of DKD and to determine if a multidisciplinary management of DKD can improve patient outcomes. Specifically the review question was: What is the impact of multidisciplinary management of DKD on patient outcomes?

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The current review considered adults aged 18 years and older who had been diagnosed with type 1 or type 2 diabetes and chronic kidney disease.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

The current review examined studies that compared multidisciplinary interventions with usual standard care in ambulatory settings for patients with DKD.

OUTCOMES

The current review considered studies with the following primary outcomes: kidney function, incidence of kidney failure, generic or specific health-related quality of life, patient self-care abilities, adherence to treatment recommendations or goals; and the following secondary clinical outcomes: mortality rates secondary to DKD, glycemic control, blood pressure (BP) control, lipid profile, incidence of cardiovascular disease/events, patient knowledge on diabetes or DKD, patient empowerment or self-efficacy, generic or specific patient satisfaction with care and patient healthcare utilization.

TYPES OF STUDIES

The current review will consider randomized and quasi-experimental trials but included only randomized controlled trials (RCTs).

SEARCH STRATEGY

A three-step search strategy was utilized starting with a search of MEDLINE and CINAHL for the identification of keywords, followed by a search using keywords and index terms across MEDLINE, CINAHL and Embase databases and clinical trials registry platforms, and finally a search of the reference list of all identified papers. Studies published from the time of the respective database inception to November 2014 in English, German and French were considered.

METHODOLOGICAL QUALITY

Two independent reviewers assessed the methodological validity of the papers prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

DATA EXTRACTION

Data were extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI.

DATA SYNTHESIS

Quantitative data were pooled using the RevMan 5 software for kidney function using estimated Glomerular Filtration Rate (eGFR), glycated hemoglobin, BP and total cholesterol (TC). Results were considered significant for P < 0.05.

RESULTS

Three RCTs were included in this review. Meta-analysis showed that multidisciplinary management was associated with a statistically significant improvement of glycated hemoglobin as compared with standard usual care (Relative Risk [RR] -0.49, at 95% confidence interval [CI] -0.83, -0.16, P < 0.01). The meta-analysis for eGFR showed a tendency to favor standard care; however, this finding cannot be conclusive because the CI was too wide (RR -3.30, at 95% CI -6.55, -0.05, P = 0.05). Meta-analysis results for BP and TC failed to show a difference between the multidisciplinary management of DKD and the usual standard care. Only one study measured patient-oriented primary and secondary outcomes and showed an improvement in health-related quality of life, patient self-care abilities, patient level of knowledge on diabetes and exercise self-efficacy.

CONCLUSION

Multidisciplinary management of DKD has the potential for improving glycemic control and thus preventing complications. Its effect on other clinical and patient-oriented outcomes, especially on delaying the progression of the disease through preserving and preventing the decline in kidney function, has yet to be determined. There is not enough evidence to recommend multidisciplinary management for preserving kidney function. Further studies are needed.

Homocysteinethiolactone and paraoxonase: novel markers of diabetic retinopathy

OBJECTIVE

Paraoxonase (PON) exhibits esterase activity (PON-AREase) and lactonase activity (PON-HCTLase), which prevent LDL oxidation and detoxify homocysteine thiolactone (HCTL). The role of HCTL and PON-HCTLase as a risk factor for the microvascular complication in diabetic retinopathy at the level of vitreous has not been investigated.

RESEARCH DESIGN AND METHODS

Undiluted vitreous from patients with proliferative diabetic retinopathy (PDR) (n = 13) and macular hole (MH) (n = 8) was used to determine PON-HCTLase and PON-AREase activity spectrophotometrically. HCTL levels were detected by liquid chromatography-tandem mass spectrometry. In vitro studies were done in primary cultures of bovine retinal capillary endothelial cells (BRECs) to determine the dose- and time-dependent effect of HCTL and homocysteine (Hcys) on PON-HCTLase activity, as well as to determine mRNA expression of PON by RT-PCR.

RESULTS

A significant increase in HCTL and PON-HCTLase activity was observed in PDR compared with MH (P = 0.036, P = 0.001), with a significant positive correlation between them (r = 0.77, P = 0.03). The in vitro studies on BRECs showed a dose- and time-dependent increase in the PON-HCTLase activity and mRNA expression of PON2 when exposed to HCTL and Hcys.

CONCLUSIONS

This is the first study showing elevated levels of vitreous HCTL and PON-HCTLase activity in PDR. These elevations are probably a protective effect to eliminate HCTL, which mediates endothelial cell dysfunction. Thus, vitreous levels of HCTL and PON activity can be markers of diabetic retinopathy. The bioinformatics analysis reveals that the structure and function of PON that can be modulated by hyperhomocysteinemia in PDR can affect the dual-enzyme activity of PON.