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Sacchetta L, Chiriacò M, Nesti L, Leonetti S, Forotti G, Natali A, Solini A, Tricò D. Synergistic effect of chronic kidney disease, neuropathy, and retinopathy on all-cause mortality in type 1 and type 2 diabetes: a 21-year longitudinal study. Cardiovasc Diabetol 2022; 21:233. [DOI: 10.1186/s12933-022-01675-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
The prognostic value of common and frequently associated diabetic microvascular complications (MVC), namely chronic kidney disease (CKD), cardiac autonomic neuropathy (CAN), peripheral neuropathy (DPN), and retinopathy (DR), is well established. However, the impact of their different combinations on long-term mortality has not been adequately assessed.
Methods
We retrospectively analyzed 21-year longitudinal data from 303 patients with long-standing type 1 (T1D) or type 2 diabetes (T2D), who were thoroughly characterized at baseline for the presence of MVC using 99mTc-DTPA dynamic renal scintigraphy, overnight urine collection, cardiovascular autonomic tests, monofilament testing, and dilated fundus oculi examination.
Results
After a 5,244 person-years follow-up, a total of 133 (43.9%) deaths occurred. The presence of CKD and CAN, regardless of other MVC, increased the adjusted all-cause mortality risk by 117% (HR 2.17 [1.45–3.26]) and 54% (HR 1.54 [1.01–2.36]), respectively. Concomitant CKD&CAN at baseline were associated with the highest mortality risk (HR 5.08 [2.52–10.26]), followed by CKD&DR (HR 2.95 [1.63–5.32]), and CAN&DR (HR 2.07 [1.11–3.85]). Compared with patients free from MVC, the mortality risk was only numerically higher in those with any isolated MVC (HR 1.52 [0.87–2.67]), while increased by 203% (HR 3.03 [1.62–5.68]) and 692% (HR 7.92 [2.93–21.37]) in patients with two and three concomitant MVC, respectively.
Conclusions
Our study demonstrates the long-term, synergistic, negative effects of single and concomitant diabetic MVC on all-cause mortality, which should encourage comprehensive screenings for MCV in both T1D and T2D to improve risk stratification and treatment.
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Hu K, Jiang M, Zhou Q, Zeng W, Lan X, Gao Q, Mei F, Zhao L, Chen F, Wu A, Tao G, Mou C, Ma B. Association of Diabetic Retinopathy With Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:626996. [PMID: 33796063 PMCID: PMC8007918 DOI: 10.3389/fneur.2021.626996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 02/08/2021] [Indexed: 01/08/2023] Open
Abstract
Background: The population-based studies conducted thus far do not provide conclusive evidence of the link between diabetic retinopathy (DR) and stroke. The aim of the present systematic review was to determine whether DR is specifically associated with stroke. Methods: MEDLINE, Embase, and Web of Science were systematically searched from their inception to July 31, 2020. All cohort studies that reported associations between the presence of DR and incident stroke were included. The pooled hazard ratios (HRs), pooled risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Results: The meta-analysis included 19 cohort studies involving 81,452 diabetic patients. The pooled effect size of any DR related to stroke was 1.25 for HR (95% CI: 1.12–1.39; P < 0.0001) and 1.96 for RR (95% CI: 1.60–2.39; P < 0.0001). Subgroup analysis for the type of diabetes yielded pooled HR of 1.29 (95% CI: 1.10–1.50; P = 0.001) in patients with type 2 diabetes mellitus (T2DM). The pooled RR was 2.29 (95% CI: 1.77–2.96; P < 0.0001) in patients with T2DM. Two studies addressed the DR-related stroke among type 1 diabetes mellitus (T1DM) patients. One study found a significant association between DR and stroke (OR: 1.6; 95% CI: 1.1–2.3; P < 0.01), while the other did not identify an association between these two conditions (RR: 1.40; 95% CI: 0.62–2.18; P = 0.178). Conclusions: The presence of DR is associated with an increased risk of stroke in diabetic patients. This correlation is robust in T2DM patients but uncertain in T1DM patients. Our findings indicate that DR is an important biomarker for the prediction of stroke. To further validate the role of DR in stroke-risk stratification, additional research is required on the association between the stage of DR and stroke risk, and more studies including T1DM patients are necessary.
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Affiliation(s)
- Kaiyan Hu
- Evidence-Based Medicine Centre, School of Basic Medical Sciences of Lanzhou University, Lanzhou, China.,Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Mengyao Jiang
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Qi Zhou
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Weiting Zeng
- Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Xuhong Lan
- Department of Critical Care Medicine, Gansu Provincial Hospital, Lanzhou, China
| | - Qianqian Gao
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Fan Mei
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Li Zhao
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Fei Chen
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Anhu Wu
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Gongcai Tao
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Chenghua Mou
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China.,The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Bin Ma
- Evidence-Based Medicine Centre, School of Basic Medical Sciences of Lanzhou University, Lanzhou, China.,Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
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Xu XH, Sun B, Zhong S, Wei DD, Hong Z, Dong AQ. Diabetic retinopathy predicts cardiovascular mortality in diabetes: a meta-analysis. BMC Cardiovasc Disord 2020; 20:478. [PMID: 33148188 PMCID: PMC7643303 DOI: 10.1186/s12872-020-01763-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/29/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The prognostic significance of diabetic retinopathy (DR) for cardiovascular diseases (CVD) remained unclear. Therefore, we performed this meta-analysis to assess whether DR predicted CVD mortality in diabetic patients. METHODS We searched PubMed, Embase, Web of Science and Cochrane Library for cohort studies reporting the association of DR and CVD mortality. Then we pooled the data for analysis. RESULTS After screening the literature, 10 eligible studies with 11,239 diabetic subjects were finally included in quantitative synthesis. The pooled risk ratio (RR) of DR, mild DR, and severe DR for CVD mortality was 1.83 (95% confidence interval (CI): 1.42, 2.36; p < 0.001), 1.13 (95% CI 0.81, 1.59; p = 0.46), and 2.26 (1.31, 3.91; p = 0.003), respectively, compared to those without DR. In type 2 DM, the patients with DR had a significantly higher CVD mortality (RR: 1.69; 95% CI 1.27, 2.24; p < 0.001). Subgroup analysis also showed a significantly higher CVD mortality in DR according to various regions, study design, data source, and follow-up period (all RR > 1; all P values < 0.05). Data from 2 studies showed no significant correlation of DR and CVD mortality in diabetic patients receiving cardiovascular surgery (RR: 2.40; 95% CI 0.63, 9.18; P = 0.200). CONCLUSIONS DR is a risk marker of cardiovascular death, and severe DR predicts a doubled mortality of CVD in diabetes. These findings indicate the importance of early identification and management of diabetic patients with DR to reduce the risk of death.
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Affiliation(s)
- Xiao-Hong Xu
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Bo Sun
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Shan Zhong
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Dong-Dong Wei
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Ze Hong
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Ai-Qiang Dong
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China.
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Seferovic JP, Bentley-Lewis R, Claggett B, Diaz R, Gerstein HC, Køber LV, Lawson FC, Lewis EF, Maggioni AP, McMurray JJV, Probstfield JL, Riddle MC, Solomon SD, Tardif JC, Pfeffer MA. Retinopathy, Neuropathy, and Subsequent Cardiovascular Events in Patients with Type 2 Diabetes and Acute Coronary Syndrome in the ELIXA: The Importance of Disease Duration. J Diabetes Res 2018; 2018:1631263. [PMID: 30648112 PMCID: PMC6311850 DOI: 10.1155/2018/1631263] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 09/18/2018] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION We investigated the association of diabetic retinopathy and neuropathy with increased risk of recurrent cardiovascular (CV) events in 6068 patients with type 2 diabetes mellitus (T2DM) and recent acute coronary syndrome (ACS) enrolled in the Evaluation of Lixisenatide in Acute Coronary Syndrome (ELIXA). METHODS History of retinopathy and neuropathy as well as duration of T2DM were self-reported at screening. Proportional hazards regression models were used to assess relationships between retinopathy, neuropathy, and recurrent CV events. RESULTS At screening, retinopathy and neuropathy were reported in 10.7% and 17.5% of patients, respectively, while 5.7% reported both. When adjusted for randomized treatment only, both retinopathy and neuropathy were associated with a primary composite outcome (CV death, nonfatal MI, stroke, or hospitalization for unstable angina) (retinopathy: HR 1.44, 95% CI 1.19-1.75; neuropathy: HR 1.33, 95% CI 1.12-1.57), CV composite (CV death, nonfatal MI, stroke, hospitalization for heart failure (HF)) (retinopathy: HR 1.57, 95% CI 1.31-1.88; neuropathy: HR 1.38, 95% CI 1.19-1.62), myocardial infarction (retinopathy: HR 1.38, 95% CI 1.08-1.76; neuropathy: HR 1.26, 95% CI 1.02-1.54), HF hospitalization (retinopathy: HR 2.03, 95% CI 1.48-2.78; neuropathy: HR 1.71, 95% CI 1.30-2.27), and all-cause mortality (retinopathy: HR 1.65, 95% CI 1.28-2.12; neuropathy: HR 1.43, 95% CI 1.14-1.78). When included in the same model, and adjusted for T2DM duration, there were no independent associations of either with CV outcomes, while T2DM duration remained strongly associated with all outcomes. Addition of demographic characteristics and CV risk factors did not further alter these relationships. CONCLUSIONS In patients with T2DM and recent ACS, a history of retinopathy and/or neuropathy and longer T2DM duration could be considered clinical markers for high risk of recurrent CV events. This trial is registered with the ELIXA (Evaluation of Lixisenatide in Acute Coronary Syndrome), ClinicalTrials.gov registration number NCT01147250.
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Affiliation(s)
- Jelena P. Seferovic
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Rosario, Argentina
| | | | - Lars V. Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Eldrin F. Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo P. Maggioni
- Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy
| | - John J. V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | | | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Zhu XR, Zhang YP, Bai L, Zhang XL, Zhou JB, Yang JK. Prediction of risk of diabetic retinopathy for all-cause mortality, stroke and heart failure: Evidence from epidemiological observational studies. Medicine (Baltimore) 2017; 96:e5894. [PMID: 28099347 PMCID: PMC5279092 DOI: 10.1097/md.0000000000005894] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To examine and quantify the potential relation between diabetic retinopathy (DR) and risk of all-cause mortality, stroke and heart failure (HF).The resources of meta-analysis of epidemiological observational studies were from Pub-med, EMBASE, CINAHL, Cochrane Library, conference, and proceedings.Random/fixed effects models were used to calculate pooled subgroup analysis stratified by different grades of DR was performed to explore the potential source of heterogeneity. Statistical manipulations were undertaken using program STATA.Of the included 25 studies, comprising 142,625 participants, 19 studies were concluded to find the relation of DR to all-cause mortality, 5 for stroke, and 3 for HF. Risk ratio (RR) for all-cause mortality with the presence of DR was 2.33 (95% CI 1.92-2.81) compared with diabetic individuals without DR. Evidences showed a higher risk of all-cause mortality associated with DR in patients with T2D or T1D (RR 2.25, 95% CI 1.91-2.65. RR 2.68, 95% CI 1.34-5.36). According to different grades of DR in patients with T2D, RR for all-cause mortality varied, the risk of nonproliferative diabetic retinopathy (NPDR) was 1.38 (1.11-1.70), while the risk of proliferative diabetic retinopathy (PDR) was 2.32 (1.75-3.06). There was no evidence of significant heterogeneity (Cochran Q test P = 0.29 vs 0.26, I = 19.6% vs 22.6%, respectively). Data from 5 studies in relation to DR and the risk of stroke showed that DR was significantly associated with increased risk of stroke (RR = 1.74, 95%CI: 1.35-2.24), compared with patients without DR. Furthermore, DR (as compared with individuals without DR) was associated with a marginal increased risk of HF in patients with diabetes mellitus (DM) (n = 3 studies; RR 2.24, 95% CI 0.98-5.14, P = 0.056).Our results showed that DR increased the risk of all-cause mortality, regardless of the different stages, compared with the diabetic individuals without DR. DR predicted increased risk of stroke and HF. Although only 3 studies about HF were available, the association between DR and HF should be careful.
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Affiliation(s)
| | - Yong-Peng Zhang
- Department of Ophthalmology, Beijing Tongren Hospital, Capital Medical University
| | - Lu Bai
- Department of Geratology, Beijing Haidian Hospital
| | | | | | - Jin-Kui Yang
- Department of Endocrinology
- Beijing Key Laboratory of Diabetes Research and Care, Beijing China
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The prognosis of diabetic retinopathy in patients with type 2 diabetes since 1996-1998: the Skaraborg Diabetes Register. Int Ophthalmol 2014; 35:503-11. [PMID: 25143261 DOI: 10.1007/s10792-014-9976-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 07/09/2014] [Indexed: 11/27/2022]
Abstract
Diabetes mellitus is the main reason for visual impairment among patients of working ages. The aim of this paper was to investigate the prognosis of eye complications in patients with diabetes during 10 years of follow-up and contributing risk factors. Data from ophthalmological records (occurrence of retinopathy and laser treatment and visual acuity), and clinical data (blood pressure, glycosylated hemoglobin (HbA1c), body mass index (BMI), and antihypertensive treatment) from the Skaraborg Diabetes Register were retrieved in the Skaraborg Screening Program of 1,258 patients diagnosed during 1996-1998. Kaplan Meyer survival analysis and Log Rank test were used to analyze eye complications in 773 patients with type 2 diabetes and ≤70 years at diagnosis. Visual acuity was above the limit for driving license in 96 % of 548 patients and only nineteen patients were treated by laser. At diagnosis of diabetes, mean HbA1c was 6.7 ± 1.7 % (59 ± 7.1 mmol/mol), and systolic blood pressure was 142.9 ± 0.7 mmHg; neither changed significantly during follow-up. Retinopathy appeared about 1 year, and maculopathy 2 years earlier, if HbA1c ≥ 7 % (63 mmol/mol) at diagnosis (p < 0.001 and p < 0.006). Antihypertensive treatment, higher BMI, and higher age at diagnosis were associated with less retinopathy during follow-up. Most patients with diabetes develop little retinopathy for the first 10 years after diagnosis. High HbA1c at baseline was associated with retinopathy and maculopathy during follow-up. Antihypertensive treatment, probably a proxy for regular controls and early detection of diabetes, was associated with less retinopathy.
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Pershing S, Enns EA, Matesic B, Owens DK, Goldhaber-Fiebert JD. Cost-effectiveness of treatment of diabetic macular edema. Ann Intern Med 2014; 160:18-29. [PMID: 24573663 PMCID: PMC4020006 DOI: 10.7326/m13-0768] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Macular edema is the most common cause of vision loss among patients with diabetes. OBJECTIVE To determine the cost-effectiveness of different treatments of diabetic macular edema (DME). DESIGN Markov model. DATA SOURCES Published literature and expert opinion. TARGET POPULATION Patients with clinically significant DME. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION Laser treatment, intraocular injections of triamcinolone or a vascular endothelial growth factor (VEGF) inhibitor, or a combination of both. OUTCOME MEASURES Discounted costs, gains in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS All treatments except laser monotherapy substantially reduced costs, and all treatments except triamcinolone monotherapy increased QALYs. Laser treatment plus a VEGF inhibitor achieved the greatest benefit, gaining 0.56 QALYs at a cost of $6975 for an ICER of $12 410 per QALY compared with laser treatment plus triamcinolone. Monotherapy with a VEGF inhibitor achieved similar outcomes to combination therapy with laser treatment plus a VEGF inhibitor. Laser monotherapy and triamcinolone monotherapy were less effective and more costly than combination therapy. RESULTS OF SENSITIVITY ANALYSIS VEGF inhibitor monotherapy was sometimes preferred over laser treatment plus a VEGF inhibitor, depending on the reduction in quality of life with loss of visual acuity. When the VEGF inhibitor bevacizumab was as effective as ranibizumab, it was preferable because of its lower cost. LIMITATION Long-term outcome data for treated and untreated diseases are limited. CONCLUSION The most effective treatment of DME is VEGF inhibitor injections with or without laser treatment. This therapy compares favorably with cost-effective interventions for other conditions. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Bello NA, Pfeffer MA, Skali H, McGill JB, Rossert J, Olson KA, Weinrauch L, Cooper ME, de Zeeuw D, Rossing P, McMurray JJV, Solomon SD. Retinopathy and clinical outcomes in patients with type 2 diabetes mellitus, chronic kidney disease, and anemia. BMJ Open Diabetes Res Care 2014; 2:e000011. [PMID: 25452859 PMCID: PMC4212578 DOI: 10.1136/bmjdrc-2013-000011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 02/10/2014] [Accepted: 02/13/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Retinopathy is an established microvascular complication of type 2 diabetes mellitus (T2DM), but its independent relationship with macrovascular and other microvascular complications is less well defined across the spectrum of kidney disease in T2DM. We examined the prognostic value of retinopathy in assessing the risk of developing end-stage renal disease (ESRD), cardiovascular morbidity or death among patients in the Trial to Reduce cardiovascular Events with Aranesp Therapy (TREAT). DESIGN TREAT enrolled 4038 patients with T2DM, chronic kidney disease (CKD) and moderate anemia. Patients were grouped by baseline history of retinopathy. Proportional hazards regression models were utilized to assess the association between retinopathy and subsequent ESRD, cardiovascular morbidity or death over an average of 2.4 years. RESULTS Although younger, the 1895 (47%) patients with retinopathy had longer duration of diabetes, lower estimated glomerular filtration rate, more proteinuria, and more microvascular complications. In univariate analysis, retinopathy was associated with a higher rate of ESRD, but not with cardiovascular events or mortality. After adjustment, retinopathy was no longer statistically significant for the prediction of ESRD or any clinical endpoint. CONCLUSIONS In a large cohort of patients with T2DM, CKD, and anemia, retinopathy was common but not independently associated with a higher risk of renal or cardiovascular morbidity or death. TRIAL REGISTRATION NUMBER NCT00093015.
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Affiliation(s)
- Natalie A Bello
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hicham Skali
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Janet B McGill
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Larry Weinrauch
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mark E Cooper
- Baker IDI Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Dick de Zeeuw
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Peter Rossing
- Steno Diabetes Center, Copenhagen, Denmark
- Health, University of Aarhus, Denmark
- CBMR, University of Copenhagen, Denmark
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Kramer CK, Rodrigues TC, Canani LH, Gross JL, Azevedo MJ. Diabetic retinopathy predicts all-cause mortality and cardiovascular events in both type 1 and 2 diabetes: meta-analysis of observational studies. Diabetes Care 2011; 34:1238-44. [PMID: 21525504 PMCID: PMC3114518 DOI: 10.2337/dc11-0079] [Citation(s) in RCA: 165] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The prognostic significance of diabetic retinopathy (DR) for death and cardiovascular (CV) outcomes is debated. We investigated the association of DR with all-cause mortality and CV events in patients with diabetes by a systematic review and meta-analysis. RESEARCH DESIGN AND METHODS The electronic databases Medline and Embase were searched for cohort studies that evaluated DR in type 2 or type 1 diabetic patients and reported total mortality and/or fatal and nonfatal CV events, including myocardial infarction, angina pectoris, coronary artery bypass graft, ischemic changes on a conventional 12-lead electrocardiogram, transient ischemic attack, nonfatal stroke, or lower leg amputation. Data extraction was performed by two reviewers independently. Pooled effect estimates were obtained by using random-effects meta-analysis. RESULTS The analysis included 20 studies that fulfilled the inclusion criteria, providing data from 19,234 patients. In patients with type 2 diabetes (n = 14,896), the presence of any degree of DR increased the chance for all-cause mortality and/or CV events by 2.34 (95% CI 1.96-2.80) compared with patients without DR. In patients with type 1 diabetes (n = 4,438), the corresponding odds ratio was 4.10 (1.50-11.18). These associations remained after adjusting for traditional CV risk factors. DR was also predictive of all-cause mortality in type 2 diabetes (odds ratio 2.41 [1.87-3.10]) and type 1 diabetes (3.65 [1.05-12.66]). CONCLUSIONS The presence of DR was associated with an increased risk of all-cause mortality and CV events in both type 2 and type 1 diabetic patients.
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Affiliation(s)
- Caroline K Kramer
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Universidade Federal do RioGrande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
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Möllsten A, Torffvit O. Tamm-Horsfall protein gene is associated with distal tubular dysfunction in patients with type 1 diabetes. ACTA ACUST UNITED AC 2010; 44:438-44. [PMID: 20624112 DOI: 10.3109/00365599.2010.504190] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The first changes in the diabetic kidney are glycogen deposits in the epithelial cells of the thick ascending limb of Henle, which leads to decreased production of Tamm-Horsfall protein (THP). The production of THP is also influenced by nitric oxide (NO). The aims of this study were to investigate whether low excretion of THP, a sign of distal tubular dysfunction, in patients with type 1 diabetes was associated with polymorphisms in the THP gene and the endothelial NO synthase (eNOS) gene. MATERIAL AND METHODS Urine was collected from 301 patients with type 1 diabetes, 164 with normoalbuminuria, 91 with microalbuminuria and 46 with macroalbuminuria. Urinary THP concentration below median (3.12 mg/l) was defined as tubular dysfunction. Representative polymorphisms were analysed in the THP and eNOS genes. RESULTS Patients with tubular dysfunction had longer diabetes duration and higher blood pressure than patients without tubular dysfunction. Tubular dysfunction was common in patients with macroalbuminuria (70% of patients) and it was associated with the AA+AT genotypes of rs12444268 in the THP gene [odds ratio (OR) 1.8, 95% confidence interval (CI) 1.1-2.8], and the GG genotype of rs1799983 in the eNOS gene (OR 1.6, 95% CI 1.03-2.6). When adjusting for other associated factors, diabetes duration, glycosylated haemoglobin (HbA(1c)), mean arterial pressure and albuminuria, the THP rs12444268 and macroalbuminuria were independently associated with tubular dysfunction. CONCLUSION Distal tubular dysfunction was associated with the THP gene and macroalbuminuria in patients with type 1 diabetes.
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Affiliation(s)
- Anna Möllsten
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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11
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Abstract
Elderly diabetic persons are 1.5 times more likely than age-matched nondiabetic persons to develop vision loss and blindness. Annually, between 12,000 and 24,000 diabetic patients in the United States become legally blind because of complications caused by diabetic retinopathy. Even more diabetic persons experience vision loss caused by comorbid ocular and periocular conditions such as dry eye syndrome, cataracts, macular degeneration, and glaucoma. This article discusses the synergy between these conditions and diabetes. Standards of care that slow the progression of vision loss and exciting new research on new strategies of care that may reverse vision loss are presented.
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Affiliation(s)
- Nina Tumosa
- Geriatrics Research, Education, and Clinical Center, St. Louis VA Medical Center, St. Louis, MO 63125, USA.
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12
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Hirai FE, Knudtson MD, Klein BE, Klein R. Clinically significant macular edema and survival in type 1 and type 2 diabetes. Am J Ophthalmol 2008; 145:700-6. [PMID: 18226797 DOI: 10.1016/j.ajo.2007.11.019] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Revised: 11/21/2007] [Accepted: 11/27/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE To investigate the association of clinically significant macular edema (CSME) and long-term survival in individuals with type 1 and type 2 diabetes. DESIGN Population-based cohort study. METHODS The Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) is an ongoing prospective population-based cohort study initiated from August 21, 1980 through July 30, 1982 of individuals with diabetes diagnosed at either younger than 30 years of age (younger-onset group; n = 996) or 30 years of age or older (older-onset group; n = 1,370). Stereoscopic color retinal photographs were graded for retinopathy using the modified Airlie House classification scheme. CSME was defined by the Early Treatment Diabetic Retinopathy Study criteria. RESULTS Prevalence of CSME was 5.9% and 7.5% for the younger- and older-onset groups, respectively. After 20 years of follow-up, 276 younger-onset and 1,197 older-onset persons died. When adjusting for age and gender, CSME was not significantly associated with all-cause mortality (hazard ratio [HR], 1.41; 95% confidence interval [CI], 0.96 to 2.07; P = .08) or ischemic heart disease mortality (HR, 1.14; 95% CI, 0.61 to 2.12; P = .68) in the younger-onset group. In the older-onset group, there was increased all-cause and ischemic heart disease mortality when CSME was present (HR, 1.55; 95% CI, 1.25 to 1.92; P < .01; and HR, 1.56; 95% CI, 1.15 to 2.13; P < .01, respectively), when adjusting for age and gender. After controlling for other risk factors, the association remained significant for ischemic heart disease (HR, 1.58; 95% CI, 1.07 to 2.35; P = .02) among those taking insulin. CSME was not significantly associated with stroke mortality in either group. CONCLUSIONS CSME seems to be a risk indicator for decreased survival in persons with older-onset diabetes mellitus. The presence of CSME may identify individuals who should be receiving care for detection and treatment of cardiovascular disease.
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