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Pinés Corrales PJ, Sastre Marcos J, López Gallardo G, Moreno Fernández J, Herranz Antolín S, Quiroga López I, Del Val Zaballos F, González López J, Alfaro Martínez JJ. All-cause mortality and risk factors in patients with type 1 diabetes in Castilla-La Mancha, Spain. DIACAM1 2010-2020 study. Prim Care Diabetes 2024; 18:59-64. [PMID: 37977987 DOI: 10.1016/j.pcd.2023.11.003] [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: 01/12/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Despite better treatments and care for patients with type 1 diabetes (T1DM), all-cause and cardiovascular mortality still remains higher compared to the general population. We evaluated mortality and risk factors for mortality in a representative cohort of patients with T1DM. METHODS DIACAM1 was a cross-sectional, multicenter study on adult patients (≥ 16 years old) and diabetes with at least 5 years since diabetes diagnosis conducted between 2009 and 2010. DIACAM1 2010-2020 study was a follow-up study, extension of DIACAM1, where vital status of patients was evaluated between June 2019 and June 2020. RESULTS 4.03% [CI95%, 2.53-5.62) of the 1465 patients with T1DM included in the cohort of the DIACAM1 in 2010 had died. Survival was lower than in the sex- and age-matched general population in the same region. 40.7% of deaths were due to cardiovascular disease. HbA1c levels < 7% and triglyceride levels < 150 mg/dL were associated with lower mortality, whereas retinopathy and plasma creatinine were associated with increased mortality. CONCLUSIONS We confirmed a lower survival in people with T1DM, with cardiovascular disease being the main cause of mortality. High HbA1c, high triglycerides, retinopathy, and high creatinine are factors associated with mortality.
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Di Marco M, Scilletta S, Miano N, Marrano N, Natalicchio A, Giorgino F, Di Mauro S, Filippello A, Scamporrino A, Tribulato P, Bosco G, Di Giacomo Barbagallo F, Scicali R, Milluzzo A, Ballirò T, Frittitta L, Castellino P, Purrello F, Piro S, Di Pino A. Cardiovascular risk and renal injury profile in subjects with type 2 diabetes and non-albuminuric diabetic kidney disease. Cardiovasc Diabetol 2023; 22:344. [PMID: 38093293 PMCID: PMC10720121 DOI: 10.1186/s12933-023-02065-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 11/13/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND In the last years, the classical pattern of diabetic kidney disease (DKD) has been partially overcome, because of the uncovering of a new DKD phenotype with significant renal dysfunction without presence of albuminuria: the non-albuminuric DKD (NA-DKD). To date, the cardiovascular risk associated with this phenotype is still debated. We investigated the cardiovascular risk and renal injury profile of NA-DKD subjects in comparison with other DKD phenotypes. METHODS Pulse wave velocity (PWV), intima-media thickness, presence of carotid atherosclerotic plaque, renal resistive index (RRI), and a panel of urinary biomarkers of kidney injury were evaluated in 160 subjects with type 2 diabetes, stratified according to estimated glomerular filtration rate (eGFR) and urinary albumin to creatinine ratio (UACR) into four groups: controls (UACR < 30 mg/g and eGFR ≥ 60 mL/min/1.73 m2), A-DKD (Albuminuric-DKD, UACR ≥ 30 mg/g and eGFR ≥ 60 mL/min/1.73 m2), NA-DKD (UACR < 30 mg/g and eGFR < 60 mL/min/1.73 m2), AL-DKD (Albuminuric and Low eGFR-DKD; UACR ≥ 30 mg/g and eGFR < 60 mL/min/1.73 m2). RESULTS Subjects with NA-DKD showed a higher PWV (11.83 ± 3.74 m/s vs. 10.24 ± 2.67 m/s, P = 0.045), RRI (0.76 ± 0.11 vs. 0.71 ± 0.09, P = 0.04), and prevalence of carotid atherosclerotic plaque (59% vs. 31%, P = 0.009) compared with controls. These characteristics were similar to those of subjects with AL-DKD, whereas the profile of A-DKD subjects was closer to controls. After multiple regression analyses, we found that RRI, that is in turn influenced by eGFR (β = - 0.01, P = 0.01), was one of the major determinants of PWV (β = 9.4, P = 0.02). Urinary TreFoil Factor 3, a marker of tubular damage, was higher in NA-DKD subjects vs. controls (1533.14 ± 878.31 ng/mL vs. 1253.84 ± 682.17 ng/mL, P = 0.047). Furthermore, after multiple regression analyses, we found that urinary osteopontin was independently associated with PWV (β = 2.6, P = 0.049) and RRI (β = 0.09, P = 0.006). CONCLUSIONS Our data showed a worse cardiovascular and renal injury profile in NA-DKD subjects. This finding emphasizes the central role of eGFR in the definition of cardiovascular risk profile of diabetic subjects together with albuminuria.
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Affiliation(s)
- Maurizio Di Marco
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Sabrina Scilletta
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Nicoletta Miano
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Nicola Marrano
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, 70124, Bari, Italy
| | - Annalisa Natalicchio
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, 70124, Bari, Italy
| | - Francesco Giorgino
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, 70124, Bari, Italy
| | - Stefania Di Mauro
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Agnese Filippello
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | - Paola Tribulato
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giosiana Bosco
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | - Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Agostino Milluzzo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Teresa Ballirò
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Lucia Frittitta
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pietro Castellino
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.
| | - Antonino Di Pino
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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Scilletta S, Di Marco M, Miano N, Filippello A, Di Mauro S, Scamporrino A, Musmeci M, Coppolino G, Di Giacomo Barbagallo F, Bosco G, Scicali R, Piro S, Purrello F, Di Pino A. Update on Diabetic Kidney Disease (DKD): Focus on Non-Albuminuric DKD and Cardiovascular Risk. Biomolecules 2023; 13:biom13050752. [PMID: 37238622 DOI: 10.3390/biom13050752] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
The classic description of diabetic kidney disease (DKD) involves progressive stages of glomerular hyperfiltration, microalbuminuria, proteinuria, and a decline in the estimated glomerular filtration rate (eGFR), leading to dialysis. In recent years, this concept has been increasingly challenged as evidence suggests that DKD presents more heterogeneously. Large studies have revealed that eGFR decline may also occur independently from the development of albuminuria. This concept led to the identification of a new DKD phenotype: non-albuminuric DKD (eGFR < 60 mL/min/1.73 m2, absence of albuminuria), whose pathogenesis is still unknown. However, various hypotheses have been formulated, the most likely of which is the acute kidney injury-to-chronic kidney disease (CKD) transition, with prevalent tubular, rather than glomerular, damage (typically described in albuminuric DKD). Moreover, it is still debated which phenotype is associated with a higher cardiovascular risk, due to contrasting results available in the literature. Finally, much evidence has accumulated on the various classes of drugs with beneficial effects on DKD; however, there is a lack of studies analyzing the different effects of drugs on the various phenotypes of DKD. For this reason, there are still no specific guidelines for therapy in one phenotype rather than the other, generically referring to diabetic patients with CKD.
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Affiliation(s)
- Sabrina Scilletta
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Maurizio Di Marco
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Nicoletta Miano
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Agnese Filippello
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Stefania Di Mauro
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Alessandra Scamporrino
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Marco Musmeci
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Giuseppe Coppolino
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | | | - Giosiana Bosco
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
| | - Antonino Di Pino
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy
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Xie Y, E J, Cai H, Zhong F, Xiao W, Gordon RE, Wang L, Zheng YL, Zhang A, Lee K, He JC. Reticulon-1A mediates diabetic kidney disease progression through endoplasmic reticulum-mitochondrial contacts in tubular epithelial cells. Kidney Int 2022; 102:293-306. [PMID: 35469894 PMCID: PMC9329239 DOI: 10.1016/j.kint.2022.02.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022]
Abstract
Recent epidemiological studies suggest that some patients with diabetes progress to kidney failure without significant albuminuria and glomerular injury, suggesting a critical role of kidney tubular epithelial cell (TEC) injury in diabetic kidney disease (DKD) progression. However, the major risk factors contributing to TEC injury and progression in DKD remain unclear. We previously showed that expression of endoplasmic reticulum-resident protein Reticulon-1A (RTN1A) increased in human DKD, and the increased RTN1A expression promoted TEC injury through endoplasmic reticulum (ER) stress response. Here, we show that TEC-specific RTN1A overexpression worsened DKD in mice, evidenced by enhanced tubular injury, tubulointerstitial fibrosis, and kidney function decline. But RTN1A overexpression did not exacerbate diabetes-induced glomerular injury or albuminuria. Notably, RTN1A overexpression worsened both ER stress and mitochondrial dysfunction in TECs under diabetic conditions by regulation of ER-mitochondria contacts. Mechanistically, ER-bound RTN1A interacted with mitochondrial hexokinase-1 and the voltage-dependent anion channel-1 (VDAC1), interfering with their association. This disengagement of VDAC1 from hexokinase-1 resulted in activation of apoptotic and inflammasome pathways, leading to TEC injury and loss. Thus, our observations highlight the importance of ER-mitochondrial crosstalk in TEC injury and the salient role of RTN1A-mediated ER-mitochondrial contact regulation in DKD progression.
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Affiliation(s)
- Yifan Xie
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York; Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing E
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York; Department of Nephrology, Ningxia People's Hospital, Ningxia, China
| | - Hong Cai
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York; Department of Nephrology, Renji Hospital, Shanghai Jiaotong University Medical School, Shanghai, China
| | - Fang Zhong
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York
| | - Wenzhen Xiao
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York
| | - Ronald E Gordon
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York
| | - Lois Wang
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York
| | - Ya-Li Zheng
- Department of Nephrology, Ningxia People's Hospital, Ningxia, China
| | - Aihua Zhang
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Kyung Lee
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York.
| | - John Cijiang He
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York; Renal Section, James J. Peters Veterans Affair Medical Center, Bronx, NY.
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Di Bonito P, Mozzillo E, Rosanio FM, Maltoni G, Piona CA, Franceschi R, Ripoli C, Ricciardi MR, Tornese G, Arnaldi C, Iovane B, Iafusco D, Zanfardino A, Suprani T, Savastio S, Cherubini V, Tiberi V, Piccinno E, Schiaffini R, Delvecchio M, Casertano A, Maffeis C, Franzese A. Albuminuric and non-albuminuric reduced eGFR phenotypes in youth with type 1 diabetes: Factors associated with cardiometabolic risk. Nutr Metab Cardiovasc Dis 2021; 31:2033-2041. [PMID: 34083127 DOI: 10.1016/j.numecd.2021.03.019] [Citation(s) in RCA: 3] [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: 03/02/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIM Albuminuria and reduced eGFR are hallmarks of Diabetic Kidney Disease in adults. Our aim was to analyze factors associated with albuminuric and non-albuminuric mildly reduced eGFR phenotypes in youths with type 1 diabetes. METHODS AND RESULTS This multicenter cross-sectional study included 1549 youths (age 5-17 years) with type 1 diabetes enrolled at 14 Italian Pediatric Diabetes Centers. Albuminuria, creatinine, glycosylated hemoglobin (HbA1c), lipids, blood pressure (BP), neutrophils (N) and lymphocytes (L) count were analyzed. Uric acid (UA) was available in 848 individuals. Estimated GFR (eGFR) was calculated using bedside Schwartz's equation. The sample was divided in three phenotypes: 1) normoalbuminuria and eGFR ≥90 mL/min/1.73 m2 (reference category, n = 1204), 2) albuminuric and normal GFR phenotype (n = 106), 3) non-albuminuric mildly reduced GFR (MRGFR) phenotype (eGFR 60-89 mL/min/1.73 m2, n = 239). Albuminuric and non-albuminuric reduced eGFR phenotypes were significantly associated with autoimmune thyroiditis (P =0.028 and P=0.044, respectively). Albuminuric phenotype showed high risk of high HbA1c (P=0.029), high BP (P < 0.001), and low HDL-C (P =0.045) vs reference category. Non-albuminuric MRGFR phenotype showed high risk of high BP (P < 0.0001), low HDL-C (P =0.042), high Triglycerides/HDL-C ratio (P =0.019), and high UA (P < 0.0001) vs reference category. CONCLUSION Non albuminuric MRGFR phenotype is more prevalent than albuminuric phenotype and shows a worst cardiometabolic risk (CMR) profile). Both phenotypes are associated with autoimmune thyroiditis. Our data suggest to evaluate both albuminuria and eGFR earlier in type 1 diabetes to timely identify young people with altered CMR profile.
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Affiliation(s)
- Procolo Di Bonito
- Department of Internal Medicine, "S. Maria Delle Grazie", Pozzuoli Hospital, Naples, Italy
| | - Enza Mozzillo
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy.
| | - Francesco M Rosanio
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy
| | - Giulio Maltoni
- Department of Woman, Child and Urological Diseases, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Claudia A Piona
- Pediatric Diabetes and Metabolic Disorders Unit, University of Verona, Verona, Italy
| | | | - Carlo Ripoli
- Pediatric Diabetology Unit, Pediatric and Microcytemia Department, AO Brotzu, Cagliari, Italy
| | - Maria R Ricciardi
- Pediatric Diabetology Unit, Pediatric and Microcytemia Department, AO Brotzu, Cagliari, Italy
| | - Gianluca Tornese
- Institute for Maternal and Child Health IRCCS 'Burlo Garofolo', Trieste, Italy
| | | | - Brunella Iovane
- Regional Diabetes Center, Children Hospital "Pietro Barilla", University Hospital of Parma, Parma, Italy
| | - Dario Iafusco
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Angela Zanfardino
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Silvia Savastio
- SCDU of Pediatrics, University Hospital Maggiore Della Carità, Novara, Italy
| | - Valentino Cherubini
- Regional Center for Diabetes in Children and Adolescents, Department of Woman and Child Health, AOU Salesi Hospital, Ancona, Italy
| | - Valentino Tiberi
- Regional Center for Diabetes in Children and Adolescents, Department of Woman and Child Health, AOU Salesi Hospital, Ancona, Italy
| | - Elvira Piccinno
- Metabolic Diseases, Clinical Genetics and Diabetology Unit, Giovanni XXIII Children's Hospital, Bari, Italy
| | | | - Maurizio Delvecchio
- Metabolic Diseases, Clinical Genetics and Diabetology Unit, Giovanni XXIII Children's Hospital, Bari, Italy
| | - Alberto Casertano
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy
| | - Claudio Maffeis
- Pediatric Diabetes and Metabolic Disorders Unit, University of Verona, Verona, Italy
| | - Adriana Franzese
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy
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Diabetic kidney disease: new clinical and therapeutic issues. Joint position statement of the Italian Diabetes Society and the Italian Society of Nephrology on "The natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function". J Nephrol 2021; 33:9-35. [PMID: 31576500 PMCID: PMC7007429 DOI: 10.1007/s40620-019-00650-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aims This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents. Data Synthesis Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., “nonalbuminuric renal impairment” and “progressive renal decline”, suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered. Conclusions The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.
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Darlington O, Dickerson C, Evans M, McEwan P, Sörstadius E, Sugrue D, van Haalen H, Garcia Sanchez JJ. Costs and Healthcare Resource Use Associated with Risk of Cardiovascular Morbidity in Patients with Chronic Kidney Disease: Evidence from a Systematic Literature Review. Adv Ther 2021; 38:994-1010. [PMID: 33432542 PMCID: PMC7889525 DOI: 10.1007/s12325-020-01607-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/11/2020] [Indexed: 12/12/2022]
Abstract
Introduction The management of chronic kidney disease (CKD) costs in excess of $114 billion in the USA and £1.45 billion in the UK annually and is projected to increase alongside the increasing disease prevalence. The aim of this review was to evaluate the risks of cardiovascular (CV) morbidity, CV mortality or all-cause mortality based on KDIGO (Kidney Disease: Improving Global Outcomes) 2012 categorisations and estimate the additional costs and healthcare resource utilisation associated with CV morbidity linked to CKD severity in US and UK settings. Methods A systematic literature review was conducted of studies reporting on the risk of CV morbidity, CV mortality or all-cause mortality characterised by CKD severity (published between January 2000 and September 2018). Additional costs and bed days associated with CKD severity in the USA and UK were estimated on the basis of median hazard ratios for CV morbidity risk at each CKD and albuminuria stage. Results Twenty-nine studies reported risk of adverse clinical outcomes based on KDIGO categorisations. Compared to stage 1 (or without) CKD, patients with stage 5 CKD and macroalbuminuria experienced a relative risk increase of 11.77–12.46 across all outcomes. Additional costs and bed days associated with stage 5 CKD and macroalbuminuria (versus stage 1 (or without) CKD) per 1000 patient years were US$3.93 million and 803 bed days and £435,000 and 1017 bed days, in the USA and UK, respectively. Conclusion Risks of adverse clinical outcomes increase with CKD and albuminuria severity and are associated with substantial additional costs and resource utilisation. Thus, early diagnosis and proactive management of CKD and its complications should be a priority for healthcare providers to alleviate the burden of CV morbidity and its management on healthcare resources. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-020-01607-4.
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Affiliation(s)
| | | | - Marc Evans
- Diabetes Resource Centre, Llandough Hospital, Cardiff, UK
| | - Phil McEwan
- Health Economics and Outcomes Research Ltd., Cardiff, UK
| | | | - Daniel Sugrue
- Health Economics and Outcomes Research Ltd., Cardiff, UK
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Chang DY, Li MR, Yu XJ, Wang SX, Chen M, Zhao MH. Clinical and Pathological Characteristics of Patients With Nonproteinuric Diabetic Nephropathy. Front Endocrinol (Lausanne) 2021; 12:761386. [PMID: 34764941 PMCID: PMC8576342 DOI: 10.3389/fendo.2021.761386] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/07/2021] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION As the most common complication of diabetes mellitus (DM), diabetic nephropathy (DN) was initially considered to begin with proteinuria preceding the progression of renal insufficiency. This clinical paradigm has been questioned in the late decades, as many DM patients without proteinuria have progressive renal insufficiency. However, the characteristics of nonproteinuric DN were not fully clear yet. PATIENTS AND METHODS A total of 390 patients with renal biopsy-proven DN in our center were retrospectively recruited in the current study. Clinical and histopathological data of the patients were analyzed. We used propensity score-matching methods to address the imbalance of age, sex, and diabetes duration for comparative analyses. RESULTS Among all the renal biopsy-proven DN patients with renal biopsy proven DN, 18 patients were classified as nonproteinuric DN. Compared with 36 propensity score-matched proteinuric DN patients, diabetic retinopathy (DR) was less frequent in nonproteinuric DN patients (38.9% vs. 66.4%, p<0.05). During the follow-up of 24.0 (12.0-42.0) months, the probability of developing the end-stage renal disease (ESRD) was significantly lower in nonproteinuric DN patients than in proteinuric ones in both the propensity score-matched cohort and overall cohort (log-rank test, p<0.001 and p<0.001, respectively). CONCLUSIONS Compared with proteinuric DN patients, DR was less frequent in nonproteinuric DN patients. Nonproteinuric DN patients had better renal outcomes than proteinuric DN patients.
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Affiliation(s)
- Dong-Yuan Chang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Meng-Rui Li
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Min Chen,
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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Garofolo M, Gualdani E, Giannarelli R, Aragona M, Campi F, Lucchesi D, Daniele G, Miccoli R, Francesconi P, Del Prato S, Penno G. Microvascular complications burden (nephropathy, retinopathy and peripheral polyneuropathy) affects risk of major vascular events and all-cause mortality in type 1 diabetes: a 10-year follow-up study. Cardiovasc Diabetol 2019; 18:159. [PMID: 31733651 PMCID: PMC6858978 DOI: 10.1186/s12933-019-0961-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/01/2019] [Indexed: 02/07/2023] Open
Abstract
Background Microvascular complications (MC) have been claimed to increase the risk for cardiovascular disease in diabetic subjects. However, the effect of MC burden on the risk of major vascular outcomes and all-cause mortality in type 1 diabetes is still poorly explored. We evaluated the relationship between microvascular complications burden and incidence of major cardiovascular events and all-cause mortality in subjects with type 1 diabetes. Methods We recruited 774 participants with type 1 diabetes in a single-center observational study over a follow-up of 10.8 ± 2.5 years. Hazard ratios (HR) for cardiovascular outcomes and all-cause death associated with microvascular complications were determined by unadjusted and adjusted Cox regression analysis. Results Out of 774 individuals, 54.9% had no-MC, 32.3% 1 MC, 9.7% 2 MC and 3.1% 3 MC. A total of 54 deaths (7.0%) occurred. Death rate increased from no-MC 2.1% (Ref) to 1 MC 7.2% (HR 3.54 [95% CI 1.59–7.87]), 2 MC 14.7% (HR 6.41 [95% CI 2.65–15.49]) and 3 MC 66.7% (HR 41.73 [95% CI 18.42–94.57], p < 0.0001). After adjustments, HRs were: 1 MC 2.05 (95% CI 0.88–4.76), 2 MC 1.98 (95% CI 0.75–5.21), 3 MC 7.02 (95% CI 2.44–20.20, p = 0.002). Forty-nine subjects (6.7%) had at least one cardiovascular event, and cumulative incidence went from no-MC 2.2% (Ref) to 1 MC 5.0%; (HR 2.27 [95% CI 0.96–5.38]), 2 MC 26.8% (HR 12.88 [95% CI 5.82–28.50]) and 3 MC 40.9% (HR 29.34 [95% CI 11.59–74.25], p < 0.0001). Upon adjustments, HRs were: 1 MC 1.59 (95% CI 0.65–3.88), 2 MC 4.33 (95% CI 1.75–10.74), 3 MC 9.31 (95% CI 3.18–27.25, p < 0.0001). Thirty-five individuals (4.8%) had at least one coronary event, which cumulative incidence increased with MC burden (p < 0.0001). Conclusions In type 1 diabetes, microvascular complications burden increases in an independent dose-dependent manner the risk of major cardiovascular outcomes and all-cause mortality. The presence and number of microvascular complications should be considered in stratifying overall cardiovascular risk in type 1 diabetes.
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Affiliation(s)
- Monia Garofolo
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Elisa Gualdani
- Epidemiology Unit, Regional Health Agency (ARS) of Tuscany, Florence, Italy
| | - Rosa Giannarelli
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Michele Aragona
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Fabrizio Campi
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Daniela Lucchesi
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Giuseppe Daniele
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Roberto Miccoli
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Paolo Francesconi
- Epidemiology Unit, Regional Health Agency (ARS) of Tuscany, Florence, Italy
| | - Stefano Del Prato
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy.
| | - Giuseppe Penno
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
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Pugliese G, Penno G, Natali A, Barutta F, Di Paolo S, Reboldi G, Gesualdo L, De Nicola L. Diabetic kidney disease: New clinical and therapeutic issues. Joint position statement of the Italian Diabetes Society and the Italian Society of Nephrology on "The natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function". Nutr Metab Cardiovasc Dis 2019; 29:1127-1150. [PMID: 31586514 DOI: 10.1016/j.numecd.2019.07.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 02/06/2023]
Abstract
AIMS This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents. DATA SYNTHESIS Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., "nonalbuminuric renal impairment" and "progressive renal decline", suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered. CONCLUSIONS The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.
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Affiliation(s)
- Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Endocrine and Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy.
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Diabetes Unit, University Hospital, Pisa, Italy
| | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Unit of Internal Medicine, University Hospital, Pisa, Italy
| | - Federica Barutta
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | | | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Nephrology, Dialysis and Transplantation Unit, "Policlinico" University Hospital, Bari, Italy
| | - Luca De Nicola
- Nephrology and Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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Value of Estimated Glomerular Filtration Rate and Albuminuria in Predicting Cardiovascular Risk in Patients with Type 2 Diabetes without Cardiovascular Disease. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8178043. [PMID: 30729117 PMCID: PMC6343162 DOI: 10.1155/2018/8178043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 12/03/2018] [Indexed: 12/22/2022]
Abstract
Introduction Onset of nephropathy in patients with type 2 diabetes (T2DM) increases the cardiovascular disease (CVD) risk. Association of the parameters of diabetic nephropathy such as albuminuria and estimated Glomerular filtration rate (eGFR) with predicted CVD risk has not been studied in Sri Lankan patients with T2DM. Methods In a cross-sectional study of patients who underwent single visit screening at a diabetes center in Sri Lanka, we obtained demographic and biochemical data. Those with urine albumin excretion over 30 mg/g creatinine were considered as having albuminuria, and eGFR was calculated using modified diet in renal disease (MDRD) formula. Ten-year coronary heart disease risk (CHDR) in all patients was calculated using United Kingdom Prospective Diabetes Study risk engine, and those with CHDR > 10% were considered as having high risk. Spearman correlation was used to study the association between eGFR and CHDR, and logistic regression analysis was carried out to study the association of albuminuria and eGFR with high (>10%) CHDR. Results Of the patients with diabetes studied (n=2434), 64% (1563) were males. Mean (SD) age and duration of diabetes were 52 (11) and 9 (3) years, respectively. Normoalbuminuria, microalbuminuria, and macroalbuminuria were observed in 16.4%, 14.8%, and 68.7% of patients, respectively. Three hundred ninety-four (16.2%) patients had eGFR < 60 ml/min. Moderate correlation was observed between eGFR and predicted CHDR [r = (-0.4), P<0.01] and between eGFR and fatal CHDR (FCHDR) [r = (-0.5), P<0.01]. Independent t-test showed that patients with eGFR < 60 ml/min were older and had longer diabetes duration and lesser BMI compared to those who had eGFR > 60 ml/min (P < 0.01). On logistic regression, nephropathy according to eGFR became a strong predictor for high CHDR (OR; 3.497, 95% CI 2.08 to 5.87), and nephropathy according to albuminuria and both albuminuria and eGFR was not significant predictor of CHDR. Conclusions Predicted CHDR shows a moderate and significant association with eGFR in patients with T2DM without symptomatic CVD. eGFR is a stronger predictor than albuminuria in predicting high CHDR in patients with T2DM. Intensification of CVD prevention measures should be done more confidently among patients with T2DM and reduced eGFR than in those with albuminuria alone.
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