Factors associated with diabetic nephropathy in children, adolescents, and adults with type 1 diabetes

Development and external validation of a machine learning model to predict diabetic nephropathy in T1DM patients in the real-world

AIMS

Studies on machine learning (ML) for the prediction of diabetic nephropathy (DN) in type 1 diabetes mellitus (T1DM) patients are rare. This study focused on the development and external validation of an explainable ML model to predict the risk of DN among individuals with T1DM.

METHODS

This was a retrospective, multicenter study conducted across 19 hospitals in Gansu Province, China (No: 2022-473). In total, 1368 patients were eligible for analysis among 1633 collected T1DM patients from January 2016 to December 2023. Recursive feature elimination using random forest and fivefold cross-validation was conducted to identify key features. Among the 12 initial ML algorithms, the optimal ML model was developed and validated externally in a distinct population, and its predictive outcomes were explained via the SHapley additive exPlanations method, which offered personalized decision insights.

RESULTS

Among the 1368 T1DM patients, 324 had DN. The extreme gradient boosting (XGBoost) model, which achieved optimal performance with an AUC of 83% (95% confidence interval [CI]: 76‒89), was selected to predict the risk of DN among T1DM patients. The DN predictive model included variables such as T1DM duration, postprandial glucose (PPG), systolic blood pressure (SBP), glycated hemoglobin (HbA1c), serum creatinine (Scr) and low-density lipoprotein cholesterol (LDL-C). External validation confirmed the reliability of the model, with an AUC of 76% (95% CI: 70‒82).

CONCLUSIONS

The ML prediction tool has potential for advancing early and precise identification of the risk of DN among T1DM patients. Although successful external validation indicated that the developed model can provide a promising strategy for clinical adoption and help improve patient outcomes through timely and accurate risk assessment, additional prospective data and further validation in diverse populations are necessary.

Evaluation of lipid profile, liver function enzymes, and trace elements in Iraqi diabetic nephropathy patients

Diabetic nephropathy, a common complication of type 2 diabetes (T2DM), is associated with abnormal lipid profiles, liver dysfunction, and kidney impairment. However, research on its association with trace elements in Iraqi patients is limited. The objective of the present study is to evaluate the association between lipid profile, liver function, and trace elements in diabetic nephropathy (DN) patients. In this study, 120 individuals were selected. Sixty of these individuals were labeled as the DN patient group, and 60 individuals were labeled as the healthy control group. A flame atomic absorption spectrophotometer (FAAS) was utilized to assess the levels of zinc (Zn), copper (Cu), and magnesium (Mg), whereas a flameless atomic absorption (FAA) was used to assess manganese (Mn). A colorimetric method was used based on the protocols included in the leaflets by Spinreact kits to determine the levels of lipid profiles and liver function enzymes in the serum. The mean value of high-density lipoprotein (HDL) decreased significantly in the DN patient group compared to the control group (p < 0.001) while cholesterol and low-density lipoprotein (LDL) decreased insignificantly. Conversely, the mean value of triglycerides (TGs) increased significantly in patient group ((p < 0.001) while very low-density lipoprotein (VLDL) increased insignificantly. On the other hand, the mean values of aspartate aminotransferase (AST), alanine transferase (ALT), alkaline phosphatase (ALP), and γ- glutamyl transferase (GGT) were significantly greater in DN patients compared to the healthy controls. Conversely, the mean values of total protein (TP) and albumin (Alb) were significantly lower in the DN patient group. In terms of trace elements, the mean values of Zn, Mg, and Mn were significantly lower in each of the patient groups compared to the healthy group. Conversely, a significant elevation in the means of Cu and Fe was observed in patients compared to the healthy group. Additionally, the findings revealed no association between BMI and lipid profile, liver enzymes, or trace elements. However, an association with age was limited to TGs, ALP, and GGT. The study's results show that the DN patients have abnormalities in their serum trace element levels. This means that these elements could be valuable indicators for monitoring and assessing the progression of DN. Understanding the correlation between lipid profile, liver function, and trace elements could offer valuable insights for managing and preventing diabetic nephropathy. More extensive studies, including an additional group of DM patients without nephropathy complications, are required, and could be used in practice due to the progression of the disease.

Glycaemic control and its associated factors among adult Omanis with type 1 diabetes mellitus: a cross-sectional survey

OBJECTIVES

This study aimed to investigate the relationship between glycemic control and diabetes self-management (DSM) and other associated factors among adult Omanis with Type-1 Diabetes Mellitus (T1DM).

METHODS

A cross-sectional, descriptive design was used to collect data among 210 adult Omanis with T1DM who were conveniently recruited. All tools were self-reported, whereas the HbA1c was collected from the patient's electronic medical records.

RESULTS

The HbA1c mean value was 8.6 (SD = 2.5), 30.5% had optimal glycemic control (<7.0). A significant negative relationship between HbA1c and DSM (r = - 0.191, p = 0.006) and diabetes knowledge (r = - 0.153, p = 0.026) was found. Furthermore, the mean HbA1c was significantly lower for persons with a single marital status, have higher education level, have children, are unemployed, were not admitted to the hospital in the last year, and have a health care professional as a family member. Additionally, marital status, level of education, DSM, and social support were significant predictors of glycemic control.

CONCLUSIONS

The results suggested that better glycemic control could be achieved by optimizing DSM, social support, and diabetes knowledge. Sociodemographic factors should be considered when treating individuals with T1DM to reach good glycemic control.

Profile of plasma free amino acids, carnitine and acylcarnitines, and JAK2v617f mutation as potential metabolic markers in children with type 1 diabetic nephropathy

Fifty diabetic nephropathy (DN) children with type 1 diabetes mellitus (T1DM) and 50 healthy matched controls were included. Chromatographic assays of 14 amino acids, free carnitine and 27 carnitine esters using high-performance liquid chromatography/electrospray ionization-mass spectroscopy, and genetic testing for JAK2v617f mutation using real-time PCR were performed. Patients had significantly lower levels of tyrosine, branched-chain amino acids (BCAAs), and BCAA/AAA (aromatic chain amino acids) ratios, glycine, arginine, ornithine, free carnitine and some carnitine esters (C5, 6, 12 and 16) and higher phenylalanine, phenylalanine/tyrosine ratio and C18 compared with the controls and in the macro-albuminuria vs. the microalbuminuria group (p < 0.05 for all) except for free carnitine. Plasma carnitine was negatively correlated with eGFR (r = -0.488, p = 0.000). There were significant positive correlations between tyrosine with UACR ratio (r = 0.296, p = 0.037). The plasma BCAA/AAA ratio showed significant negative correlations with UACR (r = -0.484, p = 0.000). There was a significantly higher frequency of the JAK2V617F gene mutation in diabetic nephropathy patients compared with the control group and in macro-albuminuria than the microalbuminuria group (p = 0.000) for both. When monitoring children with T1DM, plasma free amino acids and acylcarnitine profiles should be considered, especially if they have tested positive for JAK2V617F for the early diagnosis of DN.

Correlation of C-Peptide With Complications Observed in Children and Adolescents With Type 1 Diabetes in Tanzania: A Cross-Sectional Survey

Type 1 diabetes mellitus (T1DM) complications corelate with C-peptide levels. However, the C-Peptide role has not been explored in resource limited countries. This study explored the relationship between C-peptide and complications. A cross-sectional study involving participants aged 0 to 25 years with T1DM in Dar es salaam Tanzania, between 2021 and 2022 was done. Diabetes nephropathy and retinopathy were assessed. About 281 (92.4%) participants were screened, 144 (51.2%) were females. Mean age was 19 ± 6 years. Majority 175 (62.3%) had poor glycemic control (HbA1c) > 10%, and low C-Peptide level 201 (71.5%). Retinopathy was 11.7% and risk for nephropathy was 41.3%. About 13.4% and 41.8% with low C peptide had Retinopathy and high-risk nephropathy respectively. Age at diagnosis, poor glycemic control, low c peptide and duration of diabetes were associated with complications. Further prospective studies are needed to capture when complications set in, so to have better strategies to prevent complications.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Prevalence of nephropathy in Indian children and youth with type 1 diabetes mellitus

OBJECTIVES

Children with type 1 diabetes (T1D) having diabetic nephropathy (DN) are at increased risk of developing end stage renal disease. The present study aimed to determine the prevalence of DN and its predictors in Indian children and youth with T1D.

METHODS

This cross-sectional study included 319 children and youth (2.6-21 years) with T1D having disease duration of at least 2 years. Demographic data and laboratory findings were obtained using standard questionnaires and protocols. Diagnosis of diabetic nephropathy was based on albuminuria on two occasions within a period of 3 months.

RESULTS

The prevalence of DN in our study subjects was 13.4%. 7.5% subjects were known cases of diabetic nephropathy on treatment with enalapril. Hypertension was found in 14.3% subjects with DN in contrast to 4.1% without DN (p<0.05). Duration of diabetes and estimated glucose disposal rate were the important predictors of DN. Interestingly, of the 43 children with DN, 11.3% (n=8) were under 10 years age.

CONCLUSIONS

We found a high prevalence of DN in children and youth with T1D including in children under the age of 10 years. Early screening and timely intervention are required to retard the disease progression and avoid end stage renal disease.

Evaluation of Macular and Retinal Nerve Fiber Layer Thickness in Children with Type 1 Diabetes Mellitus without Retinopathy

PURPOSE

There are limited data from Asian countries regarding retinal thickness in children with type 1 diabetes mellitus (T1DM). This study aimed to compare the macular and retinal nerve fiber layer (RNFL) parameters between diabetic children without retinopathy and non-diabetic healthy children. We also evaluated the factors associated with RNFL thickness in children with T1DM.

METHODS

A comparative cross-sectional study was conducted among children with T1DM and healthy children aged 7 to 17 years old in Hospital Universiti Sains Malaysia from 2017 to 2019. Children with retinal disease or glaucoma were excluded. Macular and RNFL thicknesses were measured using spectral-domain optical coherence tomography. Demographic information, duration of diabetes, blood pressure, body mass index, visual acuity, and retinal examination findings were documented. Glycosylated hemoglobin levels, renal function, and blood lipid levels were also collected.

RESULTS

Forty-one children with T1DM and 80 age- and sex-matched children were enrolled. Both sexes were affected. Mean duration of diabetes mellitus was 3.66 years. The mean glycated hemoglobin levels in the T1DM group was 9.99%. The mean macular and RNFL thicknesses in children with T1DM were 277.56 (15.82) µm and 98.85 (12.05) µm, respectively. Children with T1DM had a significantly thinner average macula, superior outer macula, nasal outer macula, mean RNFL, and inferior RNFL thickness compared to controls (p < 0.05). There was a significant association between nephropathy and the mean RNFL thickness.

CONCLUSIONS

Children with T1DM had significantly decreased mean macular and RNFL thicknesses. Nephropathy is associated with an increased RNFL thickness.

Evaluation of the efficacy and safety of TWHF in diabetic nephropathy patients with overt proteinuria and normal eGFR

BACKGROUND/PURPOSE

The aim of this study was to evaluate the efficacy and safety of Tripterygium Wilfordii Hook F (TWHF) in DN patients with overt proteinuria and normal eGFR.

METHODS

124 eligible DN patients were randomly assigned into two groups to receive either valsartan 160 mg/d treatment (control group) or TWHF 60 mg/d plus valsartan 160 mg/d treatments (TWHF group) for 24 weeks. The changes of clinical, biochemical data and adverse events during observation period were all analyzed. The primary endpoint was a reduction in 24-h urine protein excretion between baseline and the end of study, the secondary endpoint was to observe the change in estimated glomerular filtration rate (eGFR) between two groups.

RESULTS

After treatment, there was a more significant decrease in proteinuria in patients who received TWHF treatment (from 4.95 ± 1.27 g/24 h to 3.36 ± 0.83 g/24 h) compared to valsartan monotherapy (from 5.21 ± 1.59 g/24 h to 4.52 ± 1.06 g/24 h). The percentage change in urine protein excretion was -32.12% in TWHF group and -13.24% in valsartan group. Patients' plasma albumin in TWHF group (from 32.53 ± 5.24 g/L to 36.91 ± 4.42 g/L) was higher than that in control group (from 33.18 ± 4.87 g/L to 34.67 ± 4.75 g/L). No significant change in blood pressure, blood glucose, eGFR, and serum potassium was observed. But the adverse events in TWHF group were higher than those in control group.

CONCLUSION

TWHF is more effective than valsartan monotherapy in reduction of proteinuria in DN patients with overt proteinuria and normal eGFR, but with more adverse effects.

Vitamin D receptor rs7975232, rs731236 and rs1544410 single nucleotide polymorphisms, and 25-hydroxyvitamin D levels in Egyptian children with type 1 diabetes mellitus: effect of vitamin D co-therapy

Purpose: We aimed to examine the possible association role of vitamin D and vitamin D receptor (VDR) single nucleotide polymorphisms (SNPs) in type 1 diabetes mellitus (T1DM) development, glycemic control and complications among a cohort of Egyptian children. Subjects and methods: A prospective case-control study has been conducted on 50 Egyptian children with T1DM who were comparable with 50 controls. Vitamin D and HbA1c were measured. VDR-SNPs [ApaI (rs7975232), TaqI (rs731236) and BsmI (rs1544410)] detection was done by polymerase chain reaction through restriction fragment length polymorphism (PCR-RFLP) technique. Vitamin D supplements were given to the included T1DM children with low vitamin D and reassessments of both HbA1c% and 25(OH)D serum levels were performed in those children three months later. Results: Eighty percent of the included diabetic patients have poor glycemic control. Vitamin D was deficient in 68% and insufficient in 16% of diabetic patients. Significant improvements in both vitamin D and glycemic status among T1DM children, who have low vitamin D and received vitamin D supplementations. There were significantly negative correlations between serum levels of vitamin D with both HbA1c % (r= -0.358, P˂0.05) and daily insulin dose (r=-0.473, P˂0.05). Compared with controls, T1DM children presented more commonly with ApaI a allele (OR: 2.87; 95%CI: 1.39-5.91, P˂0.05) and BsmI b allele (OR: 4.38; 95%CI: 2.30-8.33, P˂0.05). TaqI t allele wasn't significantly differing among patients and controls (P˃0.05). Aa+aa and Bb+bb genotypes were significantly higher among T1DM vs the controls (OR: 3.08;, 95%CI: 1.33-7.15, P˂0.05 and OR: 9.33; 95%CI: 3.61-24.17, P˂0.05respectively). Conclusion: ApaI and BsmI were associated with risk of T1DM development among Egyptian children. Low vitamin D status was frequently occurring among T1DM with significant improvement in the glycemic control of such children when adding vitamin D supplements to the standard insulin therapy.

Update of pathophysiology and management of diabetic kidney disease

Diabetic kidney disease (DKD) is a major cause of morbidity and mortality in patients with diabetes mellitus and the leading cause of end-stage renal disease in the world. The most characteristic marker of DKD is albuminuria, which is associated with renal disease progression and cardiovascular events. Renal hemodynamics changes, oxidative stress, inflammation, hypoxia and overactive renin-angiotensin-aldosterone system (RAAS) are involved in the pathogenesis of DKD, and renal fibrosis plays the key role. Intensified multifactorial interventions, including RAAS blockades, blood pressure and glucose control, and quitting smoking, help to prevent DKD development and progression. In recent years, novel agents are applied for preventing DKD development and progression, including new types of glucose-lowering agents, pentoxifylline, vitamin D analog paricalcitol, pyridoxamine, ruboxistaurin, soludexide, Janus kinase inhibitors and nonsteroidal minerocorticoid receptor antagonists. In this review, recent large studies about DKD are also summarized.