Obesity and diabetic kidney disease

Investigating the causal association of generalized and abdominal obesity with microvascular complications in patients with type 2 diabetes: A community-based prospective study

AIM

The paradoxical protective association between overweight/obesity and diabetic microvascular complications (DMC), a phenomenon well-known as the obesity paradox, has been considered a non-causal association based on methodological influences. We aimed to investigate the association of generalized and abdominal obesity, as measured by body mass index (BMI) and waist circumference (WC), respectively, with DMC in patients with type 2 diabetes (T2D), using a causal inference approach.

MATERIALS AND METHODS

We enrolled 1436 patients with clinically diagnosed T2D but not DMC at baseline in a community-based prospective cohort in China between 2017 and 2019 and followed them annually until 2022 with new-onset DMC recorded. Marginal structural Cox models with inverse probability weighting were constructed to determine the causal association. Subgroup analyses were performed to identify potential effect modifiers.

RESULTS

We observed 360 incident DMC cases, including 109 cases of diabetic nephropathy (DN) and 277 cases of diabetic retinopathy (DR) during four follow-up visits. Multivariable-adjusted hazard ratios (95% confidence intervals) for overall DMC, DN and DR were 1.037 (1.005-1.071), 1.117 (1.062-1.175) and 1.018 (0.980-1.059) for 1 kg/m2 increase in BMI, and 1.005 (0.994-1.017), 1.034 (1.018-1.051) and 1.000 (0.987-1.014) for 1 cm increase in WC, respectively. Similar patterns were observed across the BMI and WC categories, while the positive association appeared to be more pronounced in women.

CONCLUSIONS

Generalized but not abdominal obesity was associated with an increased risk for the overall DMC, whereas both obesities were causally related to DN, albeit not DR, in T2D. Routine weight management should not be neglected in diabetes care, particularly in women.

Management of hepatorenal syndrome and treatment-related adverse events

Hepatorenal Syndrome is a critical complication of liver failure, mainly in cirrhotic patients and rarely in patients with acute liver disease. It is a complex spectrum of conditions that leads to renal dysfunction in the liver cirrhosis population; the pathophysiology is characterized by a specific triad: circulatory dysfunction, nitric oxide (NO) dysfunction and systemic inflammation but a specific kidney damage has never been demonstrated, in a clinicopathological study, kidney biopsies of patients with cirrhosis showed a wide spectrum of kidney damage. In addition, the absence of significant hematuria or proteinuria does not exclude renal damage. It is estimated that 40% of cirrhotic patients will develop hepatorenal syndrome with in-hospital mortality of about one-third of these patients. The burden of the problem is dramatic considering the worldwide prevalence of more than 10 million decompensated cirrhotic patients, and the age-standardized prevalence rate of decompensated cirrhosis has gone through a significant rise between 1990 and 2017. Given the syndrome's poor prognosis, the clinician must know how to manage early treatment and any complications. The widespread adoption of albumin and vasopressors has increased Hepatorenal syndrome-acute kidney injury reversal and may increase overall survival, as previously shown. Further research is needed to define whether the subclassification of patients may allow to find a personalized strategy to treat Hepatorenal Syndrome and to define the role of new molecules and extracorporeal treatment may allow better outcomes with a reduction in treatment-related adverse effects. This review aims to examine both pharmacological and non-pharmacological treatment of hepatorenal syndrome, with a particular focus on managing adverse events caused by treatment.

Association between longitudinal changes in body composition and the risk of kidney outcomes in participants with overweight/obesity and type 2 diabetes mellitus

AIMS

To assess the relationship of longitudinal changes in fat mass (FM), lean mass (LM) and waist circumference (WC) with incident kidney outcomes in people with overweight/obesity and type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

A total of 3927 participants with baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 from the Look AHEAD (Action for Health in Diabetes) trial were included. The primary outcome was kidney outcomes, defined as a decrease in eGFR of at least 40% from baseline at follow-up visit, or end-stage kidney disease.

RESULTS

During a median follow-up of 8.0 years, 450 kidney outcomes were documented after the first 1 year. In the intensive lifestyle intervention (ILI) group, reductions in FM (per 10% decrease, adjusted hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.69-0.94) and WC (per 10% decrease, adjusted HR 0.72, 95% CI 0.59-0.88) from baseline to 1-year follow-up were significantly associated with a lower risk of kidney outcomes. The change in LM was not significantly associated with risk of kidney outcomes (per 10% decrease, adjusted HR 0.78, 95% CI 0.58-1.06). In the diabetes support and education group (control group), no significant association was found between changes in body composition and kidney outcomes. Similar results were observed for the 4-year changes in body composition.

CONCLUSIONS

In this post hoc analysis of the Look AHEAD trial, longitudinal declines in FM and WC were associated with a lower risk of kidney outcomes in the ILI group in participants with overweight/obesity and T2DM.

Challenges and Strategies in Implementing Novel Kidney Protective and Cardioprotective Therapies in Patients With Diabetes and Kidney Disease

Chronic kidney disease (CKD) is highly prevalent, estimated to affect over 800 million people worldwide. Diabetes is a leading cause of kidney disease. Both diabetes and CKD are associated with a high risk of cardiovascular disease and related morbidity and mortality. Over the last several years, there has been a shift in focus toward integrating kidney and cardiovascular care, particularly in diabetes. Sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists have rapidly become cornerstones of kidney and cardiovascular risk-focused care in diabetes and CKD. However, present-day use of these agents is low, and disparities in use by race, ethnicity, age, sex, and comorbidities are apparent. Challenges in implementation of kidney protective and cardioprotective therapies include low rates of diabetes and CKD screening, lack of provider comfort and subspecialty reliance, inconsistencies across professional society guidelines, high rates of drug discontinuation, and prohibitive costs. Effective implementation of kidney protective and cardioprotective therapies necessitates a multifaceted approach and active engagement of patients, pharmacists, primary care providers, subspecialty providers, and health care system leaders as key stakeholders. Implementation efforts should be practical and incorporate collaborative, multidisciplinary team-based approaches. Successful implementation of kidney protective and cardioprotective therapies has the potential to improve overall health outcomes and ameliorate health care disparities.

Metabolic and ultrastructural renal changes in adult Wistar rats fed by a cafeteria diet

PURPOSE

To evaluate, by quantitative and qualitative methods, the glomerular ultrastructure in Wistar rats fed a cafeteria diet.

METHODS

Male Wistar rats were divided into two groups at 21 days of age: control (C, n = 10) and cafeteria diet (CAF, n = 8). The animals were followed up until 5 months of age, followed by euthanasia. The blood, kidneys, and fat deposits--epididymal, retroperitoneal, and subcutaneous--were extracted and analyzed. Data were analyzed by Student's t test, and p < 0.05 was considered statistically significant.

RESULTS

The cafeteria diet promoted glucose intolerance, hyperglycemia (p < 0.0001), and deposition of retroperitoneal fat (p < 0.005). Scanning electron microscopy revealed that the length of the foot process was similar in both groups. The quantitative analyses by transmission electron microscopy revealed that the cafeteria diet reduced the thickness of the glomerular basement membrane (p < 0.05).

CONCLUSIONS

The intake of lipids and simple carbohydrates were found to be associated with alteration in the glomerular ultrastructure. However, more studies are needed to evaluate not only the effects of high-protein and high-fat diets on components of the glomerular filtration barrier, but also renal physiology.

Association of weight-adjusted waist index and diabetic kidney disease in type 2 diabetes mellitus

Objective

The aim of this study was to investigate the relationship between weight-adjusted-waist index (WWI) and diabetic kidney disease in individuals afflicted with type 2 diabetes.

Methods

Comprehensive data were ascertained from the National Health and Nutrition Examination Survey in 2013-March 2020. Weighted univariate, multivariate logistic regression models, subgroup analyses and tests for interaction were performed. Additionally, we employed smooth curve fitting to assess linear correlations and the threshold effects were calculated by applying a binary linear regression model. Breakpoints are identified by a model with maximum likelihood ratio and a two-step recursive approach. Receiver operating characteristic curve (ROC) along with the area under the curve (AUC) value predict the capability of WWI and body mass index for diabetic kidney disease.

Results

A total of 10,661 individuals diagnosed with type 2 diabetes were included, and the overall prevalence of diabetic kidney disease was 20.74%. WWI exhibited a positive correlation with the likelihood of diabetic kidney disease in type 2 diabetes patients (OR: 1.17, 95% CI: 1.03-1.33). The results of subgroup analysis showed significant interaction for gender (P < 0.05). Among female patients, U-shaped correlations were observed with a breakpoint at 11.48. Additionally, weight-adjusted waist index (AUC = 0.664) proved to be a more effective predictor of diabetic kidney disease compared to body mass index (AUC = 0.555).

Conclusion

In patients with type 2 diabetes, increased weight-adjusted-waist index is implicated with an increased risk of diabetic kidney disease. WWI can be used as a new anthropometric index to predict diabetic kidney disease, and its predictive ability is stronger than body mass index.

Deletion, but not heterozygosity, of eNOS raises blood pressure and aggravates nephropathy in BTBR ob/ob mice

INTRODUCTION

ob/ob mice are a leptin-deficient type 2 diabetes mellitus model, which, on a BTBR background, mimics glomerular pathophysiology of diabetic nephropathy (DN). Since leptin deficiency reduces blood pressure (BP), and endothelial nitric oxide synthase (eNOS) lowers BP and is kidney protective, we attempted to develop a more robust DN model by introducing eNOS deficiency in BTBR ob/ob mice.

METHODS

Six experimental groups included littermate male and female BTBR ob/ob or wild-type for ob (control) as well as wild-type (WT), heterozygote (HET) or knockout (KO) for eNOS. Systolic BP (by automated tail-cuff) and GFR (by FITC sinistrin plasma kinetics) were determined in awake mice at 27-30 weeks of age followed by molecular and histological kidney analyses.

RESULTS

Male and female ob/ob WT presented hyperglycemia and larger body and kidney weight, GFR, glomerular injury, and urine albumin to creatinine ratio (UACR) despite modestly lower BP vs control WT. These effects were associated with higher tubular injury score and renal mRNA expression of NGAL only in males, whereas female ob/ob WT unexpectedly had lower KIM-1 and COL1A1 expression vs control WT, indicating sex differences. HET for eNOS did not consistently alter BP or renal outcome in control or ob/ob. In comparison, eNOS KO increased BP (15-25 mmHg) and worsened renal markers of injury, inflammation and fibrosis, GFR, UACR, and survival rates, as observed in control and, more pronounced, in ob/ob mice and independent of sex.

CONCLUSIONS

Deletion, but not heterozygosity, of eNOS raises blood pressure and aggravates nephropathy in BTBR ob/ob mice.

The impact of weight loss on renal function in individuals with obesity and type 2 diabetes: a comprehensive review

Obesity and Type 2 Diabetes (T2D) are two highly prevalent diseases that exhibit a complex interplay between them. Obesity serves as a primary risk factor for the development of T2D, and conversely, individuals with T2D often exhibit comorbid obesity. Renal dysfunction emerges as a critical consequence of the convergence of obesity and Type 2 Diabetes, contributing significantly to the overall burden of complications associated with these conditions. Recognizing the profound implications of renal dysfunction in individuals contending with both obesity and Type 2 Diabetes, interventions targeting weight loss have gained prominence as potential therapeutic avenues. Weight loss not only addresses the primary risk factor of obesity but also holds the promise of mitigating the progression of Type 2 Diabetes and its associated renal complications. This comprehensive review aims to explore the impact of weight loss on renal function in individuals contending with the convergence of obesity and T2D.

Global burden and influencing factors of chronic kidney disease due to type 2 diabetes in adults aged 20-59 years, 1990-2019

Population structure and lifestyles may have contributed to the epidemiological status of Chronic Kidney Disease due to Type 2 Diabetes (CKD-T2D). This study is a secondary data analysis. Using data from the Global Burden of Disease Study, we describe the changes in CKD-T2D burden and its influencing factors in the population aged 20-59 years from 1990 to 2019. Globally, the incidence, death, and Disability Adjusted Life Years (DALYs) rate of CKD-T2D showed an upward trend and increased with age, and the burden in males was higher than that in females. Population growth and aging were important driving factors for the increase of CKD-T2D DALY burden, while high systolic blood pressure and high body-mass index were the primary attributable risk factors. High body-mass index exhibited higher contributions to high Socioeconomic Development Index (SDI) countries, whereas low SDI countries were more impacted by high systolic blood pressure. The population attributable fraction of CKD-T2D DALY caused by high body-mass index was positively correlated with SDI, while high temperature and lead exposure were negatively correlated. Therefore, strengthening disease screening for people aged 20-59 years and formulating early intervention measures based on the level of socioeconomic development may effectively alleviate the burden of CKD-T2D.

Assessment of common risk factors of diabetes and chronic kidney disease: a Mendelian randomization study

Background

The increasing prevalence of diabetes and its significant impact on mortality and morbidity rates worldwide has led to a growing interest in understanding its common risk factors, particularly in relation to chronic kidney disease (CKD). This research article aims to investigate the shared risk factors between type 1 diabetes (T1D), type 2 diabetes (T2D), and CKD using a Mendelian randomization (MR) design.

Methods

The study utilized genome-wide association study (GWAS) datasets for T1D, T2D, and CKD from the FinnGen research project. GWAS summary statistics datasets for 118 exposure traits were obtained from the IEU OpenGWAS database. MR analyses were conducted to examine the causal relationships between exposure traits and each of the three outcomes. Multiple methods, including inverse-variance weighted, weighted median, and MR-Egger, were employed for the MR studies.

Results

Phenome-wide MR analyses revealed that eosinophil percentage exhibited a significant and suggestive causal association with T1D and CKD, respectively, suggesting its potential as a shared risk factor for T1D and CKD. For T2D, 34 traits demonstrated significant associations. Among these 34 traits, 14 were also significantly associated with CKD, indicating the presence of common risk factors between T2D and CKD, primarily related to obesity, height, blood lipids and sex hormone binding globulin, blood pressure, and walking pace.

Conclusion

This research has uncovered the eosinophil percentage as a potential common risk factor for both T1D and CKD, while also identifying several traits, such as obesity and blood lipids, as shared risk factors for T2D and CKD. This study contributes to the understanding of the common risk factors between diabetes and CKD, emphasizing the need for targeted interventions to reduce the risk of these diseases.

Capybara Oil Improves Renal Pathophysiology and Inflammation in Obese Mice

Obesity is an inflammatory disease associated with secondary diseases such as kidney disease, which can cause lipotoxicity, inflammation and loss of organ function. Polyunsaturated fatty acids act in the production of lipid mediators and have anti-inflammatory characteristics. In this work, the objective was to evaluate renal histopathology in obese mice and the effects of treatment with capybara oil (CO) (5000 mg/kg/day for 4 weeks). Parameters such as body mass, lipid profile, systolic blood pressure, urinary creatinine and protein excretion, structure and ultrastructure of the renal cortex, fibrosis, tissue inflammation and oxidative stress were analyzed. CO treatment in obese mice showed improvement in the lipid profile and reduction in systolic blood pressure levels, in addition to beneficial remodeling of the renal cortex. Our data demonstrated that CO decreased inflammation, oxidative stress and renal fibrosis, as evidenced by quantifying the expression of TNF-α, IL-10, CAT, SOD, α-SMA and TGF-β. Although treatment with CO did not show improvement in renal function, ultrastructural analysis showed that the treatment was effective in restoring podocytes and pedicels, with restructuring of the glomerular filtration barrier. These results demonstrate, for the first time, that treatment with CO is effective in reducing kidney damage, being considered a promising treatment for obesity.

Renal Dysfunction Phenotypes in Patients Undergoing Obesity Surgery

Obesity surgery candidates are at an increased risk of kidney injury, but pre-operative evaluation usually neglects kidney function assessment. This study aimed to identify renal dysfunction in candidates for bariatric surgery. To reduce the sources of bias, subjects with diabetes, prediabetes under metformin treatment, neoplastic or inflammatory diseases were excluded. Patients' (n = 192) average body mass index was 41.7 ± 5.4 kg/m². Among these, 51% (n = 94) had creatinine clearance over 140 mL/min, 22.4% (n = 43) had proteinuria over 150 mg/day and 14.6% (n = 28) albuminuria over 30 mg/day. A creatinine clearance higher than 140 mL/min was associated with higher levels of proteinuria and albuminuria. Univariate analysis identified sex, glycated hemoglobin, uric acid, HDL and VLDL cholesterol as being associated with albuminuria, but not with proteinuria. On multivariate analysis, glycated hemoglobin and creatinine clearance as continuous variables were significantly associated with albuminuria. In summary, in our patient population prediabetes, lipid abnormalities and hyperuricemia were associated with albuminuria, but not with proteinuria, suggesting different disease mechanisms might be implicated. Data suggest that in obesity-associated kidney disease, tubulointerstitial injury precedes glomerulopathy. A significant proportion of obesity surgery candidates present clinically relevant albuminuria and proteinuria along with renal hyperfiltration, suggesting that routine pre-operative assessment of these parameters should be considered.

Continuous Monochromatic Blue Light Exacerbates High-Fat Diet-Induced Kidney Injury via Corticosterone-Mediated Oxidative Stress

Excessive illumination is one of the most severe environmental factors that impacts the organism. There is growing evidence that obesity significantly contributes to the onset of chronic kidney disease. However, the effect of continuous light on the kidney and which color can produce an apparent phenomenon remains elusive. In this study, C57BL/6 mice given either a normal diet (LD-WN) or a high-fat diet (LD-WF) were subjected to a light cycle of 12 h of illumination followed by 12 h of darkness for 12 weeks. Meanwhile, 48 high-fat diet mice were given a 24 h monochromatic light exposure of varying colors (white, LL-WF; blue, LL-BF; green, LL-GF) for 12 weeks. As expected, the LD-WF mice showed significant obesity, kidney injury, and renal dysfunction compared with the LD-WN group. LL-BF mice had worse kidney injury than LD-WF mice, including higher Kim-1 and Lcn2. The kidney of the LL-BF group showed marked glomerular and tubular injury, with decreased levels of Nephrin, Podocin, Cd2ap, and α-Actinin-4 compared to LD-WF. LL-BF also reduced the antioxidant capacity, including GSH-Px, CAT, and T-AOC, increased the production of MDA, and inhibited the activation of the NRF2/HO-1 signaling pathway. Furthermore, LL-BF upregulated the mRNA levels of the pro-inflammatory factors Tnf-α, Il-6, and Mcp-1, decreasing the inhibitory inflammatory Il-4 expression. We observed increased plasma corticosterone (CORT), renal glucocorticoid receptors (GR) expression, Hsp90, Hsp70, and P23 mRNA levels. These findings suggested that LL-BF increased CORT secretion and affected glucocorticoid receptors (GR) in comparison to the LD-WF group. Moreover, in vitro research demonstrated that CORT treatment increased oxidative stress and inflammation, which was counteracted by adding a GR inhibitor. Thus, the sustained blue light worsened kidney damage, possibly by inducing elevated CORT and increasing oxidative stress and inflammation via GR.

Combination of Risks of BMI and Health-Related Lifestyles on Kidney Function in the Prediabetic Japanese Population: A Prospective Cohort Study

Diabetic overweight patients are more likely to show the progression of kidney damage than the general population. The majority of people in the early stages of kidney damage do not recognize the importance of risk modification, mainly due to the asymptomatic nature of the disease. This study aimed to examine specific risk combinations of lifestyle and BMI regarding the deterioration of kidney function and to explore whether there are gender-based differences among the prediabetic population. Prediabetic participants with normal kidney function were identified via annual health examination from April 2016 to March 2019. The information on health status and lifestyle was collected at enrollment. The study subjects were followed until March 2021 to observe the progression of kidney damage. There were 2241 participants enrolled in this study. Smoking (HR = 3.5, p < 0.001), eating snacks (HR = 3.2, p < 0.001), not engaging in regular exercise (HR = 2.9, p < 0.001), and not having adequate sleep (HR = 3.0, p < 0.001) showed accelerated risks for kidney damage progression among the prediabetic population in males. These lifestyle effects were not observed in females. In conclusion, risk-based modification of lifestyle behavior is important to prevent kidney function damage among the overweight prediabetic population in males.

Impairment of kidney function and kidney cancer: A bidirectional Mendelian randomization study

BACKGROUND

Many observational epidemiology studies discovered that kidney cancer and impaired kidney function have a bidirectional relationship. However, it remains unclear whether these two kinds of traits are causally linked. In this study, we aimed to investigate the bidirectional causal relation between kidney cancer and kidney function biomarkers (creatinine-based estimated glomerular filtration rate (eGFRcrea), cystatin C-based estimated glomerular filtration rate (eGFRcys), blood urea nitrogen (BUN), serum urate, and urinary albumin-to-creatinine ratio (UACR)).

METHODS

For both directions, single-nucleotide polymorphisms (SNPs), as genetic instruments, for the five kidney function traits were selected from up to 1,004,040 individuals, and SNPs for kidney cancer were from 408,786 participants(1338 cases). In the main analysis, we applied two state-of-the-art MR methods, namely, contamination mixture and Robust Adjusted Profile Score to downweight the effect of weak instrument bias, pleiotropy, and extreme outliers. We additionally conducted traditional MR analyses as sensitivity analyses. Summary-level data of European ancestry were extracted from UK Biobank, Chronic Kidney Disease Genetics Consortium, and Kaiser Permanente.

RESULTS

Based on 99 SNPs, we found that the eGFRcrea had a significant negative causal effect on the risk of kidney cancer (OR = 0.007, 95% CI:2.6 × 10-4 -0.569, p = 0.041). After adjusting for body composition or diabetes, urate had a significant negative causal effect on kidney cancer (OR <1, p < 0.05). For UACR, it showed a strong causal effect on kidney cancer, after adjusting for body composition (OR = 14.503, 95% CI: 2.546-96.001, p = 0.032). Due to lacking significant signals and effect power for the reverse MR, further investigations are warranted.

CONCLUSIONS

Our study suggested a potential causal effect of damaged kidney function on kidney cancer. EGFRcrea and UACR might be causally associated with kidney cancer, especially when patients were comorbid with obesity or diabetes. We called for larger sample-size studies to further unravel the underlying causal relationship and the exact mechanism.

Impact of Weight Loss on the Severity of Albuminuria in Obese Diabetic Patients Undergoing Laparoscopic Sleeve Gastrectomy and One-Anastomosis Gastric Bypass

Aim

To examine the effect of weight-loss induced bariatric procedures on albuminuria levels among diabetic patients suffering from obesity.

Methods

Adults patients who suffer from morbid obesity and type 2 diabetes mellitus (T2DM) were included in a prospective cohort study. Subjects were scheduled to undergo laparoscopic sleeve gastrectomy (LSG) or one-anastomosis gastric bypass (OAGB). The albumin-to-creatinine ratio (ACR) was adopted to assess the degree of albuminuria. Microalbuminuria was determined as a ratio of >2.5-30 mg/mmol and >3.5-30 mg/mmol for males and females, respectively, while macroalbuminuria was diagnosed when the ACR exceeded >30 mg/mmol.

Results

The mean uACR decreased significantly from 20.95±16.89 to 9.92±12.69mg/mmol in LSG cohort (p <0.001), and from 19.52±16.65 to 9.34±11.77mg/mmol in the OAGB cohort, with no statistically considerable differences between both cohorts at the end of follow-up (p = 0.78). Twelve months after the procedures, the percentages of cases with microalbuminuria decreased significantly to 23.8% and 23.9%, respectively (p < 0.001); likewise, the percentages of cases with macroalbuminuria significantly decreased to 7.9% and 7.5% in the LSG and OAGB groups, respectively (p < 0.001). There were no statistically considerable differences between LSG and OAGB regarding the percentages of patients with micro or macroalbuminuria at the end of follow-up. Besides, there were no significant associations between the degree of weight loss and improvement (p = 0.959) or remission (p = 0.73) of microalbuminuria.

Conclusion

Bariatric surgery significantly reduced the severity of albuminuria 1-year after the procedure, with no preference for one procedure over the other.

Prevalence of cardiovascular risk factors and their association with renal impairment in elderly patients with type 2 diabetes mellitus in a Nigerian tertiary hospital: a cross-sectional study

Introduction

the population of elderly with Type 2 Diabetes Mellitus (T2DM) has been on the increase. The burden of cardiovascular disease and renal impairment may also increase due to the relationship between cardiovascular risk factors and ageing in those with T2DM. The prevalence of cardiovascular risk factors and their association with renal impairment in elderly with T2DM were determined.

Methods

this is a cross-sectional study that involved 96 elderly patients with T2DM and 96 elderly individuals without DM as control. The prevalence of cardiovascular risk factors was determined among the study participants. Binary logistic regression was used to determine the significant cardiovascular factors associated with renal impairment among the elderly with T2DM. P-value <0.05 was taken as significant.

Results

the mean age of the elderly with T2DM and control group were 66.73±5.18 years and 66.78±5.25years, respectively. The male: female ratio was 1: 1 for both groups. The prevalence of the cardiovascular risk factors in the elderly with T2DM and control were; hypertension (72.9%vs39.6%; p ≤0.001), high glycated haemoglobin (77.1% vs 0%; p ≤0.001), generalized obesity (34.4%vs1.0%; p ≤0.001), central obesity (50.0%vs11.5%; p ≤0.001), dyslipidemia (97.9%vs89.6%; p=0.016), albuminuria (69.8% vs 11.2%; p ≤0.001), anaemia (53.1%vs18.8%; p ≤0.001). Renal impairment was present in 44.8% of the elderly T2DM. On multivariate analysis, the cardiovascular risk factors significantly associated with renal impairment in elderly with T2DM were high glycated haemoglobin (aOR: 6.21, 95% CI: 1.61-24.04; p=0.008), albuminuria (aOR: 4.77, 95% CI: 1.59-14.31; p=0.005) and obesity (aOR: 2.78, 95%CI 1.04-7.45; p=0.042).

Conclusion

cardiovascular risks factors were highly prevalent and closely associated with renal impairment in elderly with T2DM. Early cardiovascular risk factor modification may reduce both renal and cardiovascular disease burden.

Obesity-Related Chronic Kidney Disease: Principal Mechanisms and New Approaches in Nutritional Management

Obesity is the epidemic of our era and its incidence is supposed to increase by more than 30% by 2030. It is commonly defined as a chronic and metabolic disease with an excessive accumulation of body fat in relation to fat-free mass, both in terms of quantity and distribution at specific points on the body. The effects of obesity have an important impact on different clinical areas, particularly endocrinology, cardiology, and nephrology. Indeed, increased rates of obesity have been associated with increased risk of cardiovascular disease (CVD), cancer, type 2 diabetes (T2D), dyslipidemia, hypertension, renal diseases, and neurocognitive impairment. Obesity-related chronic kidney disease (CKD) has been ascribed to intrarenal fat accumulation along the proximal tubule, glomeruli, renal sinus, and around the kidney capsule, and to hemodynamic changes with hyperfiltration, albuminuria, and impaired glomerular filtration rate. In addition, hypertension, dyslipidemia, and diabetes, which arise as a consequence of overweight, contribute to amplifying renal dysfunction in both the native and transplanted kidney. Overall, several mechanisms are closely related to the onset and progression of CKD in the general population, including changes in renal hemodynamics, neurohumoral pathways, renal adiposity, local and systemic inflammation, dysbiosis of microbiota, insulin resistance, and fibrotic process. Unfortunately, there are no clinical practice guidelines for the management of patients with obesity-related CKD. Therefore, dietary management is based on the clinical practice guidelines for the nutritional care of adults with CKD, developed and published by the National Kidney Foundation, Kidney Disease Outcome Quality Initiative and common recommendations for the healthy population. Optimal nutritional management of these patients should follow the guidelines of the Mediterranean diet, which is known to be associated with a lower incidence of CVD and beneficial effects on chronic diseases such as diabetes, obesity, and cognitive health. Mediterranean-style diets are often unsuccessful in promoting efficient weight loss, especially in patients with altered glucose metabolism. For this purpose, this review also discusses the use of non-classical weight loss approaches in CKD, including intermittent fasting and ketogenic diet to contrast the onset and progression of obesity-related CKD.

The Roles of Fatty Acids and Apolipoproteins in the Kidneys

The kidneys are organs that require energy from the metabolism of fatty acids and glucose; several studies have shown that the kidneys are metabolically active tissues with an estimated energy requirement similar to that of the heart. The kidneys may regulate the normal and pathological function of circulating lipids in the body, and their glomerular filtration barrier prevents large molecules or large lipoprotein particles from being filtered into pre-urine. Given the permeable nature of the kidneys, renal lipid metabolism plays an important role in affecting the rest of the body and the kidneys. Lipid metabolism in the kidneys is important because of the exchange of free fatty acids and apolipoproteins from the peripheral circulation. Apolipoproteins have important roles in the transport and metabolism of lipids within the glomeruli and renal tubules. Indeed, evidence indicates that apolipoproteins have multiple functions in regulating lipid import, transport, synthesis, storage, oxidation and export, and they are important for normal physiological function. Apolipoproteins are also risk factors for several renal diseases; for example, apolipoprotein L polymorphisms induce kidney diseases. Furthermore, renal apolipoprotein gene expression is substantially regulated under various physiological and disease conditions. This review is aimed at describing recent clinical and basic studies on the major roles and functions of apolipoproteins in the kidneys.

Mineralocorticoid Receptor Antagonism Prevents the Synergistic Effect of Metabolic Challenge and Chronic Kidney Disease on Renal Fibrosis and Inflammation in Mice

Obesity and/or metabolic diseases are frequently associated with chronic kidney disease and several factors associated with obesity may contribute to proteinuria and extracellular matrix production. Mineralocorticoid receptor antagonists have proven their clinical efficacy in diabetic kidney disease with preclinical data suggesting that they may also be efficient in non-diabetic chronic kidney disease associated to metabolic diseases. In the present study we developed a novel mouse model combining severe nephron reduction and High Fat Diet challenge that led to chronic kidney disease with metabolic alterations. We showed that the Mineralocorticoid Receptor antagonist canrenoate improved metabolic function, reduced albuminuria and prevented the synergistic effect of high fat diet on renal fibrosis and inflammation in chronic kidney disease mice.

Gender differences in new hypoglycemic drug effects on renal outcomes: a systematic review

INTRODUCTION

Lifetime diabetes risk is greater in women than in men. Women with diabetes mellitus (DM) have a greater prevalence of diabetic kidney disease (DKD) risk factors. The diagnosis of DM is often delayed in women, with poorer outcomes and with expected therapeutic goals missed.

AREA COVERED

A systematic literature review following PRISMA guidelines was conducted in the PubMed gateway of the MEDLINE database and Clinicaltrials.gov. The purpose of our research was to establish the sex differences on renal outcomes in users of the new hypoglycemic drugs: sodium-glucose transport protein 2 inhibitors (SGLT-2i), dipeptidyl peptidase-IV Inhibitors (DPP-IVi) and glucagon-like peptide-1 inhibitors (GLP-1i).

EXPERT OPINION

New hypoglycemic drugs represent promising tools in the treatment and prevention of severe complications of diabetes, cardiovascular diseases and chronic kidney disease. Even if renal outcomes are investigated in both randomized controlled trials and cardiovascular outcome trials, gender-based analysis is not always performed. This may lead to relevant information for risk-benefit evaluation and therapeutic choices being missed, with gender-based equality in outcomes lacking. Our systematic review demonstrated that the gap among sexes in DKD can be partially filled using new hypoglycemic drugs. Sexual dimorphism analysis could represent a keystone for the development of adequate gender-specific therapies.

Racial and ethnic disparities in cardiometabolic disease and COVID-19 outcomes in White, Black/African American, and Latinx populations: Physiological underpinnings

Coronavirus disease 2019 (COVID-19) is a highly contagious respiratory illness caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) that began spreading globally in late 2019. While most cases of COVID-19 present with mild to moderate symptoms, COVID-19 was the third leading cause of mortality in the United States in 2020 and 2021. Though COVID-19 affects individuals of all races and ethnicities, non-Hispanic Black and Hispanic/Latinx populations are facing an inequitable burden of COVID-19 characterized by an increased risk for hospitalization and mortality. Importantly, non-Hispanic Black and Hispanic/Latinx adults have also faced a greater risk of non-COVID-19-related mortality (e.g., from cardiovascular disease/CVD) during the pandemic. Contributors to the racial disparities in morbidity and mortality during the pandemic are multi-factorial as we discuss in our companion article on social determinants of health. However, profound racial variation in the prevalence of CVD and metabolic diseases may serve as a key driver of worse COVID-19-related and non-COVID-19-related health outcomes among racial and ethnic minority groups. Within this review, we provide data emphasizing the inequitable burden of CVD and metabolic diseases among non-Hispanic Black and Hispanic/Latinx populations. We also discuss the pathophysiology of these conditions, with a focus on how aberrant physiological alterations in the context of CVD and metabolic diseases manifest to increase susceptibility to severe COVID-19.

Combining Neprilysin Inhibitor With AT2R Agonist Is Superior to Combination With AT1R Blocker in Providing Reno-Protection in Obese Rats

Clinical use of the combination therapy of the neprilysin inhibitor sacubitril and angiotensin II type 1 receptor blocker valsartan is known to be associated with albuminuria. Albuminuria is both a risk factor for and an indicator of kidney injury. Earlier work from our laboratory reported that the agonist of angiotensin II type 2 receptor Compound 21 (C21) prevents proteinuria, albuminuria, and is reno-protective in obese Zucker rats fed high salt diet (HSD). Thus, we hypothesized that sacubitril/C21 combination provides superior reno-protection compared to sacubitril/valsartan. Male obese Zucker rats 10–11 weeks old were treated daily with vehicle, sacubitril + C21, or sacubitril + valsartan while fed HSD for 16 days. HSD-feeding caused kidney dysfunction, evident by significant increases in urinary protein, osteopontin, and cystatin C. HSD-feeding lowered plasma cystatin C and creatinine concentrations suggestive of hyperfiltration, which was not affected by either treatment. Unlike sacubitril/valsartan, sacubitril/C21 treatment significantly decreases proteinuria, albuminuria, the expression of nephrin, and kidney weight, independent of hyperfiltration, compared with HSD alone. Moreover, sacubitril/valsartan therapy increased plasma renin and did not prevent HSD-induced increases in renal angiotensin II, while sacubitril/C21 completely prevented these changes. Together, this study suggests that sacubitril/C21 afforded superior reno-protection compared to sacubitril/valsartan therapy in high salt-fed obese Zucker rats.

Weight Change Alters the Small RNA Profile of Urinary Extracellular Vesicles in Obesity

INTRODUCTION

Various kidney diseases reportedly show different urinary extracellular vesicle (EV) RNA profiles. Although obesity is one of the main causes of chronic kidney disease, the expression pattern of urinary EV RNA in obesity is uncertain. Our aim was to sequence the small RNA profiles of urinary EVs in obese patients before and after weight reduction and compare them to those of healthy volunteers (HVs).

METHODS

We recruited age-sex-matched obese patients and HVs. The small RNA profiles of urinary EVs were analyzed using RNA sequencing. To evaluate the effect of weight reduction, small RNA profiles of urinary EVs 6 months after bariatric surgery were also analyzed.

RESULTS

The proportion of urinary EVs transfer RNA and microRNA of obese patients differed from that of HVs. Obese patients showed differential expression of 1,343 small RNAs in urinary EVs compared to HVs (fold change ≥2 and p value <0.05). Among those, 61 small RNAs were upregulated in obese patients and downregulated after weight reduction, whereas 167 small RNAs were downregulated in obese patients and upregulated after weight reduction. RNA sequencing revealed the correlation between the specific urinary EV small RNAs and clinical parameters including body weight, low-density lipoprotein cholesterol, triglyceride, high-density lipoprotein cholesterol, serum glucose, estimated glomerular filtration rate, and albuminuria.

CONCLUSION

Obese patients showed distinct urinary EV small RNA profiles compared to HVs. Weight reduction altered urinary EV small-RNA profiles in obese patients.

Role of the adaptive immune system in diabetic kidney disease

Diabetic kidney disease (DKD) is a highly prevalent complication of diabetes and the leading cause of end-stage kidney disease. Inflammation is recognized as an important driver of progression of DKD. Activation of the immune response promotes a pro-inflammatory milieu and subsequently renal fibrosis, and a progressive loss of renal function. Although the role of the innate immune system in diabetic renal disease has been well characterized, the potential contribution of the adaptive immune system remains poorly defined. Emerging evidence in experimental models of DKD indicates an increase in the number of T cells in the circulation and in the kidney cortex, that in turn triggers secretion of inflammatory mediators such as interferon-γ and tumor necrosis factor-α, and activation of cells in innate immune response. In human studies, the number of T cells residing in the interstitial region of the kidney correlates with the degree of albuminuria in people with type 2 diabetes. Here, we review the role of the adaptive immune system, and associated cytokines, in the development of DKD. Furthermore, the potential therapeutic benefits of targeting the adaptive immune system as a means of preventing the progression of DKD are discussed.

Bariatric Surgery Improves Renal Function in Patients With Obesity

Background

Obesity affects 93.3 million adults in the United States and is a predisposing factor for the development and progression of chronic kidney disease (CKD). The objective of this study is to examine the association between weight loss and renal function in participants undergoing bariatric surgery following a 12-week multidisciplinary, community-based weight loss program.

Methodology

This is a retrospective chart review of participants who voluntarily enrolled in a 12-week multidisciplinary weight loss program prior to bariatric surgery from 2009 to 2018. The primary outcome was to assess the association between weight loss and renal function in participants undergoing bariatric surgery. Secondary outcomes included changes in hemoglobin A1c, lipids, fasting glucose, and blood pressure.

Results

Among the 55 participants, baseline glomerular filtration rate (GFR) was 49 mL/min/m², 80% were female, and the average baseline weight was 131 kg. At one-year post-intervention, 69% of patients improved in the CKD stage, with 45% of the participants improving from stage 3A to stage 2. GFR improved to 15 mL/min/1.73m² (p = 0.025), and there was a negative correlation (r_s = -0.3556) between weight and GFR (p = 0.013). Participants with hyperlipidemia had a 12 mL/min/1.73m² rise in GFR, while participants without the diagnosis at one year had a 24 mL/min/1.73m² rise in GFR (p = 0.007).

Conclusions

This study demonstrated improved renal function and reduced progression of CKD following a combined lifestyle and surgical intervention, indicating the importance of a comprehensive approach for the management of the chronic disease.

Impact of obesity in kidney transplantation: a prospective cohort study from French registries between 2008 and 2014

BACKGROUND

The access of obese patients to kidney transplantation is limited despite several studies showing that obese transplant recipients had a better survival rate than those undergoing dialysis. The aim of this study was to compare patient and graft survival rates and post-renal transplant complications in obese patients and non-obese patients and to assess the effect of pre-transplant weight loss in obese patients on transplant outcomes.

METHODS

We carried out a prospective cohort study using two French registries REIN and CRISTAL on 7 270 kidney transplant patients between 2008 and 2014 in France. We compared obese patients with non-obese patients and obese patients who lost more than 10% of weight before the transplant (Obese WL and Obese nWL).

RESULTS

The mean BMI in our obese patients was 32 kg/m2. Graft survival was lower in obese patients than in non-obese patients (HR = 1.40, IC 95% [1.09; 1.78], P = 0.007) whereas patient survival was similar (HR = 0.94, IC 95% [0.73; 1.23], P = 0.66). Graft survival was significantly lower in Obese WL than in Obese nWL (HR = 2.17, CI 95% [1.02; 4.63], P = 0.045) whereas patient survival was similar in the two groups (HR = 0.79, IC 95% [0.35; 1.77], P = 0.56).

CONCLUSION

Grade I obesity does not seem to be a risk factor for excess mortality after kidney transplantation and should not be an obstacle to having access to a graft. Weight loss before a kidney transplant in this patients should not be essential for registration on waiting list.

Perirenal Fat Thickness Is Significantly Associated With the Risk for Development of Chronic Kidney Disease in Patients With Diabetes

Perirenal fat is adjacent to kidneys and active in metabolism and adipokine secretion. We aimed to investigate whether perirenal fat is an independent predictor for chronic kidney disease (CKD) and compared it with total, subcutaneous, or visceral fat in patients with diabetes. Perirenal fat thickness (PRFT) was measured by computed tomography, and total body fat (TBF), subcutaneous adipose tissue (SAT), and visceral adipose tissue (VAT) were assessed by DEXA. In cross-sectional analysis, patients with higher PRFT had a lower estimated glomerular filtration rate (eGFR). Multiple linear regression analysis showed a negative correlation between PRFT and eGFR after confounders adjustment. No association between eGFR and TBF, SAT, or VAT was observed. Longitudinally, 190 patients with type 2 diabetes mellitus (T2DM) without CKD at baseline were followed for 2 years. A total of 29 participants developed CKD. After VAT-based multivariate adjustment, each SD (per-SD) increment in baseline PRFT was associated with a higher incidence of CKD (hazard ratio 1.67, 95% CI 1.04-2.68), while TBF, SAT, and VAT were not. Furthermore, PRFT predicted CKD, with a C-statistic (95% CI) of 0.668 (0.562, 0.774), which was higher than that of TPF [0.535 (0.433, 0.637)], SAT [0.526 (0.434, 0.618)], and VAT [0.602 (0.506, 0.698)]. In conclusion, with perirenal fat there was a higher predictive value for CKD than with total, subcutaneous, or visceral fat in T2DM.

Renal Outcomes 1 Year After Metabolic Bariatric Surgery in a Multi-ethnic Asian Cohort

PURPOSE

Obesity increases the risk of incident chronic kidney disease (CKD) and is one of the strongest risk factors for new-onset CKD even in the absence of metabolic risk factors. Weight loss has been shown to reduce renal hyperfiltration and proteinuria. Metabolic bariatric surgery (MBS) remains an effective treatment for obesity and its metabolic-related complications. However, literature on its impact on renal function remains limited.

MATERIALS AND METHODS

This was an observational retrospective study in a tertiary centre in Singapore. MBS cases performed at the centre between 2008 and 2019 were included. The primary outcome measures were estimated glomerular filtration rate (eGFR), calculated using the CKD epidemiology collaboration equation, and albuminuria (defined as urine albumin-creatinine ratio (uACR) > 3.5 mg/mmol) at baseline and 1-year post-MBS.

RESULTS

Five hundred fifty-seven patients were included. One-year post-MBS, median eGFR increased from 110.9 mL/min/1.73 m² (IQR 92.4 to 121.5) to 112.6 mL/min/1.73 m² (IQR 97.3 to 122.3), p < 0.001. Median uACR decreased from 1.00 mg/mmol (IQR 0.40 to 3.55) to 0.70 mg/mmol (IQR 0.40 to 1.80) 1-year post-MBS (p = 0.001). 12.9% of patients had improved CKD staging. The proportion of patients with albuminuria decreased from 24.8% at baseline to 1.89% 1-year post-MBS (p < 0.001). One-year post-MBS, the subgroup with reduced eGFR had significant increases in eGFR (p < 0.001), with a trend towards a reduction in uACR.

CONCLUSIONS

MBS had a positive impact on renal function with modest but statistically significant improvement in eGFR and reduction in albuminuria at 1-year post-surgery. Longer-term data is required to investigate the durability of this impact.

Young age at diabetes diagnosis amplifies the effect of diabetes duration on risk of chronic kidney disease: a prospective cohort study

AIMS/HYPOTHESIS

We postulated that the increased lifetime risk of chronic kidney disease (CKD) in young-onset diabetes is attributable to both long disease duration and more aggressive disease. We examined whether age at diabetes diagnosis modifies the effect of diabetes duration on risk of CKD.

METHODS

We included 436,744 people with incident type 2 diabetes in the Hong Kong Diabetes Surveillance Database (HKDSD) and 16,979 people with prevalent type 2 diabetes in the Hong Kong Diabetes Register (HKDR). We used Poisson models to describe joint effects of age at diabetes diagnosis, diabetes duration and attained age on incidence of CKD in HKDSD. We used Cox proportional hazards models to examine interaction effect of age at diabetes diagnosis and diabetes duration on risk of CKD with adjustment for confounders in HKDR.

RESULTS

During a median follow-up of 5.3 years, 134,043 cases of CKD were recorded in the HKDSD. The incidence rate ratio for CKD comparing people of the same attained age but diagnosed with diabetes at ages 5 years apart was higher for people with a younger age at diabetes diagnosis, but decreased with increasing age at diabetes diagnosis. During a median follow-up of 6.3 years, 6500 people developed CKD in the HKDR. The increased risk of CKD with longer diabetes duration decreased with older age at diabetes diagnosis. The adjusted HR for CKD associated with 5 year increase in diabetes duration was 1.37 (95% CI 1.13, 1.65) in people with diabetes diagnosed at 20-29 years and 1.01 (95% CI 0.87, 1.18) in those diagnosed at ≥70 years.

CONCLUSIONS/INTERPRETATION

Young age at diabetes diagnosis amplified the effect of increasing diabetes duration on increased risk of CKD.

The Impact of Diet and Exercise on Drug Responses

It is well known that lifestyle changes can alter several physiological functions in the human body. For exercise and diet, these effects are used sensibly in basic therapies, as in cardiovascular diseases. However, the physiological changes induced by exercise and a modified diet also have the capacity to influence the efficacy and toxicity of several drugs, mainly by affecting different pharmacokinetic mechanisms. This pharmacological plasticity is not clinically relevant in all cases but might play an important role in altering the effects of very common drugs, particularly drugs with a narrow therapeutic window. Therefore, with this review, we provide insights into possible food–drug and exercise–drug interactions to sharpen awareness of the potential occurrence of such effects.

Diabetes and kidney disease: emphasis on treatment with SGLT-2 inhibitors and GLP-1 receptor agonists

Kidney disease is a frequent microvascular complication of both type 1 and type 2 diabetes. Historic trials have demonstrated that a tight glycaemic control is the most powerful approach to decrease the chances of developing diabetic nephropathy. However, having an HbA1c < 7% does not completely suppress the risk of kidney disease. The observed residual risk is likely ascribable to two phenomena: 1- the presence of risk factors and alterations additive to and independent of glycaemia, and 2- the activation of long-lasting imbalances by periods of exposure to uncontrolled glycemia, a phenomenon referred to as metabolic memory or legacy effect. Long-lasting oxidative stress, epigenetic alterations, cellular senescence, and the resulting chronic low-grade inflammation are all candidate mechanisms explaining the development of nephropathy despite proper control of risk factors. Recently, two classes of drugs, i.e. glucagon-like peptide (GLP) 1 receptor agonists (RA) and sodium-glucose transporter 2 inhibitors (SGLT-i) have changed this scenario. Indeed, cardiovascular outcome and other trials have clearly shown a renoprotective effect for these drugs, well-beyond their glucose-lowering properties. In this review, we summarize: 1- selected key trials and mechanisms underlying the development of diabetic kidney disease and 2- the results relative to renal endpoints in clinical trials of GLP-1 RA and SGLT-2i. Then, we briefly discuss some of the hypotheses posited to explain the marked renoprotective properties of these two classes, evidencing the still existing gaps in knowledge and proposing future directions to further implement the use of these powerful, disease-modifying drugs.

Isosteviol Sodium Attenuates High Fat/High Cholesterol-Induced Kidney Dysfunction by Inhibiting Inflammation, Oxidative Stress and Apoptosis

The sodium salt of isosteviol (STVNa) is a beyerane diterpene synthesized through acid hydrolysis of stevioside. STVNa improves multiple types of tissue injuries. However, it is not known how isosteviol sodium affects high-fat and high cholesterol diet (HFD)-induced kidney. Therefore, in this study we examined the potential molecular mechanism underlying STVNa mediated protective effect against high fat/high cholesterol-induced kidney dysfunction in HFD-induced kidney injury. Sprague-Dawley (SD) rats were allocated into six groups: the normal group, HFD group and HFD treated with three doses of STVNa, fenofibrate treatment group. The results indicated that HFD induced kidney injury evident by a 60% increase in serum creatinine (CRE) leves. In addition, there was a significant accumulation of triglycerides (approx. 60%), fatty acids (approx. 50%) and total cholesterol (approx. 2.5 fold) in the kidneys. STVNa inhibited HFD-induced kidney injury evident by reducing the increased levels of serum CRE. Specifically, STVNa attenuated HFD-induced kidney injury by inhibiting inflammation, oxidative stress, and apoptosis. These findings indicate that STVNa has a therapeutic potential for HFD-induced kidney dysfunction. The mechanisms of this pharmacological effect are through the inhibition of inflammation, oxidative stress and apoptosis.

Rebalancing the Oral Microbiota as an Efficient Tool in Endocrine, Metabolic and Immune Disorders

The current treatment and prevention procedures of oral disorders follow a very targeted approach considering mouth and its structures as a system that is completely independent, than the rest of the body. The main therapeutic approach is to keep the levels of oral bacteria and hygiene in an acceptable range compatible with oral-mouth health, completely separated from systemic microbial homeostasis (eubiosis vs dysbiosis). This can negatively impact the diagnosis of a more complex systemic disease and its progression. Dysbiosis occurs as a consequence of imbalance in oral and gut microbiota which leads to cardiovascular diseases, diabetes mellitus, rheumatoid arthritis, and Alzheimer's disease, as reported in current literature. Likewise, there is a need to highlight and develop a novel philosophical approach in the treatments for oral diseases that will necessarily involve nonconventional approaches.

Comparison of eGFR formulas in determining chronic kidney disease stage in bariatric patients and the impact on perioperative outcomes

BACKGROUND

Chronic kidney disease (CKD) independently increases the risk of 30-day adverse outcomes following metabolic and bariatric surgery (MBS). However, no studies have evaluated the stage of CKD at which increased perioperative risk is manifested. Here, we correlate 30-day major morbidities after MBS with extent of renal disease based on CKD Stage.

OBJECTIVES

To determine the impact of CKD stage on perioperative outcomes after bariatric surgery.

SETTING

Academic Hospital.

METHODS

From the 2017 Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database, we identified patients with CKD who underwent sleeve gastrectomy or laparoscopic gastric bypass surgery. Glomerular filtration rates (GFRs) were calculated and cohorts were generated based on CKD Stage. Complication rates and rates of morbidity and mortality were compared between stages, and strengths of correlation were calculated.

RESULTS

GFR and CKD Stage were calculated for 150,283 patients. There was a significant increase in the risk of major morbidity at each progressive stage of CKD (P < .001 for all compared stages). There was a strong positive linear correlation between increasing CKD Stage and total morbidity (r² = .983), including reoperation ( r² = .784), readmission (r² = .936), unplanned ICU transfer (r² = .853), and aggregate complications such as pulmonary (r² = .900), bleeding (r² = .878), or progressive worsening of renal function (r² = .845). In logistic regression, for every 10-point decrease in GFR, odds of total morbidity increased by 6%.

CONCLUSION

An increased risk of perioperative complications may be seen in early stages of CKD, and risk is compounded in more advanced stages. Bariatric surgical candidates should be counseled on their increased risk of surgical complications even with mild CKD, and the benefits of bariatric surgery should be carefully weighed against significantly increased risks of complications in severe CKD.

Combined effect of obesity and metabolic profile on glomerular dysfunction in hypertensive subjects

AIM

The aim of this study is to explore the individual and combined effects of obesity and metabolic profile on the impairment of glomerular function among hypertensive subjects.

METHODS

This is a cross-sectional study enrolling 499 hypertensive subjects. Based on body mass index values and metabolic profile, they were assigned to one of four metabolic phenotype groups: MHNO: metabolically healthy non-obese, MHO: metabolically healthy but obese, MUHNO: metabolically unhealthy but non-obese, and MUHO: metabolically unhealthy and obese. The effect of the interaction between obesity and metabolic profile was tested on an additive scale, for both microalbuminuria and reduced estimated glomerular filtration rate (eGFR).

RESULTS

After adjustment for confounding factors, the highest risk of both microalbuminuria and decreased eGFR was found among patients of the MUHO group (OR = 6.0 [2.13], p < 0.0001, OR = 5.4 [1.26], p = 0.03, respectively). Analysis of the additive interaction indicates that 51% and 53% of the risk of microalbuminuria and its combination with low eGFR respectively is explained by the co-occurrence of obesity and metabolic disorder. The mechanism of this interaction is synergistic (synergy index = 2.6, [1.5.3]).

CONCLUSION

The decline of glomerular function in hypertensive subjects is significantly exacerbated by the interaction between obesity and metabolic disorders. The management of such high-risk subjects requires, in addition to the therapeutic regimen, an adequate dietary and physical program in order to preserve glomerular function.

Melatonin Improves Endoplasmic Reticulum Stress-Mediated IRE1α Pathway in Zücker Diabetic Fatty Rat

Obesity and diabetes are linked to an increased prevalence of kidney disease. Endoplasmic reticulum stress has recently gained growing importance in the pathogenesis of obesity and diabetes-related kidney disease. Melatonin, is an important anti-obesogenic natural bioactive compound. Previously, our research group showed that the renoprotective effect of melatonin administration was associated with restoring mitochondrial fission/fusion balance and function in a rat model of diabesity-induced kidney injury. This study was carried out to further investigate whether melatonin could suppress renal endoplasmic reticulum (ER) stress response and the downstream unfolded protein response activation under obese and diabetic conditions. Zücker diabetic fatty (ZDF) rats and lean littermates (ZL) were orally supplemented either with melatonin (10 mg/kg body weight (BW)/day) (M-ZDF and M-ZL) or vehicle (C-ZDF and C-ZL) for 17 weeks. Western blot analysis of ER stress-related markers and renal morphology were assessed. Compared to C-ZL rats, higher ER stress response associated with impaired renal morphology was observed in C-ZDF rats. Melatonin supplementation alleviated renal ER stress response in ZDF rats, by decreasing glucose-regulated protein 78 (GRP78), phosphoinositol-requiring enzyme1α (IRE1α), and ATF6 levels but had no effect on phospho-protein kinase RNA-like endoplasmic reticulum kinase (PERK) level. In addition, melatonin supplementation also restrained the ER stress-mediated apoptotic pathway, as indicated by decreased pro-apoptotic proteins phospho-c-jun amino terminal kinase (JNK), Bax, and cleaved caspase-3, as well as by upregulation of B cell lymphoma (Bcl)-2 protein. These improvements were associated with renal structural recovery. Taken together, our findings revealed that melatonin play a renoprotective role, at least in part, by suppressing ER stress and related pro-apoptotic IRE1α/JNK signaling pathway.

The Predictive Value of Visceral Adiposity Index and Lipid Accumulation Index for Microalbuminuria in Newly Diagnosed Type 2 Diabetes Patients

PURPOSE

This study aims to investigate the predictive value of visceral adiposity index (VAI) and lipid accumulation index (LAP) for microalbuminuria (MAU) in patients with newly diagnosed Type 2 diabetes (T2DM).

PATIENTS AND METHODS

This study included 335 patients with newly diagnosed T2DM patients from Hebei General Hospital. All the patients aged from 18 to 65 years old include 226 males and 109 females. Patients information and blood indicators were Collected and calculated the LAP and VAI scores. All the patients were divided into males (group A) and females (group B), and these groups were then further subdivided into A1 group which arises microalbuminuria, and A2 group which does not. With the same method, women were divided into B1 group and B2 group.

RESULTS

Baseline data analysis showed that LAP and VAI levels in A1 and B1 groups were significantly higher than those in A2 and B2 groups (P<0.05). Logistic regression analysis showed that fasting blood glucose, waist circumference, LAP, and VAI were independent risk factors for the occurrence of microalbuminuria in both males and females. ROC showed that the area under curve (AUC) of waist circumference, fasting blood glucose, LAP and VAI in male patients were 0.626, 0.676, 0.760 and 0.742, respectively, and in female patients were 0.703, 0.685, 0.787 and 0.764, respectively. In addition, the area under the curve of both LAP and VAI was higher in females than in males.

CONCLUSION

This study confirmed that both LAP and VAI had predictive values for the occurrence of urinary microalbumin in newly diagnosed T2DM patients. The predictive value was higher in the female group and the suggestion was more applicable to female patients.

Lipid Accumulation Product is Associated with Urinary Albumin-creatinine Ratio in Chinese Prediabitic Population: A Report from the REACTION Study

BACKGROUND

Lipid accumulation product (LAP) as a powerful marker of visceral obesity is an independent risk factor of chronic kidney disease. The present study attempted to explore the association between LAP and albuminuria in prediabetic individuals.

METHODS

We conducted a cross-sectional study and enrolled 26,529 participants with prediabetes over 40 years old with prediabetes from seven provinces in China. LAP was calculated from waist circumference and fasting triglycerides. Elevated albuminuria was defined by urinary albumin-creatinine ratio (uACR) ≥30 mg/g. Propensity score matching was applied to reduce bias, comparison between LAP and other traditional visceral obesity indices was performed and multiple logistic regression models were conducted to assess the association between LAP and albuminuria in the prediabetic population.

RESULTS

Individuals with uACR ≥30 mg/g were older and had higher BP, BMI, WC, TG, fasting insulin, glycohemoglobin and LAP, as well as lower eGFR and HDL level. Multiple logistic regression analysis showed elevated LAP was associated with increased odds of albuminuria (OR [95%CI]_{Q2 vs Q1} 1.09 [0.94, 1.27], OR [95%CI]_{Q3 vs Q1} 1.13 [0.97, 1.31], OR [95%CI]_{Q4 vs Q1} 1.42 [1.21, 1.67], P for trend=0.018), and superior over waist-to-hip ratio or waist-to-height ratio. Stratification indicated that the prediabetic population with higher LAP level and characterized by female gender, middle age, being overweight, and rise in blood pressure were more likely to have increased uACR.

CONCLUSION

Elevated level of LAP was associated with increased albuminuria in the prediabetic population in China.

Comorbidity Profiles among Obese-Diabetic End-Stage Renal Disease Patients: Data from REIN Registry of PACA Region of France

INTRODUCTION

The proportion of new dialysis patients with comorbidities increased by an average of 5.6% per year in the Provence-Alpes-Côte d'Azur (PACA) region, with major increases in obese, cancer, and diabetic patients. This study aimed to describe comorbidity profiles among obese-diabetic end-stage renal disease (ESRD) patients in the Renal Epidemiology and Information Network (REIN) registry of the PACA region of France on December 31, 2018.

METHODS

Data for this retrospective cross-sectional study were retrieved from the REIN registry of the PACA region. Data were analyzed using two models. Firstly, the ESRD patients were divided into two groups and binary logistic regression model used for the analysis of the data. Secondly, ESRD patients were divided into four groups and multinomial logistic regression model used. Univariate analysis was performed for group comparison using x² and t-tests, while binary logistic and multinomial logistic regression models were used for multivariate analysis to derive ORs and 95% CIs.

RESULTS

Among the 4,491 ESRD patients in this study, 623 were obese-diabetic and 3,868 nonobese-nondiabetic and obese only/ diabetic only. Obese-diabetic ESRD patients were younger (<75 years, OR 0.46, p<0.001), smoked less (OR 0.51, p<0.001), were mainly dialyzed at centers (OR 1.29, p=0.014), and less likely to be on the renal transplant waiting list (OR 0.46, p<0.001) compared to the other group. Obese-diabetic ESRD patients also had more comorbidities, including cardiovascular diseases (OR 1.38, p=0.028), coronary insufficiency (OR 1.49, p=0.001) and chronic obstructive pulmonary disease (OR 1.75, p<0.001), but had fewer cases of cancer (OR 0.68, p=0.024) compare to the other group.

CONCLUSION

Obese-diabetic patients with ESRD have many specific characteristics. These patients were younger, but had more cardiovascular comorbidities and were less likely to be on the waiting list for transplantation. They should receive special attention and be the subject of prevention and therapeutic education.

The nephrological perspective on SGLT-2 inhibitors in type 1 diabetes

Prevalence of type 1 diabetes mellitus (T1DM) is globally continuously increasing. T1DM is accompanied by a high risk of developing cardiovascular and renal comorbidities and is one of the leading causes of end-stage renal disease (ESRD). However, current therapeutic approaches for chronic and/or diabetic kidney disease (CKD/DKD) existed for a long time, and offer room for improvement, particularly in T1DM. In 2019, the European Medicines Agency (EMA) approved a first sodium/glucose co-transporter 2 inhibitor (SGLT-2i) and a first dual SGLT-1/-2i to improve glycaemic control, as an adjunctive treatment to insulin in persons with T1DM and a body mass index ≥27 kg/m². Of note, SGLT-1/2is and SGLT-2is are not approved by the Food and Drug Administration (FDA) as an adjunct treatment in T1DM, nor approved for the treatment of CKD or DKD by EMA and FDA. SGLT is have shown to mediate different renoprotective effects in type 2 diabetes mellitus in corresponding cardiovascular and renal outcome trials. First efficacy trials offer insights into potential positive effects on renal function and kidney disease of SGLTis in T1DM. This review summarizes and discusses latest available data on SGLT inhibition and provides an update on the nephrological perspective on SGLTis, specifically in T1DM.

The association between albuminuria and thyroid antibodies in newly diagnosed type 2 diabetes mellitus patients with Hashimoto's thyroiditis and euthyroidism

BACKGROUND

Microalbuminuria is a prognostic marker of diabetes kidney disease. It is generally diagnosed as the ratio of urinary albumin to creatinine (UACR) of 30-300 mg/g. Hashimoto's thyroiditis is a common disease in the endocrinology and the thyroid antibodies may associated with kidney disease. We investigated the UACR in the newly diagnosed T2DM with Hashimoto's thyroiditis and tried to detect the relationship between the UACR and thyroid antibodies.

METHODS

One hundred twenty newly diagnosed T2DM patients with Hashimoto's thyroiditis and euthyroidism and 50 sex and age-matched T2DM with non-Hashimoto's and other thyroid disease were recruited. T2DM patients were divided into 2 groups by the titer of TPOAb: (1). TPOAb (+) group: T2DM with positive TPOAb (n = 105); (2). TPOAb (-) group: T2DM with negative TPOAb (n = 65).

RESULTS

T2DM with positive TPOAb group had higher UACR than T2DM with negative TPOAb group (21.55 ± 7.28 vs 15.13 ± 5.69 mg/g, P < 0.01). UACR were positively related to BMI (r = 0.255, P < 0.05), FPG (r = 0.285, P < 0.05), HbA1c (r = 0.260, P < 0.05) and TPOAb (r = 0.349, P < 0.05). HbA1c (β = 0.793, P < 0.05), BMI (β = 0.342, P < 0.05) and lnTPOAb (β = 1.207, P < 0.05) were independently associated with UACR.

CONCLUSIONS

In the newly diagnosed T2DM patients, Hashimoto's thyroiditis with TPOAb positive had higher UACR levels. TPOAb titer, BMI and HbA1c were independent associated with UACR in these patients.

Critical Role for AMPK in Metabolic Disease-Induced Chronic Kidney Disease

Chronic kidney disease (CKD) is prevalent in 9.1% of the global population and is a significant public health problem associated with increased morbidity and mortality. CKD is associated with highly prevalent physiological and metabolic disturbances such as hypertension, obesity, insulin resistance, cardiovascular disease, and aging, which are also risk factors for CKD pathogenesis and progression. Podocytes and proximal tubular cells of the kidney strongly express AMP-activated protein kinase (AMPK). AMPK plays essential roles in glucose and lipid metabolism, cell survival, growth, and inflammation. Thus, metabolic disease-induced renal diseases like obesity-related and diabetic chronic kidney disease demonstrate dysregulated AMPK in the kidney. Activating AMPK ameliorates the pathological and phenotypical features of both diseases. As a metabolic sensor, AMPK regulates active tubular transport and helps renal cells to survive low energy states. AMPK also exerts a key role in mitochondrial homeostasis and is known to regulate autophagy in mammalian cells. While the nutrient-sensing role of AMPK is critical in determining the fate of renal cells, the role of AMPK in kidney autophagy and mitochondrial quality control leading to pathology in metabolic disease-related CKD is not very clear and needs further investigation. This review highlights the crucial role of AMPK in renal cell dysfunction associated with metabolic diseases and aims to expand therapeutic strategies by understanding the molecular and cellular processes underlying CKD.

Mortality association between obesity and pneumonia using a dual restricted cohort model

BACKGROUND

An obesity survival paradox has been reported among obese patients with pneumonia.

AIMS

To determine the impact of obesity on pneumonia outcomes and analyze the correlation between in-hospital all-cause mortality and obesity among patients with pneumonia.

METHODS

The United States Nationwide Readmissions Database (NRD) was retrospectively analyzed for patients with pneumonia from 2013 to 2014. We used a step-wise restricted and propensity score matching cohort model (dual model) to compare mortality rates and other outcomes among pneumonia patients based on BMI. Mortality was calculated by a Cox proportional hazard model, adjusted for potential confounders with propensity score matched analysis.

RESULTS

A total of 70,886,775 patients were registered in NRD during the study period. Of these, 7,786,913 patients (11.0%) were considered obese and 1,652,456 patients (2.3%) were admitted to the hospital with pneumonia. Based on the step-wise restricted cohort model, the hazard ratio comparing the mortality rates among obese pneumonia patients to mortality rates among normal BMI pneumonia patients was 0.75 (95% CI 0.60-0.94). The propensity score matched analysis estimated a hazard rate of 0.84 (95% CI 0.79-0.90) and the hazard ratio estimated from the dual model was 0.82 (95% CI 0.63-1.07).

CONCLUSIONS

With the application of a dual model, there appears to be no significant difference in mortality of obese patients with pneumonia compared to normal BMI patients with pneumonia.

Study the Association of Tumor Necrosis Factor Promoter Polymorphism with Type 2 Diabetic Nephropathy

Type 2 Diabetes Mellitus (T2DM) is well known to include an inflammatory component that has been considered to be related to diabetic complications. Diabetic nephropathy (DN) is one of the significant complications as it constitutes the most frequent cause of end-stage renal disease. Tumor Necrosis Factor-α (TNF-α) is known as a multifunctional proinflammatory cytokine which is associated with some pathological processes such as immunoregulation, proliferation, inflammation, and apoptosis. The aim was to explore the association between the TNF-α promoter -1031T/C single nucleotide polymorphism (SNP) and the serum TNF-α level in addition to nephropathy among type 2 diabetic patients. The study included 38 T2DM subjects without nephropathy (DM group), 40 subjects with DN, and 20 controls. Identification of TNF-α promoter gene polymorphism -1031T/C was done by PCR-RFLP, and genotyping was confirmed by direct sequencing. The serum TNF-α level was assessed by ELISA. Correlations were tested by Pearson's correlation analysis. Logistic regression was used to detect the most independent factor for development of DN. The serum level of TNF-α in the DM group was significantly higher than controls (p < 0.001); also, the DN group was considerably higher than controls and DM without nephropathy (p < 0.001). Also, there was a significant positive correlation between serum levels of TNF-α with FBG (fasting blood glucose), creatinine, total cholesterol, LDL-C, HbA1c, and microalbumin/creatinine ratio (ACR) among the DN group (p = 0.042, <0.001, <0.001, <0.001, 0.027, and 0.043, respectively). Mutant homozygous CC and heterozygous TC genotypes were higher in DN than in DM and controls. C allele was more represented in DN than in DM and controls (p = 0.003) while T allele was higher in controls than in DM and DN patients. The levels of TNF-α were higher in subjects who had mutant CC than the wild TT genotype among DN (p < 0.001). C allele was more risky for DN than T allele between DN and controls by 5.4-fold (CI: 1.75-16.68) as well as between DN and DM by 2.25-fold (CI: 1.1-4.59). Conclusion. Serum levels of TNF-α were higher in individuals with mutant CC genotype of -1031T/C TNF-α gene, and C allele could be associated with increased risk for nephropathy among patients with T2DM.

Renal and Cardiovascular Outcomes After Weight Loss From Gastric Bypass Surgery in Type 2 Diabetes: Cardiorenal Risk Reductions Exceed Atherosclerotic Benefits

OBJECTIVE

We examined detailed renal and cardiovascular (CV) outcomes after gastric bypass (GBP) surgery in people with obesity and type 2 diabetes mellitus (T2DM), across several renal function categories, in a nationwide cohort study.

RESEARCH DESIGN AND METHODS

We linked data from the National Diabetes Register and the Scandinavian Obesity Surgery Register with four national databases holding information on socioeconomic variables, medications, hospitalizations, and causes of death and matched 5,321 individuals with T2DM who had undergone GBP with 5,321 who had not (age 18-65 years, mean BMI >40 kg/m², mean follow-up >4.5 years). The risks of postoperative outcomes were assessed with Cox regression models.

RESULTS

During the first years postsurgery, there were small reductions in creatinine and albuminuria and stable estimated glomerular filtration rate (eGFR) in the GBP group. The incidence rates of most outcomes relating to renal function, CV disease, and mortality were lower after GBP, being particularly marked for heart failure (hazard ratio [HR] 0.33 [95% CI 0.24, 0.46]) and CV mortality (HR 0.36 [(95% CI 0.22, 0.58]). The risk of a composite of severe renal disease or halved eGFR was 0.56 (95% CI 0.44, 0.71), whereas nonfatal CV risk was lowered less (HR 0.82 [95% CI 0.70, 0.97]) after GBP. Risks for key outcomes were generally lower after GBP in all eGFR strata, including in individuals with eGFR <30 mL/min/1.73 m².

CONCLUSIONS

Our data suggest robust benefits for renal outcomes, heart failure, and CV mortality after GBP in individuals with obesity and T2DM. These results suggest that marked weight loss yields important benefits, particularly on the cardiorenal axis (including slowing progression to end-stage renal disease), whatever the baseline renal function status.