Higher HDL cholesterol levels are associated with a lower incidence of chronic kidney disease in patients with type 2 diabetes

Dose-response association of diabetic kidney disease with routine clinical parameters in patients with type 2 diabetes mellitus: a systematic review and meta-analysis

Background

Diabetic kidney disease (DKD) is a leading cause of end-stage kidney disease and is associated with high mortality rates. The influence of routine clinical parameters on DKD onset in patients with type 2 diabetes mellitus (T2DM) remains uncertain.

Methods

In this systematic review and meta-analysis, we searched multiple databases, including PubMed, Embase, Scopus, Web of Science, and Cochrane Library, for studies published from each database inception until January 11, 2024. We included cohort studies examining the association between DKD onset and various clinical parameters, including body mass index (BMI), hemoglobin A1c (HbA1c), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and serum uric acid (UA). Random-effect dose-response meta-analyses utilizing one-stage and/or cubic spline models, were used to estimate correlation strength. This study is registered in PROSPERO (CRD42022326148).

Findings

This analysis of 46 studies involving 317,502 patients found that in patients with T2DM, the risk of DKD onset increased by 3% per 1 kg/m2 increase in BMI (relative risk (RR) = 1.03, confidence interval (CI) [1.01-1.04], I2 = 70.07%; GRADE, moderate); a 12% increased risk of DKD onset for every 1% increase in HbA1c (RR = 1.12, CI [1.07-1.17], I2 = 94.94%; GRADE, moderate); a 6% increased risk of DKD onset for every 5 mmHg increase in SBP (RR = 1.06. CI [1.03-1.09], I2 = 85.41%; GRADE, moderate); a 2% increased risk of DKD onset per 10 mg/dL increase in TG (RR = 1.02, CI [1.01-1.03], I2 = 78.45%; GRADE, low); an 6% decreased risk of DKD onset per 10 mg/dL increase in HDL (RR = 0.94, CI [0.92-0.96], I2 = 0.33%; GRADE, high), and a 11% increased risk for each 1 mg/dL increase in UA (RR = 1.11, CI [1.05-1.17], I2 = 79.46%; GRADE, moderate). Subgroup analysis revealed a likely higher risk association of clinical parameters (BMI, HbA1c, LDL, and UA) in patients with T2DM for less than 10 years.

Interpretation

BMI, HbA1c, SBP, TG, HDL and UA are potential predictors of DKD onset in patients with T2DM. Given high heterogeneity between included studies, our findings should be interpreted with caution, but they suggest monitoring of these clinical parameters to identify individuals who may be at risk of developing DKD.

Funding

Shenzhen Science and Innovation Fund, the Hong Kong Research Grants Council, and the HKU Seed Funds, and Scientific and technological innovation project of China Academy of Chinese Medical Sciences.

Incidence and predictors of chronic kidney disease among patients with diabetes treated at governmental hospitals of Harari Region, eastern Ethiopia, 2022

Background

Chronic kidney disease (CKD) is the leading cause of morbidity and mortality in diabetic patients. However, limited evidence is available about its incidence and predictors in Ethiopia, specifically in the Harari region.

Methods

A retrospective follow-up study was conducted among 520 diabetes patients who followed their treatment at governmental hospitals in the Harari region between 1 September 2012, and 30 May 2022. The risk of developing CKD was calculated with a 95% CI, and the risk was stratified by type of diabetes mellitus. Predictors of CKD were determined using the Gompertz regression model with the baseline Cox model.

Results

Data from 494 patients were included in the final analysis with 26 (5%) excluded. A total of 51 patients (10.32%) developed CKD over the 10-year follow-up period with an incidence rate of 2.16 cases (95% CI 1.64-2.84) per 100 person-years of observation. The risk of CKD was increased by three times (AHR: 3.09, 45 95% CI: 1.56, 6.14) among patients older than 60 years and by more than three times (AHR: 3.53, 95% CI: 1.43, 8.71) among patients with diabetes mellitus for longer than 5 years of stay with the diabetes mellitus. Moreover, the risk of CKD was increased four-fold among patients with high-density lipoprotein cholesterol (HDL-C) levels <40 mg/dL (AHR: 3.84, 95% CI, 1.80-8.18) and those with positive baseline proteinuria (AHR: 3.77, 95% CI: 1.43-8.71).

Conclusion

We found that one in ten diabetic patients had developed CKD within 10 years of the diabetes mellitus diagnosis. Advanced age, longer duration of diabetes, lower baseline HDL-C level, and proteinuria had increased the hazards of developing CKD. We recommend a more focused follow-up of older adult patients with advanced disease status at baseline for optimal control of diabetes mellitus that prevents its furthering to CKD.

HDL Function across the Lifespan: From Childhood, to Pregnancy, to Old Age

The function of high-density lipoprotein (HDL) particles has emerged as a promising therapeutic target and the measurement of HDL function is a promising diagnostic across several disease states. The vast majority of research on HDL functional biology has focused on adult participants with underlying chronic diseases, whereas limited research has investigated the role of HDL in childhood, pregnancy, and old age. Yet, it is apparent that functional HDL is essential at all life stages for maintaining health. In this review, we discuss current data regarding the role of HDL during childhood, pregnancy and in the elderly, how disturbances in HDL may lead to adverse health outcomes, and knowledge gaps in the role of HDL across these life stages.

High Incidence of Chronic Kidney Disease among Iranian Diabetic Adults: Using CKD-EPI and MDRD Equations for Estimated Glomerular Filtration Rate

BACKGROUND

To investigate the population based incidence rate of chronic kidney disease (CKD) and its potential risk factors among Iranian diabetic adults during over 14 years of follow-up.

METHODS

Two different equations (Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI] and Modification of Diet in Renal Disease [MDRD]) were applied for the calculating the estimated glomerular filtration rate (eGFR). Among a total of 1,374 diabetic Tehranian adults, 797 and 680 individuals were eligible for CKD-EPI and MDRD analyses, respectively. CKD was defined as eGFR lower than 60 mL/min/1.73 m2. Multivariable Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CI) for all potential risk factors.

RESULTS

The incidence rates (95% CI) of CKD per 1,000 person-years were 43.84 (39.49 to 48.66) and 55.80 (50.29 to 61.91) based on CKD-EPI and MDRD equations, respectively. Being older, a history of cardiovascular disease, and having lower levels of eGFR were significant risk factors in both equations. Moreover, in CKD-EPI, using glucose-lowering medications and hypertension, and in MDRD, female sex and fasting plasma glucose ≥10 mmol/L were also independent risk factors. Regarding the discrimination index, CKD-EPI equation showed a higher range of C-index for the predicted probability of incident CKD in the full-adjusted model, compared to MDRD equation (0.75 [0.72 to 0.77] vs. 0.69 [0.66 to 0.72]).

CONCLUSION

We found an incidence rate of more than 4%/year for CKD development among our Iranian diabetic population. Compared to MDRD, it can be suggested that CKD-EPI equation can be a better choice to use for prediction models of incident CKD among the Iranian diabetic populations.

Elevated atherogenic index and higher triglyceride increase risk of kidney function decline: a 7-year cohort study in Chinese adults

Objective

This study explored whether lipid disorders or an elevated atherogenic index of plasma (AIP, a risk factor for cardiovascular diseases) could predict major kidney function decline.

Methods

We conducted a retrospective 7-year cohort study of 3712 Chinese adults followed up between 2010 and 2017. Major kidney function decline was defined as a ≥ 30% reduction in the estimated glomerular filtration rate (eGFR) from baseline. Multivariable logistic regression models were used to evaluate the relationship between lipid profiles and major kidney function decline. Smoking habits, waist circumference, and physical activity were not assessed.

Results

During the 7-year follow-up, 1.70% (n = 63) of the participants developed major kidney function decline. After adjustment for potential confounders, the odds ratios (ORs) for developing eGFR decline with per standard deviation increase were 1.23 [95% confidence interval (CI): 1.06–1.43] for triglyceride and 2.55 (95% CI: 1.01–6.42) for AIP in all participants. Furthermore, in the stratified analysis, we found sex-related differences; triglyceride and AIP were only independently associated with the risk of eGFR decline in men (OR, 1.27, 95% CI: 1.08–1.48; OR, 3.98, 95% CI: 1.22–12.99, respectively). When the participants were divided into groups according to the baseline lipid status, association was observed only between abnormal AIP and eGFR decline (all p values < 0.05).

Conclusion

Our findings suggest that a higher serum triglyceride level or an elevated AIP increases the risk of major kidney function decline in Chinese men with normal kidney function. Thus, assessment of AIP may help identify the risk of eGFR decline.

Cross-sectional study of diabetes kidney disease in the Eastern Cape, South Africa

Diabetes mellitus (DM) is an independent risk factor for the development of kidney disease. This study assesses the prevalence and determinants of asymptomatic kidney disease in individuals with DM attending health facilities in OR Tambo district, Eastern Cape, South Africa.In this cross-sectional analysis, medical data of 327 individuals receiving care for DM in primary health care centers in OR Tambo district, Eastern Cape between June and November 2013 were reviewed. Significant kidney disease was defined as estimated glomerular filtration rate less than 60 mL/min/1.73 m in accordance with the guidelines of the Society of Endocrinology, Metabolism and Diabetes of South Africa (2017).One-quarter of the 327 participants (n = 80) had significant kidney disease. Female sex [odds ratio (OR) = 5.2; 95% confidence interval (95% CI) 1.2-23.5], never used alcohol (OR = 13.4; 95% CI 2.5-72.1), hypertension (OR = 16.2; 95% CI 2.0-130.0), triglyceride (TG)/high-density lipoprotein (HDL) ratio (OR = 1.2; 95% CI 1.0-1.5), current smoker (OR = 1127.9; 95% CI 162.9-7808.9), former smoker (OR = 13.3; 95% CI 4.1-41.4), and longer duration of diabetes (OR = 4.6; 95% CI 1.6-13.0) were the independent determinants of significant kidney disease among the participants. A significant dose--effect relationship exists between renal disease and smoking status (P < .0001), duration of DM (P < .001), glycemic status (P = .025), and body mass index (P = .003).There is a high rate of undiagnosed kidney disease in this setting, which was independently associated with female sex and presence of other cardiovascular risk factors. Strategic interventions targeting screening and monitoring of renal functions in individuals with DM are urgently needed in this region.

Incidence of diabetic nephropathy in patients with type 2 diabetes mellitus at a tertiary healthcare setting in Ethiopia

BACKGROUND AND AIMS

Diabetic nephropathy (DN) is a leading cause of morbidity and mortality in diabetic patients representing a huge health and economic burden. Despite the increasing number of patients with Diabetes Mellitus in Ethiopia, the incidence of diabetic nephropathy in patients with DM has not been well established. Therefore, this study aimed to estimate the incidence and predictors of DN in patients with T2DM at tertiary healthcare setting, Ethiopia.

METHODS

An institution based retrospective follow study was conducted from March 1 to April 28, 2019. Kaplan-meier survival curve together with log rank test were used. Cox proportional hazard model was used at 5% level of significance to determine the net effect of each explanatory variable on diabetic nephropathy. An assumption was check by schoenfeld residual test.

RESULTS

The incidence rate of diabetic nephropathy was 3.6% per 100 person-years (95% CI = 2.49-11.47). The median time to develop nephropathy was 100(95% CI, 96.7-107) months. Predictors of diabetic nephropathy were males (AHR: 2.7, 95%CI: 1.39, 5.23), long duration of diabetes (AHR: 1.03, 95%CI: 1.01, 1.06), HbA1c> 7% (AHR: 1.74, 95% CI: 1.67, 3.12), high density lipoprotein (AHR: 0.37, 95% CI: 0.16, 0.83), and mixed anti-diabetic therapy (AHR: 0.07, 95% CI: 0.01, 0.59).

CONCLUSION

The incidence of diabetic nephropathy among T2DM patients was relatively high. Males, longer duration of diabetes, HbA1c, and fasting blood glucose were increase the risk of diabetic nephropathy.

Initial serum creatinine concentration affects clinical outcomes in patients with IgA nephropathy treated with mycophenolate mofetil combined with low-dose prednisone

Indicators for predicting the efficacy of mycophenolate mofetil (MMF) have so far remained elusive. The present study aimed to identify predictive indicators of the efficacy of MMF combined with low-dose prednisone in patients with IgA nephropathy. A total of 598 patients presenting with primary IgA nephropathy at our center were screened. Patients were followed up for 18 months, where the end-point was defined as complete clinical remission. Cox proportional hazards models were performed for analyzing the initial serum creatinine (SCr) concentration to predict incomplete clinical remission. In total, 7 of 71 patients (9.86%) were in complete clinical remission at the final visit. Logistic regression indicated that the hazard ratio (HR) for quartile 4 was significantly higher than the HR for quartile 1 (quartile 4 vs. quartile 1: HR, 2.51; 95% CI, 1.20-5.21; P=0.01). Additional adjustment for the confounding variables, including age, sex, systolic BP, diastolic BP, proteinuria, uric acid, serum triglyceride, hemoglobin, serum albumin, serum total cholesterol and The Oxford classification of the models, did not reduce the HRs for the association between the initial SCr concentration and risk of incomplete clinical remission (quartile 4 vs. quartile 1: HR, 7.27; 95% CI, 1.21-43.63; P=0.03). Each unit increase in the initial SCr concentration was associated with a 67 and 194% increase in the risk of incomplete clinical remission based on model 1 (95% CI, 1.02-2.73; P=0.04) and model 2 (95% CI, 1.01-8.60; P=0.048), respectively. In conclusion, in the present cohort of patients with IgA nephropathy treated with MMF plus low-dose prednisone, the initial SCr concentration was an independent risk factor for incomplete clinical remission.

Association of Lipid Parameters with the Risk of Chronic Kidney Disease: A Longitudinal Study Based on Populations in Southern China

OBJECTIVE

To investigate which plasma lipid parameters are useful for detecting chronic kidney disease (CKD) in a Chinese population without known CKD or renal impairment.

METHODS

This was a prospective study. In southern Chinese cities from 2012 to 2013, a total of 1037 subjects aged ≥ 18 years old received a survey. Logistic regression and multiple linear regression analyses were performed. The lipid parameters studied included total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), non-high-density lipoprotein cholesterol (nHDL-C), TG/HDL-C ratio, TC/HDL-C ratio and nHDL-C/HDL-C ratio.

RESULTS

After adjusting for confounding factors, the fourth percentile of logTG/HDL-C was observed to be an independent risk factor for CKD (OR = 2.453, P < 0.001), and the highest quantile of the logTG/HDL-C ratio was associated with a higher prevalence of CKD (P < 0.05). This risk was reduced when the model was adjusted with Insulin resistance (IR) (OR = 2.034, P < 0.05). In the group of women, glucose metabolism disorders, high uric acid, and obesity, this risk was increased. Multiple regression models showed that log TG and nonHDL-C/HDL-C were negatively correlated with eGFR (P < 0.05), while log TG and TC were positively correlated with logACR (P < 0.05). The area under the curve (ROC) of lgTG/HDL was 0.623 (p < 0.001).

CONCLUSION

The serum logTG/HDL-C ratio is the only suitable predictor of CKD, and IR may be the mechanism. This risk needs to be controlled in a specific population. Log TG and nonHDL-C/HDL-C were negatively correlated with eGFR, while log TG and TC were positively correlated with logACR.

Association of smoking and cardiometabolic parameters with albuminuria in people with type 2 diabetes mellitus: a systematic review and meta-analysis

AIMS

Smoking is a strong risk factor for albuminuria in people with type 2 diabetes mellitus (T2DM). However, it is unclear whether this sequela of smoking is brought about by its action on cardiometabolic parameters or the relationship is independent. The aim of this systematic review is to explore this relationship.

METHODS

Electronic databases on cross-sectional and prospective studies in Medline and Embase were searched from January 1946 to May 2018. Adult smokers with T2DM were included, and other types of diabetes were excluded.

RESULTS

A random effects meta-analysis of 20,056 participants from 13 studies found that the odds ratio (OR) of smokers developing albuminuria compared to non-smokers was 2.13 (95% CI 1.32, 3.45). Apart from smoking, the odds ratio of other risk factors associated with albuminuria were: age 1.24 (95% CI 0.84, 1.64), male sex 1.39 (95% CI 1.16, 1.67), duration of diabetes 1.78 (95% CI 1.32, 2.23), HbA1c 0.63 (95% CI 0.45, 0.81), SBP 6.03 (95% CI 4.10, 7.97), DBP 1.85 (95% CI 1.08, 2.62), total cholesterol 0.06 (95% CI - 0.05, 0.17) and HDL cholesterol - 0.01 (95% CI - 0.04, 0.02), triglyceride 0.22 (95% CI 0.12, 0.33) and BMI 0.40 (95% CI 0.00-0.80). When the smoking status was adjusted in a mixed effect meta-regression model, the duration of diabetes was the only statistically significant factor that influenced the prevalence of albuminuria. In smokers, each year's increase in the duration of T2DM was associated with an increased risk of albuminuria of 0.19 units (95% CI 0.07, 0.31) on the log odds scale or increased the odds approximately by 23%, compared to non-smokers. Prediction from the meta-regression model also suggested that the odds ratios of albuminuria in smokers after a diabetes duration of 9 years and 16 years were 1.53 (95% CI 1.10, 2.13) and 5.94 (95% CI 2.53, 13.95), respectively.

CONCLUSIONS

Continuing to smoke and the duration of diabetes are two strong predictors of albuminuria in smokers with T2DM. With a global surge in younger smokers developing T2DM, smoking cessation interventions at an early stage of disease trajectory should be promoted.

Impact of different dietary approaches on blood lipid control in patients with type 2 diabetes mellitus: a systematic review and network meta-analysis

The aim of this study was to assess the effects of different dietary approaches on low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglyceride (TG) levels in patients with type 2 diabetes (T2D) by applying network meta-analysis (NMA). Systematic electronic and hand searches were conducted until January 2018. Randomized controlled trials (RCTs) with an intervention period of ≥ 12 weeks, focussing on adults with T2D, and comparing dietary approaches regarding LDL, HDL or TGs, were included. For each outcome measure, random effects NMA was performed in order to determine the effect of each dietary approach compared to every other dietary intervention. Mean differences (MDs) and 95% confidence intervals (95% CIs) were calculated, and for the ranking, the surface under the cumulative ranking curves (SUCRA) was determined. Additionally, the credibility of evidence was evaluated. 52 RCTs (44 for LDL, 48 for HDL and 52 for TGs) comparing nine dietary approaches (low fat, vegetarian, Mediterranean, high protein, moderate carbohydrate, low carbohydrate, control, low glycaemic index/glycaemic load and Palaeolithic diet) enrolling 5360 T2D patients were included. The vegetarian diet most effectively reduced LDL levels [MD (95% CI): - 0.33 (- 0.55, - 0.12) mmol/L; compared to the control diet]. The Mediterranean diet beneficially raised HDL [MD (95% CI): 0.09 (0.04, 0.15) mmol/L] and decreased TG levels [MD (95% CI): - 0.41 (- 0.72, - 0.10) mmol/L] compared to the control diet. The Mediterranean diet was the most effective dietary approach to manage diabetic dyslipidaemia altogether (SUCRA: 79%). The overall findings are mainly limited by low credibility of evidence.

Discordance in risk factors for the progression of diabetic retinopathy and diabetic nephropathy in patients with type 2 diabetes mellitus

AIMS/INTRODUCTION

We aimed to investigate whether there are differences in the risk factors or markers for the progression of diabetic retinopathy (DR) and diabetic nephropathy (DN) in type 2 diabetes mellitus.

MATERIALS AND METHODS

We carried out a 3-year retrospective cohort study of 604 patients with type 2 diabetes mellitus. The outcomes were the progression of DR (worsening of the DR stage) and DN (an estimated glomerular filtration rate decline >12%) at the 3-year follow up. The mean hemoglobin A1c (HbA1c) level and HbA1c variability (HbA1c-VAR) were calculated.

RESULTS

The mean HbA1c and HbA1c-VAR levels were higher in the DR progressors (n = 67) than in the DR non-progressors (n = 537). The mean HbA1c was a significant predictor for DR progression independent of the duration of diabetes and HbA1c-VAR levels. The urine albumin-to-creatinine ratio at baseline and HbA1c-VAR levels were higher in the DN progressors (n = 34) than in the DN non-progressors (n = 570). The triglyceride to high-density lipoprotein cholesterol ratio at baseline tended to be higher in the DN progressors than in the DN non-progressors. HbA1c-VAR levels and the triglyceride-to-high-density lipoprotein cholesterol ratio were significant predictors for DN progression independent of estimated glomerular filtration rate and the urine albumin-to-creatinine ratio.

CONCLUSIONS

Average glycemia was significantly associated with progression of DR, whereas glycemic variability and dyslipidemia were significantly associated with progression of DN in type 2 diabetes mellitus.

Avaliação dos níveis de albuminúria em adultos obesos e sua associação com marcadores de risco cardiovascular

Introdução: A obesidade é um dos fatores mais importantes para explicar o aumento incidência das Doenças Cardiovasculares (DCV). Dentre os múltiplos fatores de risco para estas doenças, a albuminúria é dos mais importantes.  Objetivos: Avaliar os níveis de albuminúria e correlacionar com outros marcadores de risco cardiovascular em pacientes obesos que procuraram tratamento para obesidade. Materiais e métodos: Estudo transversal, retrospectivo, através dos prontuários de 183 pacientes de ambos os sexos, entre 18 e 65 anos, com índice de massa corpórea (IMC) ≥ 30 Kg/m². Todos os pacientes foram submetidos a exame físico e receberam um pedido de rotina laboratorial, incluindo de albuminúria em amostra isolada de urina. Resultados: Dados de albuminúria estavam disponíveis em 81 prontuários. Destes, 15 pacientes (18,5%) tinham valores acima de 17 mg/L de albuminúria. Nenhuma correlação foi encontrada entre os níveis de albuminúria e os parâmetros antropométricos (IMC, r=0,08; p=0,47; Cintura, r=0,17; p=0.11; Quadril, r=0,11; p=0,35; RCQ, r=0,03; p=0,75), Pressão Arterial (PA) sistólica (r=0,013; p=0,21) ou diastólica (r=0,11; p=0,32). Nenhuma diferença foi encontrada entre os pacientes que já usavam anti-hipertensivos ou não (p=0,25). Foi encontrada correlação entre os níveis de albuminúria e o high-density lipoprotein cholesterol (HDLc), (r=-0,27; p=0,012), além de uma tendência a significância com os níveis de Proteína C Reativa Ultrassensível (PCR-us; r=0,21; p= 0,081). Conclusão: Apesar da alta frequência (18,5%) de albuminúria em pacientes obesos, não foi encontrada correlação entre este marcador e os parâmetros antropométricos. Foi encontrado uma relação inversa da albuminúria com HDLc e uma tendência a significância com a PCR-us, sugerindo uma associação limitada entre a albuminúria e alguns marcadores específicos de risco cardiovascular.

Cigarette smoking as a risk factor for diabetic nephropathy: A systematic review and meta-analysis of prospective cohort studies

Background

Observational studies suggested that tobacco smoking was associated with diabetic nephropathy (DN). However, the results were conflicting and inconsistent. In the study, we performed a meta-analysis to assess the relationship between tobacco smoking and the development of DN.

Materials and methods

We searched in PubMed, Embase, Web of Science and the Cochrane Library (CENTRAL) from database inception until Mar 8, 2018, and updated our search on May 1, 2018. We screened the reference lists of the retrieved articles. Only original prospective cohort studies which have investigated the association between smoking and DN incidence or its progression were included. Pooled HRs and 95% confidence intervals (CIs) were calculated using a random effects model.

Results

A total of 9 prospective cohort studies were identified, including more than 203337 participants. Compared with those of no smoking, smoking participants increased the risk of developing DN (HR = 1.07, 95% CI: 1.01–1.13, P = 0.01). The subgroup analysis showed that the current and total smoking may increase the risk of DN, but these results did not reach statistical significance (current: HR = 1.69, 95% CI = 0.79–3.64, p = 0.17; total: HR = 1.17, 95% CI = 0.97–1.41, p = 0.10), whereas former smoking significantly increased the risk of DN (HR = 1.04, 95% CI = 1.03–1.05, p<0.001). Compared with no-smokers, smokers showed an elevated risk of developing DN (HR = 1.05; 95% CI, 1.00–1.11, P = 0.05). In patients with T2DM, those who smoked were at an increased risk of developing DN, as compared to those who had never smoked (HR = 1.05; 95% CI, 1.00–1.11, P = 0.05). However, compared to no smoking, smoking did not increase the risk of DN development in patients with T2DM (HR = 1.15; 95% CI, 0.9–1.47, P = 0.25). Univariate and multivariate meta-regression did not find any confounding factors. No publication bias was found in the meta-analysis.

Conclusions

The present study highlighted that smoking was an independent risk factor for DN, especially in patients with T1DM. This is the first meta-analysis of prospective cohort studies to discuss the relationship between smoking and DN.

Are blood lipids associated with microvascular complications among type 2 diabetes mellitus patients? A cross-sectional study in Shanghai, China

BACKGROUND

Although there are several studies to investigate the association between blood lipids and microvascular complications, these studies reported conflicting results. The aim of the current study was to explore the association between blood lipid parameters and the risk of microvascular complications, especially the dose-response association between them, among community patients with type 2 diabetes mellitus (T2DM) in Shanghai, China.

METHODS

The cross-sectional study was conducted in 6 community health service centers in Shanghai between December 2014 and December 2016.The associations between blood lipids and diabetic kidney disease (DKD) or diabetic retinopathy (DR) were assessed using multiple logistic regression. Restricted cubic spline (RCS) was employed to estimate the dose-response relation of blood lipids and the risk of microvascular complications.

RESULTS

A total of 3698 participants were included in the final analysis to study the association between blood lipids and DKD, wherein 33.2% of participants had DKD and 1374 were included for the analysis of the association between blood lipids and DR, wherein 23.2% of participants had DR. DKD odds ratio was increased by 1.16(95%CI,1.08-1.25), 1.21(95%CI,1.13-1.30), 1.18(95%CI,1.10-1.26) for comparing fourth to first quartiles of triglycerides (TG), TG/high-density lipoprotein cholesterol (HDL-C), non-HDL-C/HDL-C, respectively, and decreased by 0.83(95%CI,0.78-0.89) for comparing fourth to first quartiles of HDL-C. Furthermore, the dose-response association between TG, HDL-C, TG/HDL-C, non-HDL-C/HDL-C and the risk of DKD demonstrated turning points in TG of 1.90 mmol/L, HDL-C of 1.62 mmol/L, TG/HDL-C of 2.00, non-HDL-C/HDL-C of 3.09, respectively. However, no significant association was found between blood lipid parameters and DR.

CONCLUSIONS

This community-based study indicated that TG, HDL-C, TG/HDL-C, non-HDL-C/HDL-C were independently associated with DKD but not DR.

Incidence and predictors of chronic kidney diseases among type 2 diabetes mellitus patients at St. Paul's Hospital, Addis Ababa, Ethiopia

OBJECTIVE

This study aimed to estimate the incidence of chronic kidney disease and its predictors among newly diagnosed type 2 diabetes patients attending St. Paul's Hospital, Addis Ababa, Ethiopia.

RESULTS

The overall incidence of chronic kidney disease was a major public health issue among type 2 diabetes mellitus patients with 2178 (95% CI 12,801, 21,286) cases per 10,000 patient-months. Moreover, 62(14.25%) patients in the sample experienced chronic kidney disease. Old age [adjusted hazard ratio (AHR) = 1.06, 95%CI 1.03, 1.09], no diabetic retinopathy [AHR = 0.13, 95%CI 0.07-0.24], high density lipoprotein cholesterol ≥ 40 mg/dl [AHR = 0.55, 95%CI 0.31, 0.97] and high body mass index [AHR = 1.17, 95%CI 1.1, 1.25] were common factors for chronic kidney diseases.

Smoking and the risk of diabetic nephropathy in patients with type 1 and type 2 diabetes: a meta-analysis of observational studies

Background

Conflicting evidence exists for observational studies on whether tobacco smoking is a risk factor for diabetic nephropathy (DN) in patients with type 1 (T1DM) and type 2 diabetes mellitus (T2DM). In this meta-analysis, we aimed to assess the effects of tobacco smoking on the development of DN.

Materials and Methods

We searched MEDLINE and EMBASE databases from their inception to March 31^st, 2017 for cross-sectional, case-control, and prospective cohort studies. We screened reference lists of retrieved articles. Summary relative risks (SRRs) and 95% confidence intervals (CIs) were calculated using a random-effects model.

Results

A total of nineteen observational studies (1 case-control, 8 cross-sectional and 10 prospective cohort studies) were identified, involving more than 78,000 participants and a total of 17,832 DN cases. Compared with never-smokers, there was an augmented SRR (95% CI) of DN in ever-smokers in patients with T1DM (1.31 [1.06–1.62]; P = 0.006) and T2DM (1.44 [1.24–1.67]; P < 0.001), respectively. In patients with T1DM, the SRR (95% CI) was 1.25 (0.86–1.83) for microalbuminuria only, 1.27 (1.10–1.48) for macroalbuminuria only, and 1.06 (0.97–1.15) for end-stage renal disease (ESRD). In patients with T2DM, the SRR (95% CI) associated with ever smoking was 1.46 (0.94–2.26) for microalbuminuria only, 1.72 (1.04–2.84) for macroalbuminuria only, and 1.10 (0.36–3.33) for ESRD.

Conclusions

Our meta-analysis suggests evidence for cigarette smoking as an independent risk factor for the development of DN in patients with both T1DM and T2DM.

HDL subclasses and the common CETP TaqIB variant predict the incidence of microangiopatic complications in type 2 diabetic women: A 9years follow-up study

AIMS

Diabetic kidney disease (DKD) and retinopathy (DR) develop in a considerable number of subjects with Type 2 Diabetes (T2D) despite the achievement of the recommended targets for glycaemia and blood pressure. Atherogenic dyslipidemia may play a relevant role, especially in T2DM women.

METHODS

We report our findings on the effect of diabetic dyslipidaemia, the HDL subclasses distribution and the common cholesteryl ester transfer protein (CETP)TaqIB variant on the incidence or the progression of DKD and DR in 97 T2D women, after a ∼9years of follow-up.

RESULTS

At baseline, T2D women presented with low HDL-C levels and higher levels of large lipid rich α-1 (16.34mg/dl), α-2 (33.39mg/dl) and pre- α1 (4.81mg/dl) HDL subparticles. The CETP TaqIB polymorphism and baseline HbA1c, triglycerides, and HDL-C levels as well as specific HDL subpopulations were associated to the occurrence of RD after ∼9years of follow-up. At stepwise regression analysis, HbA1c, triglycerides and the less atheroprotective α-3 HDL particles were the only factors independently associated to the incidence of RD. These same variables were also associated with the progression from background to proliferative RD. BMI, LDL/HDL ratio and low levels of α-1 HDL particles were associated to the occurrence of DKD at univariate analysis, although BMI was the only significant predictor at stepwise multivariate regression analysis.

CONCLUSIONS

In T2D women, atherogenic dyslipidemia as well as subtle modifications in lipoprotein particles profile are associated with incidence and progression of microvascular disease.

Serum uric acid level as an indicator for CKD regression and progression in patients with type 2 diabetes mellitus-a 4.6-year cohort study

BACKGROUND

To investigate the association of serum uric acid level with renal function change in patients with type 2 diabetes mellitus (T2DM).

METHODS

T2DM patients who had been followed-up for at least 3 years were included. Participants were categorized into stable, progression, or regression groups according to their change in chronic kidney disease (CKD) stage. During the follow-up period, all numeric values of metabolic factors, including the uric acid level and the medication possession rate, were calculated in order to investigate their associations with CKD development. Multivariate Cox regression analyses were used to identify independent factors associated with change in CKD.

RESULTS

A total of 2367 T2DM patients were enrolled in this study and followed-up for a mean of 4.6 years. The numbers of patients in the stable, progression and regression groups were 1133 (47.9%), 487 (20.6%), and 747 (31.5%), respectively. The progression group had the highest serum uric acid level (6.9 ± 1.8 mg/dL), and the regression group had the lowest uric acid level (5.4 ± 1.5 mg/dL). In addition, we found that the serum uric acid level was an independent factor associated with CKD progression when the value exceeded 6.3 mg/dL. A lower uric acid level could be beneficial for CKD improvement in T2DM patients with stage 3-5 CKD.

CONCLUSIONS

Our data indicated that the serum uric acid level is associated with CKD regression and progression and suggested that a high normal serum uric acid level should be closely monitored in patients with T2DM. Copyright © 2015 John Wiley & Sons, Ltd.

The Role of Gender in Chronic Kidney Disease

Chronic kidney disease (CKD) is a common disease worldwide and is associated with high rates of morbidity and mortality. This review discusses several aspects of the relationship between gender and CKD. While the prevalence of CKD tends to be higher in women, the disease is more severe in men, who also have a higher prevalence of end-stage renal disease. Most of the evidence in the current literature suggests a higher progression rate and mortality risk of CKD in men compared with women, except in post-menopausal women and diabetic patients. However, the decrease in glomerular filtration rate and the increase in the level of albuminuria are more prominent mortality risk factors among women. Sex hormones are thought to play a major role in the biological mechanisms associated with variability in CKD prevalence and characteristics between men and women. Animal studies have demonstrated the harmful influence of testosterone and protective influence of oestrogen on several biological processes that are involved in kidney injury. However, the role of sex hormones in explaining gender-related differences in CKD in humans has not yet been established. In summary, gender has an important influence on several aspects of CKD. Further research is needed to find additional gender-related characteristics in CKD and to identify the mechanisms of sexual dimorphism in CKD.

Cardiovascular and all-cause mortality in patients with type 2 diabetes mellitus in the MADIABETES Cohort Study: Association with chronic kidney disease

AIMS

To assess the prevalence of stage 3-5 chronic kidney disease (CKD) at baseline and to identify associated risk factors. To determine the effect of CKD and CKD stage according to estimated glomerular filtration rate (eGFR) and albuminuria categories on all-cause and cardiovascular mortality after a 5-year follow-up.

METHODS

Prospective cohort study of 3443 outpatients with type 2 diabetes mellitus.

RESULTS

The prevalence of CKD was 28.32% (95% CI, 26.84-29.86); and variables most strongly associated were: age >74 years (OR, 19.88; 95% CI, 12.89-30.68) and albuminuria (OR, 2.27; 95% CI, 1.72-3.00). During follow-up, 221 CKD patients (22.90%) died compared with 203 non-CKD patients (8.31%) (p<0.01). The adjusted HR of CKD for cardiovascular and all-cause mortality was 1.82 (95% CI, 1.36-2.44) and 2.11 (95% CI, 1.61-2.76) for those with LDL cholesterol =135 mg/dl, respectively. The adjusted HR of very-high-risk CKD for all-cause mortality was 4.44 (95% CI, 2.31-8.53) in aged <75 years and 1.80 (95% CI, 1.19-2.72) in aged ≥75 years.

CONCLUSIONS

CKD at baseline is an independent risk factor for all-cause and cardiovascular mortality in the overall cohort, men and women, or in primary and secondary prevention of coronary heart disease. Albuminuria is an independent risk factor for all-cause and cardiovascular mortality only in primary prevention.

The MCP-1 Gene A-2518G Polymorphism Confers an Increased Risk of Vascular Complications in Type 2 Diabetes Mellitus Patients

OBJECTIVE

We aimed to evaluate the correlation of the monocyte chemoattractant protein 1 (MCP-1) A-2518G polymorphism with type 2 diabetes mellitus (T2DM) and vascular complications in T2DM, to aid in understanding its role in pathogenesis.

METHODS

A total of 150 T2DM patients and 50 healthy controls (group A) were enrolled. The T2DM patients were divided into three groups based on the absence of complications (group B) presence of microvascular disease (group C) or macrovascular disease (group D). DNA of all enrolled subjects was genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) for the MCP-1 A-2518G polymorphism. Serum MCP-1 levels were measured by an enzyme-linked immunosorbent assay (ELISA).

RESULTS

Participants in group D had increased serum MCP-1 levels relative to group B, group C, and group A (all p<0.01). Compared with group A, the frequencies of the MCP-1 A-2518G G/G genotype and G allele were significantly higher in group C and group D (all p<0.05). In contrast to group B, group C had higher frequencies of the G/G genotype and G allele, while group D had higher G allele frequencies (all p<0.05). Logistic regression analysis showed that lower body-mass index (BMI) and free cholesterol (FC), as well as higher high-density lipoprotein cholesterol (HDL-C) levels may be the protective factors for T2DM, while higher levels of triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and G/G genotype frequency were independent risk factors for T2DM.

CONCLUSIONS

Our data indicates a correlation between the MCP-1 A-2518G polymorphism with macrovascular complications in T2DM patients; lower BMI and FC, as well as higher HDL-C levels may be the protective factors for T2DM, while higher levels of TG, LDL-C, and G/G genotype frequency were independent risk factors for T2DM.

Non-HDL-cholesterol to HDL-cholesterol ratio as an independent risk factor for the development of chronic kidney disease

BACKGROUND AND AIMS

Dyslipidemia contributes to the development and progression of renal disease. The objective of this study was to investigate whether an elevated non-HDL-cholesterol to HDL-cholesterol ratio (NonHDLc/HDLc) predicts new-onset chronic kidney disease (CKD).

METHODS AND RESULTS

We followed 1891 Chinese adults with normal or near-normal kidney function at baseline who participated in an annual health checkup program for the occurrence of new-onset CKD [defined as an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m(2) (low eGFR) and/or proteinuria (defined as urinary protein ≥1 + on dipstick testing)] or low eGFR. Cox proportional hazards models were used to examine the independent relationship between the plasma NonHDLc/HDLc ratio and new-onset CKD. During a median follow-up period of 2.8 years, 3% (n = 57) of participants developed new-onset CKD. Compared with patients in the lowest tertile, patients with NonHDLc/HDLc ratios in the highest tertile had a 1.45-fold higher risk of new-onset CKD (hazard ratio [HR], 2.45; 95% confidence interval [95% CI], 1.07 to 5.61; P = 0.035) after adjustment for potential confounders. There was a marginally significant association with low eGFR (tertile 3 versus tertile 1: HR, 2.94; 95% CI, 0.98 to 8.82; P = 0.054).

CONCLUSIONS

NonHDLc/HDLc ratio is an independent risk factor for the development of CKD. Assessment of NonHDLc/HDLc ratio may help identify high risk groups with chronic kidney disease.

Five-year incidence of chronic kidney disease (stage 3-5) and associated risk factors in a Spanish cohort: the MADIABETES Study

Objective

To evaluate the incidence rate of Chronic Kidney Disease (CKD) stage 3-5 (persistent decreased kidney function under 60 mL/min per 1.73 m²) among patients with type 2 diabetes over five years, to identify the risk factors associated with CKD, and develop a risk table to predict five-year CKD stage 3-5 risk stratification for clinical use.

Design

The MADIABETES Study is a prospective cohort study of 3,443 outpatients with type 2 diabetes mellitus, sampled from 56 primary health care centers (131 general practitioners) in Madrid (Spain).

Results

The cumulative incidence of CKD stage 3-5 at five-years was 10.23% (95% CI = 9.12–11.44) and the incidence density was 2.07 (95% CI = 1.83–2.33) cases per 1,000 patient-months or 2.48 (95% CI = 2.19–2.79) cases per 100 patient-years. The highest hazard ratio (HR) for developing CKD stage 3-5 was albuminuria ≥300 mg/g (HR = 4.57; 95% CI= 2.46-8.48). Furthermore, other variables with a high HR were age over 74 years (HR = 3.20; 95% CI = 2.13–4.81), a history of Hypertension (HR = 2.02; 95% CI = 1.42–2.89), Myocardial Infarction (HR= 1.72; 95% IC= 1.25–2.37), Dyslipidemia (HR = 1.68; 95% CI 1.30–2.17), duration of diabetes mellitus ≥ 10 years (HR = 1.46; 95% CI = 1.14-1.88) and Systolic Blood Pressure >149 mmHg (HR = 1.52; 95% CI = 1.02–2.24).

Conclusions

After a five-year follow-up, the cumulative incidence of CKD is concordant with rates described in Spain and other countries. Albuminuria ≥ 300 mg/g and age over 74 years were the risk factors more strongly associated with developing CKD (Stage 3-5). Blood Pressure, lipid and albuminuria control could reduce CKD incidence of CKD in patients with T2DM.

Relationship between dyslipidemia and albuminuria in prediabetic adults: the Korea National Health and Nutrition Examination Survey 2011-2012

This study aimed to estimate the relationship between various lipid abnormalities and albuminuria in Korean prediabetic adults. Data obtained from the Korea National Health and Nutrition Examination Survey (KNHANES) 2011-2012 were analyzed. The study consisted of 4,811 subjects in the normal glucose group and 3,872 in the prediabetic group. Prediabetes was defined by the fasting plasma glucose or hemoglobin A1c level. Albuminuria was defined as a urine albumin to creatinine ratio (UACR) ≥30 mg/g. Various parameters of dyslipidemia were assessed. No differences were observed in the prevalence of lipid abnormalities in prediabetic men with different values of UACR. Prediabetic women with increased urinary albumin excretion showed a significantly higher prevalence of lipid abnormalities. The proportion of mixed dyslipidemia was significantly higher in prediabetic women with albuminuria. Higher levels of total cholesterol, triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C), and TC to HDL-C ratio, TG to HDL-C ratio, and LDL-C to HDL-C ratio were significantly associated with increased risk of albuminuria in prediabetic women.

CONCLUSIONS

Several lipid abnormalities were significantly associated with the increased risk of albuminuria in prediabetic women. Hence, screening for lipid abnormalities may be helpful for identification of risk for albuminuria in prediabetic subjects.

High protein weight loss diets in obese subjects with type 2 diabetes mellitus

BACKGROUND AND AIM

Diets where carbohydrate has been partially exchanged for protein have shown beneficial changes in persons with type 2 diabetes but no studies have enrolled people with albuminuria. We aim to determine if a high protein to carbohydrate ratio (HPD) in an energy reduced diet has a beneficial effect on metabolic control and cardiovascular risk factors without negatively affecting renal function.

METHOD AND RESULTS

Adult, overweight participants with type 2 diabetes, with albuminuria (30-600 mg/24 h or an albumin-to-creatinine ratio of 3.0-60 mg/mmol), and estimated GFR of >40 ml/min/1.73 m(2) were enrolled. Participants were randomized to an HPD or an SPD. Protein:fat:carbohydrate ratio was 30:30:40% of energy for the HPD and 20:30:50% for the SPD. Main outcomes were renal function, weight loss, blood pressure, serum lipids and glycaemic control. We recruited 76 volunteers and 45 (35 men and 10 women) finished. There were no overall changes in renal function at 12 months and no significant differences in weight loss between groups (9.7 ± 2.9 kg and 6.6 ± 1.4 kg HPD and SPD group respectively; p = 0.32). Fasting blood glucose decreased significantly with no treatment effect. The decrease in HbA1c differed between treatments at 6 months (HPD -0.9 vs. SPD -0.3%; p = 0.039) but not at 12 months. HDL increased significantly with no treatment effects. There were no changes in LDL or blood pressure overall but DBP was lower in the HPD group (p = 0.024) at 12 months.

CONCLUSION

Weight loss improved overall metabolic control in this group of well controlled participants with type 2 diabetes regardless of diet composition.

A population-based study on the prevalence and incidence of chronic kidney disease in the Netherlands

PURPOSE

Because most population-based studies on the epidemiology of chronic kidney disease (CKD) are cross-sectional, there is, except for end-stage renal disease, hardly any information on incidence rates.

METHODS

We conducted a retrospective cohort study in a dynamic population, using data of 784,563 adult participants retrieved from the Integrated Primary Care Information database, a primary care database containing the complete electronic longitudinal medical records. CKD (both incidence and prevalence) was based on (1) an increased urine albumin-to-creatinine ratio, (2) a decreased estimated glomerular filtration rate, or (3) explicit statement in the medical record. Results were stratified by age according to the WHO standard population, sex, and diabetes mellitus.

RESULTS

Based on a single measurement only, the incidence rate of CKD in adults was 1,213 per 100,000 person-years, and 6.7 percent of the adult population had a prevalent diagnosis of CKD. The incidence rate increased by age and was the highest in participants with diabetes with an incidence of 25,000 per 100,000 person-years, affecting over 75 percent of participants with diabetes.

CONCLUSIONS

This is the first study to report the incidence rates of all stages of CKD for the entire adult population, stratified by sex, 5-year age groups, and diabetes. Our data demonstrate that the incidence of CKD increases with age and is the highest in participants with diabetes mellitus.

High-density lipoprotein cholesterol and the risk of nephropathy in type 2 diabetic patients

BACKGROUND AND AIMS

To date, few studies have demonstrated the impact of variations in blood pressure, blood glucose and lipid levels on the progression of diabetic nephropathy (DN) in type 2 diabetic patients. This study aimed to assess the associations of mean values and variability in metabolic parameters with the development of DN in type 2 diabetic patients.

METHODS AND RESULTS

A total of 864 patients who had participated in a comprehensive diabetic care program for at least for 3 years were studied. Patients were stratified into progressor (n = 180) and non-progressor groups (n = 684) according to the status of progression of DN during the follow-up period. By Cox regression analysis, a higher mean HDL-C level was observed to be a protective factor against the progression of DN [hazard ratio (95% CI): 0.971(0.953-0.989), P = 0.002] and a higher HDL-C variation was found to be associated with a higher risk [hazard ratio (95% CI): 1.177(1.032-1.341), P = 0.015] of DN progression. By the Kaplan-Meier survival curve, patients with a higher HDL-C level and lower HDL-C variability were found to have the lowest risk of development of nephropathy.

CONCLUSIONS

Our study demonstrated for the first time that type 2 diabetic patients under a standard disease management program who have a stable and a higher mean HDL-C level were associated with a lower risk of development of DN.

High triglyceride-to-HDL cholesterol ratio associated with albuminuria in type 2 diabetic subjects

OBJECTIVE

Emerging evidence indicates that metabolic syndrome (MetS) predisposes diabetic subjects to nephropathy. Aside from hypertension and hyperglycemia, it is unclear which component of MetS also contributes to increased urinary albumin excretion (UAE). We compared the MetS profiles of subjects divided into two groups based on their UAE.

METHODS

The Asia Pacific Real-Life Effectiveness and Care Patterns of Diabetes Management (AP RECAP-DM) study is a cross-sectional survey in which type 2 diabetic subjects using oral anti-hyperglycemic drugs were enrolled. We analyzed the data of 162 type 2 diabetic subjects with normotension or taking antihypertensive medications.

RESULTS

There were 123 subjects with normal UAE (<30 mg/g) and 39 with abnormal UAE (≥30 mg/g). MetS was more prevalent in the abnormal UAE group (79.5%) than in the normal UAE group (58.5%) (P=0.018). Hypertriglyceridemia (odds ratio=8.65, P<0.001) and reduced high-density lipoprotein (HDL) cholesterol (odds ratio=3.27, P=0.022) were both independently associated with abnormal UAE. Using 3.4 as a cut-off value, a high triglyceride-to-HDL cholesterol ratio was a useful marker (odds ratio=15.05, P<0.001) for abnormal UAE.

CONCLUSIONS

A high triglyceride-to-HDL cholesterol ratio was found to be an important risk factor for nephropathy in type 2 diabetic subjects.

Inconsistency in albuminuria predictors in type 2 diabetes: a comparison between neural network and conditional logistic regression

Albuminuria is a sensitive marker to predict future cardiovascular events in patients with type 2 diabetes mellitus. However, current studies only use conventional regression models to discover predictors of albuminuria. We have used 2 different statistical models to predict albuminuria in type 2 diabetes mellitus: a multilayer perception neural network and a conditional logistic regression. Neural network models were used to predict the level of albuminuria in patients with type 2 diabetes mellitus, which include a matched case-control study for the population. For each case, we randomly selected 1 control matched by age and body mass index (BMI). The input variables were sex, duration of diabetes, systolic and diastolic blood pressure, glomerular filtration rate, high-density lipoprotein, low-density lipoprotein, triglyceride, high-density lipoprotein/triglyceride ratio, cholesterol, fasting blood sugar, and glycated hemoglobin. Age and BMI were included only in the neural network model. This model included 4 hidden layers and 1 bias. Relative error of predictions was 0.38% in the training group, 0.52% in the testing group, and 1.20% in the holdout group. The most robust predictors of albuminuria were high-density lipoprotein (21%), cholesterol (14.4%), and systolic blood pressure (9.7%). Using the conditional logistic regression model, glomerular filtration rate, time of onset to diabetes, and sex were significant indicators in the onset of albuminuria. Using a neural network model, we show that high-density lipoprotein is the most important factor in predicting albuminuria in type 2 diabetes mellitus. Our neural network model complements the current risk factor models to improve the care of patients with diabetes.

Smoking is associated with impaired long-term glucose metabolism in patients with type 1 diabetes mellitus

BACKGROUND AND AIMS

Smoking is known to negatively influence glucose metabolism both in healthy subjects and in patients with diabetes. The aim of this study was to compare glycemic control in patients with type 1 diabetes mellitus who were smokers with those who did not smoke during a prospective long-term follow-up.

METHODS AND RESULTS

In a single center, 763 patients with type 1 diabetes mellitus were included, 160 (21.0%) of them were smokers. Patients were treated with intensive insulin therapy according to existing guidelines. Glucose control was monitored quarterly, diabetes related complications and cardiovascular risk factors were assessed at least once a year. Glucose control in smokers was significantly worse than in non-smokers at baseline and during follow-up (mean HbA1c during 5047 patient-years of follow-up 7.9 ± 1.3% in smokers and 7.3 ± 1.1% in non-smokers, p < 0.001) despite a higher insulin dosage in smokers (0.71 ± 0.30 U/kg vs. 0.65 ± 0.31 U/kg in non-smokers, p = 0.046). HDL cholesterol was lower in smokers at baseline (1.53 ± 0.45 vs. 1.68 ± 0.51 in non-smokers, p = 0.048). Diabetes related complications tended to occur with a higher frequency in smokers, with a significant difference in macroalbuminuria (9.8% vs. 4.8% in non-smokers, p = 0.047).

CONCLUSION

Smoking is associated with worse glucose control in patients with type 1 diabetes mellitus despite the same treatment strategies as in non-smokers. Hyperglycemia, therefore, may contribute to an earlier incidence of diabetes related complications in these patients, in addition to direct toxic effects of smoking.

Proteomic study reveals downregulation of apolipoprotein A1 in plasma of poorly controlled diabetes: a pilot study

Proteomic approaches aid in gaining a better understanding of the pathophysiology of diabetic complications. In view of this, differential protein expression in diabetic plasma samples was studied by a combination of proteomic and western blot analyses. Diabetic plasma samples were categorized based on glycated haemoglobin levels as controlled diabetes (CD; 7-8%), poorly controlled diabetes (PCD; >8%) and non-diabetic control (ND;<6.4%). Two-dimensional electrophoresis and liquid chromatography‑mass spectrometry revealed differential expression of proteins including upregulation of fibrinogen and haptoglobin and downregulation of vitamin D binding protein, α-1-antitrypsin, transthyretin and apolipoprotein A1 (Apo A1) in diabetic compared with non-diabetic plasma samples. Amongst these proteins, Apo A1 downregulation was prominent in PCD. Downregulation of Apo A1 may serve as an early predictive marker of diabetic complications.

Low HDL cholesterol and the risk of diabetic nephropathy and retinopathy: results of the ADVANCE study

OBJECTIVE

Although low HDL cholesterol (HDL-C) is an established risk factor for atherosclerosis, data on HDL-C and the risk of microvascular disease are limited. We tested the association between HDL-C and microvascular disease in a cohort of patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 11,140 patients with type 2 diabetes and at least one additional vascular risk factor were followed a median of 5 years. Cox proportional hazards models were used to assess the association between baseline HDL-C and the development of new or worsening microvascular disease, defined prospectively as a composite of renal and retinal events.

RESULTS

The mean baseline HDL-C level was 1.3 mmol/L (SD 0.45 mmol/L [range 0.1-4.0]). During follow-up, 32% of patients developed new or worsening microvascular disease, with 28% experiencing a renal event and 6% a retinal event. Compared with patients in the highest third, those in the lowest third had a 17% higher risk of microvascular disease (adjusted hazard ratio 1.17 [95% CI 1.06-1.28], P = 0.001) after adjustment for potential confounders and regression dilution. This was driven by a 19% higher risk of renal events (1.19 [1.08-1.32], P = 0.0005). There was no association between thirds of HDL-C and retinal events (1.01 [0.82-1.25], P = 0.9).

CONCLUSIONS

In patients with type 2 diabetes, HDL-C level is an independent risk factor for the development of microvascular disease affecting the kidney but not the retina.

Triglyceride-high-density lipoprotein cholesterol is associated with microvascular complications in type 2 diabetes mellitus

The purpose of this study was to evaluate whether a high triglyceride/high-density lipoprotein cholesterol (TG/HDL-C) ratio is associated with an increased incidence of retinopathy and chronic kidney disease (CKD) in type 2 diabetes mellitus. Individuals with type 2 diabetes mellitus (n = 979) with an estimated glomerular filtration rate greater than 60 mL/min and without retinopathy and cardiovascular disease at baseline were followed up for the incidence of diabetic retinopathy (diagnosed by retinography) and CKD (diagnosed by estimated glomerular filtration rate ≤60 mL/min/1.73 m(2)). On follow-up (mean, 4.9 years), 217 (22.2% of total) subjects experienced CKD and/or diabetic-specific retinal lesions (microvascular complication). Of these, 111 subjects developed isolated retinopathy, 85 developed CKD alone, and 21 developed both complications. The TG/HDL-C ratio was positively associated with an increased risk of incident retinopathy and/or CKD (composite microvascular end point) independently of age, sex, body mass index, diabetes duration, hemoglobin A(1c), hypertension, smoking history, low-density lipoprotein cholesterol, albuminuria, and current use of hypoglycemic, antihypertensive, lipid-lowering, or antiplatelet drugs (multivariable-adjusted odds ratio, 2.15; 95% confidence intervals, 1.10-4.25; P = .04). These findings suggested that the TG/HDL-C ratio was associated with an increased incidence of microvascular complications in individuals with type 2 diabetes mellitus without prior cardiovascular disease, independently of several potential confounders.

IGF-1 levels link estimated glomerular filtration rate to insulin resistance in obesity: a study in obese, but metabolically healthy, subjects and obese, insulin-resistant subjects

BACKGROUND AND AIMS

Metabolically healthy but obese (MHO) subjects have a favourable cardio-metabolic risk profile, but whether they are also at lower risk for kidney dysfunction is still questionable.

METHODS AND RESULTS

A total of 106 MHO, 122 normal-weight and 212 insulin-resistant obese (IRO) subjects were stratified on the basis of their insulin sensitivity and body mass index (BMI). The CKD-EPI equation was used to estimate glomerular filtration rate (eGFR) and ISI index was used to estimate insulin sensitivity. eGFR was significantly lower in IRO as compared to MHO subjects after adjusting for age, gender and BMI (P = 0.008). In a logistic regression model adjusted for age, gender and BMI, IRO subjects showed an increased risk of having eGFR in the lowest quartile (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.01-3.58; P = 0.04) as compared with MHO subjects. This association was maintained when waist, lean body mass, blood pressure, HDL cholesterol, triglyceride, fasting glucose and insulin levels were additionally included into the model (OR 2.49, 95%CI 1.17-5.27; P = 0.01), but its independence was not retained with further inclusion of insulin-like growth factor-1 (IGF-1) levels (OR 2.16, 95%CI 0.93-5.04; P = 0.07) No differences in eGFR were observed between non-obese and MHO individuals.

CONCLUSIONS

These results indicate that heterogeneity in obese phenotypes may account for conflicting evidence regarding the significance of obesity as a risk factor for chronic kidney disease. Our findings suggest that obesity is associated with lower kidney function only when insulin sensitivity is reduced, and that plasma IGF-1 is likely to be an important mechanism linking the IRO phenotype with reduced eGFR.

Recognition, pathogenesis, and treatment of different stages of nephropathy in patients with type 2 diabetes mellitus

Nephropathy is a common microvascular complication among patients with type 2 diabetes mellitus and a major cause of kidney failure. It is characterized by albuminuria (≥ 300 mg/d) and a reduced glomerular filtration rate and is often present at the time of diabetes diagnosis after the kidney has been exposed to chronic hyperglycemia during the prediabetic phase. A low glomerular filtration rate (<60 mL/min/1.73 m(2)) is also an independent risk factor for cardiovascular events and death. Detection of diabetic nephropathy during its initial stages provides the opportunity for early therapeutic interventions to prevent or delay the onset of complications and improve outcomes. An intensive and multifactorial management approach is needed that targets all risk determinants simultaneously. The strategy should comprise lifestyle modifications (smoking cessation, weight loss, increased physical activity, and dietary changes) coupled with therapeutic achievement of blood glucose, blood pressure, and lipid goals that are evidence-based. Prescribing decisions should take into account demographic factors, level of kidney impairment, adverse effects, risk of hypoglycemia, tolerability, and effects on other risk factors and comorbidities. Regular and comprehensive follow-up assessments with appropriate adjustment of the therapeutic regimen to maintain risk factor control is a vital component of care, including referral to specialists, when required.

One-hour postload plasma glucose levels are associated with kidney dysfunction

BACKGROUND AND OBJECTIVES

A cutoff of 155 mg/dl for 1-hour postload plasma glucose (1hPG) during the oral glucose tolerance test (OGTT) is able to identify patients who are at high risk for type 2 diabetes and vascular atherosclerosis. We aimed to examine whether individuals with 1hPG ≥155 mg/dl are also at increased risk for chronic kidney disease (CKD).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Atherosclerosis risk factors, OGTT, and estimated GFR by Chronic Kidney Disease Epidemiology Collaboration equation were analyzed in 1075 white individuals without diabetes.

RESULTS

The area under the receiver operating characteristic curve for 1hPG was the highest (0.700) compared with the areas under the receiver operating characteristic curve of 0, 30-minute, and 2-hour glucose concentrations. Individuals with 1hPG ≥155 mg/dl had a worse cardiometabolic risk profile, exhibiting significantly higher body mass index, BP, triglycerides, and fasting insulin levels and lower HDL, IGF-1 levels, and insulin sensitivity, than individuals with 1hPG <155 mg/dl. Estimated GFR was significantly lower in individuals with 1hPG ≥155 mg/dl. In a logistic regression model adjusted for age and gender, individuals with 1hPG ≥155 mg/dl showed an increased risk for CKD compared with individuals with 1hPG <155 mg/dl. When the logistic regression analysis was restricted to individuals who had normal glucose tolerance, those with 1hPG ≥155 mg/dl showed a higher risk for CKD compared with individuals with 1hPG <155 mg/dl.

CONCLUSIONS

These data suggest that a cutoff point of 155 mg/dl for the 1hPG during OGTT may be helpful in the identification of individuals who are at increased risk for CKD.