1
|
Antioxidant and Antihyperglycemic Effects of Ephedra foeminea Aqueous Extract in Streptozotocin-Induced Diabetic Rats. Nutrients 2022; 14:nu14112338. [PMID: 35684137 PMCID: PMC9182796 DOI: 10.3390/nu14112338] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Ephedra foeminea is known in Jordan as Alanda and traditionally. It is used to treat respiratory symptoms such as asthma and skin rashes as an infusion in boiling water. The purpose of this study was to determine the antidiabetic property of Ephedra foeminea aqueous extract in streptozotocin-induced diabetic rats. Methods: The aqueous extract of Ephedra foeminea plant was used to determine the potential of its efficacy in the treatment of diabetes, and this extract was tested on diabetic rats as a model. The chemical composition of Ephedra foeminea aqueous extract was determined using liquid chromatography–mass spectrometry (LC-MS). Antioxidant activity was assessed using two classical assays (ABTS and DPPH). Results: The most abundant compounds in the Ephedra foeminea extract were limonene (6.3%), kaempferol (6.2%), stearic acid (5.9%), β-sitosterol (5.5%), thiamine (4.1%), riboflavin (3.1%), naringenin (2.8%), kaempferol-3-rhamnoside (2.3%), quercetin (2.2%), and ferulic acid (2.0%). The antioxidant activity of Ephedra foeminea aqueous extract was remarkable, as evidenced by radical scavenging capacities of 12.28 mg Trolox/g in ABTS and 72.8 mg GAE/g in DPPH. In comparison to control, induced diabetic rats treated with Ephedra foeminea extract showed significant improvement in blood glucose levels, lipid profile, liver, and kidney functions. Interleukin 1 and glutathione peroxidase levels in the spleen, pancreas, kidney, and liver of induced diabetic rats treated with Ephedra foeminea extract were significantly lower than in untreated diabetic rats. Conclusions: Ephedra foeminea aqueous extract appears to protect diabetic rats against oxidative stress and improve blood parameters. In addition, it has antioxidant properties that might be very beneficial medicinally.
Collapse
|
2
|
Rhee JJ, Zheng Y, Montez-Rath ME, Chang TI, Winkelmayer WC. Associations of Glycemic Control With Cardiovascular Outcomes Among US Hemodialysis Patients With Diabetes Mellitus. J Am Heart Assoc 2017; 6:JAHA.117.005581. [PMID: 28592463 PMCID: PMC5669174 DOI: 10.1161/jaha.117.005581] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background There is a lack of data on the relationship between glycemic control and cardiovascular end points in hemodialysis patients with diabetes mellitus. Methods and Results We included adult Medicare‐insured patients with diabetes mellitus who initiated in‐center hemodialysis treatment from 2006 to 2008 and survived for >90 days. Quarterly mean time‐averaged glycated hemoglobin (HbA1c) values were categorized into <48 mmol/mol (<6.5%) (reference), 48 to <58 mmol/mol (6.5% to <7.5%), 58 to <69 mmol/mol (7.5% to <8.5%), and ≥69 mmol/mol (≥8.5%). Medicare claims were used to identify outcomes of cardiovascular mortality, nonfatal myocardial infarction (MI), fatal or nonfatal MI, stroke, and peripheral arterial disease. We used Cox models as a function of time‐varying exposure to estimate multivariable adjusted hazard ratios and 95%CI for the associations between HbA1c and time to study outcomes in a cohort of 16 387 eligible patients. Patients with HbA1c 58 to <69 mmol/mol (7.5% to <8.5%) and ≥69 mmol/mol (≥8.5%) had 16% (CI, 2%, 32%) and 18% (CI, 1%, 37%) higher rates of cardiovascular mortality (P‐trend=0.01) and 16% (CI, 1%, 33%) and 15% (CI, 1%, 32%) higher rates of nonfatal MI (P‐trend=0.05), respectively, compared with those in the reference group. Patients with HbA1c ≥69 mmol/mol (≥8.5%) had a 20% (CI, 2%, 41%) higher rate of fatal or nonfatal MI (P‐trend=0.02), compared with those in the reference group. HbA1c was not associated with stroke, peripheral arterial disease, or all‐cause mortality. Conclusions Higher HbA1c levels were significantly associated with higher rates of cardiovascular mortality and MI but not with stroke, peripheral arterial disease, or all‐cause mortality in this large cohort of hemodialysis patients with diabetes mellitus.
Collapse
Affiliation(s)
- Jinnie J Rhee
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Yuanchao Zheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Heath, Baylor College of Medicine, Houston, TX
| |
Collapse
|
3
|
Waasdorp M, Duitman J, Spek CA. Plasmin reduces fibronectin deposition by mesangial cells in a protease-activated receptor-1 independent manner. Biochem Biophys Rep 2017; 10:152-156. [PMID: 29114573 PMCID: PMC5637235 DOI: 10.1016/j.bbrep.2017.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/17/2017] [Accepted: 03/28/2017] [Indexed: 12/31/2022] Open
Abstract
Background Protease-activated receptor-1 (PAR-1) potentiates diabetic nephropathy (DN) as evident from reduced kidney injury in diabetic PAR-1 deficient mice. Although thrombin is the prototypical PAR-1 agonist, anticoagulant treatment does not limit DN in experimental animal models suggesting that thrombin is not the endogenous PAR-1 agonist driving DN. Objectives To identify the endogenous PAR-1 agonist potentiating diabetes-induced nephropathy. Methods Unbiased protease expression profiling in glomeruli from human kidneys with DN was performed using publically available microarray data. The identified prime candidate PAR-1 agonist was subsequently analysed for PAR-1-dependent induction of fibrosis in vitro. Results Of the 553 proteases expressed in the human genome, 247 qualified as potential PAR-1 agonists of which 71 were significantly expressed above background in diabetic glomeruli. The recently identified PAR-1 agonist plasmin(ogen), together with its physiological activator tissue plasminogen activator, were among the highest expressed proteases. Plasmin did however not induce mesangial proliferation and/or fibronectin deposition in vitro. In a PAR-1 independent manner, plasmin even reduced fibronectin deposition. Conclusion Expression profiling identified plasmin as potential endogenous PAR-1 agonist driving DN. Instead of inducing fibronectin expression, plasmin however reduced mesangial fibronectin deposition in vitro. Therefore we conclude that plasmin may not be the endogenous PAR-1 agonist potentiating DN. Plasmin is highly expressed in kidneys of diabetic nephropathy patients. Plasmin limits fibronectin deposition by mesangial cells. Plasmin-dependent PAR-1 activation does not drive diabetic nephropathy.
Collapse
Affiliation(s)
- Maaike Waasdorp
- Center for Experimental and Molecular Medicine, Academic Medical Center, Amsterdam 1105 AZ, The Netherlands
| | - JanWillem Duitman
- Center for Experimental and Molecular Medicine, Academic Medical Center, Amsterdam 1105 AZ, The Netherlands.,INSERM, UMR1152, Medical School Xavier Bichat, Paris, France.,Paris Diderot University, Sorbonne Paris Cité, Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodeling), LabEx Inflamex, Paris, France
| | - C Arnold Spek
- Center for Experimental and Molecular Medicine, Academic Medical Center, Amsterdam 1105 AZ, The Netherlands
| |
Collapse
|
4
|
Rhee JJ, Ding VY, Rehkopf DH, Arce CM, Winkelmayer WC. Correlates of poor glycemic control among patients with diabetes initiating hemodialysis for end-stage renal disease. BMC Nephrol 2015; 16:204. [PMID: 26645204 PMCID: PMC4673753 DOI: 10.1186/s12882-015-0204-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/30/2015] [Indexed: 12/21/2022] Open
Abstract
Background Maintaining tight glycemic control is important for prevention of diabetes-related outcomes in end-stage renal disease patients with diabetes, especially in light of their poor prognosis. This study aimed to determine factors associated with poor glycemic control among U.S. patients with diabetes mellitus initiating hemodialysis for end-stage renal disease. Methods Using data from the U.S. Renal Data System, electronic health records of a large national dialysis provider, and U.S. Census data, we performed a cross-sectional multivariable Poisson regression analysis to characterize risk factors associated with poor glycemic control, defined as glycated hemoglobin (HbA1c) >7 vs. ≤7 %, in adult patients with diabetes who initiated hemodialysis at an outpatient facility between 2006 and 2011. Results Of 16,297 patients with diabetes, 21.2 % had HbA1c >7 %. In multivariable analysis, younger patients, patients of Native American race, and those of Hispanic ethnicity had higher prevalence of poor glycemic control. Independent correlates of poor glycemic control further included higher platelet count, white blood cell count, and ferritin; higher body mass index, systolic blood pressure, total cholesterol and triglyceride concentrations; lower HDL and albumin concentrations; lower normalized protein catabolic rate; and higher estimated glomerular filtration rate at initiation of dialysis (all P < 0.05). No independent associations were found with area-level socioeconomic indicators. Occurrence of diabetes in patients <40 years of age, a proxy for type 1 diabetes, was associated with poor HbA1c control compared with that in patients ≥40 years of age, which was classified as type 2 diabetes. These findings were robust to the different outcome definitions of HbA1c >7.5 % and >8 %. Conclusion In this cohort of incident end-stage renal disease patients with diabetes, poor glycemic control was independently associated with younger age, Native American race, Hispanic ethnicity, higher body mass index, and clinical risk factors including atherogenic lipoprotein profile, hypertension, inflammation, and markers indicative of malnutrition and a more serious systemic disease.
Collapse
Affiliation(s)
- Jinnie J Rhee
- Division of Nephrology, Stanford University School of Medicine, 1070 Arastradero Road #3C3109, Palo Alto, CA, 94304, USA.
| | - Victoria Y Ding
- Division of Bioinformatics Research, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - David H Rehkopf
- Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Cristina M Arce
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|
5
|
Ricks J, Molnar MZ, Kovesdy CP, Shah A, Nissenson AR, Williams M, Kalantar-Zadeh K. Glycemic control and cardiovascular mortality in hemodialysis patients with diabetes: a 6-year cohort study. Diabetes 2012; 61:708-15. [PMID: 22315308 PMCID: PMC3282812 DOI: 10.2337/db11-1015] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 12/01/2011] [Indexed: 11/23/2022]
Abstract
Previous observational studies using differing methodologies have yielded inconsistent results regarding the association between glycemic control and outcomes in diabetic patients receiving maintenance hemodialysis (MHD). We examined mortality predictability of A1C and random serum glucose over time in a contemporary cohort of 54,757 diabetic MHD patients (age 63 ± 13 years, 51% men, 30% African Americans, 19% Hispanics). Adjusted all-cause death hazard ratio (HR) for baseline A1C increments of 8.0-8.9, 9.0-9.9, and ≥10%, compared with 7.0-7.9% (reference), was 1.06 (95% CI 1.01-1.12), 1.05 (0.99-1.12), and 1.19 (1.12-1.28), respectively, and for time-averaged A1C was 1.11 (1.05-1.16), 1.36 (1.27-1.45), and 1.59 (1.46-1.72). A symmetric increase in mortality also occurred with time-averaged A1C levels in the low range (6.0-6.9%, HR 1.05 [95% CI 1.01-1.08]; 5.0-5.9%, 1.08 [1.04-1.11], and ≤5%, 1.35 [1.29-1.42]) compared with 7.0-7.9% in fully adjusted models. Adjusted all-cause death HR for time-averaged blood glucose 175-199, 200-249, 250-299, and ≥300 mg/dL, compared with 150-175 mg/dL (reference), was 1.03 (95% CI 0.99-1.07), 1.14 (1.10-1.19), 1.30 (1.23-1.37), and 1.66 (1.56-1.76), respectively. Hence, poor glycemic control (A1C ≥8% or serum glucose ≥200 mg/dL) appears to be associated with high all-cause and cardiovascular death in MHD patients. Very low glycemic levels are also associated with high mortality risk.
Collapse
Affiliation(s)
- Joni Ricks
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor–University of California, Los Angeles, Medical Center, Torrance, California
| | - Miklos Z. Molnar
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor–University of California, Los Angeles, Medical Center, Torrance, California
- Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Csaba P. Kovesdy
- Division of Nephrology, Salem VA Medical Center, Salem, Virginia
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Anuja Shah
- Division of Nephrology and Hypertension, Harbor–University of California, Los Angeles, Medical Center, Torrance, California
| | - Allen R. Nissenson
- DaVita Inc., Denver, Colorado
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Mark Williams
- Renal Unit, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor–University of California, Los Angeles, Medical Center, Torrance, California
- Division of Nephrology and Hypertension, Harbor–University of California, Los Angeles, Medical Center, Torrance, California
- Renal Unit, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, University of California, Los Angeles, School of Public Health, Los Angeles, California
| |
Collapse
|
6
|
Duong U, Mehrotra R, Molnar MZ, Noori N, Kovesdy CP, Nissenson AR, Kalantar-Zadeh K. Glycemic control and survival in peritoneal dialysis patients with diabetes mellitus. Clin J Am Soc Nephrol 2011; 6:1041-8. [PMID: 21511838 PMCID: PMC3087769 DOI: 10.2215/cjn.08921010] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 12/20/2010] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES The optimal target for glycemic control has not been established for diabetic peritoneal dialysis (PD) patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined mortality-predictability of hemoglobin A1c random serum glucose in a contemporary cohort of diabetic PD patients treated in DaVita dialysis clinics July 2001 through June 2006 with follow-up through June 2007. RESULTS We identified 2798 diabetic PD patients with A1c data. Serum glucose correlated with A1C (r=0.51). Adjusted all-cause death hazard ratio and 95% confidence interval for baseline A1c increments of 7.0 to 7.9%, 8.0 to 8.9%, 9.0 to 9.9%, and ≥10%, compared with 6.0 to 6.9% (reference), were 1.13 (0.97 to 1.32), 1.05 (0.88 to 1.27), 1.06 (0.84 to 1.34), and 1.48 (1.18 to 1.86); and for time-averaged A1c values were 1.10 (0.96 to 1.27), 1.28 (1.07 to 1.53), 1.34 (1.05 to 1.70), and 1.81 (1.33 to 2.46), respectively. The A1c-mortality association was modified by hemoglobin level such that higher all-cause mortality was evident only in nonanemic patients. Similar but non-significant trends in cardiovascular death risk was found across A1c increments. Adjusted all-cause death HR for time-averaged blood glucose 150 to 199, 200 to 249, 250 to 299, and ≥300 mg/dl, compared with 60 to 99 mg/dl (reference), were 1.02 (0.70 to 1.47), 1.12 (0.77 to 1.63), 1.45 (0.97 to 2.18), and 2.10 (1.37 to 3.20), respectively. CONCLUSIONS Poor glycemic control appears associated incrementally with higher mortality in PD patients. Moderate to severe hyperglycemia is associated with higher death risk especially in certain subgroups.
Collapse
Affiliation(s)
- Uyen Duong
- Harold Simmons Center for Chronic Disease Research & Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Rajnish Mehrotra
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Miklos Z. Molnar
- Harold Simmons Center for Chronic Disease Research & Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
- Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Nazanin Noori
- Harold Simmons Center for Chronic Disease Research & Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Salem VA Medical Center, Salem, Virginia
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Allen R. Nissenson
- David Geffen School of Medicine at UCLA, Los Angeles, California
- DaVita, Inc., El Segundo, California; and
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research & Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Epidemiology, UCLA School of Public Health, Los Angeles, California
| |
Collapse
|
7
|
Kovesdy CP, Park JC, Kalantar-Zadeh K. Glycemic control and burnt-out diabetes in ESRD. Semin Dial 2010; 23:148-56. [PMID: 20374552 DOI: 10.1111/j.1525-139x.2010.00701.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Treatment of early diabetes mellitus, the most common cause of chronic kidney disease (CKD), may prevent or slow the progression of diabetic nephropathy and lower mortality and the incidence of cardiovascular disease in the general diabetic population and in patients with early stages of CKD. It is unclear whether glycemic control in patients with advanced CKD, including those with end-stage renal disease (ESRD) who undergo maintenance dialysis treatment is beneficial. Aside from the uncertain benefits of treatment in ESRD, hypoglycemic interventions in this population are also complicated by the complex changes in glucose homeostasis related to decreased kidney function and to dialytic therapies, occasionally leading to spontaneous resolution of hyperglycemia and normalization of hemoglobin A1c levels, a condition which might be termed "burnt-out diabetes." Further difficulties in ESRD are posed by the complicated pharmacokinetics of antidiabetic medications and the serious flaws in our available diagnostic tools used for monitoring long-term glycemic control. We review the physiology and pathophysiology of glucose homeostasis in advanced CKD and ESRD, the available antidiabetic medications and their specifics related to kidney function, and the diagnostic tools used to monitor the severity of hyperglycemia and the therapeutic effects of available treatments, along with their deficiencies in ESRD. We also review the concept of burnt-out diabetes and summarize the findings of studies that examined outcomes related to glycemic control in diabetic ESRD patients, and emphasize areas in need of further research.
Collapse
Affiliation(s)
- Csaba P Kovesdy
- Division of Nephrology, Salem Veterans Affairs Medical Center, Salem, VA 24153, USA.
| | | | | |
Collapse
|
8
|
Kovesdy CP, Sharma K, Kalantar-Zadeh K. Glycemic Control in Diabetic CKD Patients: Where Do We Stand? Am J Kidney Dis 2008; 52:766-77. [DOI: 10.1053/j.ajkd.2008.04.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 04/01/2008] [Indexed: 11/11/2022]
|
9
|
Budhiraja S, Singh J. Protein kinase C beta inhibitors: a new therapeutic target for diabetic nephropathy and vascular complications. Fundam Clin Pharmacol 2008; 22:231-40. [PMID: 18485142 DOI: 10.1111/j.1472-8206.2008.00583.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Diabetic nephropathy (DN) has emerged as the major causative pathology in patients entering end-stage renal disease (ESRD) worldwide and it is responsible for 30-40% of all ESRD cases. Treatments for DN are centered on control of hyperglycemia and blood pressure control. However, current therapeutic regimens have not yet provided satisfactory prevention from the onset of DN. Protein kinase C (PKC) is an intracellular signaling molecule and activation of it plays an important role in the development of diabetic complications. In numerous experimental and clinical studies, inhibition of PKC (LY333531) has been shown to delay/halt the progression of diabetic complications. Presently, the drug is submitted in USA-FDA for new drug application in moderate to severe diabetic retinopathy. This review selectively discusses the role of PKC in DN and therapeutic effects produced by PKC inhibitors in DN. The role of PKC inhibitor in other diabetic complications is also discussed.
Collapse
Affiliation(s)
- S Budhiraja
- Shiksha kunj Public School, Chinnot Colony, Rohtak-124001, Haryana, India
| | | |
Collapse
|
10
|
Kalantar-Zadeh K, Kopple JD, Regidor DL, Jing J, Shinaberger CS, Aronovitz J, McAllister CJ, Whellan D, Sharma K. A1C and survival in maintenance hemodialysis patients. Diabetes Care 2007; 30:1049-55. [PMID: 17337501 DOI: 10.2337/dc06-2127] [Citation(s) in RCA: 192] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The optimal target for glycemic control has not been established in diabetic dialysis patients. RESEARCH DESIGN AND METHODS To address this question, the national database of a large dialysis organization (DaVita) was analyzed via time-dependent survival models with repeated measures. RESULTS Of 82,933 patients undergoing maintenance hemodialysis (MHD) in DaVita outpatient clinics over 3 years (July 2001 through June 2004), 23,618 diabetic MHD patients had A1C measurements at least once. Unadjusted survival analyses indicated paradoxically lower death hazard ratios (HRs) with higher A1C values. However, after adjusting for potential confounders (demographics, dialysis vintage, dose, comorbidity, anemia, and surrogates of malnutrition and inflammation), higher A1C values were incrementally associated with higher death risks. Compared with A1C in the 5-6% range, the adjusted all-cause and cardiovascular death HRs for A1C > or = 10% were 1.41 (95% CI 1.25-1.60) and 1.73 (1.44-2.08), respectively (P < 0.001). The incremental increase in death risk for rising A1C values was monotonic and robust in nonanemic patients (hemoglobin > 11.0 g/dl). In subgroup analyses, the association between A1C > 6% and increased death risk was more prominent among younger patients, those who had undergone dialysis for > 2 years, and those with higher protein intake (> 1 g x kg(-1) x day(-1)), blood hemoglobin (> 11 g/dl), or serum ferritin values (> 500 ng/ml). CONCLUSIONS In diabetic MHD patients, the apparently counterintuitive association between poor glycemic control and greater survival is explained by such confounders as malnutrition and anemia. All things equal, higher A1C is associated with increased death risk. Lower A1C levels not related to malnutrition or anemia appear to be associated with improved survival in MHD patients.
Collapse
Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California 90509-2910, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
García-Donaire JA, Segura J, Ruilope LM. An update of irbesartan and renin-angiotensin system blockade in diabetic nephropathy. Expert Opin Pharmacother 2005; 6:1587-96. [PMID: 16086646 DOI: 10.1517/14656566.6.9.1587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Type 2 diabetes is a chief cause of pathologies such as cardiovascular disease, nephropathy and retinopathy, and its prevalence is increasing worldwide. Development of renal disease can be slowed by tight glycaemic control and treatment of associated hypertension with angiotensin-converting enzyme inhibition, as The Diabetes Control and Complications Trial and the UK Prospective Diabetes Study have demonstrated. Recent clinical trials have supported the use of angiotensin II receptor antagonists in the treatment of diabetic nephropathy, resulting in the approval of new therapeutic indications in the US and Europe. The main goal of this review is to demonstrate how results from the Programme for Irbesartan Mortality and Morbidity Evaluation and other recent studies, based on the effects of renin-angiotensin system blockade, can be appropriate in clinical practice, thus displaying benefits of irbesartan therapy at any stage of renal disease in diabetics.
Collapse
|
12
|
Zaslavsky LMA, Pinotti AF, Gross JL. Diastolic dysfunction and mortality in diabetic patients on hemodialysis: a 4.25-year controlled prospective study. J Diabetes Complications 2005; 19:194-200. [PMID: 15993352 DOI: 10.1016/j.jdiacomp.2004.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2004] [Revised: 11/02/2004] [Accepted: 12/17/2004] [Indexed: 11/29/2022]
Abstract
Among patients on hemodialysis, the mortality rate is higher in individuals with diabetes than in nondiabetic individuals, especially due to cardiovascular causes. The objective of the present study was to evaluate the role of echocardiographic abnormalities to predict mortality in diabetic patients starting hemodialysis. A 4.25-year prospective study was carried out with 40 diabetic and 28 nondiabetic patients starting hemodialysis in five dialysis centers in the metropolitan area of Porto Alegre, Brazil, between August 1996 and June 1999. Cardiovascular status was evaluated based on World Health Organization criteria, resting electrocardiogram (ECG), myocardial scintigraphy (at rest and after dipyridamole administration), and M-mode and Doppler echocardiography. Left ventricular diastolic function was classified into the following filling patterns: normal, impaired relaxation, pseudonormal, or restrictive. The survival rate was analyzed by Kaplan-Meier curves and predictors of death by Cox's proportional-hazards model. At the end of the study, the overall mortality rate was higher in patients with diabetes [19/40 (47.5%)] than in those without diabetes [2/28 (7.1%), P=.0013, log rank test]. Pseudonormal and restrictive filling patterns (HR: 3.2; 95% CI: 1.2-8.8; P=.02) and presence of diabetes (HR: 4.7; 95% CI: 1.03-21.4; P=.04) were associated with mortality. In conclusion, left ventricular diastolic dysfunction (LVDD) was the main predictor of mortality in this cohort of diabetic and nondiabetic patients starting dialysis. Intensive treatment of cardiovascular risk factors before the start of dialysis and during the treatment might reduce the mortality rate in diabetic patients.
Collapse
Affiliation(s)
- Lerida M A Zaslavsky
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | | | | |
Collapse
|
13
|
Abstract
Type 2 diabetes is increasing globally and is a major cause of conditions such as cardiovascular disease, retinopathy and nephropathy. The Diabetes Control and Complications Trial and the UK Prospective Diabetes Study demonstrated that the progression of renal disease could be slowed by tight glycaemic control and treating any associated hypertension with angiotensin-converting enzyme inhibition. Recent clinical trials have supported the use of angiotensin II receptor antagonists in the treatment of diabetic nephropathy, resulting in the approval of new therapeutic indications in the United States and Europe. The objective of this review is to demonstrate how results from the Program for Irbesartan Mortality and morbidity Evaluation studies apply to clinical practice, and to show how the benefits of irbesartan therapy can be realised at any stage of renal disease in patients with diabetes.
Collapse
Affiliation(s)
- L M Ruilope
- Chief Hypertension Unit, Hospital 12 de Octubre, Madrid 28041, Spain
| |
Collapse
|
14
|
Affiliation(s)
- Zhiheng He
- Section on Vascular Cell Biology and Complications, Joslin Diabetes Center, Harvard Medical School, 1 Joslin Place, Boston, MA 02215, USA
| | | |
Collapse
|
15
|
Mosallaci M, Ghahramani N, Malek-hosseini SA, Tavakoli AR. Renal transplantation in diabetic nephropathy. Transplant Proc 2003; 35:149-51. [PMID: 12591343 DOI: 10.1016/s0041-1345(02)03896-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M Mosallaci
- Organ Transplant Unit, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | | |
Collapse
|
16
|
Reggi Junior SS, Morales PHA, Ferreira SR. Existe concordância no acometimento renal e retiniano da microangiopatia diabética? ACTA ACUST UNITED AC 2001. [DOI: 10.1590/s0004-27302001000500008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Avaliamos associações da microangiopatia a fatores de risco, a correlação entre nefropatia (ND) e retinopatia (RD) diabéticas, assim como a concordância entre os graus de acometimento destes territórios. 157 pacientes, submetidos a oftalmoscopia indireta, foram encaminhados ao Centro de Diabetes para pesquisa de ND, sendo obtidos dados sócio-demográficos e clínicos. Avaliou-se o controle glicêmico pela hemoglobina glicosilada e a presença de ND pela microalbuminúria. Atribuiu-se escores à RD e ND para análises de correlação e concordância. 103 pacientes (57,9±12,9 anos) completaram todas as etapas do estudo; 72% dos encaminhados apresentavam algum grau de RD, sendo que normais e retinopatas tinham características comparáveis. Foram subdivididos em 4 grupos segundo a presença ou ausência de cada complicação. Não houve diferença na distribuição quanto a sexo, raça e escolaridade. O tempo de DM foi maior naqueles com ND+RD quando comparados ao grupo sem RD, com ou sem ND (14,8±6,4 vs. 7,2±5,3 e 9,2±5,6 anos, p< 0,05, respectivamente). A freqüência de fumantes e dislipidemia auto-referida, o IMC, glicemia e hemoglobina glicosilada não diferiram entre os grupos. Pacientes com ambas as complicações tinham pressão arterial média maior que os grupos sem RD, com ou sem ND (147±23 vs. 128±20 e 118±18mmHg, p< 0,05, respectivamente). Indivíduos com ND, independente da presença de RD, apresentaram razão Albumina/Creatinina (A/C) mais alta que os grupos sem ND (p< 0,05); o grupo com apenas RD não diferiu do grupo normal. Os maiores níveis de A/C do grupo com ambas as complicações não diferiram estatisticamente dos nefropatas sem RD. 80% dos pacientes nefropatas apresentavam RD, enquanto 74% dos retinopatas tinham também ND (c2= 6,39; p< 0,05). Detectou-se correlação significante entre estas complicações (r= 0,47; p< 0,05), assim como a concordância entre seus graus, resultando em kappa de 0,154 (IC 95%: 0,031-0,276; p< 0,01). A hipertensão se associou aos casos de maior gravidade, caracterizados pela concomitância de RD e ND. A ocorrência de uma complicação microvascular na ausência de outra sugere a existência de fatores etiopatogênicos órgão-específicos. Nossos dados indicam correspondência entre os graus de lesão renal e retiniana na microangiopatia do DM2. Pacientes com ND se associam a maior risco de lesões retinianas, de modo que o encontro de A/C alterada em paciente diabético requer, ainda que na faixa microalbuminúrica, a investigação de acometimento retiniano.
Collapse
|