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Wearne N, Davidson B. HIV-associated kidney disease: the changing spectrum and treatment priorities. Curr Opin Nephrol Hypertens 2024:00041552-990000000-00182. [PMID: 39155827 DOI: 10.1097/mnh.0000000000001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
PURPOSE OF REVIEW This review examines the impact of HIV on kidney disease, which remains significant despite advances in antiretroviral therapy (ART). The review is timely due to the shifting epidemiology of kidney disease in people with HIV (PWH), driven by increased ART access, noncommunicable diseases, and region-specific opportunistic infections like tuberculosis. RECENT FINDINGS The literature highlights a decline in HIV-associated nephropathy (HIVAN) and a rise in tubulointerstitial diseases and noncommunicable diseases among PWH. Studies from the United States and South Africa report decreased HIVAN prevalence and increased rates of tubulointerstitial diseases linked to tenofovir disoproxil fumarate (TDF) toxicity and tuberculosis (TB). Immune complex glomerulonephritis (ICGN) and diabetic kidney disease (DKD) are also prevalent. SUMMARY The findings underscore the need for improved diagnostic tools for opportunistic infections, management of ART-related complications, and strategies to address noncommunicable diseases in PWH. There is a need to centralize care to address all health needs simultaneously. Future research should focus on APOL1-targeted therapies and the role of SGLT2 inhibitors in CKD. Enhanced transplantation outcomes and the development of guidelines for managing DKD in PWH are critical for advancing clinical practice and improving patient outcomes.
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Affiliation(s)
- Nicola Wearne
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, South Africa
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Wearne N, Davidson B, Blockman M, Jones J, Ross IL, Dave JA. Management of Type 2 Diabetes Mellitus and Kidney Failure in People with HIV-Infection in Africa: Current Status and a Call to Action. HIV AIDS (Auckl) 2023; 15:519-535. [PMID: 37700755 PMCID: PMC10493098 DOI: 10.2147/hiv.s396949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/13/2023] [Indexed: 09/14/2023] Open
Abstract
There is an increasing global burden of diabetes mellitus (DM) and chronic kidney disease (CKD), coupled with a high burden of people with HIV (PWH). Due to an increased lifespan on ART, PWH are now at risk of developing non-communicable diseases, including DM. Africa has the greatest burden of HIV infection and will experience the greatest increase in prevalence of DM over the next two decades. In addition, there is a rising number of people with CKD and progression to kidney failure. Therefore, there is an urgent need for the early identification and management of all 3 diseases to prevent disease progression and complications. This is particularly important in Africa for people with CKD where there is restricted or no access to dialysis and/or transplantation. This review focuses on the epidemiology and pathophysiology of the interaction between HIV infection and DM and the impact that these diseases have on the development and progression of CKD. Finally, it also aims to review the data on the management, which stems from the growing burden of all three diseases.
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Affiliation(s)
- Nicola Wearne
- Division of Nephrology and Hypertension, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Bianca Davidson
- Division of Nephrology and Hypertension, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Marc Blockman
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Jackie Jones
- Medicines Information Centre, Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ian L Ross
- Division of Endocrinology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Joel A Dave
- Division of Endocrinology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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de Sá JR, Rangel EB, Canani LH, Bauer AC, Escott GM, Zelmanovitz T, Bertoluci MC, Silveiro SP. The 2021-2022 position of Brazilian Diabetes Society on diabetic kidney disease (DKD) management: an evidence-based guideline to clinical practice. Screening and treatment of hyperglycemia, arterial hypertension, and dyslipidemia in the patient with DKD. Diabetol Metab Syndr 2022; 14:81. [PMID: 35690830 PMCID: PMC9188192 DOI: 10.1186/s13098-022-00843-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetic kidney disease is the leading cause of end-stage renal disease and is associated with increased morbidity and mortality. This review is an authorized literal translation of part of the Brazilian Diabetes Society (SBD) Guidelines 2021-2022. This evidence-based guideline provides guidance on the correct management of Diabetic Kidney Disease (DKD) in clinical practice. METHODS The methodology was published elsewhere in previous SBD guidelines and was approved by the internal institutional Steering Committee for publication. Briefly, the Brazilian Diabetes Society indicated 14 experts to constitute the Central Committee, designed to regulate methodology, review the manuscripts, and make judgments on degrees of recommendations and levels of evidence. SBD Renal Disease Department drafted the manuscript selecting key clinical questions to make a narrative review using MEDLINE via PubMed, with the best evidence available including high-quality clinical trials, metanalysis, and large observational studies related to DKD diagnosis and treatment, by using the MeSH terms [diabetes], [type 2 diabetes], [type 1 diabetes] and [chronic kidney disease]. RESULTS The extensive review of the literature made by the 14 members of the Central Committee defined 24 recommendations. Three levels of evidence were considered: A. Data from more than 1 randomized clinical trial or 1 metanalysis of randomized clinical trials with low heterogeneity (I2 < 40%). B. Data from metanalysis, including large observational studies, a single randomized clinical trial, or a pre-specified subgroup analysis. C: Data from small or non-randomized studies, exploratory analyses, or consensus of expert opinion. The degree of recommendation was obtained based on a poll sent to the panelists, using the following criteria: Grade I: when more than 90% of agreement; Grade IIa 75-89% of agreement; IIb 50-74% of agreement, and III, when most of the panelist recommends against a defined treatment. CONCLUSIONS To prevent or at least postpone the advanced stages of DKD with the associated cardiovascular complications, intensive glycemic and blood pressure control are required, as well as the use of renin-angiotensin-aldosterone system blocker agents such as ARB, ACEI, and MRA. Recently, SGLT2 inhibitors and GLP1 receptor agonists have been added to the therapeutic arsenal, with well-proven benefits regarding kidney protection and patients' survival.
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Affiliation(s)
- João Roberto de Sá
- Endocrinology Division, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil
| | - Erika Bevilaqua Rangel
- Nephrology Division, UNIFESP, São Paulo, Brazil
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luis Henrique Canani
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Andrea Carla Bauer
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Gustavo Monteiro Escott
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Themis Zelmanovitz
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Marcello Casaccia Bertoluci
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Sandra Pinho Silveiro
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil.
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Eckert I, Koehler IC, Bauer J, Busnello FM, Silva FM. Effects of different sources of dietary protein on markers of kidney function in individuals with diabetes: a systematic review and meta-analysis of randomized controlled trials. Nutr Rev 2021; 80:812-825. [PMID: 34338778 DOI: 10.1093/nutrit/nuab042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
CONTEXT The type of dietary protein may modulate markers of diabetic kidney disease; however, no attempt to summarize the evidence from randomized controlled trials (RCTs) has been performed to date. OBJECTIVE To assess the effects of different types of dietary protein on urinary albumin excretion and glomerular filtration rate in individuals with diabetes. DATA SOURCES MEDLINE, EMBASE, and Scopus were searched for all published RCTs, with no language restriction, up to July 2020. DATA EXTRACTION Study selection and data extraction were performed independently by 3 authors. Risk of bias was assessed independently by 2 authors, and the GRADE approach was used to assess the quality of the evidence. RESULTS Twelve RCTs were included, of which 11 (involving 228 participants) were compiled in meta-analyses of random-effects models. Interventions consisted of diets emphasizing plant or white meat protein, with reduced intake of animal or red meat protein. Pooled data from crossover trials (n = 8) favored intervention diets for urinary albumin excretion (ratio of means, 0.86; 95% confidence interval 0.80 to 0.94; I2 = 4%) and glomerular filtration rate (ratio of means, 0.90; 95% confidence interval 0.87 to 0.94; I2 = 45%), compared with control diets. Results from parallel-design studies (n = 3), however, were not statistically significant for any outcome. The quality of the evidence ranged from very low to moderate, and most studies were judged with at least some concerns in terms of risk of bias. CONCLUSION This meta-analysis found weak evidence for small to moderate improvements in markers of kidney function in favor of interventions with lower animal protein (or red meat protein) compared with usual diets in short-term crossover trials. These findings require confirmation in well-designed randomized controlled trials.
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Affiliation(s)
- Igor Eckert
- I. Eckert is with the Undergraduate Nutrition Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. I.C. Koehler is with the Undergraduate Medical Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. J. Bauer is with the Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. F.M. Busnello and F.M. Silva are with the Department of Nutrition and Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil
| | - Igor C Koehler
- I. Eckert is with the Undergraduate Nutrition Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. I.C. Koehler is with the Undergraduate Medical Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. J. Bauer is with the Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. F.M. Busnello and F.M. Silva are with the Department of Nutrition and Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil
| | - Julia Bauer
- I. Eckert is with the Undergraduate Nutrition Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. I.C. Koehler is with the Undergraduate Medical Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. J. Bauer is with the Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. F.M. Busnello and F.M. Silva are with the Department of Nutrition and Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil
| | - Fernanda M Busnello
- I. Eckert is with the Undergraduate Nutrition Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. I.C. Koehler is with the Undergraduate Medical Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. J. Bauer is with the Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. F.M. Busnello and F.M. Silva are with the Department of Nutrition and Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil
| | - Flávia M Silva
- I. Eckert is with the Undergraduate Nutrition Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. I.C. Koehler is with the Undergraduate Medical Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. J. Bauer is with the Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil. F.M. Busnello and F.M. Silva are with the Department of Nutrition and Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil
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Taylor KS, Mahtani KR, Aronson JK. Combining and converting groups when extracting data for meta-analysis. BMJ Evid Based Med 2021; 26:85-87. [PMID: 33558276 DOI: 10.1136/bmjebm-2020-111647] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Kathryn S Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
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Aggarwal D, Singh G. Effects of single and dual RAAS blockade therapy on progressive kidney disease transition to CKD in rats. Naunyn Schmiedebergs Arch Pharmacol 2019; 393:615-627. [PMID: 31773183 DOI: 10.1007/s00210-019-01759-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/30/2019] [Indexed: 12/11/2022]
Abstract
Ischemic reperfusion (I/R) is the primary cause of acute kidney injury (AKI) in hospitalized patients. Although AKI resolution occurs in few days, it predisposes kidneys to progressive renal injury. Previously, administration of rennin-angiotensin-aldosterone system (RAAS) blocker spironolactone in acute phase was reported to attenuate various manifestations of chronic kidney disease (CKD) in rats. The present study investigates the effects of RAAS blockade during progressive kidney disease (30 days onwards) on CKD outcomes in rodent model of I/R injury. CKD was induced by clamping both renal pedicles for 45 min followed by 90 days of reperfusion in rats. Single and dual RAAS blocker therapy was initiated at 30 days post-I/R injury and continued until the end of the study period. Evaluation of proteinuria and creatinine levels was done every 30 days in various study groups. Assessment of CKD was done by analyzing renal tissue oxidative stress, inflammatory biomarker levels, and histological changes after 90 days of I/R injury. After 90 days, I/R rat kidneys displayed hypertrophy, reduced body weight, increased oxidative stress, elevated inflammatory biomarker levels, and histological abnormalities such as glomerulosclerosis, mesangial expansion, and tubulointerstitial fibrosis. Treatment with losartan or spironolactone alone significantly reduced various CKD-associated features. Remarkably, combined treatment with dual RAAS blocker in low dose or high dose exhibited highest beneficial effects on various parameters in CKD model, with low-dose combination showing fewer side effects. Therefore, we propose that combined low-dose RAAS blockade therapy might serve as a better therapeutic approach for retarding progressive kidney disease transition to CKD.
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Affiliation(s)
- Devesh Aggarwal
- Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab, India
| | - Gaaminepreet Singh
- Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab, India.
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Stratigou T, Vallianou N, Koutroumpi S, Vlassopoulou B, Apostolou T, Tsagarakis S, Ioannidis G. Progression of Albuminuria Among Patients with Type 1 Diabetes Mellitus: A Long Term Observational Follow-up Study. Exp Clin Endocrinol Diabetes 2019; 129:276-282. [PMID: 30802917 DOI: 10.1055/a-0848-8076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The purpose of the present study was to determine whether patients with DM1 have shown improvement, stabilization or deterioration of their urine albumin excretion levels during a close follow-up. PATIENTS AND METHODS A cohort of 84 patients, 18-76 years of age, a median duration of diabetes of 24 years (1-50 years) and a median follow-up duration of 12 years (1-37 years) were included in the study. RESULTS Among the 84 patients for whom we had UAE levels at the beginning and by the end of the study, mean glycosylated hemoglobin was statistically significantly decreased during the follow-up period, from 8.02±2.04-7.06±1.05% (p=0.036). Normoalbuminuria was present in 66 patients and remained so in 56 patients while 9 patients progressed to microalbuminuria and one patient to macroalbuminuria by the end of the study. Microalbuminuria was present in 15 patients: regression was observed in 8 patients, and progression in one patient. Regression of macroalbuminuria to microalbuminuria was noted in one patient and to normoalbuminuria was noted in one participant, too. CONCLUSIONS Improvement of glycemic control with close monitoring of DM1 patients together with the appropriate use ACE or AT2 inhibitors and statins, seems to exert nephron-protective potential and to delay or even reverse the presence of micro/macroalbuminuria. This long term follow-up study has demonstrated a statistically significant increase in serum HDLcholesterol levels. The study also revealed that intensively treated diabetes patients may show reductions in serum ALP levels. Whether this finding is related to diabetic nephropathy, NAFLD, or diabetic hepatosclerosis remains to be assessed in future trials.
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Affiliation(s)
- Theodora Stratigou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Natalia Vallianou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stavroula Koutroumpi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Barbara Vlassopoulou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Theofanis Apostolou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - George Ioannidis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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Managing the Course of Kidney Disease in Adults With Type 2 Diabetes: From the Old to the New. Can J Diabetes 2018; 42:325-334. [DOI: 10.1016/j.jcjd.2017.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/16/2017] [Accepted: 06/20/2017] [Indexed: 02/06/2023]
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Voroneanu L, Siriopol D, Dumea R, Badarau S, Kanbay M, Afsar B, Gavrilovici C, Covic A. Addition of silymarin to renin–angiotensin system blockers in normotensive patients with type 2 diabetes mellitus and proteinuria: a prospective randomized trial. Int Urol Nephrol 2017; 49:2195-2204. [DOI: 10.1007/s11255-017-1697-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 09/04/2017] [Indexed: 12/30/2022]
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Iyngkaran P, Liew D, McDonald P, Thomas MC, Reid C, Chew D, Hare DL. Phase 4 Studies in Heart Failure - What is Done and What is Needed? Curr Cardiol Rev 2016; 12:216-30. [PMID: 27280303 PMCID: PMC5011189 DOI: 10.2174/1573403x12666160606121458] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/18/2015] [Accepted: 01/11/2016] [Indexed: 02/07/2023] Open
Abstract
Congestive heart failure (CHF) therapeutics is generated through a well-described evidence generating process. Phases 1 - 3 of this process are required prior to approval and widespread clinical use. Phase 3 in almost all cases is a methodologically sound randomized controlled trial (RCT). After this phase it is generally accepted that the treatment has a significant, independent and prognostically beneficial effect on the pathophysiological process. A major criticism of RCTs is the population to whom the result is applicable. When this population is significantly different from the trial cohort the external validity comes into question. Should the continuation of the evidence generating process continue these problems might be identified. Post marketing surveillance through phase 4 and comparative effectiveness studies through phase 5 trials are often underperformed in comparison to the RCT. These processes can help identify remote adverse events and define new hypotheses for community level benefits. This review is aimed at exploring the post-marketing scene for CHF therapeutics from an Australian health system perspective. We explore the phases of clinical trials, the level of evidence currently available and options for ensuring greater accountability for community level CHF clinical outcomes.
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Affiliation(s)
- Pupalan Iyngkaran
- Cardiologist & Senior Lecturer NT Medical School, Flinders University, Australia.
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Shen J, Huang YM, Song XN, Hong XZ, Wang M, Ling W, Zhang XX, Zhao HL. Protection against death and renal failure by renin-angiotensin system blockers in patients with diabetes and kidney disease. J Renin Angiotensin Aldosterone Syst 2016; 17:17/3/1470320316656481. [PMID: 27377659 PMCID: PMC5843910 DOI: 10.1177/1470320316656481] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 05/24/2016] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) are widely used to block the renin-angiotensin system (RAS). Yet it remains uncertain whether these drugs are equally effective and safe. METHODS Systematic reviews and meta-analyses of ACEis/ARBs in diabetes and kidney disease published in PubMed, Chinese National Knowledge Infrastructure (CNKI) and Wanfang databases were searched for clinical outcomes including all-cause mortality, end-stage renal disease (ESRD), hyperkalemia and cough. RESULTS Eight meta-analyses included 2177-61,264 patients with follow-up of 6-108 months. RAS blockers reduced mortality (relative risk ratio (RR), 0.90, 95% confidence interval (CI), 0.86-0.95) without heterogeneity. The death protection was significant specifically with ACEis (RR, 0.85, 95% CI, 0.79-0.91), but not with ARBs. Protection against ESRD was homogenously evident by ARBs (RR, 0.79, 95% CI, 0.73-0.87), ACEis (RR, 0.79, 95% , 0.64-0.94), and both (RR, 0.79, 95% CI, 0.73-0.87). Significant side effects were hyperkalemia by ARBs (RR, 2.44, 95% CI, 1.13-5.26), and cough by ACEis (RR, 2.38, 95% CI, 1.75-3.22) CONCLUSIONS: In patients with diabetes and kidney disease, ACEis and ARBs are consistently protective for the development of ESRD. Use of ACEis alone additionally reduces deaths and increases the risk for cough. Use of ARBs alone increases the risk for hyperkalemia without additional benefit of death protection.
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Affiliation(s)
- Jian Shen
- Center for Diabetic Systems Medicine, Guilin Medical University, China Department of pathology, Affiliated Hospital of Guilin Medical University, China
| | - Yan-Mei Huang
- Center for Diabetic Systems Medicine, Guilin Medical University, China
| | - Xin-Nan Song
- Department of Anesthetics, Affiliated Hospital of Guilin Medical University, China
| | - Xue-Zhi Hong
- Department of Rheumatology and Immunology, Affiliated Hospital of Guilin Medical University, China
| | - Min Wang
- Center for Diabetic Systems Medicine, Guilin Medical University, China
| | - Wei Ling
- Center for Diabetic Systems Medicine, Guilin Medical University, China
| | - Xiao-Xi Zhang
- Center for Diabetic Systems Medicine, Guilin Medical University, China
| | - Hai-Lu Zhao
- Center for Diabetic Systems Medicine, Guilin Medical University, China
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Thomson HJ, Ekinci EI, Radcliffe NJ, Seah JM, MacIsaac RJ, Jerums G, Premaratne E. Elevated baseline glomerular filtration rate (GFR) is independently associated with a more rapid decline in renal function of patients with type 1 diabetes. J Diabetes Complications 2016; 30:256-61. [PMID: 26794645 DOI: 10.1016/j.jdiacomp.2015.11.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/02/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
AIMS Renal hyperfiltration is observed prior to the development of diabetic kidney disease (DKD) in patients with type 1 diabetes (T1DM); however its significance remains uncertain. Longitudinal data were used to investigate the association between measured baseline glomerular filtration rate (GFR) and renal function decline in patients with T1DM. METHODS This study included 142 adult patients with T1DM and ≥2 measurements of glomerular filtration rate (mGFR; determined by diethylene-triamine-penta-acetic acid plasma clearance). Median follow up was 19 years. Patients were stratified by baseline mGFR quartile. The relationship between baseline mGFR and rate of renal function decline was assessed using random-effect generalized least squares regression, adjusted for age, duration of diabetes, HbA1c, blood pressure, renin-angiotensin-aldosterone system inhibitor therapy, LDL and BMI. RESULTS The average rates of decline in renal function for the 2nd (baseline mGFR: 96.4-112.6 ml min-(1) 1.73 m-(2)), 3(rd) (baseline mGFR: 112.6-125.5 ml min- (1) 1.73 m-(2)) and 4th quartiles (baseline mGFR >125.5 ml min-(1) 1.73 m-(2)) were significantly faster than the first quartile (baseline mGFR: 60.9-96.4 ml min-(1) 1.73 m-(2)). In further detail, the average rates of decline in the 2nd (rate of decline 1.25 ml min- (1) 1.73 m-(2) per year, 95% CI: 0.97; 1.52, p=0.008), 3rd (rate of decline 1.35 ml min-(1) 1.73 m-(2) per year, 95% CI: 1.08; 1.62, p= 0.001) and 4th quartiles (rate of decline 1.6 ml min-(1) 1.73 m-(2) per year, 95% CI: 1.34, 1.88, <0.0001) were significantly faster when compared to the first quartile (rate of decline 0.67 ml min-(1) 1.73 m-(2) per year, 95% CI: 0.37; 0.96). Sub-analysis of quartile 4 revealed higher HbA1c measurements throughout follow-up in those with rapid mGFR decline (>3.0 ml min(-1)1.73 m(-2)/year). CONCLUSIONS In patients with T1DM, higher baseline mGFR is associate ed with more rapid mGFR decline. Patients with high baseline mGFR who developed rapid mGFR decline had higher HbA1c measurements throughout the study. These findings are consistent with the concept that poor glycaemic control over time may be a determining factor for the rapid renal function decline observed in some hyperfiltering patients.
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Affiliation(s)
- Hilary J Thomson
- Austin Health Endocrine Centre, Heidelberg, Melbourne, VIC, Australia
| | - Elif I Ekinci
- Austin Health Endocrine Centre, Heidelberg, Melbourne, VIC, Australia; Department of Medicine, Austin Health, The University of Melbourne, Melbourne, VIC, Australia; Menzies School of Health-Darwin, Casuarina NT 0810, Australia.
| | - Nicholas J Radcliffe
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, VIC, Australia; Austin Clinical School, Heidelberg, VIC, Australia
| | - Jas-mine Seah
- Austin Health Endocrine Centre, Heidelberg, Melbourne, VIC, Australia
| | - Richard J MacIsaac
- Department of Endocrinology & Diabetes, St Vincent's Hospital, VIC, Australia; Department of Medicine, St Vincent's Health, The University of Melbourne, VIC, Australia
| | - George Jerums
- Austin Health Endocrine Centre, Heidelberg, Melbourne, VIC, Australia; Department of Medicine, Austin Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Erosha Premaratne
- Austin Health Endocrine Centre, Heidelberg, Melbourne, VIC, Australia; Department of Medicine, Austin Health, The University of Melbourne, Melbourne, VIC, Australia
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14
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Lozano-Maneiro L, Puente-García A. Renin-Angiotensin-Aldosterone System Blockade in Diabetic Nephropathy. Present Evidences. J Clin Med 2015; 4:1908-37. [PMID: 26569322 PMCID: PMC4663476 DOI: 10.3390/jcm4111908] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/27/2015] [Accepted: 10/15/2015] [Indexed: 12/14/2022] Open
Abstract
Diabetic Kidney Disease (DKD) is the leading cause of chronic kidney disease in developed countries and its prevalence has increased dramatically in the past few decades. These patients are at an increased risk for premature death, cardiovascular disease, and other severe illnesses that result in frequent hospitalizations and increased health-care utilization. Although much progress has been made in slowing the progression of diabetic nephropathy, renal dysfunction and the development of end-stage renal disease remain major concerns in diabetes. Dysregulation of the renin-angiotensin-aldosterone system (RAAS) results in progressive renal damage. RAAS blockade is the cornerstone of treatment of DKD, with proven efficacy in many arenas. The theoretically-attractive option of combining these medications that target different points in the pathway, potentially offering a more complete RAAS blockade, has also been tested in clinical trials, but long-term outcomes were disappointing. This review examines the “state of play” for RAAS blockade in DKD, dual blockade of various combinations, and a perspective on its benefits and potential risks.
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Affiliation(s)
- Luz Lozano-Maneiro
- Division of Nephrology, Department of Internal Medicine, Fuenlabrada University Hospital, Rey Juan Carlos University School of Medicine, Camino del Molino, 2, 28942 Fuenlabrada, Madrid, Spain.
| | - Adriana Puente-García
- Division of Nephrology, Department of Internal Medicine, Fuenlabrada University Hospital, Rey Juan Carlos University School of Medicine, Camino del Molino, 2, 28942 Fuenlabrada, Madrid, Spain.
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Urinary MicroRNA Profiling Predicts the Development of Microalbuminuria in Patients with Type 1 Diabetes. J Clin Med 2015; 4:1498-517. [PMID: 26239688 PMCID: PMC4519802 DOI: 10.3390/jcm4071498] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 07/06/2015] [Accepted: 07/14/2015] [Indexed: 12/27/2022] Open
Abstract
Microalbuminuria provides the earliest clinical marker of diabetic nephropathy among patients with Type 1 diabetes, yet it lacks sensitivity and specificity for early histological manifestations of disease. In recent years microRNAs have emerged as potential mediators in the pathogenesis of diabetes complications, suggesting a possible role in the diagnosis of early stage disease. We used quantiative polymerase chain reaction (qPCR) to evaluate the expression profile of 723 unique microRNAs in the normoalbuminuric urine of patients who did not develop nephropathy (n = 10) relative to patients who subsequently developed microalbuminuria (n = 17). Eighteen microRNAs were strongly associated with the subsequent development of microalbuminuria, while 15 microRNAs exhibited gender-related differences in expression. The predicted targets of these microRNAs map to biological pathways known to be involved in the pathogenesis and progression of diabetic renal disease. A microRNA signature (miR-105-3p, miR-1972, miR-28-3p, miR-30b-3p, miR-363-3p, miR-424-5p, miR-486-5p, miR-495, miR-548o-3p and for women miR-192-5p, miR-720) achieved high internal validity (cross-validated misclassification rate of 11.1%) for the future development of microalbuminuria in this dataset. Weighting microRNA measurements by their number of kidney-relevant targets improved the prognostic performance of the miRNA signature (cross-validated misclassification rate of 7.4%). Future studies are needed to corroborate these early observations in larger cohorts.
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Lucas GM, Ross MJ, Stock PG, Shlipak MG, Wyatt CM, Gupta SK, Atta MG, Wools-Kaloustian KK, Pham PA, Bruggeman LA, Lennox JL, Ray PE, Kalayjian RC. Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e96-138. [PMID: 25234519 PMCID: PMC4271038 DOI: 10.1093/cid/ciu617] [Citation(s) in RCA: 205] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/25/2014] [Indexed: 12/15/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Paul A. Pham
- Johns HopkinsSchool of Medicine, Baltimore, Maryland
| | - Leslie A. Bruggeman
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | | | - Robert C. Kalayjian
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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17
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Wang JH, Ren K, Sun WG, Zhao L, Zhong HS, Xu K. Effects of iodinated contrast agents on renal oxygenation level determined by blood oxygenation level dependent magnetic resonance imaging in rabbit models of type 1 and type 2 diabetic nephropathy. BMC Nephrol 2014; 15:140. [PMID: 25182068 PMCID: PMC4236662 DOI: 10.1186/1471-2369-15-140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 08/29/2014] [Indexed: 11/30/2022] Open
Abstract
Background To evaluate the effects of contrast agents containing increasing concentrations of iodine on the renal oxygenation level determined by blood oxygenation level dependent (BOLD) magnetic resonance imaging (MRI) in a rabbit model of diabetic nephropathy. Methods BOLD-MRI was performed using saline or iodinated (I) contrast agents (200, 240, 300, 350 and 400 mg I/mL) at 1, 24, 48, and 72 h after experimentally inducing type 2 diabetic nephropathy in rabbits. Differences in renal oxygenation levels between type 1 and type 2 diabetic nephropathy were also assessed by BOLD-MRI after injecting 400 mg I/mL of contrast agent. Results Contrast agents increased the R2* values of the renal cortex, outer medulla, and inner medulla to the maximum levels at 24 h. The R2* values then decreased to their lowest levels at 72 h. The R2* was highest following injection of 400 mg I/mL, especially in the outer medulla. The R2* values were not significantly different between types 1 and 2 diabetic nephropathy. Conclusions Iodinated contrast agents had the greatest influence on renal outer medulla oxygenation level at 24 h in type 2 diabetic nephropathy, with the greatest effects observed at the 400 mg I/mL dose level. There were no differences in BOLD-MRI values between type 1 and type 2 diabetic nephropathy after administering the contrast agent at 400 mg I/mL.
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Affiliation(s)
| | - Ke Ren
- Department of Radiology, The First Hospital of China Medical University, Shenyang, Liaoning 110001, People's Republic of China.
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18
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Pálsson R, Patel UD. Cardiovascular complications of diabetic kidney disease. Adv Chronic Kidney Dis 2014; 21:273-80. [PMID: 24780455 PMCID: PMC4045477 DOI: 10.1053/j.ackd.2014.03.003] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/09/2014] [Accepted: 03/10/2014] [Indexed: 12/24/2022]
Abstract
Diabetic nephropathy is the most common cause of CKD and represents a large and ominous public health problem. Patients with diabetic kidney disease have exceptionally high rates of cardiovascular morbidity and mortality. In fact, the excess mortality among patients with diabetes appears to be largely limited to the subgroup with kidney disease and explained by their high burden of cardiovascular disease. The mechanisms underlying the strong association between diabetic kidney disease and various forms of cardiovascular disease are poorly understood. Traditional risk factors for cardiovascular disease, although prevalent among those with diabetes, do not fully account for the heightened risk observed. Despite their susceptibility to cardiovascular disease, patients with CKD are less likely to receive appropriate risk factor modification than the general population. Moreover, because patients with CKD have commonly been excluded from major cardiovascular trials, the evidence for potential treatments remains limited. The mainstays of treatment for diabetic kidney disease currently include blockade of the renin-angiotensin-aldosterone system and control of hypertension, hyperglycemia, and dyslipidemia. Increased awareness of the vulnerability of this patient population and more timely interventions are likely to improve outcomes while large evidence gaps are filled with newer studies.
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Affiliation(s)
- Ragnar Pálsson
- Department of Medicine, Durham Veterans Affairs Medical Center and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Uptal D Patel
- Department of Medicine, Durham Veterans Affairs Medical Center and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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19
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Zhang H, Cai X, Yi B, Huang J, Wang J, Sun J. Correlation of CTGF gene promoter methylation with CTGF expression in type 2 diabetes mellitus with or without nephropathy. Mol Med Rep 2014; 9:2138-44. [PMID: 24676352 PMCID: PMC4055476 DOI: 10.3892/mmr.2014.2067] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 02/25/2014] [Indexed: 01/07/2023] Open
Abstract
Increasing evidence shows that DNA methylation is involved in the development and progression of diabetes mellitus (DM) and its complications. Previous studies conducted by our group have indicated that high glucose levels may induce the demethylation process of the connective tissue growth factor (CTGF) gene promoter and increase the expression of CTGF in human glomerular mesangial cells. Based on these findings, the aim of the present study was to investigate the methylation level of genomic DNA and the CTGF promoter in patients with type 2 DM and to analyze its possible correlation with CTGF expression. Methylation levels of the whole genomic DNA were detected by high-performance liquid chromatography in a non-diabetes control (NDM) group (n=29), a diabetes without nephropathy (NDN) group (n=37) and a diabetes with nephropathy (DN) group (n=38). CTGF promoter methylation levels were detected by methylation-specific polymerase chain reaction and bisulfite sequencing. The levels of serum CTGF were assessed using the enzyme-linked immunosorbent assay. The methylation levels of the whole genomic DNA were not significantly different among the three groups. However, the CTGF methylation levels in the two diabetes groups were significantly lower than those in the NDM group (P<0.05), with the lowest methylation level in the DN group (P<0.05). The CTGF protein levels in the DN group were significantly higher than those in the NDM and NDN groups (P<0.05). Levels of CTGF were negatively correlated with the estimated glomerular filtration rate (eGFR) and the methylation level of the promoter, while they were positively correlated with age, urinary albumin-to-creatinine ratio (UACR), blood urea nitrogen, creatinine, fasting blood sugar and postprandial blood glucose. Multiple stepwise regression analysis showed that CTGF expression was associated with the UACR, CTGF methylation level and eGFR. DNA methylation is a regulatory mechanism of CTGF expression, which is decreased in patients with DM, particularly in those with DN, and may contribute to the pathogenesis of nephropathy.
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Affiliation(s)
- Hao Zhang
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, P.R. China
| | - Xu Cai
- Department of Nephrology, The Second People's Hospital of Guangdong Province, Guangzhou, Guangdong 510317, P.R. China
| | - Bin Yi
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, P.R. China
| | - Jing Huang
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, P.R. China
| | - Jianwen Wang
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, P.R. China
| | - Jian Sun
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, P.R. China
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Lecaire TJ, Klein BEK, Howard KP, Lee KE, Klein R. Risk for end-stage renal disease over 25 years in the population-based WESDR cohort. Diabetes Care 2014; 37:381-8. [PMID: 24026564 PMCID: PMC3898749 DOI: 10.2337/dc13-1287] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In the population-based Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) cohort, we sought to examine whether a decline in the prevalence and incidence of end-stage renal disease (ESRD) was evident with increasing calendar year of type 1 diabetes diagnosis among people followed for 25 years. Factors associated with the hazard of incident ESRD that may mediate a decline were also investigated. RESEARCH DESIGN AND METHODS Participants were examined at baseline in 1980 (n = 996) and at 4-25 years of follow-up. ESRD was defined by self-reported renal transplant or dialysis. Cumulative incidence with competing risk of death was determined. Incident ESRD was modeled by period of diagnosis, adjusting for other known risk factors using discrete time hazard models. RESULTS When diabetes was diagnosed during 1970-1980, the unadjusted cumulative incidence of ESRD at 25 years was 9.3%. The unadjusted hazard of ESRD was reduced by 70% (P < 0.001), compared with those diagnosed with diabetes in 1922-1969; however, the association was attenuated by glycosylated hemoglobin level (HbA1c), systolic blood pressure, and antihypertensive use (hazard ratio [HR] 0.89 [95% CI 0.55-1.45]). HbA1c, age, and male sex remained associated with ESRD hazard after adjustment for kidney function and proliferative retinopathy. CONCLUSIONS A lower incidence of ESRD among those more recently diagnosed with type 1 diabetes was explained by improvements in glycemic and blood pressure control over the last several decades. Intensive diabetes management, especially for glycemic control, remains important even in long-standing diabetes as it may delay the development of ESRD.
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Viberti G, Karalliedde J. Commentary: the birth of microalbuminuria: a milestone in the history of medicine. Int J Epidemiol 2014; 43:18-20. [PMID: 24374830 DOI: 10.1093/ije/dyt256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Giancarlo Viberti
- Unit for Metabolic Medicine, Cardiovascular Division, King's College London School of Medicine, London, UK
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22
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Huang YC, Wu YL, Lee MH, Lee JD, Wu CY, Hsu HL, Lin YH, Huang YC, Huang WH, Weng HH, Yang JT, Lee M, Ovbiagele B. Association of renal biomarkers with 3-month and 1-year outcomes among critically ill acute stroke patients. PLoS One 2013; 8:e72971. [PMID: 24058451 PMCID: PMC3772800 DOI: 10.1371/journal.pone.0072971] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 07/16/2013] [Indexed: 01/02/2023] Open
Abstract
Background The comparative relationships of widely recognized biomarkers of renal injury with short-term and long-term outcomes among critically ill acute stroke patients are unknown. We evaluated the impact of baseline albuminuria [urine albumin-creatinine ratio (UACR)≥30 mg/g] or low estimated glomerular filtration rate (eGFR<60 ml/min per 1.73 m2) on stroke patients admitted to the intensive care unit (ICU). Methods We reviewed data on consecutive stroke patients admitted to a hospital ICU in Taiwan from September 2007 to August 2010 and followed-up for 1 year. Baseline UACR was categorized into <30 mg/g (normal), 30–299 mg/g (microalbuminuria), and ≥300 mg/g (macroalbuminuria), while eGFR was divided into ≥60, 45–59, and <45 ml/min per 1.73 m2. The outcome measure was death or disability at 3-month and 1-year after stroke onset, assessed by dichotomizing the modified Rankin Scale at 3–6 versus 0–2. Results Of 184 consecutive patients, 153 (83%) met study entry criteria. Mean age was 67.9 years and median admission NIHSS score was 16. Among the renal biomarkers, only macroalbuminuria was associated with poorer 3-month outcome (OR 8.44, 95% CI 1.38 to 51.74, P = 0.021) and 1-year outcome (OR 18.06, 95% CI 2.59 to 125.94, P = 0.003) after adjustment of relevant covariates. When ischemic and hemorrhagic stroke were analyzed separately, macroalbuminuria was associated with poorer 1-year outcome among ischemic (OR 17.10, 95% CI 1.04 to 280.07, P = 0.047) and hemorrhagic stroke patients (OR 1951.57, 95% CI 1.07 to 3561662.85, P = 0.048), respectively, after adjustment of relevant covariates and hematoma volume. Conclusions Presence of macroalbuminuria indicates poor 3-month and 1-year outcomes among critically ill acute stroke patients.
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Affiliation(s)
- Ying-Chih Huang
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yi-Ling Wu
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ming-Hsueh Lee
- Department of Neurosurgery, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chih-Ying Wu
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Huan-Lin Hsu
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ya-Hui Lin
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yen-Chu Huang
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Wen-Hung Huang
- Department of Nephrology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Hsu-Huei Weng
- Department of Diagnostic Radiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Jen-Tsung Yang
- Department of Neurosurgery, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- * E-mail:
| | - Bruce Ovbiagele
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
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Utsunomiya K. [110th Scientific Meeting of the Japanese Society of Internal Medicine: Educational lecture: 15. Treatment of diabetic nephropathy]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2013; 102:2453-2459. [PMID: 24228441 DOI: 10.2169/naika.102.2453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Færch LH, Sejling AS, Lajer M, Tarnow L, Thorsteinsson B, Pedersen-Bjergaard U. ACE genotype, phenotype and all-cause mortality in different cohorts of patients with type 1 diabetes. J Renin Angiotensin Aldosterone Syst 2013; 16:374-81. [DOI: 10.1177/1470320313494431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 05/16/2013] [Indexed: 01/08/2023] Open
Affiliation(s)
- Louise H Færch
- Department of Cardiology, Nephrology and Endocrinology, Hillerød Hospital, Denmark
| | - Anne-Sophie Sejling
- Department of Cardiology, Nephrology and Endocrinology, Hillerød Hospital, Denmark
| | | | - Lise Tarnow
- Steno Diabetes Center, Denmark
- Health, University of Aarhus, Denmark
| | - Birger Thorsteinsson
- Department of Cardiology, Nephrology and Endocrinology, Hillerød Hospital, Denmark
- Faculty of Health Sciences, University of Copenhagen, Denmark
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St Peter WL, Odum LE, Whaley-Connell AT. To RAS or not to RAS? The evidence for and cautions with renin-angiotensin system inhibition in patients with diabetic kidney disease. Pharmacotherapy 2013; 33:496-514. [PMID: 23576066 DOI: 10.1002/phar.1232] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Substantial morbidity, mortality, and costs are associated with progressive diabetic kidney disease (DKD). A goal of Healthy People 2020 is to reduce kidney disease attributable to diabetes mellitus and increase the proportion of patients who receive agents that interrupt the renin-angiotensin system (RAS), such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). The mechanisms that contribute to progressive loss of kidney function in patients with diabetes are disrupted by inhibition of the RAS. ACEIs, ARBs and direct renin inhibitors (DRIs) all reduce the effect of angiotensin II, yet each works through a different mechanism and displays properties that may or may not be replicated by the others. As single agents, RAS inhibitors and blockers have been shown to slow the rate of progression of DKD and to reduce new cases of end-stage renal disease in various subsets of patients with diabetes and proteinuria (e.g., albuminuria). However, even with contemporary use of ACEIs, ARBs, and, more recently, DRIs, the burden of kidney disease remains high. Thus investigators sought to explore the utility of combining agents (e.g., dual RAS therapy) in various regimens for cardiovascular and kidney end points. Recent data from the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) and Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints (ALTITUDE) studies suggest that kidney-related outcomes (composite of dialysis initiation, doubling serum creatinine concentration, or death) were increased with ACEI plus ARB or DRI plus ARB combinations. Consequently, dual therapy should not be routinely prescribed in patients with diabetes until further data become available from other future studies. This review provides an introduction to DKD and a rationale for using RAS inhibition; discusses screening, detection, and monitoring of patients with DKD; and summarizes results from meta-analyses and critical reviews and from recent large randomized controlled studies published since the meta-analyses or reviews. Finally, we suggest a clinical approach for using RAS agents in patients with DKD.
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Affiliation(s)
- Wendy L St Peter
- College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
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Oke J, Farmer A, Neil A, Dalton RN, Dunger D, Stevens R. Monitoring young people with type 1 diabetes for diabetic nephropathy: potential errors of annual ACR testing. Diabetes Res Clin Pract 2013; 99:307-14. [PMID: 23312483 DOI: 10.1016/j.diabres.2012.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 12/05/2012] [Accepted: 12/13/2012] [Indexed: 11/23/2022]
Abstract
AIM Type 1 diabetes guidelines recommend annual monitoring of albumin-creatinine ratio (ACR) to detect nephropathy. Annual monitoring for conditions such as dyslipidemia leads to high rates of false-positive diagnoses. We estimated rates of false-positive and false-negative diagnoses under annual, biennial and triennial monitoring. METHODS Using Oxford Regional Prospective Study (ORPS) data we modelled ACR over time. Using simulation we estimated numbers of positive and negative diagnoses and the proportion that are false, over 6 years of monitoring, when assessment intervals are 1, 2 or 3 years. RESULTS Average increase per year (95%C.I.) in ACR was 3,5% (2,0-5,0%) for males and 4,8% (3,2-6,5%) for females. By 6 years, annual monitoring would lead to 56 (49-63) false-positive diagnoses for every 100 positive diagnoses of micro-albuminuria, biennial to 49 (42-57) false-positives and triennial to 46 (39-53). For every 100 negative diagnoses, annual monitoring would lead to 1,2 (0,8-1,5) false-negatives, biennial to 2,3 (1,7-3,0) and triennial to 3,0 (2,2-3,8). CONCLUSION Less frequent monitoring would result in fewer false-positive diagnoses, but increased false negatives, or missed diagnoses. The clinical implications of these scenarios need further investigation through cost-benefit analysis.
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Affiliation(s)
- Jason Oke
- Department of Primary Health Care Sciences, University of Oxford and School of Primary Care Research, National Institute for Healthcare Research, United Kingdom.
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Cherney DZI, Scholey JW, Jiang S, Har R, Lai V, Sochett EB, Reich HN. The effect of direct renin inhibition alone and in combination with ACE inhibition on endothelial function, arterial stiffness, and renal function in type 1 diabetes. Diabetes Care 2012; 35:2324-30. [PMID: 22837362 PMCID: PMC3476932 DOI: 10.2337/dc12-0773] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes is associated with renin-angiotensin system (RAS) activation, leading to renal and systemic vascular dysfunction that contribute to end-organ injury and significant morbidity. RAS blockade with ACE inhibitors reduces, but does not abolish, RAS effects. Accordingly, our aim was to determine if direct renin inhibition alone, and in combination with an ACE inhibitor, corrects early hemodynamic abnormalities associated with type 1 diabetes. RESEARCH DESIGN AND METHODS Arterial stiffness (augmentation index), flow-mediated vasodilatation (FMD), and renal hemodynamic function (inulin and paraaminohippurate clearance) were measured at baseline under clamped euglycemic and hyperglycemic conditions (n = 21). Measures were repeated after 4 weeks of aliskiren therapy and again after aliskiren plus ramipril. RESULTS Blood pressure-lowering effects of aliskiren were similar during clamped euglycemia and hyperglycemia. Combination therapy augmented this effect under both glycemic conditions (P = 0.0005). Aliskiren reduced arterial stiffness under clamped euglycemic and hyperglycemic conditions, and the effects were augmented by dual RAS blockade (-3.4 ± 11.2 to -8.0 ± 11.5 to -14.3 ± 8.4%, respectively, during euglycemia, P = 0.0001). During clamped euglycemia, aliskiren increased FMD; dual therapy exaggerated this effect (5.1 ± 3.3 to 7.5 ± 3.0 to 10.8 ± 3.5%, repeated-measures ANOVA, P = 0.0001). Aliskiren monotherapy caused renal vasodilatation during clamped hyperglycemia only. In contrast, dual therapy augmented renal vasodilatory effects during clamped euglycemia and hyperglycemia. CONCLUSIONS In patients with uncomplicated type 1 diabetes, aliskiren-based dual RAS blockade is associated with greater arterial compliance, FMD, and renal vasodilatation.
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Affiliation(s)
- David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Ontario, Canada.
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Abstract
Diabetic nephropathy is the leading cause of end-stage renal disease in the United States. Renin-angiotensin-aldosterone system (RAAS) blockers are thought to have a specific renoprotective effect in diabetes. Hirst et al. report the results of randomized clinical trials assessing the effects of RAAS inhibitors on urinary albumin excretion levels in diabetic patients. Although reductions in urinary albumin excretion were observed, whether RAAS inhibitors offer additional protection over other antihypertensive agents is unclear.
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