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Natale P, Palmer SC, Navaneethan SD, Craig JC, Strippoli GF. Angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers for preventing the progression of diabetic kidney disease. Cochrane Database Syst Rev 2024; 4:CD006257. [PMID: 38682786 PMCID: PMC11057222 DOI: 10.1002/14651858.cd006257.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
BACKGROUND Guidelines suggest that adults with diabetes and kidney disease receive treatment with angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). This is an update of a Cochrane review published in 2006. OBJECTIVES We compared the efficacy and safety of ACEi and ARB therapy (either as monotherapy or in combination) on cardiovascular and kidney outcomes in adults with diabetes and kidney disease. SEARCH METHODS We searched the Cochrane Kidney and Transplants Register of Studies to 17 March 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included studies evaluating ACEi or ARB alone or in combination, compared to each other, placebo or no treatment in people with diabetes and kidney disease. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS One hundred and nine studies (28,341 randomised participants) were eligible for inclusion. Overall, the risk of bias was high. Compared to placebo or no treatment, ACEi may make little or no difference to all-cause death (24 studies, 7413 participants: RR 0.91, 95% CI 0.73 to 1.15; I2 = 23%; low certainty) and with similar withdrawals from treatment (7 studies, 5306 participants: RR 1.03, 95% CI 0.90 to 1.19; I2 = 0%; low certainty). ACEi may prevent kidney failure (8 studies, 6643 participants: RR 0.61, 95% CI 0.39 to 0.94; I2 = 0%; low certainty). Compared to placebo or no treatment, ARB may make little or no difference to all-cause death (11 studies, 4260 participants: RR 0.99, 95% CI 0.85 to 1.16; I2 = 0%; low certainty). ARB have uncertain effects on withdrawal from treatment (3 studies, 721 participants: RR 0.85, 95% CI 0.58 to 1.26; I2 = 2%; low certainty) and cardiovascular death (6 studies, 878 participants: RR 3.36, 95% CI 0.93 to 12.07; low certainty). ARB may prevent kidney failure (3 studies, 3227 participants: RR 0.82, 95% CI 0.72 to 0.94; I2 = 0%; low certainty), doubling of serum creatinine (SCr) (4 studies, 3280 participants: RR 0.84, 95% CI 0.72 to 0.97; I2 = 32%; low certainty), and the progression from microalbuminuria to macroalbuminuria (5 studies, 815 participants: RR 0.44, 95% CI 0.23 to 0.85; I2 = 74%; low certainty). Compared to ACEi, ARB had uncertain effects on all-cause death (15 studies, 1739 participants: RR 1.13, 95% CI 0.68 to 1.88; I2 = 0%; low certainty), withdrawal from treatment (6 studies, 612 participants: RR 0.91, 95% CI 0.65 to 1.28; I2 = 0%; low certainty), cardiovascular death (13 studies, 1606 participants: RR 1.15, 95% CI 0.45 to 2.98; I2 = 0%; low certainty), kidney failure (3 studies, 837 participants: RR 0.56, 95% CI 0.29 to 1.07; I2 = 0%; low certainty), and doubling of SCr (2 studies, 767 participants: RR 0.88, 95% CI 0.52 to 1.48; I2 = 0%; low certainty). Compared to ACEi plus ARB, ACEi alone has uncertain effects on all-cause death (6 studies, 1166 participants: RR 1.08, 95% CI 0.49 to 2.40; I2 = 20%; low certainty), withdrawal from treatment (2 studies, 172 participants: RR 0.78, 95% CI 0.33 to 1.86; I2 = 0%; low certainty), cardiovascular death (4 studies, 994 participants: RR 3.02, 95% CI 0.61 to 14.85; low certainty), kidney failure (3 studies, 880 participants: RR 1.36, 95% CI 0.79 to 2.32; I2 = 0%; low certainty), and doubling of SCr (2 studies, 813 participants: RR 1.14, 95% CI 0.70 to 1.85; I2 = 0%; low certainty). Compared to ACEi plus ARB, ARB alone has uncertain effects on all-cause death (7 studies, 2607 participants: RR 1.02, 95% CI 0.76 to 1.37; I2 = 0%; low certainty), withdrawn from treatment (3 studies, 1615 participants: RR 0.81, 95% CI 0.53 to 1.24; I2 = 0%; low certainty), cardiovascular death (4 studies, 992 participants: RR 3.03, 95% CI 0.62 to 14.93; low certainty), kidney failure (4 studies, 2321 participants: RR 1.15, 95% CI 0.67 to 1.95; I2 = 29%; low certainty), and doubling of SCr (3 studies, 2252 participants: RR 1.18, 95% CI 0.85 to 1.64; I2 = 0%; low certainty). Comparative effects of different ACEi or ARB and low-dose versus high-dose ARB were rarely evaluated. No study compared different doses of ACEi. Adverse events of ACEi and ARB were rarely reported. AUTHORS' CONCLUSIONS ACEi or ARB may make little or no difference to all-cause and cardiovascular death compared to placebo or no treatment in people with diabetes and kidney disease but may prevent kidney failure. ARB may prevent the doubling of SCr and the progression from microalbuminuria to macroalbuminuria compared with a placebo or no treatment. Despite the international guidelines suggesting not combining ACEi and ARB treatment, the effects of ACEi or ARB monotherapy compared to dual therapy have not been adequately assessed. The limited data availability and the low quality of the included studies prevented the assessment of the benefits and harms of ACEi or ARB in people with diabetes and kidney disease. Low and very low certainty evidence indicates that it is possible that further studies might provide different results.
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Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | | | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Chan JCN, Lim LL, Luk AOY, Ozaki R, Kong APS, Ma RCW, So WY, Lo SV. From Hong Kong Diabetes Register to JADE Program to RAMP-DM for Data-Driven Actions. Diabetes Care 2019; 42:2022-2031. [PMID: 31530658 DOI: 10.2337/dci19-0003] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 08/14/2019] [Indexed: 02/03/2023]
Abstract
In 1995, the Hong Kong Diabetes Register (HKDR) was established by a doctor-nurse team at a university-affiliated, publicly funded, hospital-based diabetes center using a structured protocol for gathering data to stratify risk, triage care, empower patients, and individualize treatment. This research-driven quality improvement program has motivated the introduction of a territory-wide diabetes risk assessment and management program provided by 18 hospital-based diabetes centers since 2000. By linking the data-rich HKDR to the territory-wide electronic medical record, risk equations were developed and validated to predict clinical outcomes. In 2007, the HKDR protocol was digitalized to establish the web-based Joint Asia Diabetes Evaluation (JADE) Program complete with risk levels and algorithms for issuance of personalized reports to reduce clinical inertia and empower self-management. Through this technologically assisted, integrated diabetes care program, we have generated big data to track secular trends, identify unmet needs, and verify interventions in a naturalistic environment. In 2009, the JADE Program was adapted to form the Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) in the publicly funded primary care clinics, which reduced all major events by 30-60% in patients without complications. Meanwhile, a JADE-assisted assessment and empowerment program provided by a university-affiliated, self-funded, nurse-coordinated diabetes center, aimed at complementing medical care in the community, also reduced all major events by 30-50% in patients with different risk levels. By combining universal health coverage, public-private partnerships, and data-driven integrated care, the Hong Kong experience provides a possible solution than can be adapted elsewhere to make quality diabetes care accessible, affordable, and sustainable.
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Affiliation(s)
- Juliana C N Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China .,Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Asia Diabetes Foundation, Hong Kong SAR, China
| | - Lee-Ling Lim
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Asia Diabetes Foundation, Hong Kong SAR, China.,Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Andrea O Y Luk
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Asia Diabetes Foundation, Hong Kong SAR, China
| | - Risa Ozaki
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Alice P S Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Ronald C W Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Wing-Yee So
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.,Hospital Authority, Hong Kong SAR, China
| | - Su-Vui Lo
- Hospital Authority, Hong Kong SAR, China
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Blood pressure and proteinuria control remains a challenge in patients with type 2 diabetes mellitus and chronic kidney disease: experience from the prospective observational ALICE-PROTECT study. BMC Nephrol 2016; 17:135. [PMID: 27655374 PMCID: PMC5031346 DOI: 10.1186/s12882-016-0336-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/23/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Type 2 diabetes (T2DM) is the leading cause of chronic kidney disease (CKD) in western countries. The combination of both increases the risk of end stage renal disease (ESRD), cardiovascular events and all-cause mortality. Early control of blood pressure (BP) and proteinuria (Pu) is crucial to slow down the progression of the CKD and prevent cardiovascular events and mortality. The primary objective of the study was to assess BP and Pu control after a 2-year follow-up in T2DM patients with CKD. METHODS Prospective, multicenter, observational study. Overall, 153 French nephrologists included 986 T2DM patients with Pu (≥0.5 g/day) and an eGFR >15 ml/min/1.73 m2. Data from 729 patients were available after a 2-year follow-up. BP and Pu control were respectively defined as less than 140/90 mmHg and 0.5 g/day. We also looked at renal and cardiovascular events. RESULTS At baseline, 74 % of the patients were male, mean age was 70 years. The mean T2DM duration was 17 years with a mean HbA1c of 7.4 %. All were treated for hypertension and 33 % had a controlled BP; 81 % had dyslipidemia and LDLc was <1 g/L for 54 %; 44 % had retinopathy, 40 % macrovascular complications and 12 % heart failure. Mean Pu was 2 g/day and eGFR 40 ± 20 mL/min/1.73 m2, with 13, 18, 32 and 37 % of the patients in respectively stage 2, 3a, 3b and 4 CKD. After two years, 21 % reached the Pu target and 39 % the BP target. The mean eGFR of 40 ± 20.3 ml/min/1.73 m2 at baseline dropped to 33.9 ± 22.6 ml/min/1.73 m2 by year two (p < 0.001). This corresponded to a mean annual eGFR reduction of 3.2 ml/min/1.73 m2. 118 patients presented a renal event (16.2 %): doubling of serum creatinine for 86 patients (11.8 %) and start of dialysis for 72 (9.9 %); 176 patients (24.1 %) developed at least one cardiovascular complication (mainly coronary events and acute heart failure) during the follow-up period, and among these, 50 had also developed renal complications. Sixty patients died, i.e., 8.2 %, 26 patients from cardiovascular causes. CONCLUSION Our study highlights that achieving BP and Pu targets remains a major challenge in patients with T2DM and nephropathy. Renal failure emerges as a more frequent event than death.
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Chan JCN, Ozaki R, Luk A, Kong APS, Ma RCW, Chow FCC, Wong P, Wong R, Chung H, Chiu C, Wolthers T, Tong PCY, Ko GTC, So WY, Lyubomirsky G. Delivery of integrated diabetes care using logistics and information technology--the Joint Asia Diabetes Evaluation (JADE) program. Diabetes Res Clin Pract 2014; 106 Suppl 2:S295-304. [PMID: 25550057 DOI: 10.1016/s0168-8227(14)70733-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diabetes is a global epidemic, and many affected individuals are undiagnosed, untreated, or uncontrolled. The silent and multi-system nature of diabetes and its complications, with complex care protocols, are often associated with omission of periodic assessments, clinical inertia, poor treatment compliance, and care fragmentation. These barriers at the system, patient, and care-provider levels have resulted in poor control of risk factors and under-usage of potentially life-saving medications such as statins and renin-angiotensin system inhibitors. However, in the clinical trial setting, use of nurses and protocol with frequent contact and regular monitoring have resulted in marked differences in event rates compared to epidemiological data collected in the real-world setting. The phenotypic heterogeneity and cognitive-psychological-behavioral needs of people with diabetes call for regular risk stratification to personalize care. Quality improvement initiatives targeted at patient education, task delegation, case management, and self-care promotion had the largest effect size in improving cardio-metabolic risk factors. The Joint Asia Diabetes Evaluation (JADE) program is an innovative care prototype that advocates a change in clinic setting and workflow, coordinated by a doctor-nurse team and augmented by a web-based portal, which incorporates care protocols and a validated risk engine to provide decision support and regular feedback. By using logistics and information technology, supported by a network of health-care professionals to provide integrated, holistic, and evidence-based care, the JADE Program aims to establish a high-quality regional diabetes database to reflect the status of diabetes care in real-world practice, confirm efficacy data, and identify unmet needs. Through collaborative efforts, we shall evaluate the feasibility, acceptability, and cost-effectiveness of this "high tech, soft touch" model to make diabetes and chronic disease care more accessible, affordable, and sustainable.
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Affiliation(s)
- Juliana C N Chan
- Department of Medicine and Therapeutics, China; Hong Kong Institute of Diabetes and Obesity, China; Li Ka Shing Institute of Health Sciences, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China; Asia Diabetes Foundation, Prince of Wales Hospital, Shatin, China.
| | - Risa Ozaki
- Department of Medicine and Therapeutics, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China
| | - Andrea Luk
- Department of Medicine and Therapeutics, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China
| | - Alice P S Kong
- Department of Medicine and Therapeutics, China; Hong Kong Institute of Diabetes and Obesity, China; Li Ka Shing Institute of Health Sciences, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China
| | - Ronald C W Ma
- Department of Medicine and Therapeutics, China; Hong Kong Institute of Diabetes and Obesity, China; Li Ka Shing Institute of Health Sciences, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China
| | - Francis C C Chow
- Department of Medicine and Therapeutics, China; Hong Kong Institute of Diabetes and Obesity, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China; Asia Diabetes Foundation, Prince of Wales Hospital, Shatin, China
| | - Patrick Wong
- Asia Diabetes Foundation, Prince of Wales Hospital, Shatin, China
| | - Rebecca Wong
- Department of Medicine and Therapeutics, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China
| | - Harriet Chung
- Hong Kong Institute of Diabetes and Obesity, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China
| | - Cherry Chiu
- Department of Medicine and Therapeutics, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China
| | - Troels Wolthers
- Asia Diabetes Foundation, Prince of Wales Hospital, Shatin, China
| | - Peter C Y Tong
- Department of Medicine and Therapeutics, China; Qualigenics Diabetes Centre, Central, Hong Kong SAR, China
| | - Gary T C Ko
- Department of Medicine and Therapeutics, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China
| | - Wing-Yee So
- Department of Medicine and Therapeutics, China; International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, China
| | - Greg Lyubomirsky
- Asia Diabetes Foundation, Prince of Wales Hospital, Shatin, China
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Abstract
Fetal programming associated with in utero exposure to maternal stress is thought to alter gene expression, resulting in phenotypes that promote survival in a pathogen-rich and nutrient-poor environment but substantially increase the risk of cardiovascular, metabolic and renal disorders (such as diabetes mellitus) in adults with obesity. These (epi)genetic phenomena are modified by environmental and socioeconomic factors, resulting in multiple subphenotypes and clinical consequences. In individuals from areas undergoing rapid economic development, which is associated with a transition from communicable to noncommunicable diseases, an efficient innate immune response can exaggerate obesity-associated inflammation. By contrast, in individuals with a genetic predisposition to autoimmune or monogenic diabetes mellitus, obesity can lead to atypical presentation of diabetes mellitus, termed 'double diabetes mellitus'. The increasingly young age at diagnosis of diabetes mellitus in developing countries results in prolonged exposure to glucolipotoxicity, low-grade inflammation and increased oxidative stress, which put enormous strain on pancreatic β cells and renal function. These conditions create a metabolic milieu conducive to cancer growth. This Review discusses how rapid changes in technology and human behaviour have brought on the global epidemic of metabolic diseases, and suggests that solutions will be based on using system change, technology and behavioural strategies to combat this societal-turned-medical problem.
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Affiliation(s)
- Alice P S Kong
- Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT Hong Kong Special Administrative Region, China
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Szeto CC, Kwan BCH, Chow KM, Leung CB, Li PKT. The safety and short-term efficacy of aliskiren in the treatment of immunoglobulin a nephropathy--a randomized cross-over study. PLoS One 2013; 8:e62736. [PMID: 23675422 PMCID: PMC3651209 DOI: 10.1371/journal.pone.0062736] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 03/25/2013] [Indexed: 12/16/2022] Open
Abstract
Background Laboratory research and previous study suggest that aliskiren, a direct renin inhibitor, has anti-proteinuric effects. We conducted a randomized crossover study to evaluate the anti-proteinuric effect of aliskiren in patients with immunoglobulin A (IgA) nephropathy. Methods We studied 22 patients with biopsy-proven IgA nephropathy and persistent proteinuria despite angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). Patients were randomized to either oral aliskiren 300 mg/day or placebo for 16 weeks and then crossed over to the other treatment arm after a washout period. Proteinuria, estimated glomerular filtration rate (eGFR), blood pressure, and serum potassium were monitored. Results After aliskiren treatment, there was a significant reduction in proteinuria in 4 weeks (1.76±0.95 to 1.03±0.69 g:g-Cr, p<0.0001), which remained at a low level throughout the treatment period. There was a significant difference in proteinuria between the aliskiren and placebo groups from 4 to 16 weeks after treatment (p<0.01 for all comparisons). After aliskiren treatment, there were modest but statistically significant reductions in eGFR (57.2±29.1 to 54.8±29.3 ml/min/1.73 m2, p = 0.013) and diastolic blood pressure (72.6±12.3 to 66.2±11.2 mmHg, p<0.0001). None of the patient developed severe hyperkalemia (serum potassium ≥6.0 mmol/l) during the study period. Conclusions Aliskiren has anti-proteinuric effect in patients with IgA nephropathy and persistent proteinuria despite ACE inhibitor or ARB. Further studies are needed to confirm the renal protecting effect of direct renin inhibition in chronic proteinuric kidney diseases. Trial Registration ClinicalTrials.gov NCT00870493
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China.
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Ko GT, So WY, Tong PC, Le Coguiec F, Kerr D, Lyubomirsky G, Tamesis B, Wolthers T, Nan J, Chan J. From design to implementation--the Joint Asia Diabetes Evaluation (JADE) program: a descriptive report of an electronic web-based diabetes management program. BMC Med Inform Decis Mak 2010; 10:26. [PMID: 20465815 PMCID: PMC2876072 DOI: 10.1186/1472-6947-10-26] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 05/13/2010] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The Joint Asia Diabetes Evaluation (JADE) Program is a web-based program incorporating a comprehensive risk engine, care protocols, and clinical decision support to improve ambulatory diabetes care. METHODS The JADE Program uses information technology to facilitate healthcare professionals to create a diabetes registry and to deliver an evidence-based care and education protocol tailored to patients' risk profiles. With written informed consent from participating patients and care providers, all data are anonymized and stored in a databank to establish an Asian Diabetes Database for research and publication purpose. RESULTS The JADE electronic portal (e-portal: http://www.jade-adf.org) is implemented as a Java application using the Apache web server, the mySQL database and the Cocoon framework. The JADE e-portal comprises a risk engine which predicts 5-year probability of major clinical events based on parameters collected during an annual comprehensive assessment. Based on this risk stratification, the JADE e-portal recommends a care protocol tailored to these risk levels with decision support triggered by various risk factors. Apart from establishing a registry for quality assurance and data tracking, the JADE e-portal also displays trends of risk factor control at each visit to promote doctor-patient dialogues and to empower both parties to make informed decisions. CONCLUSIONS The JADE Program is a prototype using information technology to facilitate implementation of a comprehensive care model, as recommended by the International Diabetes Federation. It also enables health care teams to record, manage, track and analyze the clinical course and outcomes of people with diabetes.
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Affiliation(s)
- Gary T Ko
- Asia Diabetes Foundation, Flat 4B, Block B, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Wing-Yee So
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Peter C Tong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | | | - Debborah Kerr
- Merck Sharp & Dohme (MSD), a subsidiary of Merck & Co. Inc., USA
| | - Greg Lyubomirsky
- Merck Sharp & Dohme (MSD), a subsidiary of Merck & Co. Inc., USA
| | - Beaver Tamesis
- Merck Sharp & Dohme (MSD), a subsidiary of Merck & Co. Inc., USA
| | - Troels Wolthers
- Merck Sharp & Dohme (MSD), a subsidiary of Merck & Co. Inc., USA
| | - Jennifer Nan
- Asia Diabetes Foundation, Flat 4B, Block B, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Juliana Chan
- Asia Diabetes Foundation, Flat 4B, Block B, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
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Chan JC, So WY, Yeung CY, Ko GT, Lau IT, Tsang MW, Lau KP, Siu SC, Li JK, Yeung VT, Leung WY, Tong PC. Effects of structured versus usual care on renal endpoint in type 2 diabetes: the SURE study: a randomized multicenter translational study. Diabetes Care 2009; 32:977-82. [PMID: 19460913 PMCID: PMC2681013 DOI: 10.2337/dc08-1908] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Multifaceted care has been shown to reduce mortality and complications in type 2 diabetes. We hypothesized that structured care would reduce renal complications in type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 205 Chinese type 2 diabetic patients from nine public hospitals who had plasma creatinine levels of 150-350 micromol/l were randomly assigned to receive structured care (n = 104) or usual care (n = 101) for 2 years. The structured care group was managed according to a prespecified protocol with the following treatment goals: blood pressure <130/80 mmHg, A1C <7%, LDL cholesterol <2.6 mmol/l, triglyceride <2 mmol/l, and persistent treatment with renin-angiotensin blockers. The primary end point was death and/or renal end point (creatinine >500 micromol/l or dialysis). RESULTS Of these 205 patients (mean +/- SD age 65 +/- 7.2 years; disease duration 14 +/- 7.9 years), the structured care group achieved better control than the usual care group (diastolic blood pressure 68 +/- 12 vs. 71 +/- 12 mmHg, respectively, P = 0.02; A1C 7.3 +/- 1.3 vs. 8.0 +/- 1.6%, P < 0.01). After adjustment for age, sex, and study sites, the structured care (23.1%, n = 24) and usual care (23.8%, n = 24; NS) groups had similar end points, but more patients in the structured care group attained >or=3 treatment goals (61%, n = 63, vs. 28%, n = 28; P < 0.001). Patients who attained >or=3 treatment targets (n = 91) had reduced risk of the primary end point (14 vs. 34; relative risk 0.43 [95% CI 0.21-0.86] compared with that of those who attained <or=2 targets (n = 114). CONCLUSIONS Attainment of multiple treatment targets reduced the renal end point and death in type 2 diabetes. In addition to protocol, audits and feedback are needed to improve outcomes.
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Affiliation(s)
- Juliana C Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Chan JCN. Diabetes in Asia – From Understanding to Action. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2008. [DOI: 10.47102/annals-acadmedsg.v37n11p903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- Juliana CN Chan
- The Chinese University of Hong Kong, The Prince of Wales Hospital, Hong Kong SAR, China Director, Hong Kong Institute of Diabetes and Obesity, Hong Kong SAR, China
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Combe C, Rigothier C, Vendrely B, Chauveau P, Rigalleau V, Lasseur C. [Strategies to slow the progression of chronic kidney disease]. Presse Med 2007; 36:1849-55. [PMID: 17656065 DOI: 10.1016/j.lpm.2007.04.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Accepted: 04/26/2007] [Indexed: 01/13/2023] Open
Abstract
High blood pressure and proteinuria are the major factors that drive progression of chronic kidney disease. Target levels for preserving renal function are blood pressure less than 130/80 mmHg and proteinuria less than 0.5 g/day. Angiotensin II converting enzyme inhibitors and sartans should be used as first-line therapy to reach these targets. Their use requires close monitoring of renal function and serum potassium levels. Moderate sodium restriction, possibly combined with diuretic therapy, helps to maximize the effect of renin-angiotensin inhibitors. Patients with chronic kidney disease have a high risk of acute kidney failure, especially due to drugs. All prescriptions must take into account the existence and extent of kidney disease. Patient adhesion and collaboration between health professionals are required if these measures are to be effective in the long term.
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Affiliation(s)
- Christian Combe
- Département de néphrologie, Centre hospitalier universitaire de Bordeaux, Hôpital Pellegrin, Bordeaux.
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Abstract
PURPOSE OF REVIEW This review summarizes recent studies designed to identify improved treatments for diabetic nephropathy. RECENT FINDINGS Recent data support the concept that angiotensin converting enzyme inhibitors and angiotensin II receptor blockers have similar renoprotective effects. Aggressive blockade of the renin-angiotensin system appears to have benefits beyond those achieved with conventional doses of single agents. Dual blockade using angiotensin converting enzyme inhibitors and angiotensin II receptor blockers is effective. Aldosterone receptor antagonists may potentiate the effect of these two classes of compounds. It remains unclear, however, whether maximum benefit can be obtained by the combination of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers or aldosterone receptor antagonists as compared to larger doses of single agents. Not enough data are available currently to recommend thiazolidinedione hypoglycemic agents for renal protection. Trials are being conducted with several new classes of agents. SUMMARY Evidence from short-term studies favors aggressive blockade of the renin-angiotensin system. Long-term studies, however, remain to be performed. A multifactorial approach that incorporates established interventions affords our best means to retard the progression of diabetic nephropathy.
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Affiliation(s)
- Yiming Z Lit
- Department of Medicine and Nephrology, Stanford University and VA Palo Alto HCS, Stanford, California 93401, USA
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Li PKT, Leung CB, Chow KM, Cheng YL, Fung SKS, Mak SK, Tang AWC, Wong TYH, Yung CY, Yung JCU, Yu AWY, Szeto CC. Hong Kong study using valsartan in IgA nephropathy (HKVIN): a double-blind, randomized, placebo-controlled study. Am J Kidney Dis 2006; 47:751-60. [PMID: 16632013 DOI: 10.1053/j.ajkd.2006.01.017] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Accepted: 01/04/2006] [Indexed: 01/13/2023]
Abstract
BACKGROUND Previous studies showed that angiotensin-receptor blocker (ARB) therapy decreased proteinuria and possibly slowed the rate of renal function decline in patients with chronic proteinuric nephropathies. We performed a double-blind, randomized, placebo-controlled, multicenter study on the ARB valsartan in the treatment of patients with immunoglobulin A (IgA) nephropathy. METHODS From 6 centers, we recruited 109 patients with IgA nephropathy who had either: (1) proteinuria with protein greater than 1 g/d and serum creatinine level less than 2.8 mg/dL (< 250 micromol/L), or (2) serum creatinine level of 1.4 to 2.8 mg/dL (120 to 250 micromol/L) regardless of degree of proteinuria. Patients were randomly assigned to administration of either valsartan, 80 mg/d (titrated up to 160 mg/d for blood pressure control), or placebo for 104 weeks. Additional antihypertensive therapy was allowed to achieve a target blood pressure of 140/90 mm Hg. The primary end point was doubling of serum creatinine level or dialysis-dependent renal failure. Secondary outcomes included change in proteinuria and decrease in glomerular filtration rate (GFR). RESULTS There were 54 patients in the treatment group and 55 patients in the placebo group. Baseline clinical characteristics were similar between groups, although the treatment group had a marginally greater baseline GFR (87 +/- 36 versus 78 +/- 38 mL/min/1.73 m2 [1.45 +/- 0.60 versus 1.30 +/- 0.63 mL/s/1.73 m2];P = 0.29) and less proteinuria (protein, 1.8 +/- 1.2 versus 2.3 +/- 1.7 g/d; P = 0.21) than the placebo group. Average blood pressures during the study were 92.7 +/- 10.6 mm Hg in the treatment group and 100.9 +/- 9.1 mm Hg in the placebo group (P < 0.001). During the study period, 4 patients in the placebo group and 1 patient in the treatment group reached the primary end point (log-rank test, P = 0.18). Proteinuria decreased significantly in the treatment group (protein, 1.8 +/- 1.2 to 1.2 +/- 1.2 g/d; P = 0.03), but did not change in the placebo group. With multiple linear regression models, valsartan treatment resulted in a 33.0% decrease in proteinuria (95% confidence interval, 10.9 to 55.1) after adjusting for other confounding factors. There was a significant decrease in mean rate of GFR decrease in the valsartan-treated group (-5.62 +/- 6.79 mL/min/y [-0.09 +/- 0.11 mL/s/y]) compared with the placebo group (-6.98 +/- 6.17 mL/min/y [-0.12 +/- 0.10 mL/s/y]) throughout the study period after adjustment for average blood pressure and proteinuria (P = 0.014). CONCLUSION Valsartan significantly decreases proteinuria and slows renal deterioration in patients with IgA nephropathy after adjustment for confounding factors, notably blood pressure. The long-term benefit of valsartan needs to be confirmed with additional studies.
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Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong.
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Stanton R. Intensive treatment of diabetic nephropathy. Curr Diab Rep 2004; 4:433-4. [PMID: 15539007 DOI: 10.1007/s11892-004-0052-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Robert Stanton
- Department of Nephrology, Joslin Diabetes Center, Boston, MA 02215, USA.
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