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Association of poorly controlled HbA1c with increased risk of progression to end-stage kidney disease and all-cause mortality in patients with diabetes and chronic kidney disease. PLoS One 2022; 17:e0274605. [PMID: 36155491 PMCID: PMC9512200 DOI: 10.1371/journal.pone.0274605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 08/31/2022] [Indexed: 11/19/2022] Open
Abstract
Glycosylated hemoglobin (HbA1c) targets for patients with chronic kidney disease (CKD) and type 2 diabetes remain controversial. To evaluate whether baseline HbA1c and HbA1c trajectories are associated with the risk of end-stage kidney disease (ESKD) and all-cause mortality, we recruited adult patients with CKD and type 2 diabetes from a “Pre-ESKD Program” at a medical center in Taiwan from 2003 to 2017. Group-based trajectory modeling was performed to identify distinct patient groups that contained patients with similar longitudinal HbA1c patterns. Cox proportional hazard models were used to estimate hazard ratios (HRs) of ESKD and mortality associated with baseline HbA1c levels and HbA1c trajectories. In the analysis related to baseline HbA1c (n = 4543), the adjusted HRs [95% confidence interval (CI)] of all-cause mortality were 1.06 (0.95–1.18) and 1.25 (95% CI, 1.07–1.46) in patients with an HbA1c level of 7%–9% (53–75 mmol/mol) and >9% (>75 mmol/mol), respectively, as compared with those with an HbA1c level < 7% (<53 mmol/mol). In the trajectory analysis (n = 2692), three distinct longitudinal HbA1c trajectories were identified: nearly optimal (55.9%), moderate to stable (34.2%), and poor control (9.9%). Compared with the “nearly optimal” HbA1c trajectory group, the “moderate-to-stable” group did not have significantly higher mortality, but the “poorly controlled” group had 35% higher risk of mortality (adjusted HR = 1.35, 95% CI = 1.06–1.71). Neither baseline levels of HbA1c nor trajectories were associated with ESKD risk. In conclusion, in patients with CKD and type 2 diabetes, poor glycemic control was associated with an elevated risk of mortality but not associated with a risk of progression to ESKD.
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Gan L, Lyu X, Yang X, Zhao Z, Tang Y, Chen Y, Yao Y, Hong F, Xu Z, Chen J, Gu L, Mao H, Liu Y, Sun J, Zhou Z, Du X, Jiang H, Li Y, Sun N, Liang X, Zuo L. Application of Angiotensin Receptor–Neprilysin Inhibitor in Chronic Kidney Disease Patients: Chinese Expert Consensus. Front Med (Lausanne) 2022; 9:877237. [PMID: 35928297 PMCID: PMC9343998 DOI: 10.3389/fmed.2022.877237] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic kidney disease (CKD) is a global public health problem, and cardiovascular disease is the most common cause of death in patients with CKD. The incidence and prevalence of cardiovascular events during the early stages of CKD increases significantly with a decline in renal function. More than 50% of dialysis patients die from cardiovascular disease, including coronary heart disease, heart failure, arrhythmia, and sudden cardiac death. Therefore, developing effective methods to control risk factors and improve prognosis is the primary focus during the diagnosis and treatment of CKD. For example, the SPRINT study demonstrated that CKD drugs are effective in reducing cardiovascular and cerebrovascular events by controlling blood pressure. Uncontrolled blood pressure not only increases the risk of these events but also accelerates the progression of CKD. A co-crystal complex of sacubitril, which is a neprilysin inhibitor, and valsartan, which is an angiotensin receptor blockade, has the potential to be widely used against CKD. Sacubitril inhibits neprilysin, which further reduces the degradation of natriuretic peptides and enhances the beneficial effects of the natriuretic peptide system. In contrast, valsartan alone can block the angiotensin II-1 (AT1) receptor and therefore inhibit the renin–angiotensin–aldosterone system. These two components can act synergistically to relax blood vessels, prevent and reverse cardiovascular remodeling, and promote natriuresis. Recent studies have repeatedly confirmed that the first and so far the only angiotensin receptor–neprilysin inhibitor (ARNI) sacubitril/valsartan can reduce blood pressure more effectively than renin–angiotensin system inhibitors and improve the prognosis of heart failure in patients with CKD. Here, we propose clinical recommendations based on an expert consensus to guide ARNI-based therapeutics and reduce the occurrence of cardiovascular events in patients with CKD.
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Affiliation(s)
- Liangying Gan
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Xiaoxi Lyu
- Institute of Materia Medica, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | | | - Zhanzheng Zhao
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Tang
- The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Yuanhan Chen
- Guangdong Provincial People's Hospital, Guangzhou, China
| | - Ying Yao
- Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | | | - Zhonghao Xu
- Bethune First Hospital of Jilin University, Changchun, China
| | - Jihong Chen
- Shenzhen Bao'an People's Hospital, Shenzhen, China
| | - Leyi Gu
- Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Ying Liu
- First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jing Sun
- Shandong Provincial Hospital, Jinan, China
| | - Zhu Zhou
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xuanyi Du
- The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hong Jiang
- People's Hospital of Xinjiang, Urumqi, China
| | - Yong Li
- Huashan Hospital, Fudan University, Shanghai, China
| | - Ningling Sun
- Peking University People's Hospital, Beijing, China
| | - Xinling Liang
- Guangdong Provincial People's Hospital, Guangzhou, China
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
- *Correspondence: Li Zuo
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Fioretto P, Del Prato S, Buse JB, Goldenberg R, Giorgino F, Reyner D, Langkilde AM, Sjöström CD, Sartipy P. Efficacy and safety of dapagliflozin in patients with type 2 diabetes and moderate renal impairment (chronic kidney disease stage 3A): The DERIVE Study. Diabetes Obes Metab 2018; 20:2532-2540. [PMID: 29888547 PMCID: PMC6175614 DOI: 10.1111/dom.13413] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 05/31/2018] [Accepted: 06/08/2018] [Indexed: 01/10/2023]
Abstract
AIMS Dapagliflozin is a selective inhibitor of sodium glucose co-transporter 2 (SGLT2). This study assessed the efficacy and safety of dapagliflozin 10 mg vs placebo in patients with type 2 diabetes (T2D) and moderate renal impairment (estimated glomerular filtration rate [eGFR], 45-59 mL/min/1.73 m2 ; chronic kidney disease [CKD] stage 3A). MATERIALS AND METHODS In this double-blind, parallel group, Phase 3 study (NCT02413398, clinicaltrials.gov) patients with inadequately controlled T2D (HbA1c 7.0%-11.0%) were randomized (1:1) to dapagliflozin 10 mg once daily (N = 160) or matching placebo (N = 161) for 24 weeks. Randomization was stratified by pre-enrolment glucose-lowering therapy. The primary endpoint was change from baseline in HbA1c at Week 24. RESULTS At Week 24, compared with placebo, dapagliflozin significantly decreased HbA1c (difference [95% CI], -0.34% [-0.53, -0.15]; P < 0.001), body weight (difference [95% CI], -1.25 kg [-1.90, -0.59]; P < 0.001), fasting plasma glucose (difference [95% CI], -0.9 mmol/L [-1.5, -0.4]; P = 0.001) and systolic blood pressure (difference [95% CI], -3.1 mm Hg [-6.3, 0.0]; P < 0.05). Decreases from baseline in eGFR were greater with dapagliflozin than placebo at Week 24 (-2.49 mL/min/1.73 m2 [-4.96, -0.02]), however, eGFR returned to baseline levels at Week 27 (3 weeks post-treatment) (0.61 mL/min/1.73 m2 [-1.59, 2.81]). No increase in adverse events (AEs; 41.9% vs 47.8%) or serious AEs (5.6% vs 8.7%) were reported with dapagliflozin versus placebo. No AEs of bone fractures, amputations or DKA were reported. CONCLUSIONS The findings of this study (NCT02413398, clinicaltrials.gov) support the positive benefit/risk profile of dapagliflozin for the treatment of patients with T2D and CKD 3A.
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Affiliation(s)
| | - Stefano Del Prato
- Department of Clinical & Experimental MedicineUniversity of PisaPisaItaly
| | - John B. Buse
- Department of MedicineUniversity of North Carolina School of MedicineChapel HillNorth Carolina
| | | | - Francesco Giorgino
- Department of Emergency and Organ TransplantationUniversity of Bari Aldo MoroBariItaly
| | | | | | | | - Peter Sartipy
- AstraZenecaGothenburgSweden
- School of Bioscience, Systems Biology Research CenterUniversity of SkövdeSkövdeSweden
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Schernthaner G, Schernthaner-Reiter MH. Diabetes in the older patient: heterogeneity requires individualisation of therapeutic strategies. Diabetologia 2018; 61:1503-1516. [PMID: 29417185 PMCID: PMC6445482 DOI: 10.1007/s00125-018-4547-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/29/2017] [Indexed: 12/11/2022]
Abstract
Owing to the worldwide increase in life expectancy, the high incidence of diabetes in older individuals and the improved survival of people with diabetes, about one-third of all individuals with diabetes are now older than 65 years. Evidence is accumulating that type 2 diabetes is associated with cognitive impairment, dementia and frailty. Older people with diabetes have significantly more comorbidities, such as myocardial infarction, stroke, peripheral arterial disease and renal impairment, compared with those without diabetes. However, as a consequence of the increased use of multifactorial risk factor intervention, a considerable number of older individuals can now survive for many years without any vascular complications. Given the heterogeneity of older individuals with type 2 diabetes, an individualised approach is warranted, which must take into account the health status, presence or absence of complications, and life expectancy. In doing so, undertreatment of otherwise healthy older individuals and overtreatment of those who are frail may be avoided. Specifically, overtreatment of hyperglycaemia in older patients is potentially harmful; in particular, insulin and sulfonylureas should be avoided or, if necessary, used with caution. Instead, glucose-dependent drugs that do not induce hypoglycaemia are preferable since older patients with diabetes and impaired kidney function are especially vulnerable to this adverse event.
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Affiliation(s)
- Guntram Schernthaner
- Department of Medicine 1, Rudolfstiftung Hospital, Juchgasse 25, 1030, Vienna, Austria.
| | - Marie Helene Schernthaner-Reiter
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel, 18-20 1090, Vienna, Austria.
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Haneda M, Kadowaki T, Ito H, Sasaki K, Hiraide S, Ishii M, Matsukawa M, Ueno M. Safety and Efficacy of Teneligliptin in Patients with Type 2 Diabetes Mellitus and Impaired Renal Function: Interim Report from Post-marketing Surveillance. Diabetes Ther 2018; 9:1083-1097. [PMID: 29637459 PMCID: PMC5984919 DOI: 10.1007/s13300-018-0416-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Teneligliptin is a novel oral dipeptidyl peptidase-4 inhibitor for the treatment of type 2 diabetes mellitus (T2DM). Safety and efficacy of teneligliptin have been demonstrated in clinical studies; however, data supporting its use in patients with moderate or severe renal impairment are limited. This interim analysis of a post-marketing surveillance of teneligliptin, exploRing the long-term efficacy and safety included cardiovascUlar events in patients with type 2 diaBetes treated bY teneligliptin in the real-world (RUBY), aims to verify the long-term safety and efficacy of teneligliptin in Japanese patients with T2DM and impaired renal function. METHODS For this analysis, we used the data from case report forms of the RUBY surveillance between May 2013 and June 2017. The patients were classified into G1-G5 stages of chronic kidney disease according to estimated glomerular filtration rate (eGFR) at initiation of teneligliptin treatment. Safety and efficacy were evaluated in these subgroups. Patients on dialysis were also assessed. Safety was assessed from adverse drug reactions (ADRs). Glycemic control was evaluated up to 2 years after teneligliptin initiation. RESULTS A total of 11,677 patients were enrolled in the surveillance and 11,425 patient case-report forms were collected for the interim analysis. The incidence of ADRs in each subgroup was 2.98-6.98% of patients, with no differences in the ADR profile (including hypoglycemia and renal function ADRs) between subgroups. At 1 and 2 years after starting teneligliptin, the least-squares mean change in HbA1c adjusted to the baseline was - 0.68 to - 0.85% and - 0.71 to - 0.85% across the eGFR groups, respectively. Treatment with teneligliptin in patients on dialysis reduced or tended to reduce glycated albumin levels [- 2.29%, (p < 0.001) after 1 year; - 1.64%, (p = 0.064) after 2 years]. CONCLUSIONS During long-term treatment, teneligliptin was generally well tolerated in patients with any stage of renal impairment from normal to end-stage renal disease, including those on dialysis, and improved glycemic control. TRIAL REGISTRATION NUMBER Japic CTI-153047. FUNDING Mitsubishi Tanabe Pharma Corporation and Daiichi Sankyo Co, Ltd.
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Affiliation(s)
- Masakazu Haneda
- Department of Medicine, Asahikawa Medical University, Hokkaido, Japan
- Medical Corporation Kyousoukai, Osaka, Japan
| | - Takashi Kadowaki
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kazuyo Sasaki
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Osaka, Japan.
| | - Sonoe Hiraide
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Osaka, Japan
| | - Manabu Ishii
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Osaka, Japan
| | - Miyuki Matsukawa
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Osaka, Japan
| | - Makoto Ueno
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Osaka, Japan
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Zhang H, Wang H, Yan M, Zhao T, Lu X, Zhu B, Gong Y, Li P. A recombinant TGF-β1 vaccine ameliorates diabetic nephropathy in OLETF rats. Immunotherapy 2016; 8:1045-57. [PMID: 27485077 DOI: 10.2217/imt-2015-0005] [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: 11/21/2022] Open
Abstract
AIM The aim of this study was to investigate the potential of a recombinant vaccine encoding TGF-β1 in OLETF rats with diabetic nephropathy (DN). METHODS OLETF rats were treated with vehicle or TGF-β1 vaccine. LETO rats were used as normal controls. At 42 weeks after immunization with vaccine, samples from blood, urine and kidney were collected for biochemical, histologic, immunohistochemical and molecular analyses. RESULTS OLETF rats treated with the vaccine reduced blood glucose levels, improved renal pathological changes, and inhibited overexpression of TGF-β1 and p-Smad3, as well as MCP-1, TNF-α and IL-1β. CONCLUSION TGF-β1 vaccine attenuated diabetic nephropathy in OLETF rats through reduction of inflammation, improvement of kidney fibrosis and partial correction of glucose metabolism.
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Affiliation(s)
- Haojun Zhang
- Beijing Key Lab for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Science, China-Japan Friendship Hospital, Beijing, China
| | - Hua Wang
- Beijing Key Lab for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Science, China-Japan Friendship Hospital, Beijing, China
| | - Meihua Yan
- Beijing Key Lab for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Science, China-Japan Friendship Hospital, Beijing, China
| | - Tingting Zhao
- Beijing Key Lab for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Science, China-Japan Friendship Hospital, Beijing, China
| | - Xiaoguang Lu
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Bin Zhu
- Beijing Key Lab for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Science, China-Japan Friendship Hospital, Beijing, China
| | - Yuewen Gong
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ping Li
- Beijing Key Lab for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Science, China-Japan Friendship Hospital, Beijing, China
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Mera JI, Okada E, Okuda M, Ota T, Sibata S, Uchida S. Long-term efficacy of vildagliptin in patients with type 2 diabetes undergoing hemodialysis. J Diabetes Metab Disord 2015; 14:83. [PMID: 26550558 PMCID: PMC4635589 DOI: 10.1186/s40200-015-0214-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/22/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND There are few studies evaluating long-term glycemic control using a dipeptidyl peptidase-4 inhibitor in type 2 diabetes patients with end-stage renal disease (ESRD). The aim of this study was to evaluate the safety and efficacy of vildagliptin therapy over 2 years in type 2 diabetes with ESRD. METHODS Patients with ESRD resulting from type 2 diabetes requiring dialysis who had ≥20 % glycated albumin (GA) were enrolled. Vildagliptin 50 mg once daily was administered for 2 years. Changes in GA and dry weight were evaluated. RESULTS In 32 patients (24 men and 8 women) aged 68.3 ± 1.9 years, vildagliptin 50 mg once daily was administered for 2 years, but the dose was increased to 50 mg twice daily in 15 patients. GA was significantly reduced by 2.6 ± 0.6 %, from 22.4 ± 0.6 % at baseline to 19.8 ± 0.4 % at 2 years. After 2 years of vildagliptin therapy, 15 (46.9 %) of 32 patients achieved a GA level of <20 %. Dry weight changed slightly, with an increase of 1.3 ± 0.8 kg at 2 years. No adverse drug reactions related to treatment with vildagliptin were seen. CONCLUSIONS Vildagliptin is a promising therapeutic option for safe, effective glycemic control in type 2 diabetic patients with ESRD.
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Affiliation(s)
- Jun-ichiro Mera
- />Department of Hemodialysis, Shinsen Ikebukuro Clinic, Tobu Annex Bldg. 4F, 1-10-10, Nishi-Ikebukuro, Toshima-ku, Tokyo, 171-0021 Japan
| | - Eiko Okada
- />Department of Urology, Higashi-Omiya General Hospital, 5-18, Higashi-Omiya, Minuma-ku, Saitama, 337-0051 Japan
| | - Masumi Okuda
- />Department of Nephrology, Bousei Hospital, 1-8-14, Harigaya, Urawa-ku, Saitama, 330-0075 Japan
| | - Tatsuru Ota
- />Department of Nephrology, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-ku, Tokyo, 173-8606 Japan
| | - Shigeru Sibata
- />Department of Nephrology, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-ku, Tokyo, 173-8606 Japan
| | - Shunya Uchida
- />Department of Nephrology, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-ku, Tokyo, 173-8606 Japan
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Huri HZ, Lim LP, Lim SK. Glycemic control and antidiabetic drugs in type 2 diabetes mellitus patients with renal complications. Drug Des Devel Ther 2015; 9:4355-71. [PMID: 26300627 PMCID: PMC4535549 DOI: 10.2147/dddt.s85676] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Good glycemic control can delay the progression of kidney diseases in type 2 diabetes mellitus (T2DM) patients with renal complications. To date, the association between antidiabetic agents and glycemic control in this specific patient population is not well established. PURPOSE This study aimed to identify antidiabetic regimens as well as other factors that associated with glycemic control in T2DM patients with different stages of chronic kidney disease (CKD). PATIENTS AND METHODS This retrospective, cross-sectional study involved 242 T2DM inpatients and outpatients with renal complications from January 2009 to March 2014 and was conducted in a tertiary teaching hospital in Malaysia. Glycated hemoglobin (A1C) was used as main parameter to assess patients' glycemic status. Patients were classified to have good (A1C <7%) or poor glycemic control (A1C ≥7%) based on the recommendations of the American Diabetes Association. RESULTS Majority of the patients presented with CKD stage 4 (43.4%). Approximately 55.4% of patients were categorized to have poor glycemic control. Insulin (57.9%) was the most commonly prescribed antidiabetic medication, followed by sulfonylureas (43%). Of all antidiabetic regimens, sulfonylureas monotherapy (P<0.001), insulin therapy (P=0.005), and combination of biguanides with insulin (P=0.038) were found to be significantly associated with glycemic control. Other factors including duration of T2DM (P=0.004), comorbidities such as anemia (P=0.024) and retinopathy (P=0.033), concurrent medications such as erythropoietin therapy (P=0.047), α-blockers (P=0.033), and antigouts (P=0.003) were also correlated with A1C. CONCLUSION Identification of factors that are associated with glycemic control is important to help in optimization of glucose control in T2DM patients with renal complication.
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Affiliation(s)
- Hasniza Zaman Huri
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Clinical Investigation Centre, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Lay Peng Lim
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Soo Kun Lim
- Renal Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Hertel J, Locatelli F, Spasovski G, Dimkovic N, Wanner C. Randomized, Double-Blind, Placebo-Controlled, Withdrawal Study of Colestilan after Dose Titration in Chronic Kidney Disease Dialysis Patients with Hyperphosphatemia. Nephron Clin Pract 2015; 130:229-38. [DOI: 10.1159/000431289] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 05/11/2015] [Indexed: 11/19/2022] Open
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Abstract
In patients with diabetes receiving chronic haemodialysis, both very high and low glucose levels are associated with poor outcomes, including mortality. Conditions that are associated with an increased risk of hypoglycaemia in these patients include decreased gluconeogenesis in the remnant kidneys, deranged metabolic pathways, inadequate nutrition, decreased insulin clearance, glucose loss to the dialysate and diffusion of glucose into erythrocytes during haemodialysis. Haemodialysis-induced hypoglycaemia is common during treatments with glucose-free dialysate, which engenders a catabolic status similar to fasting; this state can also occur with 5.55 mmol/l glucose-containing dialysate. Haemodialysis-induced hypoglycaemia occurs more frequently in patients with diabetes than in those without. Insulin therapy and oral hypoglycaemic agents should, therefore, be used with caution in patients on dialysis. Several hours after completion of haemodialysis treatment a paradoxical rebound hyperglycaemia may occur via a similar mechanism as the Somogyi effect, together with insulin resistance. Appropriate glycaemic control tailored for patients on haemodialysis is needed to avoid haemodialysis-induced hypoglycaemia and other glycaemic disarrays. In this Review we summarize the pathophysiology and current management of glycaemic disarrays in patients on haemodialysis.
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Affiliation(s)
- Masanori Abe
- Divisions of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-chou, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine, 101 The City Drive South, Orange, CA 92868, USA
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Ioannidis I. Diabetes treatment in patients with renal disease: Is the landscape clear enough? World J Diabetes 2014; 5:651-658. [PMID: 25317242 PMCID: PMC4138588 DOI: 10.4239/wjd.v5.i5.651] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 03/31/2014] [Accepted: 07/18/2014] [Indexed: 02/05/2023] Open
Abstract
Diabetes is the most important risk factors for chronic kidney disease (CKD). The risk of CKD attributable to diabetes continues to rise worldwide. Diabetic patients with CKD need complicated treatment for their metabolic disorders as well as for related comorbidities. They have to treat, often intensively, hypertension, dyslipidaemia, bone disease, anaemia, and frequently established cardiovascular disease. The treatment of hypoglycaemia in diabetic persons with CKD must tie their individual goals of glycaemia (usually less tight glycaemic control) and knowledge on the pharmacokinetics and pharmacodynamics of drugs available to a person with kidney disease. The problem is complicated from the fact that in many efficacy studies patients with CKD are excluded so data of safety and efficacy for these patients are missing. This results in fear of use by lack of evidence. Metformin is globally accepted as the first choice in practically all therapeutic algorithms for diabetic subjects. The advantages of metformin are low risk of hypoglycaemia, modest weight loss, effectiveness and low cost. Data of UKPDS indicate that treatment based on metformin results in less total as well cardiovascular mortality. Metformin remains the drug of choice for patients with diabetes and CKD provided that their estimate Glomerular Filtration Rate (eGFR) remains above 30 mL/min per square meter. For diabetic patients with eGFR between 30-60 mL/min per square meter more frequent monitoring of renal function and dose reduction of metformin is needed. The use of sulfonylureas, glinides and insulin carry a higher risk of hypoglycemia in these patients and must be very careful. Lower doses and slower titration of the dose is needed. Is better to avoid sulfonylureas with active hepatic metabolites, which are renally excreted. Very useful drugs for this group of patients emerge dipeptidyl peptidase 4 inhibitors. These drugs do not cause hypoglycemia and most of them (linagliptin is an exception) require dose reduction in various stages of renal disease.
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Schernthaner G, Mogensen CE, Schernthaner GH. The effects of GLP-1 analogues, DPP-4 inhibitors and SGLT2 inhibitors on the renal system. Diab Vasc Dis Res 2014; 11:306-23. [PMID: 25116004 PMCID: PMC4230539 DOI: 10.1177/1479164114542802] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Diabetic nephropathy (DN) affects an estimated 20%-40% of patients with type 2 diabetes mellitus (T2DM). Key modifiable risk factors for DN are albuminuria, anaemia, dyslipidaemia, hyperglycaemia and hypertension, together with lifestyle factors, such as smoking and obesity. Early detection and treatment of these risk factors can prevent DN or slow its progression, and may even induce remission in some patients. DN is generally preceded by albuminuria, which frequently remains elevated despite treatment in patients with T2DM. Optimal treatment and prevention of DN may require an early, intensive, multifactorial approach, tailored to simultaneously target all modifiable risk factors. Regular monitoring of renal function, including urinary albumin excretion, creatinine clearance and glomerular filtration rate, is critical for following any disease progression and making treatment adjustments. Dipeptidyl peptidase (DPP)-4 inhibitors and sodium-glucose cotransporter 2 (SGLT2) inhibitors lower blood glucose levels without additional risk of hypoglycaemia, and may also reduce albuminuria. Further investigation of the potential renal benefits of DPP-4 and SGLT2 inhibitors is underway.
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Affiliation(s)
| | - Carl Erik Mogensen
- Medical Department M (Diabetes & Endocrinology), Aarhus University Hospital, Aarhus, Denmark
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Shamkhalova MS, Yarek-Martynova IR, Trubitcyna NP, Shestakova MV. Glucose-lowering therapies in patients with diabetes mellitus and chronic kidney disease. DIABETES MELLITUS 2013. [DOI: 10.14341/2072-0351-823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Expansion of diabetic population (predominantly due to type 2 diabetes mellitus) with chronic kidney disease (CKD) comorbidityconstitutes one of the major challenges in modern medicine.Throughout the course of diabetes nephropathy development, from its debut to the terminal stage, survival rate and quality of life arelower than those of other categories of patients. This indicates crucial role of hyperglycemia in accelerated metabolic degradation typicalof CKD.Renal disease severely narrows the spectrum of available glucose-lowering agents. Concurrent treatment for hypertension and dyslipidemia,as well as anti-platelet therapy and stimulation of erythropoiesis becomes a complex issue. A creative and patient-orientedapproach with clear metabolic and cardiovascular goals should be instrumental in its solution.
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Avogaro A, Schernthaner G. Achieving glycemic control in patients with type 2 diabetes and renal impairment. Acta Diabetol 2013; 50:283-91. [PMID: 23212669 DOI: 10.1007/s00592-012-0442-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 11/05/2012] [Indexed: 12/31/2022]
Abstract
Defining optimal regimens for the management of diabetes among patients with renal impairment is often clinically challenging, and guidance on the optimal management of these patients in clinical practice can vary considerably. Moreover, as many anti-diabetes agents are predominantly excreted renally, treatment options to control blood glucose levels are limited for patients with type 2 diabetes and concomitant chronic kidney disease. Many of the widely used and more established anti-diabetes drugs cannot be used in this population either or must be down-titrated to reduce the increased risk of severe hypoglycemic episodes. A number of more recently available anti-diabetes drugs are indicated for use in patients with type 2 diabetes and chronic kidney disease. Newer drugs that may improve the currently very limited treatment options for patients with type 2 diabetes and renal impairment include the glucagon-like peptide-1 receptor agonists and the dipeptidyl peptidase-4 inhibitors. This review paper, based on a literature search for both original and review articles (Medline), relevant clinical practice/regulatory guidelines and integrating our own knowledge of the field, provides an up-to-date examination of the current treatment options available. However, further studies with larger populations of patients with type 2 diabetes and chronic kidney disease are needed to clarify the efficacy and safety of the different treatment options, including newer drugs.
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Affiliation(s)
- Angelo Avogaro
- Department of Medicine, School of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
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Arjona Ferreira JC, Corry D, Mogensen CE, Sloan L, Xu L, Golm GT, Gonzalez EJ, Davies MJ, Kaufman KD, Goldstein BJ. Efficacy and safety of sitagliptin in patients with type 2 diabetes and ESRD receiving dialysis: a 54-week randomized trial. Am J Kidney Dis 2013; 61:579-87. [PMID: 23352379 DOI: 10.1053/j.ajkd.2012.11.043] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 11/07/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Treatment with oral antihyperglycemic agents has not been well characterized in patients with type 2 diabetes and end-stage renal disease (ESRD). The efficacy and safety of sitagliptin and glipizide monotherapy in patients with type 2 diabetes and ESRD on dialysis therapy were assessed in this study. STUDY DESIGN 54-week, randomized, double-blind, parallel-arm study. SETTING & PARTICIPANTS From 31 clinical sites in 12 countries, 129 patients 30 years or older with type 2 diabetes and ESRD who were on dialysis therapy and had a hemoglobin A1c (HbA1c) level of 7%-9% were randomly assigned 1:1 to treatment. INTERVENTION Monotherapy with sitagliptin, 25 mg daily or glipizide (initiated with 2.5 mg daily and titrated up to a potential maximum dose of 10 mg twice daily or down to avoid hypoglycemia). OUTCOMES Primary end points were 54-week change in HbA1c level from baseline and tolerability with sitagliptin. A secondary end point was the comparison of sitagliptin versus glipizide on the incidence of symptomatic hypoglycemia. RESULTS Of 129 patients randomly assigned, 64 were in the sitagliptin group (mean baseline age, 61 years; HbA1c, 7.9%) and 65 were in the glipizide group (mean baseline age, 59 years; HbA1c, 7.8%). After 54 weeks, the least squares mean change from baseline in HbA1c level was -0.72% (95% CI, -0.95% to -0.48%) with sitagliptin and -0.87% (95% CI, -1.11% to -0.63%) with glipizide, for a difference of 0.15% (95% CI, -0.18% to 0.49%). The incidences of symptomatic hypoglycemia and severe hypoglycemia were 6.3% versus 10.8% (between-group difference, -4.8% [95% CI, -15.7% to 5.6%]) and 0% versus 7.7% (between-group difference, -7.8% [95% CI, -17.1% to -1.9%]) in the sitagliptin and glipizide groups, respectively. Higher incidences (ie, 95% CI around between-treatment difference excluded 0) of cellulitis and headache were found with sitagliptin compared to glipizide (6.3% vs 0%, respectively, for both). LIMITATIONS Small sample size limits between-group comparisons. CONCLUSIONS Treatment with sitagliptin or glipizide monotherapy was effective and well tolerated over 54 weeks in patients with type 2 diabetes and ESRD who were receiving dialysis.
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Bose S, Bomback AS, Mehta NN, Chen SC, Li S, Whaley-Connell A, Benjamin J, McCullough PA. Dysglycemia but not lipids is associated with abnormal urinary albumin excretion in diabetic kidney disease: a report from the Kidney Early Evaluation Program (KEEP). BMC Nephrol 2012; 13:104. [PMID: 22958709 PMCID: PMC3480932 DOI: 10.1186/1471-2369-13-104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 08/20/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The relationship between glycemic control and lipid abnormalities with urinary albumin-creatinine ratio (ACR) in chronic kidney disease (CKD) patients with diabetes mellitus (DM) is unknown. We sought to investigate the association of dyslipidemia and glycemic control with levels of albuminuria in the National Kidney Foundation (NKF) Kidney Early Evaluation Program (KEEP) participants with DM and CKD stage 3 or higher. METHODS We performed a cross-sectional study of 6639 eligible KEEP patients with DM and CKD Stage 3 to 5 from June 2008 to December 2009. Multivariate logistic regression was used to evaluate the association of lipid parameters (per 10 mg/dl change in serum level) and glycosylated hemoglobin (HbA1c) values with three degrees of albuminuria normo (<30 mg/g), micro (30 to 300 mg/g) and macro (>300 mg/g). RESULTS 2141 KEEP participants were included. HbA1c levels were strongly associated with micro-albuminuria (compared to normo-albuminuria) and macro-albuminuria (compared to normo-albuminuria and micro-albuminuria). Each 1.0% increase in HbA1c increased the odds of micro-albuminuria by 32% (OR 1.32, 95% CI 1.23-1.42) and the odds of macro-albuminuria (vs. microalbuminuria) by 16% (OR 1.16, 95% CI 1.05-1.28). Only increases in serum HDL were associated with decreased odds of micro-albuminuria; otherwise, the association between other components of the serum lipid profile with urinary ACR did not reach statistical significance. CONCLUSION In this cross-sectional study of 2141 KEEP participants with DM and CKD stages 3-5, overall glycemic control but not lipids were associated with abnormal urinary albumin excretion, a marker of increased risk for progressive disease.
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Affiliation(s)
- Subhasish Bose
- Department of Nephrology, Temple University Hospital, Philadelphia, PA, USA.
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Affiliation(s)
- Eberhard Ritz
- Department of Internal Medicine, Nierenzentrum, Im Neuenheimer Feld, Heidelberg, Germany.
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Pateinakis P, Papagianni A. Cardiorenal syndrome type 4-cardiovascular disease in patients with chronic kidney disease: epidemiology, pathogenesis, and management. Int J Nephrol 2011; 2011:938651. [PMID: 21331317 PMCID: PMC3038631 DOI: 10.4061/2011/938651] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 01/03/2011] [Indexed: 01/08/2023] Open
Abstract
The term cardiorenal syndrome refers to the interaction between the heart and the kidney in disease and encompasses five distinct types according to the initial site affected and the acute or chronic nature of the injury. Type 4, or chronic renocardiac syndrome, involves the features of chronic renal disease (CKD) leading to cardiovascular injury. There is sufficient epidemiologic evidence linking CKD with increased cardiovascular morbidity and mortality. The underlying pathophysiology goes beyond the highly prevalent traditional cardiovascular risk burden affecting renal patients. It involves CKD-related factors, which lead to cardiac and vascular pathology, mainly left ventricular hypertrophy, myocardial fibrosis, and vascular calcification. Risk management should consider both traditional and CKD-related factors, while therapeutic interventions, apart from appearing underutilized, still await further confirmation from large trials.
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Affiliation(s)
- Panagiotis Pateinakis
- Department of Nephrology, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “Hippokration”, Papanastasiou 50, 546 42 Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “Hippokration”, Papanastasiou 50, 546 42 Thessaloniki, Greece
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Tessier DM. Optimal glycemic control in the elderly: where is the evidence and who should be targeted? ACTA ACUST UNITED AC 2011. [DOI: 10.2217/ahe.10.86] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In the near future, with the continuous increase in life expectancy observed in the population and with the aging of the baby boomers, an increase is expected in the absolute and relative number of the elderly population. With the aging phenomenon, the prevalence of a number of chronic diseases is increasing and requires interventions from different health professionals. Type 2 diabetes mellitus is a very frequent condition in the elderly and is characterized by variable degrees of hyperglycemia while ketosis is exceptional in this condition. The question of who should be offered optimal glycemic control becomes more and more pertinent as the older diabetic population grows but it has to be considered that the consequences of hypoglycemia related to the medications used to lower glycemia are not benign in the older population. Hence, the advantages and disadvantages of tight glycemic control will be reviewed in the light of recent data.
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Affiliation(s)
- Daniel M Tessier
- Centre de Santé et des Services Sociaux, Sherbrooke Geriatric University Institute, 375 Argyll Sherbrooke, Québec, J1J 3H5, Canada
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