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Ou SH, Chang WC, Wu LY, Wang SI, Wei JCC, Lee PT. Diabetic Macular Edema Is Predictive of Renal Failure in Patients With Diabetes Mellitus and Chronic Kidney Disease. J Clin Endocrinol Metab 2024; 109:761-770. [PMID: 37804118 DOI: 10.1210/clinem/dgad581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/16/2023] [Accepted: 09/27/2023] [Indexed: 10/08/2023]
Abstract
CONTEXT Chronic hyperglycemia in patients with diabetes mellitus (DM) causes retinal damage and leakage, resulting in vision loss. Although diabetic retinopathy (DR) and diabetic kidney disease (DKD) are usually correlated, the relationship between diabetic macular edema (DME) and DKD remains unknown. OBJECTIVE To assess whether DME presence can predict renal failure in patients with DM and chronic kidney disease (CKD). METHODS This retrospective cohort study used data from 120 healthcare organizations in the TriNetX network. Electronic medical records of approximately 90 million patients were reviewed. The study population was classified into DME and non-DME cohorts. Primary and secondary outcomes were new-onset end-stage renal disease (ESRD) and all-cause mortality, respectively. Covariate factors were incorporated to reduce confounding effects. RESULTS Before matching, the DME cohort used more medication and had poorer renal function and blood sugar control than the non-DME cohort. Subsequently, the 2 groups were well-matched in demographics, socioeconomic status, lifestyle, comorbidities, and medication usage. The DME cohort had a significantly higher risk of ESRD, dialysis, and renal transplantation than the non-DME cohort. Subgroup analyses showed consistent results irrespective of follow-up duration, initial estimated glomerular filtration rate, or glycated hemoglobin levels. Additionally, the DME cohort had a lower risk of all-cause mortality than the non-DME cohort. CONCLUSION Statistically significant 5-year increased risks of ESRD, dialysis, and renal transplantation were observed in patients with concurrent DME. Therefore, close monitoring and follow-up of the renal function in DM patients with DME are necessary and strongly recommended.
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Affiliation(s)
- Shih-Hsiang Ou
- Division of Nephrology, Department of Internal Medicine, Pingtung Veterans General Hospital, Pingtung 900, Taiwan
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813414, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Wei-Che Chang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813414, Taiwan
| | - Ling-Ying Wu
- Department of Obstetrics and Gynecology, Kaohsiung Municipal Feng Shan Hospital-Under the management of Chang Gung Medical Foundation, Kaohsiung 830, Taiwan
| | - Shiow-Ing Wang
- Center for Health Data Science, Department of Medical Research, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Department of Nursing, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli 356006, Taiwan
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Department of Nursing, Chung Shan Medical University, Taichung 40201, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung 413, Taiwan
| | - Po-Tsang Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813414, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
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Duan J, Liu D, Zhao Z, Liang L, Pan S, Tian F, Yu P, Li G, Liu Z. Short-term duration of diabetic retinopathy as a predictor for development of diabetic kidney disease. J Transl Int Med 2023; 11:449-458. [PMID: 38130638 PMCID: PMC10732346 DOI: 10.2478/jtim-2022-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Background Diabetic retinopathy (DR) is a risk factor for diabetic kidney disease (DKD). Whether the duration, especially the short-term duration, of DR is associated with the development and progression of DKD remains unclear. Materials and Methods A retrospective study and two-sample Mendelian randomization (MR) analysis were conducted. Kidney disease was defined by the urinary albumin-to-creatinine ratio (ACR) and the estimated glomerular filtration rate (eGFR). DR was diagnosed by an expert ophthalmologist by using a digital fundus camera. Binary and ordinal logistic regression analyses were performed. A restricted cubic spline was utilized to detect nonlinear associations. Summary statistics for DR- and DKD-associated single-nuclear polymorphisms (SNPs) were extracted from the FinnGen and the UK Biobank consortia. Results A total of 2674 patients with type 2 diabetes mellitus (T2DM) and type 2 diabetic kidney disease (T2DKD) were included. The prevalence and mean duration of DR increased with elevation of ACR and decline in eGFR. Renal function was significantly reduced in patients with DR in the fifth year of life. Binary and ordinal logistic regression showed that each 1-year increase in DR duration was associated with a 19% risk increase in the development of DKD, 16% in the elevation of ACR, and 21% in the decline of renal function. MR estimates indicated that DR was causally associated with DKD development, with an odds ratio of 2.89. Conclusions DR and the duration of DR were independent risk factors for the development and progression of DKD. The short-term duration of DR may be associated with DKD development. DR had a statistically significant effect on DKD.
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Affiliation(s)
- Jiayu Duan
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou450052, Henan Province, China
- TCM-Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou450052, Henan Province, China
- Henan Province Research Center for Kidney Disease, Zhengzhou450052, Henan Province, China
| | - Dongwei Liu
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou450052, Henan Province, China
- TCM-Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou450052, Henan Province, China
- Henan Province Research Center for Kidney Disease, Zhengzhou450052, Henan Province, China
| | - Zihao Zhao
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou450052, Henan Province, China
- Henan Province Research Center for Kidney Disease, Zhengzhou450052, Henan Province, China
| | - Lulu Liang
- TCM-Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou450052, Henan Province, China
| | - Shaokang Pan
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou450052, Henan Province, China
- TCM-Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou450052, Henan Province, China
| | - Fei Tian
- TCM-Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou450052, Henan Province, China
| | - Pei Yu
- Henan Province Research Center for Kidney Disease, Zhengzhou450052, Henan Province, China
| | - Guangpu Li
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou450052, Henan Province, China
- TCM-Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou450052, Henan Province, China
| | - Zhangsuo Liu
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou450052, Henan Province, China
- TCM-Integrated Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou450052, Henan Province, China
- Henan Province Research Center for Kidney Disease, Zhengzhou450052, Henan Province, China
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Wang L, Jin L, Wang W, Gong X, Li Y, Li W, Liang X, Huang W, Liu Y. Association of renal function with diabetic retinopathy and macular oedema among Chinese patients with type 2 diabetes mellitus. Eye (Lond) 2023; 37:1538-1544. [PMID: 35864160 PMCID: PMC10219992 DOI: 10.1038/s41433-022-02173-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 06/17/2022] [Accepted: 06/30/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To investigate the associations of renal function with diabetic retinopathy (DR) and diabetic macular oedema (DMO) in diabetic patients. METHODS A total of 1877 diabetic participants aged 30 to 80 years were consecutively recruited between October 2017 and April 2019. The presence of DR, vision-threatening DR (VTDR) and DMO were graded using seven-field fundus photographs. Renal function was defined as normal, mildly impaired or indicative of chronic kidney disease (CKD) based on different estimated glomerular filtration rates (GFR). RESULTS In the multivariable logistic regression model, decreased GFR was associated with the presence of any DR only in the presence of microalbuminuria (OR = 2.40 for mildly impaired and 3.37 for CKD, all P < 0.05), while an impaired GFR was an independent risk factor for VTDR regardless of microalbuminuria status (all P < 0.05). The risks of any DR (OR = 1.74 for quartile 2 and 3.09 for quartile 4) and VTDR (OR = 3.27 for quartile 2 and 6.41 for quartile 4) increased gradually along with microalbuminuria quartile (all P < 0.05). CKD (OR = 3.07, P = 0.012) and high microalbuminuria (OR = 3.22 for quartile 3 and 5.25 for quartile 4, all P < 0.05) were independent DMO risk factors. CONCLUSIONS AND RELEVANCE There is a strong association between GFR and VTDR, whereas the association between GFR and any DR was significant only under the premise of microalbuminuria. High microalbuminuria and CKD were significantly associated with DMO.
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Affiliation(s)
- Lanhua Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Ling Jin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Wei Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Xia Gong
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Yuting Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Wangting Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Xiaoling Liang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Wenyong Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China.
| | - Yizhi Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
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Wang D, Fan K, He Z, Guo X, Gong X, Xiong K, Wei D, Chen B, Kong F, Liao M, Wang W, Huang W, Liu H. The relationship between renal function and diabetic retinopathy in patients with type 2 diabetes: A three-year prospective study. Heliyon 2023; 9:e14662. [PMID: 37095916 PMCID: PMC10121393 DOI: 10.1016/j.heliyon.2023.e14662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Objective To explore the association of diabetic retinopathy (DR) and diabetic macular edema (DME) with renal function in patients with type 2 diabetes mellitus (T2DM). Design A prospective cohort study. Methods This single-centre study included patients with no DR, mild non-proliferative DR (NPDR), and no DME at baseline. DR and DME were assessed using 7-field fundus photography and swept-source OCT (SS-OCT). The baseline renal function assessed included the estimated glomerular filtration rate (eGFR) and microalbuminuria (MAU). Cox regression analyses were used to assess the hazard ratio (HR) of renal function with the progression of DR and the development of DME. Results A total of 1409 patients with T2DM (1409 eyes) were included. During 3 years of follow-up,143 patients had DR progression, and 54 patients developed DME. Low eGFR levels at baseline were associated with the development of DR (HR, 1.044 per 1-SD decrease; 95% CI, 1.035-1.053; P < 0.001). Compared to the participants with eGFRs >90 mL/min/1.73 m2, the participants with eGFRs of 60-90 mL/min/1.73 m2 (HR, 1.649; 95% CI, 1.094-2.485; P = 0.017) or < 60 mL/min/1.73 m2 (HR, 2.106; 95% CI, 1.039-4.269; P = 0.039) had a higher risk of DR progression. Increasing MAU tertiles were associated with progression of DR (Tertile 2: HR, 2.577; 95% CI, 1.561-4.256; P < 0.001; Tertile 3: HR, 3.135; 95% CI, 1.892-5.194; P < 0.001). No significant relationship was found between renal function and the development of DME (P > 0.05). Conclusions Abnormal renal profiles (i.e., low levels of eGFR and high levels of MAU) were associated with the progression of DR, but not with the development of DME.
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Betzler BK, Sabanayagam C, Tham YC, Cheung CY, Cheng CY, Wong TY, Nusinovici S. Retinal Vascular Profile in Predicting Incident Cardiometabolic Diseases among Individuals with Diabetes. Microcirculation 2022; 29:e12772. [PMID: 35652745 DOI: 10.1111/micc.12772] [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: 12/02/2021] [Revised: 04/12/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the longitudinal associations between retinal vascular profile (RVP) and four major cardiometabolic diseases; and to quantify the predictive improvements when adding RVP beyond traditional risk factors in individuals with diabetes. METHODS Subjects were enrolled from the Singapore Epidemiology of Eye Disease (SEED) study, a multi-ethnic population-based cohort. Four incident cardiometabolic diseases, calculated over a ~6-year period, were considered: cardiovascular disease (CVD), hypertension (HTN), diabetic kidney disease (DKD) and hyperlipidaemia (HLD). The RVP - vessel tortuosity, branching angle, branching coefficient, fractal dimension, vessel calibre, and DR status - was characterized at baseline using a computer-assisted program. Traditional risk factors at baseline included age, gender, ethnicity, smoking, blood pressure (BP), HbA1c, estimated glomerular filtration rate (eGFR) or cholesterol. The improvements in predictive performance when adding RVP (compared to only traditional risk factors) was calculated using several metrics including area under the receiver operating characteristics curve (AUC) and Net Reclassification Improvement (NRI). RESULTS Among 1,770 individuals with diabetes, incidences were 6.3% (n=79/1259) for CVD, 48.7% (n=166/341) for HTN, 14.6% (n=175/1199) for DKD, and 59.4% (n=336/566) for HLD. DR preceded the onset of CVD (RR 1.85[1.14;3.00]) and DKD (1.44 [1.06;1.96]). Narrower arteriolar calibre preceding the onset of HTN (0.84 [0.72;0.99]), and changes in arteriolar branching angle preceded the onset of CVD (0.78 [0.62;0.98]) and HTN (1.15 [1.03;1.29]). The largest predictive improvement was found for HTN with AUC increment of 3.4% (p=0.027) and better reclassification of 11.4% of the cases and 4.6% of the controls (p=0.008). CONCLUSION We found that RVPs improved the prediction of HTN in individuals with diabetes, but add limited information for CVD, DKD and HLD predictions.
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Affiliation(s)
- Bjorn Kaijun Betzler
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Yih-Chung Tham
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Carol Y Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Ching-Yu Cheng
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tien-Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Simon Nusinovici
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore
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Diabetic Retinopathy Is a Predictor of Progression of Diabetic Kidney Disease: A Systematic Review and Meta-Analysis. Int J Nephrol 2022; 2022:3922398. [PMID: 35531467 PMCID: PMC9076335 DOI: 10.1155/2022/3922398] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/24/2022] [Indexed: 12/05/2022] Open
Abstract
Methods A systematic search was conducted on PubMed, Embase, and the Google scholar for eligible studies through September 2021. The quality of selected articles was assessed using JBI checklist. Higgins and Thompson's I2 statistic was used to see the degree of heterogeneity. Based on degree of heterogeneity, fixed or random effects model was used to estimate pooled effect using inverse variance method. Results were expressed as hazard ratios and odds ratios with 95% CIs. Results After scrutinizing 18017 articles, data from ten relevant studies (seven prospective and three retrospective) was extracted. DR was significantly associated with DKD progression with a pooled HR of 2.42 (95% CI: 1.70–3.45) and a pooled OR of 2.62 (95% CI: 1.76–3.89). There was also a significant association between the severity of DR and risk of progression of DKD with a pooled OR of 2.13 (95% CI: 1.82–2.50) for nonproliferative DR and 2.56 (95% CI: 2.93–.33) for proliferative DR. Conclusion Our study suggests that presence of DR is a strong predictor of risk of kidney disease progression in DKD patients. Furthermore, the risk of DKD progression increases with DR severity. Screening for retinal vascular changes could potentially help in prognostication and risk-stratification of patients with DKD.
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Kong H, Zang S, Hu Y, Lin Z, Liu B, Zeng X, Xiao Y, Du Z, Guanrong W, Ren Y, Fang Y, Xiaohong Y, Yu H. Effect of High Myopia and Cataract Surgery on the Correlation Between Diabetic Retinopathy and Chronic Kidney Disease. Front Med (Lausanne) 2022; 9:788573. [PMID: 35721047 PMCID: PMC9198540 DOI: 10.3389/fmed.2022.788573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 03/21/2022] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To investigate the effect of high myopia and cataract surgery on the grading of diabetic retinopathy (DR) and their roles in the correlation between DR and chronic kidney disease (CKD). METHODS A total of 1,063 eyes of 1,063 diabetic patients were enrolled. We conducted binary and multiple multivariate regressions to analyze the ocular and systemic risk factors of DR. Based on the presence of myopia and history of cataract surgery, we divided the cases into four subgroups, namely those with high myopia, with the history of cataract surgery, with both conditions, and with neither, then determined the correlation between the stages of DR and CKD in each subgroup. RESULTS In the binary analysis, high myopia was identified as the protective factor for DR odds ratio (OR): 0.312 [95% confidence interval (CI): 0.195-0.500, p < 0.001], whereas cataract surgery was one of the independent risk factors for DR [OR: 2.818 (95% CI: 1.507-5.273), p = 0.001]. With increased stages of DR, high myopia played an increasingly protective role [mild non-proliferative DR (NPDR), OR = 0.461, p = 0.004; moderate NPDR OR = 0.217, p = 0.003; severe NPDR, OR = 0.221, p = 0.008; proliferative DR (PDR), OR = 0.125, p = 0.001], whereas cataract surgery became a stronger risk factor, especially in PDR (mild NPDR, OR = 1.595, p = 0.259; moderate NPDR, OR = 3.955, p = 0.005; severe NPDR, OR = 6.836, p < 0.001; PDR, OR = 9.756, p < 0.001). The correlation between the stages of DR and CKD in the group with neither high myopia nor cataract surgery history was the highest among all subgroups. CONCLUSION High myopia was a protective factor, whereas cataract surgery is a risk factor for DR, and both factors showed stronger effects throughout the (natural disease) grading of DR. The stages of DR and CKD showed a higher correlation after adjustment of the ocular confounding factors.
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Affiliation(s)
- Huiqian Kong
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
| | - Siwen Zang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
| | - Yijun Hu
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
- Refractive Surgery Center, Guangzhou Aier Eye Hospital, Aier Institute of Refractive Surgery, Guangzhou, China
- Aier School of Ophthalmology, Central South University, Changsha, China
| | - Zhanjie Lin
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
- Graduate School, Shantou University Medical College, Shantou, China
| | - Baoyi Liu
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
| | - Xiaomin Zeng
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
| | - Yu Xiao
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
| | - Zijing Du
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
| | - Wu Guanrong
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
| | - Yun Ren
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
- Graduate School, Shantou University Medical College, Shantou, China
| | - Ying Fang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
| | - Yang Xiaohong
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
- *Correspondence: Yang Xiaohong
| | - Honghua Yu
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Southern Medical University, Guangdong Academy of Medical Sciences/The Second School of Clinical Medicine, Guangzhou, China
- Honghua Yu
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Nusinovici S, Sabanayagam C, Lee KE, Zhang L, Cheung CY, Tai ES, Tan GSW, Cheng CY, Klein BEK, Wong TY. Retinal microvascular signs and risk of diabetic kidney disease in asian and white populations. Sci Rep 2021; 11:4898. [PMID: 33649427 PMCID: PMC7921402 DOI: 10.1038/s41598-021-84464-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/11/2021] [Indexed: 12/19/2022] Open
Abstract
The objective was to examine prospectively the association between retinal microvascular signs and development of diabetic kidney disease (DKD) in Asian and White populations. We analysed two population-based cohorts, composing of 1,221 Asians (SEED) and 703 White (WESDR) adults with diabetes. Retinal microvascular signs at baseline included vascular caliber (arteriolar—CRAE, and venular—CRVE) and diabetic retinopathy (DR). Incident cases of DKD were identified after ~ 6-year. Incident cases were defined based on eGFR in SEED and proteinuria or history of renal dialysis in WESDR. The incidence of DKD were 11.8% in SEED and 14.0% in WESDR. Wider CRAE in SEED (OR = 1.58 [1.02, 2.45]) and wider CRVE (OR = 1.69 [1.02, 2.80)) in WESDR were associated with increased risk of DKD. Presence of DR was associated with an increased risk of DKD in both cohorts (SEED: OR = 1.91 [1.21, 3.01] in SEED, WESDR: OR = 1.99 [1.18, 3.35]). Adding DR and retinal vascular calibers in the model beyond traditional risk factors led to an improvement of predictive performance of DKD risk between 1.1 and 2.4%; and improved classification (NRI 3 between 9%). Microvascular changes in the retina are longitudinally associated with risk of DKD.
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Affiliation(s)
- Simon Nusinovici
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, 168751, Singapore
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, 168751, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Kristine E Lee
- Department of Ophthalmology and Visual Sciences, University of Wisconsin Medical School, Madison, WI, USA.,Department of Biostatistics and Medical Informatics, University of Wisconsin Medical School, Madison, WI, USA
| | - Liang Zhang
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, 168751, Singapore
| | - Carol Y Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, 168751, Singapore.,Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - E Shyong Tai
- Department of Medicine, National University Health System, National University of Singapore, Singapore, Singapore
| | - Gavin S W Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, 168751, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Ching Yu Cheng
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, 168751, Singapore
| | - Barbara E K Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin Medical School, Madison, WI, USA
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, 168751, Singapore. .,Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore.
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Hu Y, Li Q, Min R, Deng Y, Xu Y, Gao L. The association between serum uric acid and diabetic complications in patients with type 2 diabetes mellitus by gender: a cross-sectional study. PeerJ 2021; 9:e10691. [PMID: 33520463 PMCID: PMC7811288 DOI: 10.7717/peerj.10691] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/11/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The relationship between serum uric acid (SUA) and several diabetic complications or co-morbidities remains a matter of debate. The study aims to explore the association between SUA levels and the prevalence of non-alcoholic fatty liver disease (NAFLD), diabetic retinopathy (DR), diabetic nephropathy (DN) and diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus (T2DM). METHODS A total of 2,809 participants (1,784 males and 1,025 females) were included in this cross-sectional study. Clinical characteristics and the prevalence of each of the four diseases were analyzed based on gender-specific quartiles of SUA levels. The Pearson correlation analysis and linear-regression analysis were used to access the correlation between SUA levels and clinical characteristics. Furthermore, a binary logistic regression analysis was carried out to determine whether SUA was an independent risk factor for each of the four complications. RESULTS SUA levels were positively correlated to BMI, BUN, Scr and TG, but negatively associated with eGFR, HDL, FBG, 2h-PG and HbA1c% for the patients with T2DM. The prevalence of NAFLD and DN, but not DR or DPN, were increased with SUA levels from the first to the fourth quartile. Binary logistic regression further disclosed that SUA was an independent risk factor for NAFLD (ORs Male = 1.002, ∗ P = 0.0013; ORs Female = 1.002, ∗ P = 0.015) and DN (ORs Male = 1.006, ∗ P < 0.001; ORs Female = 1.005, ∗ P < 0.001), but not for DR and DPN. After adjustment for the confounders, SUA levels were significantly associated with NAFLD within the 3rd (ORs = 1.829, P = 0.004) and 4th quartile (ORs = 2.064, P = 0.001) for women, but not independently associated with SUA for man. On the other hand, our results revealed increased prevalence of DN for SUA quartile 2 (ORs = 3.643, P = 0.039), quartile 3 (ORs = 3.967, P = 0.024) and quartile 4 (ORs = 9.133, P < 0.001) in men; however, SUA quartiles were significantly associated with DN only for quartile 4 (ORs = 4.083, P = 0.042) in women. CONCLUSION For patients with T2DM, elevated SUA concentration is an independent risk factor for the prevalence of NAFLD and DN after adjustment for other indicators, but not DR or DPN.
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Affiliation(s)
- Yimeng Hu
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wu Han, Hu Bei, China
| | - Qinge Li
- Department of Endocrinology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Rui Min
- Department of Endocrinology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yingfeng Deng
- Department of Internal Medicine, University of Texas Southwestern Medical Center, TX, USA
| | - Yancheng Xu
- Department of Endocrinology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ling Gao
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wu Han, Hu Bei, China
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Almutairi NM, Alahmadi S, Alharbi M, Gotah S, Alharbi M. The Association Between HbA1c and Other Biomarkers With the Prevalence and Severity of Diabetic Retinopathy. Cureus 2021; 13:e12520. [PMID: 33564524 PMCID: PMC7863112 DOI: 10.7759/cureus.12520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Diabetes mellitus (DM) is considered to be a significant public health problem globally. According to the American Society of Retina Specialists, diabetic retinopathy (DR) is a complication of diabetes that causes damage to the blood vessels of the retina. In a Japanese study showed that HbA1c and fasting blood glucose values can be considered as predictors for the future development of DR. Thus, this study aimed to determine the prevalence and severity of DR among diabetic patients in Medina, Saudi Arabia, and to assess its relationship with HbA1c and other biomarkers. METHODS This cross-sectional study was conducted at Prince Abdulaziz Bin Majed Diabetes Center and Charitable Healthcare Society in Medina, Saudi Arabia, in July 2018. The data were collected from direct interview questionnaires that were administered to 130 randomly selected diabetic subjects. The subjects' demographic information, eye disease history, medical backgrounds, and laboratory biomarkers were noted. Fundus examinations using a slit lamp were conducted by ophthalmic physicians to diagnose and grade DR. The data were analyzed using Statistical Package for Social Sciences (SPSS) (IBM Corp., Armonk, NY, USA). RESULTS All 130 diabetic patients were examined for DR. DR was prevalent among 35 (26.9%) of the participants. According to the DR severity grading, 95 (73.1%) had no apparent DR, 11 (8.5%) had mild non-proliferative diabetic retinopathy (NPDR), 11 (8.5%) had moderate NPDR, 11 (8.5%) had severe NPDR, and only two (1.5%) had proliferative diabetic retinopathy (PDR). There was a significant association between the development of DR and HbA1c levels (p = 0.040). The duration of DM was also determined to be a significant risk factor for DR (p = 0.001). No other factors were found to have a significant association with DR. CONCLUSION Around one-third of the participants in our study had DR. HbA1c levels and duration of DM were established as important risk factors for DR. Screening is necessary, even in patients with good HbA1c levels, to avoid the late presentation of severe DR and to prevent blindness.
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Affiliation(s)
| | | | - Mona Alharbi
- College of Medicine, Taibah University, Medina, SAU
| | - Sarah Gotah
- College of Medicine, Taibah University, Medina, SAU
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11
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Hsieh JT, Chang FP, Yang AH, Tarng DC, Yang CY. Timing of kidney biopsy in type 2 diabetic patients: a stepwise approach. BMC Nephrol 2020; 21:131. [PMID: 32293326 PMCID: PMC7161016 DOI: 10.1186/s12882-020-01794-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/05/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Diabetic nephropathy (DN) is the most prevalent cause of renal disease in type 2 diabetic patients and is usually diagnosed clinically. A kidney biopsy is considered when non-diabetic renal disease (NDRD) is suspected, such as rapid progression in renal function impairment and severe proteinuria. Still, there is yet no consensus on the timing of kidney biopsy in type 2 diabetic patients. This study aims to identify markers that can help differentiate between DN and NDRD and guide the decision of kidney biopsy. METHODS We retrospectively reviewed patients with type 2 diabetes who received kidney biopsy from 2008 to 2017 at Taipei Veterans General Hospital. Ophthalmologist consultation and outpatient records, diagnosis of kidney biopsy, laboratory data, and clinical characteristics were collected. RESULTS This study enrolled 160 type 2 diabetic patients, among which 120 (75%) had isolated DN and 40 (25%) had NDRD ± DN (26 had isolated NDRD, and 14 had NDRD superimposed on DN). In multivariate logistic regression analysis, DM duration (odds ratio [OR]: 0.907; 95% confidence interval [CI]: 0.842-0.977; P = 0.01), diabetic retinopathy (OR: 0.196; 95% CI: 0.061-0.627; P = 0.006), and urinary RBC (OR: 1.068; 95% CI: 1.024-1.115; P = 0.002) were independent predictors of NDRD. In patients with diabetic retinopathy (n = 112, 70%), the presence of proliferative diabetic retinopathy, pan-retinal photocoagulation, and hematuria were factors predicting NDRD; and in patients without diabetic retinopathy (n = 48, 30%), short DM duration and hematuria were factors predicting NDRD. CONCLUSIONS Using diabetic retinopathy, DM duration, and hematuria, we developed a 3-step approach to stratify patients into three categories with the different likelihoods of having NDRD. Then different strategies could be taken accordingly. Our stepwise approach is easy to follow and may serve as an appropriate and useful tool to help clinicians in making decisions of kidney biopsy in type 2 DM patients presenting with kidney diseases.
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Affiliation(s)
- Jyh-Tong Hsieh
- Division of Nephrology, Department of Medicine, Chiayi Branch, Taichung Veterans General Hospital, Chiayi, Taiwan
| | - Fu-Pang Chang
- Department of Pathology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - An-Hang Yang
- Department of Pathology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Der-Cherng Tarng
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, Taiwan
- Department and Institute of Physiology, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Yu Yang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, Taiwan.
- Stem Cell Research Center, National Yang-Ming University, Taipei, Taiwan.
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12
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Zhuang X, Cao D, Yang D, Zeng Y, Yu H, Wang J, Kuang J, Xie J, Zhang S, Zhang L. Association of diabetic retinopathy and diabetic macular oedema with renal function in southern Chinese patients with type 2 diabetes mellitus: a single-centre observational study. BMJ Open 2019; 9:e031194. [PMID: 31494622 PMCID: PMC6731866 DOI: 10.1136/bmjopen-2019-031194] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The association of diabetic retinopathy (DR) and diabetic macular oedema (DME) with renal function in southern Chinese patients with diabetes is poorly understood. So we aimed to study the correlation between stage of DR and DME with stage of estimated glomerular filtration rate (eGFR) and stage of urine albumin-to-creatinine ratio (UACR), and to explore the systemic risk factors for DR and DME. DESIGN AND SETTING This single-centre retrospective observational study was conducted from December 2017 to November 2018. PARTICIPANTS 413 southern Chinese patients with type 2 diabetes mellitus. OUTCOME MEASURES The correlations between stage of DR and DME with stage of eGFR/UACR were assessed by Spearman's or χ² analyses and represented with histograms. Risk factors associated with the occurrence of DR and DME were performed by logistic regression and represented with nomograms. RESULTS Stage of DR had a positive correlation with stage of eGFR (r=0.264, p<0.001) and stage of UACR (r=0.542, p<0.001). With the stage of eGFR/UACR being more severe, the prevalence of DME became higher as well (both p<0.001). The risk factors for DR were DM duration (OR 1.072; 95% CI 1.032 to 1.114; p<0.001), stage of UACR (OR 2.001; 95% CI 1.567 to 2.555; p<0.001) and low-density lipoprotein (LDL) (OR 1.301; 95% CI 1.139 to 1.485; p<0.001), while risk factors for DME were stage of UACR (OR 2.308; 95% CI 1.815 to 2.934; p<0.001) and LDL (OR 1.460; 95% CI 1.123 to 1.875; p=0.008). CONCLUSIONS Among southern Chinese patients, stage of DR and DME were positively correlated with renal function, while stage of UACR performed a better relevance than stage of eGFR.
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Affiliation(s)
- Xuenan Zhuang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Dan Cao
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Dawei Yang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Yunkao Zeng
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Honghua Yu
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Jun Wang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Jian Kuang
- Department of Endocrinology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Jianteng Xie
- Department of Nephrology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Shuting Zhang
- Department of Endocrinology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Liang Zhang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangzhou, China
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13
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Yamamoto M, Fujihara K, Ishizawa M, Osawa T, Kaneko M, Ishiguro H, Matsubayashi Y, Seida H, Yamanaka N, Tanaka S, Kodama S, Hasebe H, Sone H. Overt Proteinuria, Moderately Reduced eGFR and Their Combination Are Predictive of Severe Diabetic Retinopathy or Diabetic Macular Edema in Diabetes. ACTA ACUST UNITED AC 2019; 60:2685-2689. [DOI: 10.1167/iovs.19-26749] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Masahiko Yamamoto
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Kazuya Fujihara
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Masahiro Ishizawa
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Taeko Osawa
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Masanori Kaneko
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Hajime Ishiguro
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Yasuhiro Matsubayashi
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | | | | | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoru Kodama
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Hiruma Hasebe
- Department of Ophthalmology, Niigata University Faculty of Medicine, Niigata, Japan
| | - Hirohito Sone
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
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14
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Pearce I, Simó R, Lövestam‐Adrian M, Wong DT, Evans M. Association between diabetic eye disease and other complications of diabetes: Implications for care. A systematic review. Diabetes Obes Metab 2019; 21:467-478. [PMID: 30280465 PMCID: PMC6667892 DOI: 10.1111/dom.13550] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/12/2018] [Accepted: 09/25/2018] [Indexed: 02/06/2023]
Abstract
The aim of this systematic review was to examine the associations between diabetic retinopathy (DR) and the common micro- and macrovascular complications of diabetes mellitus, and how these could potentially affect clinical practice. A structured search of the PubMed database identified studies of patients with diabetes that assessed the presence or development of DR in conjunction with other vascular complications of diabetes. From 70 included studies, we found that DR is consistently associated with other complications of diabetes, with the severity of DR linked to a higher risk of the presence of, or of developing, other micro- and macrovascular complications. In particular, DR increases the likelihood of having or developing nephropathy and is also a strong predictor of stroke and cardiovascular disease, and progression of DR significantly increases this risk. Proliferative DR is a strong risk factor for peripheral arterial disease, which carries a risk of lower extremity ulceration and amputation. Additionally, our findings suggest that a patient with DR has an overall worse prognosis than a patient without DR. In conclusion, this analysis highlights the need for a coordinated and collaborative approach to patient management. Given the widespread use of DR screening programmes that can be performed outside of an ophthalmology office, and the overall cost-effectiveness of DR screening, the presence and severity of DR can be a means of identifying patients at increased risk for micro- and macrovascular complications, enabling earlier detection, referral and intervention with the aim of reducing morbidity and mortality among patients with diabetes. Healthcare professionals involved in the management of diabetes should encourage regular DR screening.
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Affiliation(s)
- Ian Pearce
- St Paul's Eye UnitRoyal Liverpool University HospitalLiverpoolUK
| | - Rafael Simó
- Vall d'Hebron Research Institute (VHIR) and Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM)BarcelonaSpain
| | | | - David T. Wong
- St. Michael's Hospital, University of TorontoTorontoCanada
| | - Marc Evans
- University Hospital Llandough, LlandoughWalesUK
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15
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Kaewput W, Thongprayoon C, Rangsin R, Ruangkanchanasetr P, Mao MA, Cheungpasitporn W. Associations of renal function with diabetic retinopathy and visual impairment in type 2 diabetes: A multicenter nationwide cross-sectional study. World J Nephrol 2019; 8:33-43. [PMID: 30815379 PMCID: PMC6388308 DOI: 10.5527/wjn.v8.i2.33] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/07/2019] [Accepted: 01/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diabetic retinopathy (DR) separately has been noted as a major public health problem worldwide as well. Currently, many studies have demonstrated an association between diabetic nephropathy and DR in type 1 diabetes mellitus (T1DM) patients, but this association is less strong in T2DM. The evidence for an association between renal function and DR and visual impairment among T2DM patients is limited, particularly in the Asian population.
AIM To assess the association between glomerular filtration rate (GFR) and DR, severe DR, and severe visual impairment among T2DM patients in Thailand.
METHODS We conducted a nationwide cross-sectional study based on the DM/HT study of the Medical Research Network of the Consortium of Thai Medical Schools. This study evaluated adult T2DM patients from 831 public hospitals in Thailand in the year 2013. GFR was categorized into ≥ 90, 60-89, 30-59 and < 30 mL/min/1.73 m2. The association between GFR and DR, severe DR, and severe visual impairment were assessed using multivariate logistic regression.
RESULTS A total of 13192 T2DM patients with available GFR were included in the analysis. The mean GFR was 66.9 ± 25.8 mL/min/1.73 m2. The prevalence of DR, proliferative DR, diabetic macular edema, and severe visual impairment were 12.4%, 1.8%, 0.2%, and 2.1%, respectively. Patients with GFR of 60-89, 30-59 and < 30 mL/min/1.73 m2 were significantly associated with increased DR and severe DR when compared with patients with GFR of ≥ 90 mL/min/1.73 m2. In addition, increased severe visual impairment was associated with GFR 30-59 and < 30 mL/min/1.73 m2.
CONCLUSION Decreased GFR was independently associated with increased DR, severe DR, and severe visual impairment. GFR should be monitored in diabetic patients for DR awareness and prevention.
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Affiliation(s)
- Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Ram Rangsin
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
| | - Prajej Ruangkanchanasetr
- Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok 10400, Thailand
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, United States
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16
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Liu D, Huang T, Chen N, Xu G, Zhang P, Luo Y, Wang Y, Lu T, Wang L, Xiong M, Geng J, Nie S. The modern spectrum of biopsy-proven renal disease in Chinese diabetic patients-a retrospective descriptive study. PeerJ 2018; 6:e4522. [PMID: 29607256 PMCID: PMC5877445 DOI: 10.7717/peerj.4522] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/28/2018] [Indexed: 11/20/2022] Open
Abstract
Background Renal biopsies performed in diabetic patients are increasing and becoming more complex. Comprehensive data on modern spectrum of biopsy-proven renal disease in Chinese diabetic patients are lacking. Methods In a nationwide renal biopsy survey including 71,151 native biopsies from 2004 to 2014, diabetic patients were identified according to the clinical diagnosis from referral records. The clinical data were extracted from referral records and pathological reports. Results A total of 1,604 diabetic patients, including 61 patients with T1DM, were analyzed in this study. The median age is 51.39 ± 11.37 years. Male patients accounted for 58% of the population. We found that only 44.7% of diabetic patients had the isolated pathological diagnosis of diabetic nephropathy (DN), while 49.1% had non-diabetic renal disease (NDRD) alone, and 6.2% had NDRD superimposed on DN. Nephrotic syndrome (n = 824, 51.4%) was the most common clinical indication for renal biopsy. Among 887 patients with NDRD, membranous nephropathy (n = 357) was the leading diagnosis, followed by IgA nephropathy (n = 179). Hypertensive renal disease (n = 32), tubulointerstitial nephropathy (n = 27) and acute tubular necrosis (n = 16) accounted for 3.5%, 2.9%, 1.7% of the NDRD cases respectively. Nearly a half (49.2%) of patients with T1DM had NDRD. Discussion Over 55% diabetic patients with kidney disease were diagnosed as non-diabetic renal disease, among which MN and IgAN were the most common two pathological types.
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Affiliation(s)
- Diankun Liu
- The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ting Huang
- The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Nan Chen
- Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Gang Xu
- Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Ping Zhang
- Sichuan Provincial People's Hospital, Sichuan Academy of Medical Science, Chengdu, China
| | - Yang Luo
- Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yongping Wang
- The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tao Lu
- The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Long Wang
- The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Mengqi Xiong
- The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jian Geng
- King Medical Diagnostics Center, Guangzhou, China.,School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Sheng Nie
- The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
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17
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Ahmed MH, Elwali ES, Awadalla H, Almobarak AO. The relationship between diabetic retinopathy and nephropathy in Sudanese adult with diabetes: population based study. Diabetes Metab Syndr 2017; 11 Suppl 1:S333-S336. [PMID: 28325541 DOI: 10.1016/j.dsx.2017.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/03/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Diabetic nephropathy is responsible for nearly third of the world cases of end stage renal disease; it becomes a major public health problem with social and economic burden. The aim of this study is to explore if there is an association between retinopathy and nephropathy. MATERIAL AND METHODS In a cross sectional hospital based study a total of 316 individuals with diabetes were recruited from Makkah eye complex retina clinic. Demographic data, medical history and life style characteristics were taken through standard questionnaire. In addition, urine samples were collected to check for presence of albuminuria, blood samples were taken to measure HbA1c, lipid profile and renal function test. RESULTS The mean age of participants was 58±10 years old. Only 39.8 and 40.2% of females were diagnosed with retinopathy and nephropathy, respectively. In addition, 60.2 and 59.8% of males were diagnosed with retinopathy and nephropathy, respectively. Hypertension was identified as risk factors for both retinopathy and nephropathy (P<0.001 and P<0.07). Serum creatinine and blood urea are significantly associated with retinopathy (P<0.01 and P<0.01). Body mass index (BMI) and HbA1c are not significantly associated with retinopathy and nephropathy. The prevalence of nephropathy among individuals with retinopathy was 35.6%. There was significant association between nephropathy and development of retinopathy (P<0.01). Logistic regression showed that two absolute risk factors are: nephropathy and having hypertension with P value of 0.009 and 0.003, respectively. CONCLUSIONS Almost third of diabetic patients developed nephropathy, significant association between nephropathy and development of retinopathy was found.
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Affiliation(s)
- Mohamed H Ahmed
- Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire, UK.
| | - Einas S Elwali
- Public and Tropical Heath Program, Graduate College, University of Medical Sciences and Technology, Khartoum, Sudan
| | - Heitham Awadalla
- Department of Community Medicine, University of Khartoum, Khartoum, Sudan.
| | - Ahmed O Almobarak
- Department of Pathology, Faculty of Medicine, University of Medical Sciences and Technology, Khartoum, Sudan.
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18
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Ng WY, Teo BW, Tai ES, Sethi S, Lamoureux E, Tien Yin W, Sabanayagam C. Cystatin C, chronic kidney disease and retinopathy in adults without diabetes. Eur J Prev Cardiol 2016; 23:1413-20. [PMID: 26928726 DOI: 10.1177/2047487316637182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 02/15/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Serum cystatin C, a novel marker of renal function has been shown to be superior to serum creatinine in predicting renal function decline and adverse outcomes of chronic kidney disease (CKD). Our aim was to investigate the association between cystatin C and retinopathy in adults without diabetes. METHODS We examined 1725 Indian adults, aged 40-80 years who participated in the Singapore Indian Eye Study (2007-2009) and were free of diabetes mellitus. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2) determined from serum cystatin C (CKD-eGFRcys, n = 199), and serum creatinine (CKD-eGFRcr, n = 81). Retinopathy was assessed from digital fundus photographs of both eyes by trained graders using the modified Airlie House classification. The associations of CKD defined by the two markers alone and in combination (confirmed CKD, eGFRcr <60 and eGFRcys <60, n = 58) with retinopathy were examined using logistic regression models adjusted for potential confounding factors including preexisting cardiovascular disease and albuminuria. RESULTS The prevalence of retinopathy among those with CKD-eGFRcr and CKD-eGFRcys was 9.9% and 8.5%, respectively. In separate models, the associations of retinopathy with both CKD-eGFRcys (odds ratio (OR) (95% confidence interval (CI)) = 2.18 (1.14-4.16)) and CKD-eGFRcr were significant (OR (95% CI) = 2.63 (1.10-6.28)). In models including both markers, compared to optimal kidney function (eGFRcr ≥60 and eGFRcys ≥60), confirmed CKD was associated with a fourfold higher odds of retinopathy (OR (95% CI) = 4.01 (1.52-10.60)). CONCLUSIONS In a population-based sample of Indian adults without diabetes, CKD defined by both cystatin C and creatinine was strongly associated with retinopathy.
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Affiliation(s)
- Wei Yan Ng
- Singapore National Eye Centre, Singapore
| | - Boon Wee Teo
- Department of Medicine, National University of Singapore, Singapore
| | - E Shyong Tai
- Department of Medicine, National University of Singapore, Singapore
| | - Sunil Sethi
- Department of Pathology, National University of Singapore, Singapore
| | - Ecosse Lamoureux
- Singapore Eye Research Institute, Singapore Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore Department of Ophthalmology, National University of Singapore, Singapore
| | - Wong Tien Yin
- Singapore National Eye Centre, Singapore Singapore Eye Research Institute, Singapore Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore Department of Ophthalmology, National University of Singapore, Singapore
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore Department of Ophthalmology, National University of Singapore, Singapore
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Rodríguez-Poncelas A, Mundet-Tudurí X, Miravet-Jiménez S, Casellas A, Barrot-De la Puente JF, Franch-Nadal J, Coll-de Tuero G. Chronic Kidney Disease and Diabetic Retinopathy in Patients with Type 2 Diabetes. PLoS One 2016; 11:e0149448. [PMID: 26886129 PMCID: PMC4757564 DOI: 10.1371/journal.pone.0149448] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 01/31/2016] [Indexed: 11/18/2022] Open
Abstract
Purpose To explore the relationship between chronic kidney disease (CKD) and diabetic retinopathy (DR) in a representative population of type 2 diabetes mellitus (DM2) patients in Catalonia (Spain). Methods This was a population-based, cross-sectional study. A total of 28,344 patients diagnosed with DM2 who had recorded ophthalmologic and renal functional examinations were evaluated. Data were obtained from a primary healthcare electronic database of medical records. CKD was defined as an estimated glomerular filtration ratio (eGFR) of <60 ml/min/1.73m2 and/or urine albumin to creatinine ratio (UACR) ≥30 mg/g. DR was categorized as non-vision threatening diabetic retinopathy and vision threatening diabetic retinopathy. Results CKD was associated with a higher rate of DR [OR], 95% confidence interval [CI], 1.5 (1.4–1.7). When we analyzed the association between different levels of UACR and DR prevalence observed that DR prevalence rose with the increase of UACR levels, and this association was significant from UACR values ≥10 mg/g, and increased considerably with UACR values ≥300mg/g (Odds ratio [OR], 95% confidence interval [CI], 2.0 (1.6–2.5). This association was lower in patients with eGFR levels 44 to 30 mL/min/1.73m2 [OR], 95% confidence interval [CI], 1.3 (1.1–1.6). Conclusions These results show that CKD, high UACR and/or low eGFR, appear to be associated with DR in this DM2 population.
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Affiliation(s)
- Antonio Rodríguez-Poncelas
- Primary Health Care Center Anglès, Gerència Territorial Girona, Institut Català de la Salut, Girona, Spain
- Unitat de Suport a la Recerca Girona, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Xavier Mundet-Tudurí
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Universitat Autonoma de Barcelona, Bellaterra, Spain
- * E-mail:
| | - Sonia Miravet-Jiménez
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Primary Health Care Center Martorell, Gerència Territorial Metropolitana Sud, Institut Català de la Salut, l’Hospitalet de LLobregat, Barcelona, Spain
| | - Aina Casellas
- Unitat de Suport a la Recerca Girona, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Joan F. Barrot-De la Puente
- Unitat de Suport a la Recerca Girona, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Primary Health Care Center Jordi Nadal (Salt), Gerència Territorial Girona, Institut Català de la Salut, Girona, Spain
| | - Josep Franch-Nadal
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Primary Health Care Center Raval Sud, Gerència d’Àmbit d’Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Gabriel Coll-de Tuero
- Primary Health Care Center Anglès, Gerència Territorial Girona, Institut Català de la Salut, Girona, Spain
- Unitat de Suport a la Recerca Girona, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
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Teng J, Dwyer KM, Hill P, See E, Ekinci EI, Jerums G, MacIsaac RJ. Spectrum of renal disease in diabetes. Nephrology (Carlton) 2015; 19:528-36. [PMID: 24899354 DOI: 10.1111/nep.12288] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2014] [Indexed: 11/30/2022]
Abstract
The spectrum of renal disease in patients with diabetes encompasses both diabetic kidney disease (including albuminuric and non-albuminuric phenotypes) and non-diabetic kidney disease. Diabetic kidney disease can manifest as varying degrees of renal insufficiency and albuminuria, with heterogeneity in histology reported on renal biopsy. For patients with diabetes and proteinuria, the finding of non-diabetic kidney disease alone or superimposed on the changes of diabetic nephropathy is increasingly reported. It is important to identify non-diabetic kidney disease as some forms are treatable, sometimes leading to remission. Clinical indications for a heightened suspicion of non-diabetic kidney disease and hence consideration for renal biopsy in patients with diabetes and nephropathy include absence of diabetic retinopathy, short duration of diabetes, atypical chronology, presence of haematuria or other systemic disease, and the nephrotic syndrome.
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Affiliation(s)
- Jessie Teng
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Northern Territory, Victoria, Australia
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Wong CW, Teo BW, Lamoureux E, Ikram MK, Wang JJ, Tai ES, Sethi S, Wong TY, Sabanayagam C. Serum Cystatin C, Markers of Chronic Kidney Disease, and Retinopathy in Persons with Diabetes. J Diabetes Res 2015; 2015:404280. [PMID: 26576434 PMCID: PMC4630396 DOI: 10.1155/2015/404280] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/13/2015] [Indexed: 12/14/2022] Open
Abstract
PURPOSE We examined the association of CKD defined by serum creatinine, serum cystatin C, and albuminuria with moderate diabetic retinopathy (DR). METHODS We examined 1,119 Indian adults with diabetes, aged 40-80 years, who participated in the Singapore Indian Eye Study (2007-2009), a population-based cross-sectional study. The associations of CKD defined by each of the three markers alone and in combination with moderate DR were examined using logistic regression models adjusted for potential confounding factors including duration of diabetes, smoking, body mass index, systolic blood pressure, and HbA1c. RESULTS The prevalence of moderate DR was significantly higher among those with CKD defined by triple markers (41.1%) compared to CKD defined separately by creatinine (26.6%), cystatin C (20.9%), and albuminuria (23.4%). People with CKD defined by triple markers had a fourteenfold higher odds of moderate DR (OR (95% CI) = 13.63 (6.08-30.54)) compared to those without CKD by any marker. Nearly half (48.7%) of participants with cystatin C ≥ 1.12 mg/L have moderate DR. CONCLUSIONS CKD defined by a triple marker panel was strongly associated with moderate DR in this Asian population with diabetes.
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Affiliation(s)
- Chee Wai Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore 169856
| | - Boon Wee Teo
- Department of Medicine, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Ecosse Lamoureux
- Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore 169856
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, 8 College Road, Singapore 119074
- Department of Ophthalmology, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Mohammad Kamran Ikram
- Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore 169856
- Department of Ophthalmology, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Jie Jin Wang
- Westmead Millennium Institute for Medical Research, C24 Westmead Hospital, University of Sydney, Sydney, NSW 2006, Australia
| | - E. Shyong Tai
- Department of Medicine, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Sunil Sethi
- Department of Pathology, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore 169856
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, 8 College Road, Singapore 119074
- Department of Ophthalmology, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore 169856
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, 8 College Road, Singapore 119074
- Department of Ophthalmology, Singapore National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074
- *Charumathi Sabanayagam:
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