Mild anemia is frequent and associated with micro- and macroangiopathies in patients with type 2 diabetes mellitus

Anemia combined with albuminuria increases the risk of cardiovascular and renal events, regardless of a reduced glomerular filtration rate, in patients with type 2 diabetes: a prospective observational study

Aim

The incidence of cardiovascular and renal events was investigated in patients with type 2 diabetes who were classified according to anemia and the components of dialysis-independent chronic kidney disease (CKD) in a prospective observational study.

Methods

A population of 778 Japanese patients with type 2 diabetes was prospectively analyzed for 4 years. The outcomes were the incidence of cardiovascular events and renal events.

Results

In all subjects, the incidence of cardiovascular and renal events was found to be 5% and 11%, respectively. Even after adjusting for a reduced estimated glomerular filtration rate (eGFR <60 mL/min/1.73 m2), the incidence of cardiovascular events was significantly higher (hazard ratio [HR]: 5.73) in patients with anemia and albuminuria than in those without anemia and albuminuria. The incidence of renal events was significantly higher in patients with no anemia and albuminuria (HR: 2.93) and further in those with anemia and albuminuria (HR: 7.56) than in those without anemia and albuminuria even after adjusting for a reduced eGFR.

Conclusion

Anemia combined with albuminuria is a risk factor for vascular events in patients with type 2 diabetes, regardless of the eGFR.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-023-00637-x.

Changes in the estimated glomerular filtration rate and predictors of the renal prognosis in Japanese patients with type 2 diabetes: A retrospective study during the 12 months after the initiation of tofogliflozin

BACKGROUND

The changes in the estimated glomerular filtration rate (eGFR) and predictors of the renal prognosis were retrospectively assessed over the 12 months after the initiation of tofogliflozin, which has the shortest half-life among sodium-glucose cotransporter 2 (SGLT2) inhibitors, in Japanese patients with type 2 diabetes and renal impairment.

METHODS

In total, 158 patients treated with tofogliflozin between 2019 and 2021 were studied as the safety analysis set. One hundred and thirty subjects whose medication was continued over 12 months were investigated as the full analysis set. The subjects were divided into two groups based on the eGFR: normal- (eGFR ≥60 mL/min/1.73 m2, n = 87) and low- (eGFR <60 mL/min/1.73 m2, n = 43) eGFR groups.

RESULTS

The body weight, blood pressure, urinary protein excretion, and serum uric acid concentration decreased from baseline in both eGFR groups while the hemoglobin level increased. The eGFR did not significantly differ over time, except for the initial dip (-4.3±9.6 mL/min/1.73 m2 in the normal-eGFR group and -1.5±5.3 mL/min/1.73 m2 in the low-eGFR group). The change in the eGFR at 12 months after the initiation of tofogliflozin was -1.9±9.0 mL/min/1.73 m2 and 0.2±6.0 mL/min/1.73 m2 in the normal- and low-eGFR group, respectively. In the normal-eGFR group, the change in the eGFR showed a significant negative correlation with the HbA1c and eGFR at baseline, according to a multiple regression analysis. In the low-eGFR group, the change in the eGFR showed a significant negative correlation with urate-lowering agent use. The frequencies of adverse events specific for SGLT2 inhibitors were not significantly different between the normal- and low-eGFR groups.

CONCLUSIONS

Tofogliflozin may preserve renal function in the medium term in patients with type 2 diabetes and kidney impairment without an increase in specific adverse events.

Relationship Between the Effect of Roxadustat and Comorbid Diabetes in Non-dialyzed Chronic Kidney Disease Patients: A Retrospective Observational Study

Introduction The dose of roxadustat, a hypoxia-inducible factor prolyl hydroxylase (HIF-PH) inhibitor, required to treat anemia, the hemoglobin level and the rate of hemoglobin target achievement were retrospectively investigated in non-dialyzed chronic kidney disease (CKD) patients with and without type 2 diabetes. Methods As the full analysis set, 25 subjects (10 with diabetes and 15 without diabetes) were observed over six months among 44 non-dialyzed CKD patients who received roxadustat. The target hemoglobin level was set at 110-130 g/L. Results The comorbidities of diabetes and body weight at baseline were significantly associated with each dose of roxadustat at six months and the change in each dose of roxadustat from the initiation of roxadustat treatment. There was no significant difference in the amount of increase in the hemoglobin level (14±11 g/L vs. 15±8 g/L) and the rate of hemoglobin target achievement (70% vs. 67%) between patients with and without diabetes. Each dose of roxadustat gradually decreased in patients without diabetes, whereas it increased in those with diabetes. Each dose of roxadustat was significantly higher in patients with diabetes than in those without diabetes at 3 (60±21 mg vs. 42±14 mg) and 6 (61±22 mg vs. 41±14 mg) months after the initiation of roxadustat treatment. Conclusion Roxadustat is useful for the treatment of anemia in both CKD patients with and without diabetes. However, the dose required to achieve the target hemoglobin level may be higher in patients with diabetes than in those without diabetes.

Hematocrit elevation after SGLT2 inhibitor administration may be associated with the degree of proximal tubular damage

The renal protective effects of SGLT2 inhibitors are known to be due to the elimination of glomerular hypertension and improvement of hypoxia and oxidative stress in the proximal tubule. Therefore, this increased hematocrit (ΔHct) level has been hypothesized to indicate restored tubular function and improved renal prognosis. To analyze the relationship between ΔHct and decreased estimated glomerular filtration rate (eGFR) after SGLT2 inhibitor administration backward from medical record data. Data from 206 patients who continued SGLT2 inhibitors for >3 years were analyzed. The decreased eGFR after administration of SGLT2 inhibitors was defined as Slope B. Factors statistically significantly associated with Slope B in multiple regression analysis were systolic blood pressure (sBP) (β -.211, P = .03), short-term decreased eGFR after SGLT2 inhibitor administration (initial dip) (β -.235, P = .003), ΔHct (β -.185, P = .026), and urine protein (β -.204, P = .015). These findings were the opposite of our hypothesis. ΔHct was not a marker indicating improved renal prognosis and may reflect the extent of the proximal tubular disorder before administering SGLT2 inhibitors.

Anemia in Diabetes and Pre-Diabetes with Normal Kidney Function: Prevalence and Clinical Outcomes

OBJECTIVE

Anemia is a known complication of diabetes mellitus (DM); however, its prevalence and prognostic relevance in patients with DM and pre-DM with normal kidney function is not well-defined. This study assessed the prevalence of anemia in DM and pre-DM patients and evaluated its association with clinical outcomes during 4-years' follow-up.

METHODS

This retrospective analysis included patients with DM and pre-DM referred to the Meir Medical Center Endocrine Institute during 2015. Patients with estimated glomerular filtration rate (eGFR) <60 ml/min or other recognized cause of anemia were excluded. The risk of developing microvascular or macrovascular complications, or death during four years follow-up was determined.

RESULTS

A total of 622 patients (408 with DM and 214 with pre-DM) were included. Mean age was 64±10.6 years, and 70% were women. Baseline HbA1c was 7.1±1.7% and eGFR was 86.1±15.3 ml/min. At inclusion 77 (19%) patients with DM and 23 (11%) with pre-DM, had anemia (hemoglobin 11.9±0.8 and 11.8±0.8 g/dl, respectively) vs. normal hemoglobin levels of 13.8±0.9 and 13.7±0.9 g/dl, respectively in the others. Multivariable analysis demonstrated an inverse correlation between baseline hemoglobin (as a continuous variable) and mortality (P=0.035), microvascular complications (P=0.003) and eGFR decline (P<0.001), but not with macrovascular complications (P=0.567).

CONCLUSION

This study found a significant prevalence of anemia unrelated to renal failure, both in DM and pre-DM. Anemia in these patients is associated with development of microvascular complications, eGFR decline and mortality. These results underscore the need for intensive lifestyle and pharmacological interventions among these patients.

Prevalence of and Factors Associated with Diabetic Retinopathy in Patients with Diabetes Mellitus at Siriraj Hospital - Thailand's Largest National Tertiary Referral Center

PURPOSE

We aimed to determine the prevalence of and factors associated with diabetic retinopathy (DR) in patients with diabetes mellitus (DM) and to evaluate the relationship between significant factors and severity of DR.

PATIENTS AND METHODS

A retrospective cross-sectional study of 1130 diabetic patients (mean age: 60 years, 62.7% female, 91% type 2 diabetes) was conducted in the diabetes clinic of Siriraj Hospital (Bangkok, Thailand) during January 2012 to June 2015. DR was graded as absent, mild, moderate, or severe non-proliferative DR, or proliferative DR. Multivariate logistic regression analysis was used to identify independent risk factors for DR in DM patients.

RESULTS

The overall prevalence of DR was 34.78%. Multivariate analysis revealed duration of diabetes, glycated hemoglobin level (HbA_1c), presence of albuminuria, and abnormal protective sensation to be independent risk factors for DR. The prevalence of DR increased with longer duration of diabetes (p < 0.001), deterioration of glucose control (p = 0.006 for HbA_1c), presence of significant albuminuria (p = 0.010), and loss of protective sensation (p = 0.001).

CONCLUSION

In this study, one-third of DM were found to have DR. The independent predictors of DR were duration of diabetes, HbA_1c level, presence of significant albuminuria, and impaired protective sensation. Heightened awareness of these risk factors will decrease the prevalence and severity of DR, and will improve early diagnosis and treatment of DR.

Relationship between anemia, serum bilirubin concentrations, and diabetic retinopathy in individuals with type 2 diabetes

This study sought to assess the hypothesis that anemia is associated with diabetic retinopathy in type 2 diabetes mellitus (DM) and investigate the factors mediating the relationship between anemia and diabetic retinopathy.In total, 1637 individuals with type 2 DM were examined in a cross-sectional study. Anemia was defined as hemoglobin level <120 g/L in women and <130 g/L in men. A logistic regression model was used to determine the association between anemia and diabetic retinopathy.Anemia was more prevalent in individuals with diabetic retinopathy. Logistic regression analysis found a statistically significant association between anemia and diabetic retinopathy after adjustment for traditional risk factors (odds ratio, 1.44; 95% confidence interval, 1.10-1.89, P = .009). Further adjustment for serum bilirubin levels removed the statistically significant association.In individuals with type 2 DM, anemia is related to diabetic retinopathy, and its association may be mediated by a correlated change in serum bilirubin levels.

Serum Albumin, but not Bilirubin, is Associated with Diabetic Chronic Vascular Complications in a Chinese Type 2 Diabetic Population

To identify the factors associated with serum total bilirubin (STB) and determine whether STB is independently associated with diabetic retinopathy (DR) or diabetic kidney disease (DKD), 1,665 Chinese patients with type 2 diabetes (T2DM) (248 outpatients newly diagnosed with T2DM [NDM] and 1,417 inpatients previously diagnosed with T2DM [PDM]) were studied. Clinical and biochemical information was collected, and a single nucleotide polymorphism (rs6704078) of the UGT1A1 gene was genotyped in 1,059 individuals. Multiple linear regression showed that STB was associated with haemoglobin concentration, platelet count, and serum triglyceride concentration in NDM and PDM patients, and with serum albumin, duration of diabetes, and smoking in PDM patients. In patients with PDM, multiple logistic regression revealed that serum albumin was associated with DR (odds ratio [OR] = 0.92, 95% confidence interval [CI]: 0.87-0.96, p = 0.001) and DKD (OR = 0.93, 95% CI: 0.88-0.98, p = 0.005) after adjustment for STB, STB-related factors, and risk factors for DR and DKD. In addition, patients with the T allele of rs6704078 had higher STB (13.2 [10.4-17.9] μmol/L versus 11.8 (9.4-14.8) μmol/L; p < 0.001) and similar risks of DR or DKD to those without the T allele. Thus, serum albumin, but not STB, is associated with DR and DKD.

Anemia is inversely associated with serum C-peptide concentrations in individuals with type 2 diabetes

The purpose of the study was to test the hypothesis that anemia is related with serum C-peptide concentrations in individuals with type 2 diabetes mellitus (DM).This cross-sectional study was carried out in 1300 individuals with type 2 DM. We measured fasting C-peptide, 2-hour postprandial C-peptide, and postprandial C-peptide minus fasting C-peptide (ΔC-peptide) concentrations. Anemia was defined as hemoglobin (Hb) concentrations <130 g/L in men and <120 g/L in women. Anemia was graded into 2 groups: grade I anemia of Hb concentrations ≥110 g/L and grade II anemia of Hb concentrations <110 g/L.Fasting C-peptide, postprandial C-peptide, and ΔC-peptide concentrations were lower in individuals with anemia. According to the grade of anemia, the average C-peptide concentrations differed significantly after adjusting for other covariates. In the multivariable model, the statistically significant relation between anemia and serum C-peptide concentrations remained after adjusting for confounders, including age, gender, family history of diabetes, body mass index, duration of diabetes, glycated Hb, free fatty acids, hypertension, and hyperlipidemia (fasting C-peptide concentration: β = -0.057, P = .032; postprandial C-peptide concentration: β = -0.098, P < .001; ΔC-peptide concentration: β = -0.095, P < .001).Anemia was inversely associated with serum C-peptide concentrations in individuals with type 2 DM.

Comorbidities, repeated hospitalizations, and age ≥ 80 years as indicators of anemia development in the older population

Anemia represents a common condition among the elderly; however, its prevalence and causes are not well known. This retrospective analysis was performed on 981 patients aged ≥ 60 in Poland over 2013-2014. The prevalence of anemia was 17.2% and increased with age. The predominant causes of anemia were the following: anemia of chronic disease (33.1%), unexplained anemia (28.4%), deficiency anemia (22.5%, including iron deficiency 13%), and chemo-/radiotherapy-induced anemia (8.9%). In the multivariate logistic regression model, factors increasing the risk of anemia were the following: age ≥ 80 years (OR 2.29; 95%CI 1.19-4.42; P = 0.013), the number of comorbidities (two diseases OR 2.85; 95%CI 1.12-7.30; P = 0.029, three diseases OR 6.28; 95%CI 2.22-17.76; P = 0.001, four diseases OR 4.64; 95%CI 1.27-17.01; P = 0.021), and hospitalizations (OR 1.34; 95%CI 1.13-1.58; P = 0.001). After a 2-year follow-up, the cumulative survival among patients without anemia in relation to the group with anemia was 90.76 vs. 78.08% (P < 0.001). In the multivariate model, anemia (HR 3.33, 95%CI 1.43-7.74, P = 0.005), heart failure (HR 2.94, 95%CI 1.33-6.50, P = 0.008), and cancer (HR 3.31, 95%CI 1.47-7.49, P < 0.004) were all significantly correlated with mortality. In patients ≥ 60 years, the incidence of anemia increases with age, number of comorbidities, and frequency of hospitalizations and has an adverse impact on survival.

Burden of Anemia in Chronic Kidney Disease Patients in Japan: A Literature Review

Anemia is a common complication for patients with chronic kidney disease (CKD) and is associated with cardiovascular comorbidities and reduced quality of life. The incidence of anemia increases as kidney function declines and affects approximately 32% of Japanese patients with stage 3-5 CKD. This review examined the current literature on anemia in CKD patients in Japan to provide an overview of the burden of anemia in CKD. Medline, Embase, and Igaku Chuo Zasshi databases were searched to identify relevant manuscripts and abstracts published from 2004 onward. The population included CKD patients with anemia, and the outcomes of interest were epidemiology, economic, humanistic, and treatment patterns. Observational studies, database analysis, and economic evaluation studies were included in the analysis. A total of 1151 references were identified, and 50 were eligible for final review. Economic burden was reported in most studies (n = 37) followed by treatment patterns (n = 26), and epidemiological (n = 25) and humanistic (n = 1) burdens. Prevalence of anemia varied largely (0-95%) based on the different definitions of anemia, and increased with CKD severity. Higher mortality was associated with erythropoiesis-stimulating agent (ESA) resistance and lower hemoglobin levels among patients treated with ESA. Drug dosage was the most reported economic burden (n = 33), followed by medical, and non-medical outcomes. Costs associated with anemia were considerable and depended on dialysis status and ESA treatment. Only one study reported data on quality of life, suggesting that further investigation on the humanistic burden of anemia in CKD is needed.

Markers of Anemia in Children with Type 1 Diabetes

AIM

The aim of the study was to assess markers of anemia in type 1 diabetes (T1D) children, compare them to results obtained in the control group, and estimate their relation to BMI SDS.

METHODS

94 (59% ♀) T1D children without other autoimmune disorders, aged 12.5 ± 4.1 years, T1D duration: 4.2 ± 3.6 years, HbA1c 7.3 ± 1.5% (57 ± 12.6 mmol/mol). Sex- and age-matched controls (43 children). In all children, anthropometric measurements, the blood count, iron turnover parameters, and vitamin B12 concentration were taken.

RESULTS

T1DM children had significantly higher red cell distribution width (RDW) (13.6 versus 12.6%; p < 0.001), hepcidin (0.25 versus 0.12 ng/ml; p < 0.001), and vitamin B12 concentrations (459 versus 397 pg/ml; p < 0.01) and lower TIBC (59.09 versus 68.15 μmol/l; p < 0.001) than in the control group. Logistic regression revealed that RDW, TIBC (both p < 0.001), and hepcidin (p < 0.05) significantly differentiated both groups. In T1DM children, BMI SDS negatively correlated with vitamin B12 (p < 0.01) concentration and mean corpuscular hemoglobin concentration (p < 0.05) and positively with TIBC (p < 0.01) and HbA1c (p < 0.001).

CONCLUSIONS

Patients and controls differed especially in terms of RDW and TIBC. In studied T1DM children, BMI SDS was associated to iron metabolism parameters and vitamin B12 concentration.

Anemia complicating type 2 diabetes: Prevalence, risk factors and prognosis

AIMS

To determine the prevalence, risk factors and prognosis of anemia in representative community-based patients with type 2 diabetes.

METHODS

Data from the Fremantle Diabetes Study Phase II (FDS2; n=1551, mean age 65.7years, 51.9% males) and Busselton Diabetes Study (BDS; n=186, mean age 70.2years, 50.0% males) cohorts, and from 186 matched BDS participants without diabetes, were analyzed. The prevalence of anemia (hemoglobin ≤130g/L males, ≤120g/L females) was determined in each sample. In FDS2, associates of anemia were assessed using multiple logistic regression and Cox proportional hazards modeling identified predictors of death during 4.3±1.2years post-recruitment.

RESULTS

The prevalence of anemia at baseline was 11.5% in FDS2 participants, 17.8% in BDS type 2 patients and 5.4% in BDS participants without diabetes. In FDS2, 163 of 178 patients with anemia (91.6%) had at least one other risk factor (serum vitamin B₁₂<140pmol/L, serum ferritin <30μg/L and/or transferrin saturation<20%, serum testosterone <10nmol/L (males), glitazone therapy, estimated glomerular filtration rate (eGFR) <60mL/min 1.73m², malignancy, hemoglobinopathy). More anemic than non-anemic FDS2 patients died (28.7% versus 8.0%; P<0.001). After adjustment for other independent predictors (age as time-scale, male sex, Aboriginality, marital status, smoking, eGFR), anemia was associated with a 57% increase in mortality (P=0.015).

CONCLUSIONS

Type 2 diabetes at least doubles the risk of anemia but other mostly modifiable risk factors are usually present. Anemia is associated with an increased risk of death after adjustment for other predictors.

Anemia, bilirubin, and cardiovascular autonomic neuropathy in patients with type 2 diabetes

To investigate the relationship among anemia, physiological serum bilirubin levels, and cardiovascular autonomic neuropathy (CAN) in subjects with type 2 diabetes. In total, 2230 subjects with type 2 diabetes were evaluated in this cross-sectional study. CAN was diagnosed with a cardiovascular reflex test. The prevalence of anemia was greater in subjects with CAN. In multivariable analysis, the relationship between anemia and CAN remained statistically significant after adjusting for the risk factors (odds ratio [OR] 1.39; 95% confidence interval [CI] 1.07-1.80, P = .015). Additional adjustment for serum bilirubin concentrations abolished this relationship (OR 1.20, 95% CI 0.91-1.58, P = .189). Anemia is positively associated with the prevalence of CAN in subjects with type 2 diabetes. In addition, our results suggest that the putative increased CAN risk associated with anemia might be mediated by a correlated decrease in serum bilirubin levels.

Current Metabolic Status Affects Urinary Liver-Type Fatty-Acid Binding Protein in Normoalbuminuric Patients With Type 2 Diabetes

Background

We aimed to study the association between urinary liver-type fatty acid-binding protein (L-FABP), a biomarker of tubulointerstitial injury, and the clinical characteristics of normoalbuminuric and albuminuric patients with type 2 diabetes in order to detect the factors affecting urinary L-FABP.

Methods

Urinary L-FABP levels were measured in 788 patients with type 2 diabetes and again in 666 patients at 6 months after the initial measurement. The association between the urinary L-FABP level and the clinical parameters was investigated in a retrospective cross-sectional study and a subsequent observation.

Results

The HbA1c (odds ratio (OR): 1.42; 95% confidence interval (CI): 1.11 - 1.79; P < 0.01), systolic blood pressure (OR: 1.03; 95% CI: 1.01 - 1.05; P < 0.01) levels and estimated glomerular filtration rate (OR: 0.98; 95% CI: 0.96 - 1.00; P = 0.01) were significantly associated with the high levels of urinary L-FABP (> 8.4 μg/gCr) in normoalbuminuric patients. However, a logistic regression analysis revealed that use of renin-angiotensin system (RAS) inhibitors (OR: 2.22; 95% CI: 1.16 - 4.89; P = 0.02), urinary albumin-to-creatinine ratio (ACR) (OR: 1.01; 95% CI: 1.00 - 1.01; P < 0.01) and serum HDL-cholesterol concentration (OR: 0.33; 95% CI: 0.11 - 0.89; P = 0.03) were significantly associated in albuminuric patients. In the follow-up observation, the change in urinary L-FABP was found to be significantly (P < 0.01) influenced by the change in the HbA1c level in both the normoalbuminuric and albuminuric patients.

Conclusions

High urinary L-FABP is associated with part of the current metabolic abnormalities, including high levels of HbA1c and systolic blood pressure among normoalbuminuric patients with type 2 diabetes.

The Prevalence of the Risk Factors for Atherosclerosis among Type 2 Diabetic Patients Is Greater in the Progressive Stages of Chronic Kidney Disease

BACKGROUND/AIMS

The prevalence of the risk factors for atherosclerosis, other than diabetes mellitus, among type 2 diabetic patients with different stages of chronic kidney disease (CKD) determined by glomerular filtration rate (GFR) was investigated.

METHODS

The prevalence of ten risk factors (age ≥65 years, history of smoking, male gender, obesity, albuminuria, hypertension, hypercholesterolemia, hypo-HDL-cholesterolemia, hyperuricemia and anemia) was determined in 2,107 Japanese type 2 diabetic patients with different stages of CKD (six stages according to GFR).

RESULTS

The risk factors for age ≥65 years and male gender were found in 49 and 62% of the study subjects, respectively. The percentages of subjects with a current history of smoking, obesity, albuminuria, hypertension, hypercholesterolemia, hypo-HDL-cholesterolemia, hyperuricemia and anemia were 35, 44, 47, 70, 61, 13, 21 and 26%, respectively. The prevalence of age ≥65 years, male gender, albuminuria, hypertension, hypo-HDL-cholesterolemia, hyperuricemia and anemia was greater in the later stages of GFR, whereas the prevalence of hypercholesterolemia and obesity did not differ between stages. The prevalence of a current history of smoking was lower in the later stages of GFR. The cumulative number of risk factors increased from 3.1 to 6.8 in the later stages of GFR.

CONCLUSION

Among type 2 diabetic patients with CKD, the total number of risk factors increases with the progression of renal dysfunction. It is important to pay attention to newly recognized risk factors for hyperuricemia and anemia, in addition to hypertension, albuminuria and hypo-HDL-cholesterolemia, in monitoring diabetic patients with later stages of CKD.

The usefulness of the revised classification for chronic kidney disease by the KDIGO for determining the frequency of diabetic micro- and macroangiopathies in Japanese patients with type 2 diabetes mellitus

AIMS

A new classification of chronic kidney disease (CKD) was proposed by the Kidney Disease: Improving Global Outcomes (KDIGO) in 2011. The major point of revision of this classification was the introduction of a two-dimensional staging of the CKD according to the level of albuminuria in addition to the GFR level. Furthermore, the previous CKD stage 3 was subdivided into two stages (G3a and G3b). We examined the prevalence of diabetic micro- and macroangiopathies in patients with type 2 diabetes mellitus based on the new classification.

METHODS

A cross-sectional study was performed in 2018 patients with type 2 diabetes mellitus.

RESULTS

All of the diabetic micro- and macroangiopathies significantly more common in the later stages of both the GFR and albuminuria. The proportion of subjects with diabetic retinopathy, neuropathy, cerebrovascular disease and coronary heart disease was significantly higher in the G3b group than in the G3a group. The brachial-ankle pulse wave velocity, which is one of the surrogate markers for atherosclerosis, was also significantly greater in the G3b group compared to the G3a group.

CONCLUSION

The subdivision of the G3 stage in the revised classification proposed by the KDIGO is useful to evaluate the risk for diabetic vascular complications.