Dyslipidemia in diabetic kidney disease classified by proteinuria and renal dysfunction: A cross-sectional study from a regional diabetes cohort

Estimated small dense low-density lipoprotein-cholesterol and the risk of kidney and cardiovascular outcomes in diabetic kidney disease

AIMS

This study aimed to investigate the correlations between estimated small dense low-density lipoprotein-cholesterol (esd-LDL-c) and the development of end-stage kidney disease (ESKD), cardiovascular mortality, and all-cause mortality in individuals with diabetic kidney disease (DKD) or diabetes mellitus (DM) concomitant chronic kidney disease (CKD).

METHODS

We analyzed the data from a biopsy-proven DKD cohort conducted at West China Hospital of Sichuan University between 2009 and 2021 (the DKD cohort) and participants with DM and CKD in the National Health and Nutrition Examination Survey (NHANES) 2011-2014 (the NHANES DM-CKD cohort). Cox regression analysis was also used to estimate associations between esd-LDL-c and the incidence of ESKD, cardiovascular mortality, and all-cause mortality.

RESULTS

There were 175 ESKD events among 338 participants in the DKD cohort. Patients were divided into three groups based on esd-LDL-c tertiles (T1 < 33.7 mg/dL, T2 ≥ 33.7 mg/dL to <45.9 mg/dL, T3 ≥ 45.9 mg/dL). The highest tertile of esd-LDL-c was associated with ESKD (adjusted HR 2.016, 95% CI 1.144-3.554, p = .015). Furthermore, there were 99 deaths (39 cardiovascular) among 293 participants in the NHANES DM-CKD cohort. Participants were classified into three groups in line with the tertile values of esd-LDL-c in the DKD cohort. The highest tertile of esd-LDL-c was associated with cardiovascular mortality (adjusted HR 3.95, 95% CI 1.3-12, p = .016) and all-cause mortality (adjusted HR 2.37, 95% CI 1.06-5.32, p = .036).

CONCLUSIONS

Higher esd-LDL-c was associated with increased risk of ESKD in people with biopsy-proven DKD, and higher cardiovascular and all-cause mortality risk among those with DM-CKD.

Phloretamide Protects against Diabetic Kidney Damage and Dysfunction in Diabetic Rats by Attenuating Hyperglycemia and Hyperlipidemia, Suppressing NF-κβ, and Upregulating Nrf2

Potent hypoglycemic and antioxidant effects were recently reported for the apple-derived phenolic compound phloretamide (PLTM). The renoprotective effects of this compound are yet to be shown. This study aimed to examine the potential of PLTM to prevent diabetic nephropathy in streptozotocin-induced diabetic rats and to examine the possible mechanisms of protection. Non-diabetic and STZ-diabetic male rats were treated orally by gavage with either the vehicle or with PTLM (200 mg/kg; twice/week) for 12 weeks. PTLM significantly increased urine volume and prevented glomerular and tubular damage and vacuolization in STZ-diabetic rats. It also increased creatinine excretion and reduced urinary albumin levels and the renal levels of kidney injury molecule-1 (KIM-1), 8-hydroxy-2'-deoxyguanosine (8-OHdG), neutrophil gelatinase-associated lipocalin (NGAL), and nephrin in the diabetic rats. PTLM also prevented an increase in the nuclear levels of NF-κβ, as well as the total levels of tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6), caspase-3, and Bax in the kidneys of diabetic rats. These effects were associated with reduced serum levels of triglycerides, cholesterol, and low-density lipoprotein cholesterol. In both the control and diabetic rats, PTLM significantly reduced fasting plasma glucose and enhanced the renal mRNA and cytoplasmic levels of Nrf2, as well as the levels of Bcl2, superoxide dismutase (SOD), and glutathione (GSH). However, PTLM failed to alter the cytoplasmic levels of keap1 in diabetic rats. In conclusion, PTLM prevents renal damage and dysfunction in STZ-diabetic rats through its hypoglycemic and hypolipidemic activities, as well as through its antioxidant potential, which is mediated by activating the Nrf2/antioxidant axis.

Association of systemic immune-inflammation index with diabetic kidney disease in patients with type 2 diabetes: a cross-sectional study in Chinese population

Objective

Systemic immune-inflammation index (SII), a novel inflammatory marker, has been reported to be associated with diabetic kidney disease (DKD) in the U.S., however, such a close relationship with DKD in other countries, including China, has not been never determined. We aimed to explore the association between SII and DKD in Chinese population.

Methods

A total of 1922 hospitalized patients with type 2 diabetes mellitus (T2DM) included in this cross-sectional study were divided into three groups based on estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (ACR): non-DKD group, DKD stages 1-2 Alb group, and DKD-non-Alb+DKD stage 3 Alb group. The possible association of SII with DKD was investigated by correlation and multivariate logistic regression analysis, and receiver-operating characteristic (ROC) curves analysis.

Results

Moving from the non-DKD group to the DKD-non-Alb+DKD stage 3 Alb group, SII level was gradually increased (P for trend <0.01). Partial correlation analysis revealed that SII was positively associated with urinary ACR and prevalence of DKD, and negatively with eGFR (all P<0.01). Multivariate logistic regression analysis showed that SII remained independently significantly associated with the presence of DKD after adjustment for all confounding factors [(odds ratio (OR), 2.735; 95% confidence interval (CI), 1.840-4.063; P < 0.01)]. Moreover, compared with subjects in the lowest quartile of SII (Q1), the fully adjusted OR for presence of DKD was 1.060 (95% CI 0.773-1.455) in Q2, 1.167 (95% CI 0.995-1.368) in Q3, 1.266 (95% CI 1.129-1.420) in the highest quartile (Q4) (P for trend <0.01). Similar results were observed in presence of DKD stages 1-2 Alb or presence of DKD-non- Alb+DKD stage 3 Alb among SII quartiles. Last, the analysis of ROC curves revealed that the best cutoff values for SII to predict DKD, Alb DKD stages 1- 2, and DKD-non-Alb+ DKD stage 3 Alb were 609.85 (sensitivity: 48.3%; specificity: 72.8%), 601.71 (sensitivity: 43.9%; specificity: 72.3%), and 589.27 (sensitivity: 61.1%; specificity: 71.1%), respectively.

Conclusion

Higher SII is independently associated with an increased risk of the presence and severity of DKD, and SII might be a promising biomarker for DKD and its distinct phenotypes in Chinese population.

Specific Increase in Small Dense Low-Density Lipoprotein-Cholesterol Levels beyond Triglycerides in Patients with Diabetes: Implications for Cardiovascular Risk of MAFLD

AIMS

Small dense (sd) low-density lipoprotein (LDL)-cholesterol (C) is the most powerful predictor of cardiovascular (CV) disease among lipid biomarkers and is generated by hypertriglyceridemia and insulin resistance. Metabolic dysfunction-associated fatty liver disease (MAFLD) is a newly proposed liver disease with a high CV risk. We investigated the specific association of sdLDL-C with MAFLD beyond triglycerides (TG) and obesityMethods: Participants were 839 non-alcoholic drinkers with type 2 diabetes enrolled in a regional diabetes cohort. Fatty liver (FL) and visceral fat area (VFA) was detected by computed tomography scan. sdLDL-C and LDL-TG were measured by our established homogeneous assay. TG rich lipoprotein (TRL) was calculated by subtracting LDL-C plus HDL-C from total-C. Grade of sdLDL-C (≤ 24, 25-34, 35-44, and ≥ 45 mg/dL) was classified according to the Hisayama study.

RESULTS

Compared to non-FL counterparts, FL subjects were younger, predominantly male and smokers; and had higher body mass index (BMI), VFA, hemoglobin A1c, C-peptide, TG, and sdLDL-C, while had similar levels of LDL-C, LDL-TG, and TRL-C. Multivariate logistic analysis revealed that sdLDL-C was the most powerful lipid parameter for identifying FL, independent of TG, HDL-C, BMI, and VFA. The independent association between TG and FL was lost when sdLDL-C was added to the analysis. These results remained the same when lipid-lowering drug users were excluded. After adjustment for confounders, the odds ratio for FL was 2.4-2.7 at sdLDL ≥ 35 mg/dL based on sdLDL ≤ 24 mg/dL.

CONCLUSIONS

sdLDL-C levels are specifically elevated in patients with diabetes and MAFLD, independent of TG and VFA, suggesting liver-centered metabolic abnormalities.

Protective effect of eriodictyol against hyperglycemia-induced diabetic nephropathy in rats entails antioxidant and anti-inflammatory effects mediated by activating Nrf2

The pathogenesis of diabetic nephropathy (DN) involves cellular activation of oxidative stress and inflammation. Eriodictyol is a citrus-derived flavonoid with multiple pharmacological and protective effects in various conditions. The protective role of Eriodictyol against diabetes and diabetic nephropathy is less investigated. The current research aimed to explore the role of eriodictyol in protecting against DN prompted by streptozotocin in male rats and investigate some possible mechanisms of action. Diabetes was brought about in rats by an i.p injection of a lone dose (65 mg/kg). Five groups of rats were included (n = 8 each) as control (non-diabetic), eriodictyol (20 mg/kg, orally), STZ-diabetic, STZ + eriodictyol (20 mg/kg, orally), and STZ + eriodictyol (20 mg/kg, orally) + ML385 (30 µg/kg, i.p.). Kidney histology and the levels of some markers of kidney function, renal oxidative stress, and renal inflammation were analyzed in all groups of rats. Treatment with eriodictyol prevented the damage in the renal glomeruli and tubules and reduced renal immune cell infiltration in STZ-treated animals. It also spiked urinary creatinine excretion and reduced urine volume and urinary levels of albumin, monocyte chemoattractant protein 1 (MCP-1), urinary kidney injury molecule-1 (KIM-1), and nephrin in these diabetic rats. In addition, eriodictyol stimulated the nuclear protein accumulation of Nrf2 and boosted the expression of superoxide dismutase (SOD), glutathione (GSH), heme oxygenase-1 (HO-1), and catalase (CAT) in the diabetic rat kidneys. In concomitance, it reduced the nuclear levels of NF-κB and levels of interleukine-6 (IL-6), malondialdehyde (MDA), and tumor necrosis factor-α (TNF-α) and attenuated the reduction in renal ATP levels and the increase in the mitochondria transition pore opening (mtTPT). However, the administration of eriodictyol did not affect rats' body weights and fasting glucose and insulin levels but significantly reduced serum levels of cholesterol, triglycerides, LDL-c, and oxidized LDL-c (ox-LDL-c). In conclusion, eriodictyol prevents STZ-induced nephropathy by a hypolipidemic effect and concomitant antioxidant and anti-inflammatory effects mediated by activating Nrf2/NF-κB/antioxidant axis.

High-sulfated derivative of polysaccharide from Ulva pertusa improves Adriamycin-induced nephrotic syndrome by suppressing oxidative stress

Nephrotic syndrome (NS) is characterized by proteinuria, hyperlipidemia, and hypoalbuminemia. Ulva pertusa, a green seaweed, is a nutritional supplement. In this study, the high-sulfated derivative of Ulva pertusa polysaccharide (HU) was prepared by combining U pertusa polysaccharide with chlorosulfonic acid. The NS rat model was established by tail vein single injection of Adriamycin (6.0 mg kg-1). Normal rats were used as the control group. NS rat models were treated with HU or U (173 mg kg-1 day-1). After treatment for 6 weeks, we assessed urine protein, renal function, and blood lipids, and observed morphology and histologic injury of the kidney and glomerular microstructure. Furthermore, we detected antioxidant enzyme activity and expression level of the Keap1/Nrf2 signaling pathway to explore the potential mechanism of HU. Results showed that HU not only alleviated hyperlipidemia and hypoalbuminemia, but also reduced urine protein by inhibiting podocyte detachment, thickening of the glomerular basement membrane, and expression of kidney fibrosis markers (collagens I and IV). In addition, HU enhanced antioxidant enzyme activity (GSH-Px, CAT, SOD) in both serum and the kidney, which may be due to upregulating the expression of Nrf2 and downregulating the expression of Keap1. In conclusion, HU appears to be effective in attenuating NS in rats through suppressing oxidative stress by regulating the Keap1/Nrf2 signaling pathway.

Association of urinary albumin-to-creatinine ratio with lipid abnormalities and glycemic control in patients with type 2 diabetes mellitus

Introduction

While proteinuria aggravates dyslipidemia in diabetic patients, dyslipidemia further worsens proteinuria via inflammatory cytokines-mediated glomerular damage. Urinary albumin creatinine ratio (ACR) is an easy and reliable method of detecting proteinuria. This study aims to determine the association of ACR with lipid abnormalities and glycemic control in the Nepalese population.

Methods

This was a cross-sectional study conducted among 201 diabetes patients visiting the outpatient department of internal medicine. Based on ACR values, patients were categorized as nonalbuminuric (less than 300 μg/mg) or albuminuric (more than 300 μg/mg). An unpaired t-test was used to compare the mean of various lipoproteins in these two categories. Binary logistic regression was used to check the association of ACR with sociodemographic factors (age, sex, and education), hypertension, and glycated hemoglobin.

Results

Albuminuric patients had higher mean cholesterol (192.8±53.5 vs. 184.2± 37.6; P=0.209), triglyceride (194.9±97.8 vs. 164.4±73.7; P=0.017) and low-density lipoprotein (99.9±38.4 vs. 90.0±27.4; P=0.034) but lower high-density lipoprotein (53.9±18.5 vs. 61.3±19.9; P=0.008) compared to nonalbuminuric patients. There was a significant difference in mean HbA1c values across albuminuria and nonalbuminuria groups (7.1±1.1 vs. 6.7±0.8; OR: 1.4, 95% CI=1.1-1.9, P=0.030).

Conclusions

Urine ACR of more than 30 mg/gram was associated with higher triglyceride and low-density lipoprotein levels and lower high-density lipoprotein levels. The HbA1c level strongly correlates with the development of albuminuria.

Diphenyl-substituted triazine derivatives: synthesis, α-glucosidase inhibitory activity, kinetics and in silico studies

Background: Diabetes mellitus (DM) is a chronic disorder, considered to be a major global health challenge in the 21st century. α-Glucosidase enzyme is a well-known drug target to treat Type II DM. Methods: A new library of biphenyl-substituted triazines was synthesized and confirmed by various spectroscopic techniques. Results: All compounds showed potent α-glucosidase inhibitory activity, with IC50 values ranging from 35.35 ± 0.34 to 564.41 ± 0.91 μM, as the standard acarbose, IC50 value of 750.7 ± 0.13 μM. Our in silico study has predicted key interactions with the enzyme's active site. Drug-likeness and absorption, distribution, metabolism, excretion and toxicity were also studied. Conclusion: This study has identified a range of potential hits against the α-glucosidase enzyme that may serve as antidiabetic agents after further investigations.

Accuracy of Small Dense Low-density Lipoprotein-cholesterol Concentration Estimated via Sampson's Equation in Healthy Subjects and Patients with Diabetes

AIM

Sampson et al. proposed a method to calculate small dense low-density lipoprotein-cholesterol (sdLDL-C) concentrations using common lipid measurements, but its accuracy remains unresolved. We examined the difference between Sampson's equation and direct measurement in patients with diabetes.

METHODS

sdLDL-C was measured directly by our established homogeneous assay and estimated by Sampson's equation in patients with diabetes (n=1542) and healthy control subjects (n=673). Large-buoyant (lb)LDL-C was estimated using triglycerides and LDL-C, and sdLDL-C was obtained by subtracting lbLDL-C from LDL-C. The effect of fasting/nonfasting state or lipid-lowering drug therapy on sdLDL-C values was also examined in 30 and 43 patients with diabetes, respectively.

RESULTS

The coefficient of determination (R2) between calculated sdLDL-C and direct measurement was 0.73 and 0.61 for healthy controls and patients with diabetes, respectively. The R2 between calculated sdLDL-C and nonHDL-C or apolipoprotein B was 0.64 and 0.65, respectively. Calculated sdLDL-C was 4-5 mg/dl or 17%-18% higher than the direct measurement. The lower the plasma lipids, especially sdLDL-C, the greater the dissociation between the two methods. Sampson sdLDL-C was also found to give a positive bias when calculated for the nonfasting samples. Statins and pemafibrate significantly reduced sdLDL-C, but their therapeutic effect was underestimated by 5 mg/dl (24%) via Sampson's equation.

CONCLUSIONS

The correlation between Sampson's equation and direct measurements of sdLDL-C was reduced in patients with diabetes. Furthermore, the correlations with nonHDL-C and apolipoprotein B were even higher than those with direct sdLDL-C. The accuracy of Sampson's equation decreased with lower sdLDL-C concentrations and was also influenced by diet.

Hypertriglyceridemia contributes significantly to high prevalence of small dense LDL-cholesterol in patients with type 2 diabetes, even when LDL-C targets are achieved

Background

Small-dense (sd)LDL-cholesterol (C) is a potent risk factor for atherosclerotic cardiovascular disease (ASCVD) beyond LDL-C, and 35 mg/dL has been proposed as a cut-off value for high-sdLDL-C. sdLDL-C levels are strongly regulated by triglycerides (TG) and LDL-C levels. LDL-C has detailed targets for the prevention of ASCVD, while TG is only defined as abnormal at  ≥ 150 mg/dL. We investigated the effect of hypertriglyceridemia on the prevalence of high-sdLDL-C in patients with type 2 diabetes and explored the optimal TG levels that would suppress high-sdLDL-C.

Methods

Fasting plasma was obtained from 1569 patients with type 2 diabetes who were enrolled in the regional cohort study. sdLDL-C concentrations were measured by the homogeneous assay established by us. High-sdLDL-C was defined as ≤ 35 mg/dL according to the Hisayama Study. Hypertriglyceridemia was defined as ≥ 150 mg/dL.

Results

All lipid parameters except HDL-C were higher in the high-sdLDL-C group than in the normal-sdLDL-C group. The receiver operating characteristic (ROC) curves revealed that high sdLDL-C was identified sensitively by TG and LDL-C, with cut-off values of 115 mg/dL for TG and 110 mg/dL for LDL-C. The presence of hypertriglyceridemia increased the prevalence of high-sdLDL-C sixfold more than the normotriglyceridemic counterpart, regardless of statin use. This substantial influence of hypertriglyceridemia was found even within the control target of LDL-C levels (70-120 mg/dL) for diabetic subjects.

Conclusions

The TG cut-off for high-sdLDL-C was well below 150 mg/dL in a diabetic population. Amelioration of hypertriglyceridemia is needed even when LDL-C targets for diabetes are achieved.

Correlation between different levels and patterns of dyslipidemia and glomerular filtration rate in patients with type 2 diabetes: A cross-sectional survey of a regional cohort

BACKGROUND

Due to the high cardiovascular risk in patients with diabetic nephropathy, more attention should be paid to lipid levels and dyslipidemia in these patients. The current study investigated the association between single and mixed dyslipidemia patterns, estimated glomerular filtration rate (eGFR), and different chronic kidney disease (CKD) stages.

METHODS

This cross-sectional study evaluated 4059 patients with type 2 diabetes (T2D). TG, TC, LDL-C, and HDL-C were measured. Non-HDL-C and AIP were calculated. We estimated eGFR using the CKD-EPI equation.

RESULTS

With the progression of the kidney failure stage, mean levels of TG, LDL-C, non-HDL-C, and AIP decreased. HDL-C levels decreased with the advance of the CKD stage in men but did not change significantly in women. The prevalence of single dyslipidemia, including high LDL-C and high non-HDL-C, decreased with the advancing CKD stage. The prevalence of mixed dyslipidemia patterns, including high AIP and high LDL-C, high AIP and high non-HDL-C, showed a significant downward tendency. TG and AIP levels were negatively, and HDL-C levels were positively correlated with eGFR after adjusting for the risk factors. Also, CKD stage 3 was positively related to the risk of high TG and low HDL-C.

CONCLUSION

This study shows that blood lipids decreased with the progression of renal failure in patients with T2D. However, after adjustment, TG and AIP levels had negative, and HDL-C levels had a positive correlation with eGFR, which could be consistent with the hypothesis that eGFR decreases with increasing TG or AIP levels or decreasing HDL-C levels.

Clinical significance of skin autofluorescence for diabetic macroangiopathy and comparison with conventional markers of atherosclerosis: a cross-sectional and prospective study

Background

Skin autofluorescence (SAF) is a marker for the accumulation of advanced glycation end products (AGEs), and is associated with diabetic macroangiopathy. However, whether SAF is superior to conventional markers of atherosclerosis such as carotid intima-media thickness (IMT) and pulse wave velocity (PWV) in detecting macroangiopathy remains unclear.

Methods

We recruited 845 patients with type 2 diabetes enrolled in a community diabetes cohort (ViNA cohort) who had SAF, IMT, and PWV measured at baseline. The prevalence of macroangiopathy at baseline and new cardiovascular events during the 2-year follow-up period was investigated. SAF was measured using an AGE reader. Coronary artery calcification (CAC) was measured by computed tomography in 485 patients. Peripheral artery disease (PAD) was defined as the ankle-brachial blood pressure ratio of ≤ 0.9.

Results

SAF, IMT, and PWV were significantly correlated with each other, and age, diabetes duration, and estimated glomerular filtration rate were their strong confounders. SAF was associated with baseline stroke and new stroke after adjusting for confounders, but not with coronary artery disease (CAD) or PAD. The nonsignificant relationship between SAF and CAD was consistent with the relationship between SAF and CAC. Multivariate analysis showed a significant association of SAF with baseline and new stroke independent of IMT and PWV. Maximum-IMT was significantly associated with baseline CAD, PAD, and stroke, but not with a new stroke, whereas PWV was associated with a new stroke.

Conclusion

Among diabetic macroangiopathies, SAF is a good stroke biomarker, but not for CAD and PAD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-022-00608-8.

Estimation of Small Dense LDL-Cholesterol Levels in Patients with Acute Coronary Syndrome

Small dense LDL-cholesterol is an established risk factor for atherosclerosis, but it is not routinely measured in clinical practice, and its measurement has not yet been reimbursed. The Sampson equation that uses triglyceride and LDL-cholesterol levels has very recently been proposed to estimate small dense LDL-cholesterol levels. We validated its accuracy in patients with acute coronary syndrome.Serum samples were obtained on admission from hospitalized patients with acute coronary syndrome before heparinization. Small dense LDL-cholesterol levels were measured directly and were also estimated from triglyceride and LDL-cholesterol levels using the Sampson equation. The correlation between the Sampson's equation and direct measurement was investigated.A total of 55 patients were enrolled. The median age was 75 (65, 84) years old, and 35 (64%) were men. There was a moderate correlation between the two methods (r = 0.76, P < 0.001). A lower level of small dense LDL-cholesterol was independently associated with a greater overestimation of the Sampson equation.The Sampson equation is useful for estimating small dense LDL-cholesterol levels in patients with acute coronary syndrome. However, the estimated value may be overestimated in patients with low lipid profiles.

Study on the relationship between lipoprotein (a) and diabetic kidney disease

OBJECTIVE

Little is currently known about the role of lipid metabolism in diabetic kidney disease (DKD), warranting further study. The present study sought to investigate the correlation between lipid metabolism and renal function as well as renal pathological grade/score in DKD patients.

METHODS

A total of 224 patients diagnosed with DKD by pathological examination were retrospectively analyzed, of which 74 patients were further evaluated by DKD pathological grade/score. ANOVA was used to investigate serum lipoprotein (a) [Lp (a)] levels in DKD patients with different chronic kidney disease (CKD) stages. Spearman correlation analysis was used to evaluate the relationship between Lp (a) and renal function-related indicators. The DKD pathological grade/score was also evaluated with this method. The receiver operating characteristic (ROC) curve was used to analyze the value of Lp (a) in assessing renal function and pathological changes.

RESULTS

There were significant differences in Lp (a) levels among different CKD stages (H = 17.063, p = 0.002) and glomerular grades (H = 12.965, p = 0.005). Lp (a) levels correlated with serum creatinine (p = 0.000), blood urea nitrogen (p = 0.000), estimated glomerular filtration rate (p = 0.000), 24-h proteinuria (24hUPro, p = 0.000), urine microalbumin (p = 0.000), urine albumin creatinine ratio (p = 0.000), glomerular basement membrane thickness (p = 0.003), and glomerular grade (p = 0.039). ROC curve demonstrated good performance of Lp (a) as an indicator to assess CKD stage 4-5 (AUC = 0.684, p = 0.000), 24hUPro > 3.5 g (AUC = 0.720, p = 0.000), and glomerular grade III-IV (AUC = 0.695, p = 0.012).

CONCLUSIONS

Elevated levels of Lp (a) are associated with decreased GFR, increased proteinuria, and renal pathological progression, suggesting they could be used to monitor changes in DKD patients.

Prognostic value of low-density lipoprotein cholesterol in IgA nephropathy and establishment of nomogram model

BACKGROUND

Dyslipidemia is closely related to kidney disease. We aimed to investigate the relationship between low-density lipoprotein cholesterol (LDL-C) and prognosis of IgA nephropathy (IgAN) and build a nomogram prognostic model.

METHODS

519 IgAN patients with 61 months median follow-up were enrolled and divided into two groups based on the cut-off value of baseline LDL-C (2.60 mmol/L): the high group (n=253) and the low group (n=266). Renal survival was assessed by Kaplan⁃Meier (KM) survival curve. Risk factors were identified by COX regression analysis. The area under the receiver operating characteristic (ROC) curves (AUC), concordance index (C-index), and calibration curves were applied to evaluate the nomogram model.

RESULTS

KM survival curve analysis showed that the high LDL-C group had worse renal survival than the low LDL-C group (χ2 = 8.555, p=0.003). After adjusting for confounding factors, Cox regression analysis showed the baseline LDL-C level was an independent risk factor of end-stage renal disease (ESRD) in IgAN (HR=3.135, 95% CI 1.240~7.926, p =0.016). LDL-C, segmental sclerosis, tubular atrophy/interstitial fibrosis, the prevalence of cardiovascular disease, 24-hour proteinuria were identified and entered into the nomogram models, with AUC of 0.864, 0.827, and 0.792 respectively to predict the 5-, 8-, and 10-year risk of ESRD in IgAN. The C-index of this prediction model was respectively 0.862, 0.838, and 0.800 and was well-calibrated.

CONCLUSION

Elevated LDL-C level is a predictive factor for the prognosis of IgAN. We developed a nomogram model that can predict the risk of ESRD in IgAN by using LDL-C ≥ 2.60 mmol/L.

Diabetic kidney disease treatment: new perspectives

Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease and end-stage kidney disease worldwide, as the obesity epidemic and the burden of diabetes continue to rise globally. In general, guideline management of patients with DKD recommends lifestyle modifications, blood pressure and glycemic control, and dyslipidemia treatment along with other cardiovascular disease risk reduction measures. The inhibition of the renin-angiotensin system (RAS) using an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker remains the foundational therapy for DKD. In type 2 diabetes (T2D), significant advances in therapeutics, including the sodium-glucose cotransporter-2 inhibitors (SGLT2i), the glucagon-like peptide-1 receptor agonists (GLP-1 RA), and the nonsteroidal mineralocorticoid receptor agonist (MRA) finerenone, have dramatically expanded the armamentarium for treating DKD and its cardiovascular complications. Initiating, optimizing, and sustaining evidence-based pharmacological therapy using a therapeutic combination of RAS inhibitor + SGLT2i/GLP-1 RA + nonsteroidal MRA + statin is likely to significantly improve outcomes for T2D with DKD. Research into potential novel therapeutic targets for DKD remains particularly active and brings much anticipation and optimism to this field.

Diabetic kidney disease progression is associated with decreased lower-limb muscle mass and increased visceral fat area in T2DM patients

AIM

This study aimed to explore the relationship between lower-limb muscle mass/visceral fat area and diabetic kidney disease (DKD) progression in patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 879 participants with T2DM were divided into 4 groups according to the prognosis of CKD classification from Kidney Disease: Improving Global Outcomes (KDIGO). Rectus femoris cross-sectional area (RFCSA) was measured through ultrasound, and visceral fat area (VFA) was evaluated with bioelectric impedance analysis (BIA).

RESULTS

T2DM patients with high to very high prognostic risk of DKD showed a reduced RFCSA (male P < 0.001; female P < 0.05), and an enlarged VFA (male P < 0.05; female P < 0.05). The prognostic risk of DKD was negatively correlated with RFCSA (P < 0.05), but positively correlated with VFA (P < 0.05). Receiver-operating characteristic analysis revealed that the cutoff points of T2DM duration combined with RFCSA and VFA were as follows: (male: 7 years, 6.60 cm2, and 111 cm2; AUC = 0.82; 95% CI: 0.78-0.88; sensitivity, 78.0%; specificity, 68.6%, P < 0.001) (female: 9 years, 5.05 cm2, and 91 cm2; AUC = 0.73; 95% CI: 0.66-0.81; sensitivity, 73.9%; specificity, 63.3%, P < 0.001).

CONCLUSION

A significant association was demonstrated between reduced RFCSA/increased VFA and high- to very high-prognostic risk of DKD. T2DM duration, RFCSA, and VFA may be valuable markers of DKD progression in patients with T2DM.

CLINICAL TRIAL REGISTRATION

http://www.chictr.org.cn, identifier ChiCTR2100042214.

Comparison of Nonalbuminuric and Albuminuric Diabetic Kidney Disease Among Patients With Type 2 Diabetes: A Systematic Review and Meta-Analysis

BACKGROUND

Diabetic kidney disease (DKD) is one of most common complications of diabetes. Recently, the classical phenotype of DKD, which is characterized by albuminuria preceding renal insufficiency, has been challenged since a subset of diabetic patients with renal insufficiency but without albuminuria has been increasingly reported. However, the available evidence is inconsistent. Thus, the present systematic review will assess and summarize the available data regarding nonalbuminuric diabetic kidney disease (NADKD).

METHODS

PubMed, Embase, and Cochrane were searched for clinical trials related to NADKD. The results were limited to full-text articles published in English, without restrictions on the publication time. The quality of clinical trials was appraised, and the data were extracted. Meta-analysis was conducted using a random-effects model. Descriptive analysis was performed if the data were insufficient.

RESULTS

A final total of 31 articles were included in this review. The meta-analysis of 18 studies showed that compared with albuminuric DKD, patients with NADKD were older (MD = 1.04 years old, 95% CI [0.52, 1.57], p < 0.05); were more often women (Male RR = 0.74, 95% CI [0.68, 0.81], p < 0.05); had shorter diabetes duration (MD = -2.9 years, 95% CI [-3.63, -2.18], p < 0.05), lower HbA1c levels (MD = -0.34%, 95% CI [-0.42, -0.25], p < 0.05), and lower blood pressure (systolic blood pressure MD = -6.21 mmHg, 95% CI [-9.41, -3.0], p < 0.05; diastolic blood pressure MD = -1.27 mmHg, 95% CI [-2.15, 4.0], p < 0.05); less frequently experienced diabetic retinopathy (RR = 0.58, 95% CI [0.51, 0.67], p < 0.05); and less frequently used renin-angiotensin-aldosterone system (RAAS) inhibitors. The underlying pathology of NADKD might be different from that of the classic phenotype of DKD, which is associated with more advanced tubulointerstitial and vascular lesions but mild typical glomerular lesions. The annual estimated glomerular filtration rate decline tended to be lower in patients with NADKD than in those with albuminuric DKD. The risk for cardiovascular disease, end-stage renal disease, and all-cause death was lower for patients with NADKD than patients with albuminuric DKD.

CONCLUSIONS

The prevalence of NADKD has increased in recent decades, and its characteristics, pathology, and prognosis are different from those of albuminuric DKD; thus, diagnosis and treatment strategies should be different. More attention should be given to this phenotype.