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Kanbay M, Guldan M, Ozbek L, Copur S, Covic AS, Covic A. Exploring the nexus: The place of kidney diseases within the cardiovascular-kidney-metabolic syndrome spectrum. Eur J Intern Med 2024; 127:1-14. [PMID: 39030148 DOI: 10.1016/j.ejim.2024.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/25/2024] [Accepted: 07/11/2024] [Indexed: 07/21/2024]
Abstract
Cardiovascular-kidney-metabolic (CKM) syndrome and chronic kidney disease (CKD) are two significant comorbidities affecting a large proportion of the general population with considerable crosstalk. In addition to substantial co-incidence of CKD and CKM syndrome in epidemiological studies, clinical and pre-clinical studies have identified similar pathophysiological pathways leading to both entities. Patients with CKM syndrome are more prone to develop acute kidney injury and CKD, while therapeutic alternatives and their success rates are considerably lower in such patient groups. Nevertheless, the association between CKM syndrome and CKD or ESKD is bidirectional rather than being a cause-effect relationship as patients with CKD are also prone to develop peripheral insulin resistance, high blood pressure, and dyslipidemia. Furthermore, such patients are less likely to receive kidney transplantation in addition to the higher allograft dysfunction risk. We hereby aim to evaluate the association in-between kidney diseases and CKM syndrome, including epidemiological data, pre-clinical studies with pathophysiological pathways, and potential therapeutic perspectives.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey.
| | - Mustafa Guldan
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Lasin Ozbek
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Division of Internal Medicine, Koç University School of Medicine, Istanbul, Turkey
| | | | - Adrian Covic
- University of Medicine "Grigore T Popa" Iasi, Romania
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2
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Williams ME, Steenkamp D, Wolpert H. Making sense of glucose sensors in end-stage kidney disease: A review. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:1025328. [PMID: 36992784 PMCID: PMC10012164 DOI: 10.3389/fcdhc.2022.1025328] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022]
Abstract
Diabetes mellitus remains the leading cause of end-stage kidney disease worldwide. Inadequate glucose monitoring has been identified as one of the gaps in care for hemodialysis patients with diabetes, and lack of reliable methods to assess glycemia has contributed to uncertainty regarding the benefit of glycemic control in these individuals. Hemoglobin A1c, the standard metric to evaluate glycemic control, is inaccurate in patients with kidney failure, and does not capture the full range of glucose values for patients with diabetes. Recent advances in continuous glucose monitoring have established this technology as the new gold standard for glucose management in diabetes. Glucose fluctuations are uniquely challenging in patients dependent on intermittent hemodialysis, and lead to clinically significant glycemic variability. This review evaluates continuous glucose monitoring technology, its validity in the setting of kidney failure, and interpretation of glucose monitoring results for the nephrologist. Continuous glucose monitoring targets for patients on dialysis have yet to be established. While continuous glucose monitoring provides a more complete picture of the glycemic profile than hemoglobin A1c and can mitigate high-risk hypoglycemia and hyperglycemia in the context of the hemodialysis procedure itself, whether the technology can improve clinical outcomes merits further investigation.
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Affiliation(s)
- Mark E. Williams
- Renal Unit, Joslin Diabetes Center, Boston MA, United States
- *Correspondence: Mark E. Williams,
| | - Devin Steenkamp
- Section of Endocrinology, Diabetes, and Nutrition, Department of Medicine, Boston Medical Center, Boston, MA, United States
| | - Howard Wolpert
- Boston University School of Medicine, Boston, MA, United States
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3
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Akwo EA, Sahinoz M, Alsouqi A, Siew ED, Ikizler TA, Hung AM. Effect Modification of Body Mass Index and Kidney Function on Insulin Sensitivity Among Patients With Moderate CKD and Healthy Controls. Kidney Int Rep 2021; 6:2811-2820. [PMID: 34805633 PMCID: PMC8589704 DOI: 10.1016/j.ekir.2021.08.031] [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: 07/13/2021] [Revised: 08/07/2021] [Accepted: 08/30/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Insulin resistance and obesity are prevalent in chronic kidney disease (CKD) patients. The interaction of body mass index (BMI) and kidney function across the continuum of estimated glomerular filtration rate (eGFR) is unknown. Methods In a cross-sectional study of 139 patients, 52 with CKD stages 3 and 4 and 87 patients with normal eGFR, we measured the insulin sensitivity index (ISI) using the hyperinsulinemic euglycemic clamp and homeostasis model assessment of insulin resistance (HOMA-IR). We investigated the interaction between eGFR and BMI in their association with ISI and HOMA-IR using linear models with robust standard errors. Results Median age was 56 (42, 66) years, 50.4% were female, and 36% were African American. Patients with low eGFR (∼30 ml/min per 1.73 m2) had low ISI (2.3 mg/min per μU/ml) regardless of BMI. Among patients with preserved eGFR (>90 ml/min per 1.73m2), BMI had a greater effect on ISI (6.3 mg/min per μU/ml at a BMI of 20 kg/m2 vs. 4.6 mg/min per μU/ml at a BMI of 30 kg/m2) (P for interaction = 0.046). In models adjusted for demographics, and log transformed interleukin-6, high-sensitivity C-reactive protein, leptin, and adiponectin, a 1-SD (28 ml/min per 1.73 m2) lower eGFR was associated with a statistically significant 1.14-unit decrease in ISI (95% confidence interval = −1.80, −0.48) among nonobese patients. Among obese patients, the effect estimate was −0.25 (95% confidence interval = −0.88, 0.39). The association between BMI and HOMA-IR was stronger in patients with lower eGFR (P for interaction = 0.005). Conclusion Both eGFR and BMI are independently associated with insulin sensitivity, but the strength of the association between BMI and insulin sensitivity varies significantly across eGFR.
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Affiliation(s)
- Elvis A Akwo
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA.,Tennessee Valley Healthcare System, Nashville VA Medical Center, Nashville, Tennessee, USA
| | - Melis Sahinoz
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aseel Alsouqi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA.,Tennessee Valley Healthcare System, Nashville VA Medical Center, Nashville, Tennessee, USA
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA.,Tennessee Valley Healthcare System, Nashville VA Medical Center, Nashville, Tennessee, USA
| | - Adriana M Hung
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA.,Tennessee Valley Healthcare System, Nashville VA Medical Center, Nashville, Tennessee, USA.,Vanderbilt Precision Nephrology Program, Nashville, Tennessee, USA
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4
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William JH, Morales A, Rosas SE. When ESKD complicates the management of diabetes mellitus. Semin Dial 2020; 33:209-222. [PMID: 32274852 DOI: 10.1111/sdi.12873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Given the increased incidence and prevalence of ESKD (end-stage kidney disease) attributed to diabetes mellitus, it is important to consider the physiological and global sociodemographic factors that give rise to unique challenges in providing excellent care to this population. The individual with diabetes and ESKD faces alterations of glucose homeostasis that require close therapeutic attention, as well as the consideration of safe and effective means of maintaining glycemic control. Implementation of routine monitoring of blood glucose and thoughtful alteration of the individual's hypoglycemic drug regimen must be employed to reduce the risk of neurological, cardiovascular, and diabetes-specific complications that may arise as a result of ESKD. Titration of insulin therapy may become quite challenging, as kidney replacement therapy often significantly impacts insulin requirements. New medications have significantly improved the ability of the clinician to provide effective therapies for the management of diabetes, but have also raised an equal amount of uncertainty with respect to their safety and efficacy in the ESKD population. Additionally, the clinician must consider the challenges related to the delivery of kidney replacement therapy, and how inter-modality differences may impact glycemic control, diabetes, and ESKD-related complications, and issues surrounding dialysis vascular access creation.
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Affiliation(s)
- Jeffrey H William
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexander Morales
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sylvia E Rosas
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Kidney and Hypertension Unit, Joslin Diabetes Center, Boston, MA, USA
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5
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Taguchi K, Elias BC, Brooks CR, Ueda S, Fukami K. Uremic Toxin-Targeting as a Therapeutic Strategy for Preventing Cardiorenal Syndrome. Circ J 2019; 84:2-8. [PMID: 31827008 DOI: 10.1253/circj.cj-19-0872] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease (CKD) is a global health problem. CKD patients are at high risk of developing cardiovascular disease (CVD), including coronary artery disease, heart failure and stroke. Several factors invoke a vicious cycle of CKD and CVD, which is referred as to "cardiorenal syndrome". Among these factors, the compounds retained through loss of renal excretion play a pathological role in causing atherosclerosis and CVD. These compounds have been broadly classified as uremic toxins because of their accumulation with declining renal function and cytotoxicity. The major uremic toxins contributing to CVD are asymmetric dimethylarginine (ADMA), advanced glycation endproducts (AGE), and trimethyl amine N-oxide (TMAO). ADMA is linked to CVD through regulation of nitric oxide, reactive oxygen species, and renal anemia. AGE not only directly accumulates in the heart and kidney, but interacts with the receptor for AGE (RAGE), leading to cell damage in CVD. TMAO correlates with a high prevalence of CVD and promotes organ fibrosis by itself. The levels of these and other uremic toxins rise with worsening CKD, inducing multiplicative damage in the heart and kidney. Therefore, a better understanding of uremic toxins has great clinical importance for preventing cardiorenal syndrome. This review highlights the molecular mechanism by which these uremic toxins are implicated in CVD and suggests the possible mutual relationship between them.
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Affiliation(s)
- Kensei Taguchi
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine.,Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Bertha C Elias
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Craig R Brooks
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Seiji Ueda
- Division of Nephrology, Department of Internal Medicine, Juntendo University
| | - Kei Fukami
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine
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6
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Mitochondrial Activity and Skeletal Muscle Insulin Resistance in Kidney Disease. Int J Mol Sci 2019; 20:ijms20112751. [PMID: 31195596 PMCID: PMC6600571 DOI: 10.3390/ijms20112751] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 05/28/2019] [Accepted: 06/04/2019] [Indexed: 12/17/2022] Open
Abstract
Insulin resistance is a key feature of the metabolic syndrome, a cluster of medical disorders that together increase the chance of developing type 2 diabetes and cardiovascular disease. In turn, type 2 diabetes may cause complications such as diabetic kidney disease (DKD). Obesity is a major risk factor for developing systemic insulin resistance, and skeletal muscle is the first tissue in susceptible individuals to lose its insulin responsiveness. Interestingly, lean individuals are not immune to insulin resistance either. Non-obese, non-diabetic subjects with chronic kidney disease (CKD), for example, exhibit insulin resistance at the very onset of CKD, even before clinical symptoms of renal failure are clear. This uraemic insulin resistance contributes to the muscle weakness and muscle wasting that many CKD patients face, especially during the later stages of the disease. Bioenergetic failure has been associated with the loss of skeletal muscle insulin sensitivity in obesity and uraemia, as well as in the development of kidney disease and its sarcopenic complications. In this mini review, we evaluate how mitochondrial activity of different renal cell types changes during DKD progression, and discuss the controversial role of oxidative stress and mitochondrial reactive oxygen species in DKD. We also compare the involvement of skeletal muscle mitochondria in uraemic and obesity-related muscle insulin resistance.
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7
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Du H, Wang Q, Yang X. Fu Brick Tea Alleviates Chronic Kidney Disease of Rats with High Fat Diet Consumption through Attenuating Insulin Resistance in Skeletal Muscle. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2019; 67:2839-2847. [PMID: 30829482 DOI: 10.1021/acs.jafc.8b06927] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Fu brick tea is a unique post-fermented dark tea product which undergoes controlled fermentation by "golden flower" fungus Eurotium cristatum. This study examined the effects of Fu brick tea aqueous extract (FTE) to alleviate insulin resistance, chronic kidney disease (CKD), and its regulatory mechanism in high fat diet (HFD)-induced obese rats. Sixteen-week administration of FTE at 400 mg/kg bw in rats significantly antagonized HFD-induced insulin resistance and CKD with elevations in serum leptin, TC, TG, LDL-C, blood urea nitrogen, uric acid, and creatinine levels, respectively ( p < 0.05). FTE treatment decreased the glomerular area, the thickness of basement membrane of renal tubules, and kidney fibrosis in HFD-fed rats. FTE alleviated insulin resistance through down-regulation of SIRP-α expression and activation of the insulin signaling Akt/GLUT4, FoxO1, and mTOR/S6K1 pathways in skeletal muscle. Furthermore, FTE prevented the HFD-caused kidney dysfunction and lipid or collagen accumulation, which was accompanied by the inhibition of GSK-3β phosphorylation and the action of PI3K/Akt and nuclear accumulation of Nrf2 in kidney. These results indicated that FTE alleviated insulin resistance and CKD through modulating insulin signal transduction cascades in skeletal muscle and enhanced the Nrf2 expression in kidney.
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Affiliation(s)
- Haiping Du
- Shaanxi Engineering Laboratory for Food Green Processing and Safety Control, and Shaanxi Key Laboratory for Hazard Factors Assessment in Processing and Storage of Agricultural Products, College of Food Engineering and Nutritional Science , Shaanxi Normal University , Xi'an 710119 , China
| | - Qi Wang
- Shaanxi Engineering Laboratory for Food Green Processing and Safety Control, and Shaanxi Key Laboratory for Hazard Factors Assessment in Processing and Storage of Agricultural Products, College of Food Engineering and Nutritional Science , Shaanxi Normal University , Xi'an 710119 , China
| | - Xingbin Yang
- Shaanxi Engineering Laboratory for Food Green Processing and Safety Control, and Shaanxi Key Laboratory for Hazard Factors Assessment in Processing and Storage of Agricultural Products, College of Food Engineering and Nutritional Science , Shaanxi Normal University , Xi'an 710119 , China
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8
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Saleh N, Elayan HE, Zihlif M. THE EFFECT OF SALBUTAMOL ON PGC-1 α AND GLUT4 mRNA EXPRESSION IN THE LIVER AND MUSCLE OF ELDERLY DIABETIC MICE. ACTA ENDOCRINOLOGICA-BUCHAREST 2018; 14:184-191. [PMID: 31149256 DOI: 10.4183/aeb.2018.184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) plays an important role in the regulation of cellular energy metabolism, and it is involved in obesity and type 2 diabetes mellitus (T2DM). Its expression is elevated in the liver of T2DM mouse models. Literature reports show that chronic β2 stimulation improved insulin sensitivity in T2DM. Objectives We aimed to test the hypotheses that chronic β2 stimulation-induced improvement in insulin sensitivity involves changes in the expression of PGC-1α and glucose transporter 4 (GLUT4). Animals and Methods We fed a locally inbred, 8 months old mice, a high fat diet (HFD) to induce diabetes. These mice gained weight and became insulin resistant. The β2 agonist salbutamol had a beneficial effect on both glucose tolerance and insulin sensitivity after 4 weeks. Results Salbutamol beneficial effect persisted after 4 weeks of its discontinuation. HFD caused an up regulation of the hepatic PGC-1 α expression by 5.23 folds (P< 0.041) and salbutamol reversed this effect and caused a down regulation by 30.3 folds (P< 0.0001). PGC-1 α and GLUT4 expression in the muscle was not affected by salbutamol (P> 0.05). Conclusion Down regulation of the liver's PGC-1 α contributes to the beneficial effect of the chronic β2 stimulation on glucose tolerance and insulin sensitivity in T2DM mice.
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Affiliation(s)
- N Saleh
- University of Jordan, Faculty of Medicine, Department of Pharmacology, Amman, Jordan
| | - H E Elayan
- University of Jordan, Faculty of Medicine, Department of Pharmacology, Amman, Jordan
| | - M Zihlif
- University of Jordan, Faculty of Medicine, Department of Pharmacology, Amman, Jordan
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9
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A polygenic score for schizophrenia predicts glycemic control. Transl Psychiatry 2017; 7:1295. [PMID: 29249829 PMCID: PMC5802590 DOI: 10.1038/s41398-017-0044-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/28/2017] [Accepted: 09/23/2017] [Indexed: 12/23/2022] Open
Abstract
Schizophrenia is substantially comorbid with type 2 diabetes (T2D), but the molecular basis of this effect is incompletely understood. Here, we show that a cortical schizophrenia expression score predicts glycemic control from pancreatic islet cell expression. We used machine learning to identify a cortical expression signature in 212 schizophrenia patients and controls, which explained ~25% of the illness-associated variance. The algorithm was predicted in expression data from 51 subjects (9 with T2D), explained up to 26.3% of the variance in the glycemic control indicator HbA1c and could significantly differentiate T2D patients from controls. The cross-tissue prediction was driven by processes previously linked to diabetes. Genes contributing to this prediction were involved in the electron transport chain as well as kidney development and support oxidative stress as a molecular process underlying the comorbidity between both conditions. Together, the present results suggest a molecular commonality between schizophrenia and glycemic markers of type 2 diabetes.
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Gortan Cappellari G, Semolic A, Ruozi G, Vinci P, Guarnieri G, Bortolotti F, Barbetta D, Zanetti M, Giacca M, Barazzoni R. Unacylated ghrelin normalizes skeletal muscle oxidative stress and prevents muscle catabolism by enhancing tissue mitophagy in experimental chronic kidney disease. FASEB J 2017; 31:5159-5171. [PMID: 28778977 DOI: 10.1096/fj.201700126r] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/17/2017] [Indexed: 12/18/2022]
Abstract
Unacylated ghrelin (UnAG) may lower skeletal muscle oxidative stress, inflammation, and insulin resistance in lean and obese rodents. UnAG-induced autophagy activation may contribute to these effects, likely involving removal of dysfunctional mitochondria (mitophagy) and redox state maintenance. In chronic kidney disease (CKD) oxidative stress, inflammation and insulin resistance may negatively influence patient outcome by worsening nutritional state through muscle mass loss. Here we show in a 5/6 nephrectomy (Nx) CKD rat model that 4 d s.c. UnAG administration (200 µg twice a day) normalizes CKD-induced loss of gastrocnemius muscle mass and a cluster of high tissue mitochondrial reactive oxygen species generation, high proinflammatory cytokines, and low insulin signaling activation. Consistent with these results, human uremic serum enhanced mitochondrial reactive oxygen species generation and lowered insulin signaling activation in C2C12 myotubes while concomitant UnAG incubation completely prevented these effects. Importantly, UnAG enhanced muscle mitophagy in vivo and silencing RNA-mediated autophagy protein 5 silencing blocked UnAG activities in myotubes. UnAG therefore normalizes CKD-induced skeletal muscle oxidative stress, inflammation, and low insulin signaling as well as muscle loss. UnAG effects are mediated by autophagy activation at the mitochondrial level. UnAG administration and mitophagy activation are novel potential therapeutic strategies for skeletal muscle metabolic abnormalities and their negative clinical impact in CKD.-Gortan Cappellari, G., Semolic, A., Ruozi, G., Vinci, P., Guarnieri, G., Bortolotti, F., Barbetta, D., Zanetti, M., Giacca, M., Barazzoni, R. Unacylated ghrelin normalizes skeletal muscle oxidative stress and prevents muscle catabolism by enhancing tissue mitophagy in experimental chronic kidney disease.
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Affiliation(s)
| | - Annamaria Semolic
- Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy
| | - Giulia Ruozi
- Molecular Medicine Laboratory, International Centre for Genetic Engineering and Biotechnology, Trieste, Italy
| | - Pierandrea Vinci
- Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy
| | - Gianfranco Guarnieri
- Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy
| | - Francesca Bortolotti
- Molecular Medicine Laboratory, International Centre for Genetic Engineering and Biotechnology, Trieste, Italy
| | | | - Michela Zanetti
- Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy
| | - Mauro Giacca
- Molecular Medicine Laboratory, International Centre for Genetic Engineering and Biotechnology, Trieste, Italy
| | - Rocco Barazzoni
- Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy;
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11
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Dion F, Dumayne C, Henley N, Beauchemin S, Arias EB, Leblond FA, Lesage S, Lefrançois S, Cartee GD, Pichette V. Mechanism of insulin resistance in a rat model of kidney disease and the risk of developing type 2 diabetes. PLoS One 2017; 12:e0176650. [PMID: 28459862 PMCID: PMC5411038 DOI: 10.1371/journal.pone.0176650] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/13/2017] [Indexed: 12/19/2022] Open
Abstract
Chronic kidney disease is associated with homeostatic imbalances such as insulin resistance. However, the underlying mechanisms leading to these imbalances and whether they promote the development of type 2 diabetes is unknown. The effect of chronic kidney disease on insulin resistance was studied on two different rat strains. First, in a 5/6th nephrectomised Sprague-Dawley rat model of chronic kidney disease, we observed a correlation between the severity of chronic kidney disease and hyperglycemia as evaluated by serum fructosamine levels (p<0.0001). Further, glucose tolerance tests indicated an increase of 25% in glycemia in chronic kidney disease rats (p<0.0001) as compared to controls whereas insulin levels remained unchanged. We also observed modulation of glucose transporters expression in several tissues such as the liver (decrease of ≈40%, p≤0.01) and muscles (decrease of ≈29%, p≤0.05). Despite a significant reduction of ≈37% in insulin-dependent glucose uptake in the muscles of chronic kidney disease rats (p<0.0001), the development of type 2 diabetes was never observed. Second, in a rat model of metabolic syndrome (Zucker Leprfa/fa), chronic kidney disease caused a 50% increased fasting hyperglycemia (p<0.0001) and an exacerbated glycemic response (p<0.0001) during glucose challenge. Similar modulations of glucose transporters expression and glucose uptake were observed in the two models. However, 30% (p<0.05) of chronic kidney disease Zucker rats developed characteristics of type 2 diabetes. Thus, our results suggest that downregulation of GLUT4 in skeletal muscle may be associated with insulin resistance in chronic kidney disease and could lead to type 2 diabetes in predisposed animals.
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Affiliation(s)
- François Dion
- Centre de recherche de l’Hôpital Maisonneuve-Rosemont, Faculté de Médecine, Centre affilié à l’Université de Montréal, Montréal, Québec, Canada
- Département de pharmacologie, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- * E-mail: (VP); (FD)
| | - Christopher Dumayne
- Centre de recherche de l’Hôpital Maisonneuve-Rosemont, Faculté de Médecine, Centre affilié à l’Université de Montréal, Montréal, Québec, Canada
- Département de pharmacologie, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Nathalie Henley
- Centre de recherche de l’Hôpital Maisonneuve-Rosemont, Faculté de Médecine, Centre affilié à l’Université de Montréal, Montréal, Québec, Canada
| | - Stéphanie Beauchemin
- Centre de recherche de l’Hôpital Maisonneuve-Rosemont, Faculté de Médecine, Centre affilié à l’Université de Montréal, Montréal, Québec, Canada
| | - Edward B. Arias
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - François A. Leblond
- Centre de recherche de l’Hôpital Maisonneuve-Rosemont, Faculté de Médecine, Centre affilié à l’Université de Montréal, Montréal, Québec, Canada
| | - Sylvie Lesage
- Centre de recherche de l’Hôpital Maisonneuve-Rosemont, Faculté de Médecine, Centre affilié à l’Université de Montréal, Montréal, Québec, Canada
- Département de microbiologie, infectiologie et immunologie, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Stéphane Lefrançois
- Centre INRS-Institut Armand-Frappier, Institut National de la Recherche Scientifique, Laval, Québec, Canada
- Department of Anatomy and Cell Biology, McGill University, Montreal, Quebec, Canada
| | - Gregory D. Cartee
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Vincent Pichette
- Centre de recherche de l’Hôpital Maisonneuve-Rosemont, Faculté de Médecine, Centre affilié à l’Université de Montréal, Montréal, Québec, Canada
- Département de pharmacologie, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- * E-mail: (VP); (FD)
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12
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Zhang X, Lerman LO. The metabolic syndrome and chronic kidney disease. Transl Res 2017; 183:14-25. [PMID: 28025032 PMCID: PMC5393937 DOI: 10.1016/j.trsl.2016.12.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/22/2016] [Accepted: 12/02/2016] [Indexed: 02/07/2023]
Abstract
The metabolic syndrome (MetS) is a cluster of cardiovascular risk factors including insulin resistance (IR), dyslipidemia, and hypertension, which may also foster development of chronic kidney disease. The mechanisms of MetS-induced kidney disease are not fully understood. The purpose of this review is to summarize recent discoveries regarding the impact of MetS on the kidney, particularly on the renal microvasculature and cellular mitochondria. Fundamental manifestations of MetS include IR and adipose tissue expansion, the latter promoting chronic inflammation and oxidative stress that exacerbate IR. Those in turn can elicit various kidney injurious events through endothelial dysfunction, activation of the renin-angiotensin-aldosterone system, and adipokine imbalance. Inflammation and IR are also major contributors to microvascular remodeling and podocyte injury. Hence, these events may result in hypertension, albuminuria, and parenchymal damage. In addition, dyslipidemia and excessive nutrient availability may impair mitochondrial function and thereby promote progression of kidney cell damage. Elucidation of the link between MetS and kidney injury may help develop preventative measures and possibly novel therapeutic targets to alleviate and avert development of renal manifestations.
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Affiliation(s)
- Xin Zhang
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minn
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minn.
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13
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Spoto B, Pisano A, Zoccali C. Insulin resistance in chronic kidney disease: a systematic review. Am J Physiol Renal Physiol 2016; 311:F1087-F1108. [DOI: 10.1152/ajprenal.00340.2016] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/28/2016] [Indexed: 01/07/2023] Open
Abstract
Insulin resistance (IR) is an early metabolic alteration in chronic kidney disease (CKD) patients, being apparent when the glomerular filtration rate is still within the normal range and becoming almost universal in those who reach the end stage of kidney failure. The skeletal muscle represents the primary site of IR in CKD, and alterations at sites beyond the insulin receptor are recognized as the main defect underlying IR in this condition. Estimates of IR based on fasting insulin concentration are easier and faster but may not be adequate in patients with CKD because renal insufficiency reduces insulin catabolism. The hyperinsulinemic euglycemic clamp is the gold standard for the assessment of insulin sensitivity because this technique allows a direct measure of skeletal muscle sensitivity to insulin. The etiology of IR in CKD is multifactorial in nature and may be secondary to disturbances that are prominent in renal diseases, including physical inactivity, chronic inflammation, oxidative stress, vitamin D deficiency, metabolic acidosis, anemia, adipokine derangement, and altered gut microbiome. IR contributes to the progression of renal disease by worsening renal hemodynamics by various mechanisms, including activation of the sympathetic nervous system, sodium retention, and downregulation of the natriuretic peptide system. IR has been solidly associated with intermediate mechanisms leading to cardiovascular (CV) disease in CKD including left ventricular hypertrophy, vascular dysfunction, and atherosclerosis. However, it remains unclear whether IR is an independent predictor of mortality and CV complications in CKD. Because IR is a modifiable risk factor and its reduction may lower CV morbidity and mortality, unveiling the molecular mechanisms responsible for the pathogenesis of CKD-related insulin resistance is of importance for the identification of novel therapeutic targets aimed at reducing the high CV risk of this condition.
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Affiliation(s)
- Belinda Spoto
- Consiglio Nazionale delle Ricerche-Istituto di Fisiologia Clinica, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio di Calabria, Italy
| | - Anna Pisano
- Consiglio Nazionale delle Ricerche-Istituto di Fisiologia Clinica, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio di Calabria, Italy
| | - Carmine Zoccali
- Consiglio Nazionale delle Ricerche-Istituto di Fisiologia Clinica, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio di Calabria, Italy
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Miyamoto Y, Miyazaki T, Honda A, Shimohata H, Hirayama K, Kobayashi M. Retention of acetylcarnitine in chronic kidney disease causes insulin resistance in skeletal muscle. J Clin Biochem Nutr 2016; 59:199-206. [PMID: 27895387 PMCID: PMC5110933 DOI: 10.3164/jcbn.15-146] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/08/2016] [Indexed: 12/24/2022] Open
Abstract
Insulin resistance occurs frequently in patients with chronic kidney disease. However, the mechanisms of insulin resistance associated with chronic kidney disease are unclear. It is known that an increase in the mitochondrial acetyl-CoA (AcCoA)/CoA ratio causes insulin resistance in skeletal muscle, and this ratio is regulated by carnitine acetyltransferase that exchanges acetyl moiety between CoA and carnitine. Because excess acetyl moiety of AcCoA is excreted in urine as acetylcarnitine, we hypothesized that retention of acetylcarnitine might be a cause of insulin resistance in chronic kidney disease patients. Serum acetylcarnitine concentrations were measured in chronic kidney disease patients, and were significantly increased with reduction of renal function. The effects of excess extracellular acetylcarnitine on insulin resistance were studied in cultured skeletal muscle cells (C2C12 and human myotubes), and insulin-dependent glucose uptake was significantly and dose-dependently inhibited by addition of acetylcarnitine. The added acetylcarnitine was converted to carnitine via reverse carnitine acetyltransferase reaction, and thus the AcCoA concentration and AcCoA/CoA ratio in mitochondria were significantly elevated. The results suggest that increased serum acetylcarnitine in CKD patients causes AcCoA accumulation in mitochondria by stimulating reverse carnitine acetyltransferase reaction, which leads to insulin resistance in skeletal muscle.
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Affiliation(s)
- Yasunori Miyamoto
- Department of Internal Medicine, Division of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami, Inashiki, Ibaraki 300-0395, Japan
| | - Teruo Miyazaki
- Joint Research Center, Tokyo Medical University Ibaraki Medical Center, Ami, Inashiki, Ibaraki 300-0395, Japan
| | - Akira Honda
- Joint Research Center, Tokyo Medical University Ibaraki Medical Center, Ami, Inashiki, Ibaraki 300-0395, Japan; Department of Internal Medicine, Division of Gastroenterology and Hepatology, Tokyo Medical University Ibaraki Medical Center, Ami, Inashiki, Ibaraki 300-0395, Japan
| | - Homare Shimohata
- Department of Internal Medicine, Division of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami, Inashiki, Ibaraki 300-0395, Japan
| | - Kouichi Hirayama
- Department of Internal Medicine, Division of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami, Inashiki, Ibaraki 300-0395, Japan
| | - Masaki Kobayashi
- Department of Internal Medicine, Division of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami, Inashiki, Ibaraki 300-0395, Japan
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Selective Insulin Resistance in the Kidney. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5825170. [PMID: 27247938 PMCID: PMC4876201 DOI: 10.1155/2016/5825170] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/04/2016] [Accepted: 04/07/2016] [Indexed: 12/12/2022]
Abstract
Insulin resistance has been characterized as attenuation of insulin sensitivity at target organs and tissues, such as muscle and fat tissues and the liver. The insulin signaling cascade is divided into major pathways such as the PI3K/Akt pathway and the MAPK/MEK pathway. In insulin resistance, however, these pathways are not equally impaired. For example, in the liver, inhibition of gluconeogenesis by the insulin receptor substrate (IRS) 2 pathway is impaired, while lipogenesis by the IRS1 pathway is preserved, thus causing hyperglycemia and hyperlipidemia. It has been recently suggested that selective impairment of insulin signaling cascades in insulin resistance also occurs in the kidney. In the renal proximal tubule, insulin signaling via IRS1 is inhibited, while insulin signaling via IRS2 is preserved. Insulin signaling via IRS2 continues to stimulate sodium reabsorption in the proximal tubule and causes sodium retention, edema, and hypertension. IRS1 signaling deficiency in the proximal tubule may impair IRS1-mediated inhibition of gluconeogenesis, which could induce hyperglycemia by preserving glucose production. In the glomerulus, the impairment of IRS1 signaling deteriorates the structure and function of podocyte and endothelial cells, possibly causing diabetic nephropathy. This paper mainly describes selective insulin resistance in the kidney, focusing on the proximal tubule.
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Molecular mechanisms of insulin resistance in chronic kidney disease. Kidney Int 2015; 88:1233-1239. [PMID: 26444029 PMCID: PMC4675674 DOI: 10.1038/ki.2015.305] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 06/26/2015] [Accepted: 07/01/2015] [Indexed: 02/06/2023]
Abstract
Insulin resistance refers to reduced sensitivity of organs to insulin-initiated biologic processes that result in metabolic defects. Insulin resistance is common in patients with end-stage renal disease but also occurs in patients with chronic kidney disease (CKD), even when the serum creatinine is minimally increased. Following insulin binding to its receptor, auto-phosphorylation of the insulin receptor is followed by kinase reactions that phosphorylate insulin receptor substrate-1 (IRS-1), phosphatidylinositol 3-kinase (PI3K) and Akt. In fact, low levels of Akt phosphorylation (p-Akt) identifies the presence of the insulin resistance that leads to metabolic defects in insulin-initiated metabolism of glucose, lipids and muscle proteins. Besides CKD, other complex conditions (e.g., inflammation, oxidative stress, metabolic acidosis, aging and excess angiotensin II) reduce p-Akt resulting in insulin resistance. Insulin resistance in each of these conditions is due to activation of different, E3 ubiquitin ligases which specifically conjugate ubiquitin to IRS-1 marking it for degradation in the ubiquitin-proteasome system (UPS). Consequently, IRS-1 degradation suppresses insulin-induced intracellular signaling, causing insulin resistance. Understanding mechanisms of insulin resistance could lead to therapeutic strategies that improve the metabolism of patients with CKD.
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Zhang X, Lerman LO. Obesity and renovascular disease. Am J Physiol Renal Physiol 2015; 309:F273-9. [PMID: 26041447 DOI: 10.1152/ajprenal.00547.2014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 06/02/2015] [Indexed: 12/19/2022] Open
Abstract
Obesity remains a prominent public health concern. Obesity not only contributes greatly to cardiovascular events but has also been identified to initiate and affect the progression of preexisting chronic kidney disease. The prevalence of renal artery stenosis is growing world-wide, especially in the elderly population and in individuals with atherosclerotic risk factors such as obesity. Prolonged renovascular disease causes inflammation and microvascular remodeling within the post-stenotic kidney, which promote tissue scarring and may account for irreversible renal damage. Obesity has been shown to aggravate kidney damage via several pathways, including exacerbation of microvascular regression and renal cell injury mediated by adipocytes and insulin resistance, thereby worsening the structural and functional outcomes of the kidney in renovascular disease. Dietary modification and inhibition of the renin-angiotensin-aldosterone system have been shown to alleviate obesity-induced tissue injury and remodeling. Possibly, angiogenic factors may boost microvascular repair in the ischemic kidney in the obesity milieu. Novel therapeutic interventions targeting deleterious pathways that are activated by obesity and responsible for kidney damage need to be explored in future studies.
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Affiliation(s)
- Xin Zhang
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota; and
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota; and Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Jia T, Risérus U, Xu H, Lindholm B, Ärnlöv J, Sjögren P, Cederholm T, Larsson TE, Ikizler TA, Carrero JJ. Kidney function, β-cell function and glucose tolerance in older men. J Clin Endocrinol Metab 2015; 100:587-93. [PMID: 25429626 PMCID: PMC4318901 DOI: 10.1210/jc.2014-3313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Kidney dysfunction induces insulin resistance, but it is unknown if β cell function is affected. OBJECTIVE To investigate insulin release (β cell function) and glucose tolerance following a standardized oral glucose tolerance test (OGTT) across kidney function strata. SETTING AND DESIGN Community-based cohort study from the Uppsala Longitudinal Study of Adult Men (ULSAM). PARTICIPANTS AND MAIN OUTCOME MEASURE: Included were 1015 nondiabetic Swedish men aged 70-71 years. All participants underwent OGTT and euglycaemic hyperinsulinaemic clamp (HEGC) tests, allowing determination of insulin sensitivity, β cell function, and glucose tolerance. Kidney function was estimated by cystatin C-algorithms. Mixed models were used to identify determinants of insulin secretion after the hyperglycemic load. RESULTS As many as 466 (46%) of participants presented moderate-advanced kidney disease. Insulin sensitivity (by HEGC) decreased across decreasing kidney function quartiles. After the OGTT challenge, however, β cell function indices (area under the curve for insulin release, the estimated first phase insulin release, and the insulinogenic index) were incrementally higher. Neither the oral disposition index nor the 2-h postload glucose tolerance differed across the kidney function strata. Mixed models showed that dynamic insulin release during the OGTT was inversely associated with kidney function, despite the correction for each individual's insulin sensitivity or its risk factors. CONCLUSIONS In older men, β cell function after a hyperglycemic load appropriately compensated the loss in insulin sensitivity that accompanies kidney dysfunction. As a result, the net balance between insulin sensitivity and β cell function was preserved.
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Affiliation(s)
- Ting Jia
- Divisions of Renal Medicine and Baxter Novum, Departments of Clinical Science, Intervention and Technology (T.J., H.X., B.L., T.E.L., J.J.C.), Public Health Sciences (T.J.), and Center for Molecular Medicine (J.J.C.), Karolinska Institutet, Stockholm, Sweden; Department of Public Health and Caring Sciences, Section of Geriatrics (J.A.), Clinical Nutrition and Metabolism (U.R., P.S., T.C.), Uppsala University, Uppsala, Sweden; School of Health and Social Studies (J.A.), Dalarna University, Falun, Sweden; and Department of Medicine (T.A.I.), Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee
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Affiliation(s)
- Sarah Leyking
- Division of Nephrology and Hypertension, Department of Internal Medicine IV, Saarland University, Homburg, Germany
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20
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Signal regulatory protein-α interacts with the insulin receptor contributing to muscle wasting in chronic kidney disease. Kidney Int 2013; 84:308-16. [PMID: 23515050 PMCID: PMC3777429 DOI: 10.1038/ki.2013.97] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 01/08/2013] [Accepted: 01/10/2013] [Indexed: 02/06/2023]
Abstract
Insulin resistance from chronic kidney disease (CKD) stimulates muscle protein wasting but mechanisms causing this resistance are controversial. To help resolve this, we used microarray analyses to identify initiators of insulin resistance in the muscles of mice with CKD, glucose intolerance, and insulin resistance. CKD raised mRNAs of inflammatory cytokines in muscles and there was a 5.2-fold increase in signal regulatory protein-α (SIRP-α), a transmembrane glycoprotein principally present in muscle membranes. By immunoprecipitation we found it interacts with the insulin receptor and insulin receptor substrate-1 (IRS-1). Treatment of myotubes with a mixture of inflammatory cytokines showed that SIRP-α expression was increased by a NF-κB-dependent pathway. Blockade of NF-κB using a small-molecule chemical inhibitor or a dominant-negative IKKβ reduced cytokine-induced SIRP-α expression. The overexpression of SIRP-α in myotubes impaired insulin signaling and raised proteolysis while SIRP-α knockdown with siRNAs in skeletal muscle cells increased tyrosine phosphorylation of the insulin receptor and IRS-1 despite inclusion of cytokines. This led to increased p-Akt and suppression of protein degradation. Thus, SIRP-α is part of a novel mechanism for inflammation-mediated insulin resistance in muscle. In catabolic conditions with impaired insulin signaling, targeting SIRP-α may improve insulin sensitivity and prevent muscle atrophy.
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Park J, Lertdumrongluk P, Molnar MZ, Kovesdy CP, Kalantar-Zadeh K. Glycemic control in diabetic dialysis patients and the burnt-out diabetes phenomenon. Curr Diab Rep 2012; 12:432-9. [PMID: 22638938 PMCID: PMC5796524 DOI: 10.1007/s11892-012-0286-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Diabetes mellitus (DM) is the most common cause of end-stage kidney disease and a major risk of morbidity and mortality. It is not clear whether medical management of DM has any significant beneficial effect on clinical outcomes at the end-stage of diabetic nephropathy with full-blown micro- and macro-angiopathic complications. Both loss of kidney function and dialysis treatment interfere with glucose homeostasis and confound glycemic control. Given the unique nature of uremic milieu and dialysis therapy related alterations, there have been some debates about reliance on the conventional measures of glycemic control, in particular the clinical relevance of hemoglobin A1c and its recommended target range of <7 % in diabetic dialysis patients. Moreover, a so-called burnt-out diabetes phenomenon has been described, in that many diabetic dialysis patients experience frequent hypoglycemic episodes prompting cessation of their anti-diabetic therapies transiently or even permanently. By reviewing the recent literature we argue that the use of A1c for management of diabetic dialysis patients should be encouraged if appropriate target ranges specific for these patients (e.g. 6 to 8 %) are used. We also argue that "burnt-out diabetes" is a true biologic phenomenon and highly prevalent in dialysis patients with established history and end-stage diabetic nephropathy and explore the role of protein-energy wasting to this end. Similarly, the J- or U-shaped associations between A1c or blood glucose concentrations and mortality are likely biologically plausible phenomena that should be taken into consideration in the management of diabetic dialysis patients to avoid hypoglycemia and its fatal consequences in diabetic dialysis patients.
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Affiliation(s)
- Jongha Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Paungpaga Lertdumrongluk
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Miklos Z Molnar
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Csaba P Kovesdy
- Division of Nephrology, University of Virginia, Charlottesville, VA, USA
- Division of Nephrology, Salem VA Medical Center, Salem, VA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- David Geffen School of Medicine at UCLA, and Fielding School of Public Health at UCLA, Los Angeles, CA, USA
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Pham H, Robinson-Cohen C, Biggs ML, Ix JH, Mukamal KJ, Fried LF, Kestenbaum B, Siscovick DS, de Boer IH. Chronic kidney disease, insulin resistance, and incident diabetes in older adults. Clin J Am Soc Nephrol 2012; 7:588-94. [PMID: 22383749 DOI: 10.2215/cjn.11861111] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Insulin resistance is a complication of advanced CKD. Insulin resistance is less well characterized in earlier stages of CKD. The response of the pancreatic β cell, effects on glucose tolerance, and risk of diabetes are not clear. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Cardiovascular Health Study included 4680 adults without baseline diabetes. The Chronic Kidney Disease Epidemiology Collaboration creatinine equation was used to obtain the estimated GFR (eGFR). Insulin resistance was evaluated as fasting insulin concentration. The insulin sensitivity index, β cell function, and glucose tolerance were assessed by oral glucose tolerance testing. Incident diabetes was defined as fasting glucose ≥126 mg/dl, nonfasting glucose ≥200 mg/dl, or use of glucose-lowering medications. RESULTS Mean age was 72.5 years (range, 65-98 years). Mean eGFR was 72.2 (SD 17.1) ml/min per 1.73 m(2). After adjustment, each 10 ml/min per 1.73 m(2) lower eGFR was associated with a 2.2% higher fasting insulin concentration (95% confidence interval [CI], 1.4%, 2.9%; P<0.001) and a 1.1% lower insulin sensitivity index (95% CI, 0.03%, 2.2%; P=0.04). Surprisingly, eGFR was associated with an augmented β cell function index (P<0.001), lower 2-hour glucose concentration (P=0.002), and decreased risk of glucose intolerance (P=0.006). Over a median 12 years' follow-up, 437 participants (9.3%) developed diabetes. eGFR was not associated with the risk of incident diabetes. CONCLUSIONS Among older adults, lower eGFR was associated with insulin resistance. However, with lower eGFR, β cell function was appropriately augmented and risks of impaired glucose tolerance and incident diabetes were not increased.
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Affiliation(s)
- Hien Pham
- Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, 98195, USA.
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Abstract
PURPOSE OF REVIEW Insulin resistance is a known complication of end-stage renal disease that also appears to be present in earlier stages of chronic kidney disease (CKD). It is a risk factor for cardiovascular disease and an important potential therapeutic target in this population. Measurement of insulin resistance is reviewed in the context of known pathophysiologic abnormalities in CKD. RECENT FINDINGS Insulin resistance in CKD is due to a high prevalence of known risk factors (e.g. obesity) and to unique metabolic abnormalities. The site of insulin resistance in CKD is localized to skeletal muscle. Estimates based on fasting insulin concentration may not adequately capture insulin resistance in CKD because they largely reflect hepatic defects and because CKD impairs insulin catabolism. A variety of dynamic tests are available to directly measure insulin-mediated glucose uptake. SUMMARY Insulin resistance may be an important therapeutic target in CKD. Complementary methods are available to assess insulin resistance, and each method has unique advantages, disadvantages, and levels of complexity. These characteristics, and the likelihood that CKD alters the performance of some insulin resistance measurements, must be considered when designing and interpreting clinical studies.
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Kovesdy CP, Park JC, Kalantar-Zadeh K. Glycemic control and burnt-out diabetes in ESRD. Semin Dial 2010; 23:148-56. [PMID: 20374552 DOI: 10.1111/j.1525-139x.2010.00701.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Treatment of early diabetes mellitus, the most common cause of chronic kidney disease (CKD), may prevent or slow the progression of diabetic nephropathy and lower mortality and the incidence of cardiovascular disease in the general diabetic population and in patients with early stages of CKD. It is unclear whether glycemic control in patients with advanced CKD, including those with end-stage renal disease (ESRD) who undergo maintenance dialysis treatment is beneficial. Aside from the uncertain benefits of treatment in ESRD, hypoglycemic interventions in this population are also complicated by the complex changes in glucose homeostasis related to decreased kidney function and to dialytic therapies, occasionally leading to spontaneous resolution of hyperglycemia and normalization of hemoglobin A1c levels, a condition which might be termed "burnt-out diabetes." Further difficulties in ESRD are posed by the complicated pharmacokinetics of antidiabetic medications and the serious flaws in our available diagnostic tools used for monitoring long-term glycemic control. We review the physiology and pathophysiology of glucose homeostasis in advanced CKD and ESRD, the available antidiabetic medications and their specifics related to kidney function, and the diagnostic tools used to monitor the severity of hyperglycemia and the therapeutic effects of available treatments, along with their deficiencies in ESRD. We also review the concept of burnt-out diabetes and summarize the findings of studies that examined outcomes related to glycemic control in diabetic ESRD patients, and emphasize areas in need of further research.
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Affiliation(s)
- Csaba P Kovesdy
- Division of Nephrology, Salem Veterans Affairs Medical Center, Salem, VA 24153, USA.
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Rabkin R, Sun DF, Chen Y, Tan J, Schaefer F. Growth hormone resistance in uremia, a role for impaired JAK/STAT signaling. Pediatr Nephrol 2005; 20:313-8. [PMID: 15692835 DOI: 10.1007/s00467-004-1713-8] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2004] [Revised: 09/24/2004] [Accepted: 09/27/2004] [Indexed: 12/11/2022]
Abstract
Resistance to growth hormone (GH) is a significant complication of advanced chronic renal failure. Thus while the circulating GH levels are normal or even elevated in uremia, resistance to the hormone leads to stunting of body growth in children and contributes to muscle wasting in adults. Insensitivity to GH is the consequence of multiple defects in the GH/insulin-like growth factor-1 (IGF-1) system. Expression of the GH receptor may be reduced, although this is not a consistent finding, GH activation of the Janus kinase 2-signal transducer (JAK2) and activator of transcription (STAT) signal transduction pathway is depressed and this leads to reduced IGF-1 expression, and finally there is resistance to IGF-1, a major mediator of GH action. We review these various defects with an emphasis on the GH-activated JAK2-STAT5 pathway, since this pathway is essential for normal body growth and there has been recent progress in our understanding of the perturbations that occur in uremia.
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Affiliation(s)
- Ralph Rabkin
- Veterans Affairs, Palo Alto Health Care System, Palo Alto, California 94304, USA.
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Gaster M, Staehr P, Beck-Nielsen H, Schrøder HD, Handberg A. GLUT4 is reduced in slow muscle fibers of type 2 diabetic patients: is insulin resistance in type 2 diabetes a slow, type 1 fiber disease? Diabetes 2001; 50:1324-9. [PMID: 11375332 DOI: 10.2337/diabetes.50.6.1324] [Citation(s) in RCA: 196] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To gain further insight into the mechanisms underlying muscle insulin resistance, the influence of obesity and type 2 diabetes on GLUT4 immunoreactivity in slow and fast skeletal muscle fibers was studied. Through a newly developed, very sensitive method using immunohistochemistry combined with morphometry, GLUT4 density was found to be significantly higher in slow compared with fast fibers in biopsy specimens from lean and obese subjects. In contrast, in type 2 diabetic subjects, GLUT4 density was significantly lower in slow compared with fast fibers. GLUT4 density in slow fibers from diabetic patients was reduced by 9% compared with the weight-matched obese subjects and by 18% compared with the lean control group. The slow-fiber fraction was reduced to 86% in the obese subjects and to 75% in the diabetic subjects compared with the control group. Estimated GLUT4 contribution from slow fibers was reduced to 77% in the obese subjects and to 61% in type 2 diabetic patients compared with the control subjects. We propose that a reduction in the fraction of slow-twitch fibers, combined with a reduction in GLUT4 expression in slow fibers, may reduce the insulin-sensitive GLUT4 pool in type 2 diabetes and thus contribute to skeletal muscle insulin resistance.
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Affiliation(s)
- M Gaster
- Department of Pathology, Odense University Hospital, DK-5000 Odense, Denmark
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Sebeková K, Spustová V, Dzúrik R. Inhibition of glucose uptake by 5-hydroxyindoleacetic acid in the isolated rat soleus muscle. Int Urol Nephrol 1996; 28:123-31. [PMID: 8738631 DOI: 10.1007/bf02550149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Accumulated end-products were identified to participate in the late development of glucose intolerance and insulin resistance (IR) in patients with chronic renal insufficiency. The possible pathophysiological role of accumulated 5-hydroxy-indoleacetic acid (5HIAA) in the genesis of IR was investigated employing an in vitro animal model. 5HIAA inhibited the basal glucose uptake in isolated rat soleus muscle with intact membrane with A50 = 1.25 mumol/l, and Emax = 88.6%. 5HIAA significantly inhibited the insulin, and tolbutamide stimulated glucose uptake. In Ca and Mg depletion 5HIAA showed a partially additive inhibitory effect, while nonadditive inhibitory activity was observed in the case of K+ excess. It is concluded that 5HIAA is a metabolically active end-product interfering with glucose uptake in muscle at an insulin postreceptor level, and its effect is related to Ca modulation in the insulin regulatory cascade.
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Affiliation(s)
- K Sebeková
- Clinic of Pharmacotherapy, Institute of Preventive and Clinical Medicine, Bratislava, Slovakia
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Ciaraldi TP, Abrams L, Nikoulina S, Mudaliar S, Henry RR. Glucose transport in cultured human skeletal muscle cells. Regulation by insulin and glucose in nondiabetic and non-insulin-dependent diabetes mellitus subjects. J Clin Invest 1995; 96:2820-7. [PMID: 8675652 PMCID: PMC185992 DOI: 10.1172/jci118352] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A primary human skeletal muscle culture (HSMC) system, which retains cellular integrity and insulin responsiveness for glucose transport was employed to evaluate glucose transport regulation. As previously reported, cells cultured from non-insulin-dependent diabetic (NIDDM) subjects displayed significant reductions in both basal and acute insulin-stimulated transport compared to nondiabetic controls (NC). Fusion/differentiation of NC and NIDDM HSMC in elevated media insulin (from 22 pM to 30 microM) resulted in increased basal transport activities but reduced insulin-stimulated transport, so that cells were no longer insulin responsive. After fusion under hyperinsulinemic conditions, GLUT1 protein expression was elevated in both groups while GLUT4 protein level was unaltered. Fusion of HSMC under hyperglycemic conditions (10 and 20 mM) decreased glucose transport in NC cells only when combined with hyperinsulinemia. Hyperglycemia alone down-regulated transport in HSMC of NIDDM, while the combination of hyperglycemia and hyperinsulinemia had greater effects. In summary: (a) insulin resistance of glucose transport can be induced in HSMC of both NC and NIDDM by hyperinsulinemia and is accompanied by unaltered GLUT4 but increased GLUT1 levels; and (b) HSMC from NIDDM subjects demonstrate an increased sensitivity to impairment of glucose transport by hyperglycemia. These results indicate that insulin resistance in skeletal muscle can be acquired in NC and NIDDM from hyperinsulinemia alone but that NIDDM is uniquely sensitive to the additional influence of hyperglycemia.
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Affiliation(s)
- T P Ciaraldi
- Medical Research Service (9111G), San Diego Veterans Affairs Medical Center, California 92161, USA
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Friedman JE, Dohm GL, Leggett-Frazier N, Elton CW, Tapscott EB, Pories WP, Caro JF. Restoration of insulin responsiveness in skeletal muscle of morbidly obese patients after weight loss. Effect on muscle glucose transport and glucose transporter GLUT4. J Clin Invest 1992; 89:701-5. [PMID: 1737857 PMCID: PMC442905 DOI: 10.1172/jci115638] [Citation(s) in RCA: 128] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
A major defect contributing to impaired insulin action in human obesity is reduced glucose transport activity in skeletal muscle. This study was designed to determine whether the improvement in whole body glucose disposal associated with weight reduction is related to a change in skeletal muscle glucose transport activity and levels of the glucose transporter protein GLUT4. Seven morbidly obese (body mass index = 45.8 +/- 2.5, mean +/- SE) patients, including four with non-insulin-dependent diabetes mellitus (NIDDM), underwent gastric bypass surgery for treatment of their obesity. In vivo glucose disposal during a euglycemic clamp at an insulin infusion rate of 40 mU/m2 per min was reduced to 27% of nonobese controls (P less than 0.01) and improved to 78% of normal after weight loss of 43.1 +/- 3.1 kg (P less than 0.01). Maximal insulin-stimulated glucose transport activity in incubated muscle fibers was reduced by approximately 50% in obese patients at the time of gastric bypass surgery but increased twofold (P less than 0.01) to 88% of normal in five separate patients after similar weight reduction. Muscle biopsies obtained from vastus lateralis before and after weight loss revealed no significant change in levels of GLUT4 glucose transporter protein. These data demonstrate conclusively that insulin resistance in skeletal muscle of mobidly obese patients with and without NIDDM cannot be causally related to the cellular content of GLUT4 protein. The results further suggest that morbid obesity contributes to whole body insulin resistance through a reversible defect in skeletal muscle glucose transport activity. The mechanism for this improvement may involve enhanced transporter translocation and/or activation.
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Affiliation(s)
- J E Friedman
- Department of Medicine, School of Medicine, East Carolina University, Greenville, North Carolina 27858-4354
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