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Yu MG, Gordin D, Fu J, Park K, Li Q, King GL. Protective Factors and the Pathogenesis of Complications in Diabetes. Endocr Rev 2024; 45:227-252. [PMID: 37638875 PMCID: PMC10911956 DOI: 10.1210/endrev/bnad030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/13/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
Chronic complications of diabetes are due to myriad disorders of numerous metabolic pathways that are responsible for most of the morbidity and mortality associated with the disease. Traditionally, diabetes complications are divided into those of microvascular and macrovascular origin. We suggest revising this antiquated classification into diabetes complications of vascular, parenchymal, and hybrid (both vascular and parenchymal) tissue origin, since the profile of diabetes complications ranges from those involving only vascular tissues to those involving mostly parenchymal organs. A major paradigm shift has occurred in recent years regarding the pathogenesis of diabetes complications, in which the focus has shifted from studies on risks to those on the interplay between risk and protective factors. While risk factors are clearly important for the development of chronic complications in diabetes, recent studies have established that protective factors are equally significant in modulating the development and severity of diabetes complications. These protective responses may help explain the differential severity of complications, and even the lack of pathologies, in some tissues. Nevertheless, despite the growing number of studies on this field, comprehensive reviews on protective factors and their mechanisms of action are not available. This review thus focused on the clinical, biochemical, and molecular mechanisms that support the idea of endogenous protective factors, and their roles in the initiation and progression of chronic complications in diabetes. In addition, this review also aimed to identify the main needs of this field for future studies.
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Affiliation(s)
- Marc Gregory Yu
- Research Division, Joslin Diabetes Center, Boston, MA 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
| | - Daniel Gordin
- Research Division, Joslin Diabetes Center, Boston, MA 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
- Department of Nephrology, University of Helsinki and Helsinki University Central Hospital, Stenbäckinkatu 9, FI-00029 Helsinki, Finland
- Minerva Foundation Institute for Medical Research, Tukholmankatu 8, 00290 Helsinki, Finland
| | - Jialin Fu
- Research Division, Joslin Diabetes Center, Boston, MA 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
| | - Kyoungmin Park
- Research Division, Joslin Diabetes Center, Boston, MA 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
| | - Qian Li
- Research Division, Joslin Diabetes Center, Boston, MA 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
| | - George Liang King
- Research Division, Joslin Diabetes Center, Boston, MA 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
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Kulecki M, Uruska A, Naskret D, Zozulinska-Ziolkiewicz D. Arterial Stiffness and Type 1 Diabetes: The Current State of Knowledge. Curr Diabetes Rev 2022; 18:e140621194054. [PMID: 35546329 DOI: 10.2174/1573399817666210614113827] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/01/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
The most common cause of mortality among people with type 1 diabetes is cardiovascular diseases. Arterial stiffness allows predicting cardiovascular complications, cardiovascular mortality, and all-cause mortality. There are different ways to measure arterial stiffness; the gold standard is pulse wave velocity. Arterial stiffness is increased in people with type 1 diabetes compared to healthy controls. It increases with age and duration of type 1 diabetes. Arterial stiffness among people with type 1 diabetes positively correlates with systolic blood pressure, obesity, glycated hemoglobin, waist circumference, and waist to hip ratio. It has a negative correlation with the estimated glomerular filtration rate, high-density lipoprotein, and the absence of carotid plaques. The increased arterial stiffness could result from insulin resistance, collagen increase due to inadequate enzymatic glycation, and endothelial and autonomic dysfunction. The insulin-induced decrease in arterial stiffness is impaired in type 1 diabetes. There are not enough proofs to use pharmacotherapy in the prevention of arterial stiffness, but some of the medicaments got promising results in single studies, for example, renin-angiotensin-aldosterone system inhibitors, statins, and SGLT2 inhibitors. The main strategy of prevention of arterial stiffness progression remains glycemic control and a healthy lifestyle.
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Affiliation(s)
- Michal Kulecki
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznań, Poland
| | - Aleksandra Uruska
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznań, Poland
| | - Dariusz Naskret
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznań, Poland
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Perkins BA, Lovblom LE, Lanctôt SO, Lamb K, Cherney DZI. Discoveries from the study of longstanding type 1 diabetes. Diabetologia 2021; 64:1189-1200. [PMID: 33661335 DOI: 10.1007/s00125-021-05403-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/07/2020] [Indexed: 12/21/2022]
Abstract
Award programmes that acknowledge the remarkable accomplishments of long-term survivors with type 1 diabetes have naturally evolved into research programmes to determine the factors associated with survivorship and resistance to chronic complications. In this review, we present an overview of the methodological sources of selection bias inherent in survivorship research (selection of those with early-onset diabetes, incidence-prevalence bias and bias from losses to follow-up in cohort studies) and the breadth and depth of literature focusing on this special study population. We focus on the learnings from the study of longstanding type 1 diabetes on discoveries about the natural history of insulin production loss and microvascular complications, and mechanisms associated with them that may in future offer therapeutic targets. We detail descriptive findings about the prevalence of preserved insulin production and resistance to complications, and the putative mechanisms associated with such resistance. To date, findings imply that the following mechanisms exist: strategies to maintain or recover beta cells and their function; activation of specific glycolytic enzymes such as pyruvate kinase M2; modification of AGE production and processing; novel mechanisms for modification of renin-angiotensin-aldosterone system activation, in particular those that may normalise afferent rather than efferent renal arteriolar resistance; and activation and modification of processes such as retinol binding and DNA damage checkpoint proteins. Among the many clinical and public health insights, research into this special study population has identified putative mechanisms that may in future serve as therapeutic targets, knowledge that likely could not have been gained without studying long-term survivors.
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Affiliation(s)
- Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sebastien O Lanctôt
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Krista Lamb
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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4
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Lytvyn Y, Bjornstad P, Lovshin JA, Boulet G, Farooqi MA, Lai V, Tse J, Cham L, Lovblom LE, Weisman A, Keenan HA, Brent MH, Paul N, Bril V, Advani A, Sochett E, Perkins BA, Cherney DZI. Renal Hemodynamic Function and RAAS Activation Over the Natural History of Type 1 Diabetes. Am J Kidney Dis 2019; 73:786-796. [PMID: 30799029 DOI: 10.1053/j.ajkd.2018.12.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 12/17/2018] [Indexed: 01/11/2023]
Abstract
RATIONALE & OBJECTIVE The renin-angiotensin-aldosterone system (RAAS) is associated with renal and cardiovascular disease in diabetes. Unfortunately, early RAAS blockade in patients with type 1 diabetes mellitus (T1DM) does not prevent the development of complications. We sought to examine the role of hyperfiltration and RAAS activation across a wide range of T1DM duration to better understand renal hemodynamic status in patients with T1DM. STUDY DESIGN Post hoc analysis of blood samples. SETTING & PARTICIPANTS 148 Canadian patients with T1DM: 28 adolescents (aged 16.2±2.0 years), 54 young adults (25.4±5.6 years), and 66 older adults (65.7±7.5 years) studied in a clinical investigation unit. EXPOSURE Angiotensin II infusion (1ng/kg/min; a measure of RAAS activation) during a euglycemic clamp. OUTCOMES Glomerular filtration rate measured using inulin clearance, effective renal plasma flow measured using para-aminohippurate, afferent (RA) and efferent (RE) arteriolar resistances, and glomerular hydrostatic pressure estimated using the Gomez equations. RESULTS In a stepwise fashion, glomerular filtration rate, effective renal plasma flow, and glomerular hydrostatic pressure were higher, while renal vascular resistance and RA were lower in adolescents versus young adults versus older adults. RE was similar in adolescents versus young adults but was higher in older adults. Angiotensin II resulted in blunted renal hemodynamic responses in older adults (renal vascular resistance increase of 3.3% ± 1.6% vs 4.9% ± 1.9% in adolescents; P<0.001), suggesting a state of enhanced RAAS activation. LIMITATIONS Homogeneous study participants limit the generalizability of findings to other populations. Studying older adult participants with T1DM may be associated with a survivorship bias. CONCLUSIONS A state of relatively low RAAS activity and predominant afferent dilation rather than efferent constriction characterize early adolescents and young adults with T1DM. This state of endogenous RAAS inactivity in early T1DM may explain why pharmacologic blockade of this neurohormonal system is often ineffective in reducing kidney disease progression in this setting. Older adults with long-standing T1DM who have predominant afferent constriction and RAAS activation may experience renoprotection from therapies that target the afferent arteriole. Further work is required to understand the potential role of non-RAAS pharmacologic agents that target RA in patients with early and long-standing T1DM.
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Affiliation(s)
- Yuliya Lytvyn
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Petter Bjornstad
- Division of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Julie A Lovshin
- Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Genevieve Boulet
- Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed A Farooqi
- Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vesta Lai
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Josephine Tse
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Leslie Cham
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Leif E Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sounai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alanna Weisman
- Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Hillary A Keenan
- Mount Sinai Hospital, Toronto, Ontario, Canada; Genzyme, Cambridge, MA
| | - Michael H Brent
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Narinder Paul
- Division of Cardiothoracic Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Canada
| | - Vera Bril
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada; Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; Institute for Research and Medical Consultations, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Andrew Advani
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Ontario, Canada
| | - Etienne Sochett
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Lovshin JA, Boulet G, Lytvyn Y, Lovblom LE, Bjornstad P, Farooqi MA, Lai V, Cham L, Tse J, Orszag A, Scarr D, Weisman A, Keenan HA, Brent MH, Paul N, Bril V, Perkins BA, Cherney DZ. Renin-angiotensin-aldosterone system activation in long-standing type 1 diabetes. JCI Insight 2018; 3:96968. [PMID: 29321380 PMCID: PMC5821172 DOI: 10.1172/jci.insight.96968] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/28/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND In type 1 diabetes (T1D), adjuvant treatment with inhibitors of the renin-angiotensin-aldosterone system (RAAS), which dilate the efferent arteriole, is associated with prevention of progressive albuminuria and renal dysfunction. Uncertainty still exists as to why some individuals with long-standing T1D develop diabetic kidney disease (DKD) while others do not (DKD resistors). We hypothesized that those with DKD would be distinguished from DKD resistors by the presence of RAAS activation. METHODS Renal and systemic hemodynamic function was measured before and after exogenous RAAS stimulation by intravenous infusion of angiotensin II (ANGII) in 75 patients with prolonged T1D durations and in equal numbers of nondiabetic controls. The primary outcome was change in renal vascular resistance (RVR) in response to RAAS stimulation, a measure of endogenous RAAS activation. RESULTS Those with DKD had less change in RVR following exogenous RAAS stimulation compared with DKD resistors or controls (19%, 29%, 31%, P = 0.008, DKD vs. DKD resistors), reflecting exaggerated endogenous renal RAAS activation. All T1D participants had similar changes in renal efferent arteroilar resistance (9% vs. 13%, P = 0.37) irrespective of DKD status, which reflected less change versus controls (20%, P = 0.03). In contrast, those with DKD exhibited comparatively less change in afferent arteriolar vascular resistance compared with DKD resistors or controls (33%, 48%, 48%, P = 0.031, DKD vs. DKD resistors), indicating higher endogenous RAAS activity. CONCLUSION In long-standing T1D, the intrarenal RAAS is exaggerated in DKD, which unexpectedly predominates at the afferent rather than the efferent arteriole, stimulating vasoconstriction. FUNDING JDRF operating grant 17-2013-312.
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Affiliation(s)
- Julie A. Lovshin
- Division of Endocrinology and Metabolism and
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Geneviève Boulet
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Leif E. Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Petter Bjornstad
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Research Division, Barbara Davis Center for Diabetes, Aurora, Colorado, USA
| | - Mohammed A. Farooqi
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Vesta Lai
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Leslie Cham
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Josephine Tse
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrej Orszag
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alanna Weisman
- Division of Endocrinology and Metabolism and
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Hillary A. Keenan
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Michael H. Brent
- Department of Ophthalmology and Vision Sciences, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Narinder Paul
- Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Krembil Neuroscience Centre, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A. Perkins
- Division of Endocrinology and Metabolism and
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David Z.I. Cherney
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Dietary restriction but not angiotensin II type 1 receptor blockade improves DNA damage-related vasodilator dysfunction in rapidly aging Ercc1Δ/− mice. Clin Sci (Lond) 2017; 131:1941-1953. [DOI: 10.1042/cs20170026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 06/07/2017] [Accepted: 06/15/2017] [Indexed: 11/17/2022]
Abstract
DNA damage is an important contributor to endothelial dysfunction and age-related vascular disease. Recently, we demonstrated in a DNA repair-deficient, prematurely aging mouse model (Ercc1Δ/− mice) that dietary restriction (DR) strongly increases life- and health span, including ameliorating endothelial dysfunction, by preserving genomic integrity. In this mouse mutant displaying prominent accelerated, age-dependent endothelial dysfunction we investigated the signaling pathways involved in improved endothelium-mediated vasodilation by DR, and explore the potential role of the renin-angiotensin system (RAS). Ercc1Δ/− mice showed increased blood pressure and decreased aortic relaxations to acetylcholine (ACh) in organ bath experiments. Nitric oxide (NO) signaling and phospho-Ser1177-eNOS were compromised in Ercc1Δ/−. DR improved relaxations by increasing prostaglandin-mediated responses. Increase of cyclo-oxygenase 2 and decrease of phosphodiesterase 4B were identified as potential mechanisms. DR also prevented loss of NO signaling in vascular smooth muscle cells and normalized angiotensin II (Ang II) vasoconstrictions, which were increased in Ercc1Δ/− mice. Ercc1Δ/− mutants showed a loss of Ang II type 2 receptor-mediated counter-regulation of Ang II type 1 receptor-induced vasoconstrictions. Chronic losartan treatment effectively decreased blood pressure, but did not improve endothelium-dependent relaxations. This result might relate to the aging-associated loss of treatment efficacy of RAS blockade with respect to endothelial function improvement. In summary, DR effectively prevents endothelium-dependent vasodilator dysfunction by augmenting prostaglandin-mediated responses, whereas chronic Ang II type 1 receptor blockade is ineffective.
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Lytvyn Y, Har R, Locke A, Lai V, Fong D, Advani A, Perkins BA, Cherney DZI. Renal and Vascular Effects of Uric Acid Lowering in Normouricemic Patients With Uncomplicated Type 1 Diabetes. Diabetes 2017; 66:1939-1949. [PMID: 28408434 DOI: 10.2337/db17-0168] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/05/2017] [Indexed: 11/13/2022]
Abstract
Higher plasma uric acid (PUA) levels are associated with lower glomerular filtration rate (GFR) and higher blood pressure (BP) in patients with type 1 diabetes (T1D). Our aim was to determine the impact of PUA lowering on renal and vascular function in patients with uncomplicated T1D. T1D patients (n = 49) were studied under euglycemic and hyperglycemic conditions at baseline and after PUA lowering with febuxostat (FBX) for 8 weeks. Healthy control subjects were studied under normoglycemic conditions (n = 24). PUA, GFR (inulin), effective renal plasma flow (para-aminohippurate), BP, and hemodynamic responses to an infusion of angiotensin II (assessment of intrarenal renin-angiotensin-aldosterone system [RAAS]) were measured before and after FBX treatment. Arterial stiffness, flow-mediated dilation (FMD), nitroglycerin-mediated dilation (GMD), urinary nitric oxide (NO), and inflammatory markers were measured before and after FBX treatment. Gomez equations were used to estimate arteriolar afferent resistance, efferent resistance (RE), and glomerular hydrostatic pressure (PGLO). FBX had a modest systolic BP-lowering effect in T1D patients (112 ± 10 to 109 ± 9 mmHg, P = 0.049) without impacting arterial stiffness, FMD, GMD, or NO. FBX enhanced the filtration fraction response to hyperglycemia in T1D patients through larger increases in RE, PGLO, and interleukin-18 but without impacting the RAAS. FBX lowered systolic BP and modulated the renal RE responses to hyperglycemia but without impacting the RAAS or NO levels, suggesting that PUA may augment other hemodynamic or inflammatory mechanisms that control the renal response to hyperglycemia at the efferent arteriole. Ongoing outcome trials will determine cardiorenal outcomes of PUA lowering in patients with T1D.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Ronnie Har
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Amy Locke
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vesta Lai
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Derek Fong
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Advani
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Yasumoto M, Tsuda A, Ishimura E, Uedono H, Ohno Y, Ichii M, Ochi A, Nakatani S, Mori K, Uchida J, Emoto M, Nakatani T, Inaba M. Significant association between glycemic status and increased estimated postglomerular resistance in nondiabetic subjects - study of inulin and para-aminohippuric acid clearance in humans. Physiol Rep 2015; 3:3/3/e12321. [PMID: 25742958 PMCID: PMC4393156 DOI: 10.14814/phy2.12321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
We investigated whether glomerular hemodynamic parameters in nondiabetic subjects, including healthy subjects, are associated with glycemic status indices, by simultaneous measurement of inulin (Cin) and para-aminohippuric acid (CPHA) clearance. Twenty-six subjects (age 49.5 ± 13.3 years; 13 men and 13 women; 14 healthy subjects and 12 subjects with mild proteinuria) were enrolled. Cin and CPAH were measured simultaneously. All 26 subjects were nondiabetics. Estimated preglomerular resistance, estimated postglomerular resistance, and estimated glomerular hydrostatic pressure (Pglo) were calculated according to Gomez’ formula. Pglo correlated significantly and positively with hemoglobin A1c (HbA1c) in both healthy subjects (r = 0.532, P = 0.0498) and subjects with mild proteinuria (r = 0.681, P = 0.015). While there was no significant correlation between estimated preglomerular resistance and HbA1c, estimated postglomerular resistance correlated significantly and positively with HbA1c both in healthy subjects (r = 0.643, P = 0.013) and subjects with mild proteinuria (r = 0.589, P = 0.044). Glomerular filtration fraction, estimated Pglo and estimated postglomerular resistance in total subjects were associated significantly with HbA1c after adjustment for age, gender, and body mass index. These results demonstrate that, even in nondiabetic subjects, glycemic status is associated with estimated postglomerular resistance, but not estimated preglomerular resistance. It is suggested that increased estimated postglomerular resistance associated with higher HbA1c levels, even within the normal range, causes increased estimated Pglo, leading to increased FF. Thus, hemodynamic abnormalities associated with higher HbA1c levels may be related to glomerular hypertension, even in nondiabetic subjects.
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Affiliation(s)
- Mari Yasumoto
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akihiro Tsuda
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Eiji Ishimura
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hideki Uedono
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshiteru Ohno
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Mitsuru Ichii
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akinobu Ochi
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinya Nakatani
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Katsuhito Mori
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masanori Emoto
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tatsuya Nakatani
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masaaki Inaba
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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Lytvyn Y, Perkins BA, Cherney DZI. Uric acid as a biomarker and a therapeutic target in diabetes. Can J Diabetes 2015; 39:239-46. [PMID: 25600084 DOI: 10.1016/j.jcjd.2014.10.013] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/21/2014] [Accepted: 10/10/2014] [Indexed: 02/07/2023]
Abstract
Diabetic nephropathy is a long-standing microvascular complication of diabetes mellitus and is the leading cause of end stage renal disease in developed countries. Current therapeutic strategies used to prevent or delay diabetic nephropathy exert limited clinical protective effects and can have serious adverse effects. Thus, identification of new pharmacologic agents that protect against the initiation and progression of complications of diabetes is of the utmost importance. Uric acid (UA) recently emerged as an inflammatory factor that increases oxidative stress and promotes activation of the renin angiotensin aldosterone system. As a consequence, higher UA levels are associated with various stages of the onset and progression of diabetic nephropathy, including metabolic, cardiovascular and kidney function abnormalities. If UA-lowering drugs, such as the xanthine oxidase inhibitors, block the mechanisms responsible for micro- and macrovascular injury in diabetes, these agents could represent a critical step toward preventing the progression of diabetes. This review focuses on the evidence that supports serum UA levels as a biomarker of renal and cardiovascular risk and as a potential additional therapeutic target in diabetes.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Department of Medicine, Division of Endocrinology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Bjornstad P, Cree-Green M, Baumgartner A, Maahs DM, Cherney DZ, Pyle L, Regensteiner JG, Reusch JE, Nadeau KJ. Renal function is associated with peak exercise capacity in adolescents with type 1 diabetes. Diabetes Care 2015; 38:126-31. [PMID: 25414156 PMCID: PMC4274775 DOI: 10.2337/dc14-1742] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetic nephropathy and cardiovascular disease are strongly related in adults with type 1 diabetes, yet little is known about this relationship in adolescents prior to the onset of detectable clinical disease. We hypothesized that cardiopulmonary fitness would be directly associated with albumin-to-creatinine ratio (ACR) and inversely related to estimated glomerular filtration rate (eGFR) in adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS Sixty-nine adolescents with type 1 diabetes and 13 nondiabetic control subjects of similar pubertal stage and BMI had insulin sensitivity (glucose infusion rate [GIR]), measured by hyperinsulinemic-euglycemic clamp, and lean body mass, measured by DEXA. Cardiopulmonary fitness was measured by cycle ergometry to obtain peak volume of oxygen (VO2peak), and renal function was measured by eGFR using the Bouvet equation (measuring creatinine and cystatin C levels) and ACR. RESULTS Adolescents (15.5 ± 2.2 years of age) with type 1 diabetes (6.3 ± 3.8 years diabetes duration) had reduced VO2peak (31.5 ± 6.3 vs. 36.2 ± 7.9 mL/kg ⋅ min, P = 0.046) and VO2peak/lean kg (43.7 ± 7.0 vs. 51.0 ± 8.6 mL/lean kg ⋅ min, P = 0.007) compared with nondiabetic control subjects. eGFR was inversely associated with VO2peak and VO2peak/lean kg after adjusting for sex, Tanner stage, GIR, HbA1c level, systolic blood pressure, and LDL cholesterol level (β ± SE, VO2peak: -0.19 ± 0.07, P = 0.02; VO2peak/lean kg: -0.19 ± 0.09, P = 0.048). Moreover, participants in the highest tertile for eGFR had significantly lower sex- and Tanner-adjusted VO2peak and VO2peak/lean kg compared with participants in the lowest tertile. CONCLUSIONS Adolescents with type 1 diabetes had reduced exercise capacity, which was strongly associated with renal health, independent of insulin sensitivity. Future studies should examine the underlying interrelated pathophysiology in order to identify probable targets for treatment to reduce cardiovascular and renal complications.
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Affiliation(s)
- Petter Bjornstad
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Melanie Cree-Green
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO Center for Women's Health Research, University of Colorado School of Medicine, Aurora, CO
| | - Amy Baumgartner
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - David Z Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Laura Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Judith G Regensteiner
- Center for Women's Health Research, University of Colorado School of Medicine, Aurora, CO Department of Medicine, Divisions of Internal Medicine and Cardiology, University of Colorado School of Medicine, Aurora, CO
| | - Jane E Reusch
- Center for Women's Health Research, University of Colorado School of Medicine, Aurora, CO Department of Medicine, Division of Internal Medicine, Denver VA Medical Center, Denver, CO
| | - Kristen J Nadeau
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO Center for Women's Health Research, University of Colorado School of Medicine, Aurora, CO
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Lytvyn Y, Škrtić M, Yang GK, Yip PM, Perkins BA, Cherney DZI. Glycosuria-mediated urinary uric acid excretion in patients with uncomplicated type 1 diabetes mellitus. Am J Physiol Renal Physiol 2014; 308:F77-83. [PMID: 25377916 DOI: 10.1152/ajprenal.00555.2014] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Plasma uric acid (PUA) is associated with metabolic, cardiovascular, and renal abnormalities in patients with type 2 diabetes but is less well understood in type 1 diabetes (T1D). Our aim was to compare PUA levels and fractional uric acid excretion (FEUA) in patients with T1D vs. healthy controls (HC) during euglycemia and hyperglycemia. PUA, FEUA, blood pressure (BP), glomerular filtration rate (GFR-inulin), and effective renal plasma flow (ERPF-paraaminohippurate) were evaluated in patients with T1D (n = 66) during clamped euglycemia (glucose 4-6 mmol/l) and hyperglycemia (9-11 mmol/l), and in HC (n = 41) during euglycemia. To separate the effects of hyperglycemia vs. increased glycosuria, parameters were evaluated during clamped euglycemia in a subset of T1D patients before and after sodium glucose cotransporter 2 (SGLT2) inhibition for 8 wk. PUA was lower in T1D vs. HC (228 ± 62 vs. 305 ± 75 μmol/l, P < 0.0001). In T1D, hyperglycemia further decreased PUA (228 ± 62 to 199 ± 65 μmol/l, P < 0.0001), which was accompanied by an increase in FEUA (7.3 ± 3.8 to 11.6 ± 6.7, P < 0.0001). In T1D, PUA levels correlated positively with SBP (P = 0.029) and negatively with ERPF (P = 0.031) and GFR (P = 0.028). After induction of glycosuria with SGLT2 inhibition while maintaining clamped euglycemia, PUA decreased (P < 0.0001) and FEUA increased (P < 0.0001). PUA is lower in T1D vs. HC and positively correlates with SBP and negatively with GFR and ERPF in T1D. Glycosuria rather than hyperglycemia increases uricosuria in T1D. Future studies examining the effect of uric acid-lowering therapies should account for the impact of ambient glycemia, which causes an important uricosuric effect.
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Affiliation(s)
- Yuliya Lytvyn
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Marko Škrtić
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gary K Yang
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul M Yip
- Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada; and
| | - Bruce A Perkins
- Division of Endocrinology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada;
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Bjornstad P, Maahs DM, Cherney DZ, Cree-Green M, West A, Pyle L, Nadeau KJ. Insulin sensitivity is an important determinant of renal health in adolescents with type 2 diabetes. Diabetes Care 2014; 37:3033-9. [PMID: 25071077 PMCID: PMC4207204 DOI: 10.2337/dc14-1331] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetic nephropathy (DN) remains the most common cause of end-stage renal disease and is a major cause of mortality in type 2 diabetes. Insulin sensitivity is an important determinant of renal health in adults with type 2 diabetes, but limited data exist in adolescents. We hypothesized that measured insulin sensitivity (glucose infusion rate [GIR]) would be associated with early markers of DN reflected by estimated glomerular filtration rate (eGFR) and albumin-creatinine ratio (ACR) in adolescents with type 2 diabetes. RESEARCH DESIGN AND METHODS Type 2 diabetic (n = 46), obese (n = 29), and lean (n = 19) adolescents (15.1 ± 2.2 years) had GIR measured by hyperinsulinemic-euglycemic clamps. ACR was measured and GFR was estimated by the Bouvet equation (combined creatinine and cystatin C). RESULTS Adolescents with type 2 diabetes had significantly lower GIR, and higher eGFR and ACR than obese or lean adolescents. Moreover, 34% of type 2 diabetic adolescents had albuminuria (ACR ≥30 mg/g), and 24% had hyperfiltration (≥135 mL/min/1.73 m2). Stratifying ACR and eGFR into tertiles, adolescents with type 2 diabetes in the highest tertiles of ACR and eGFR had respectively lower GIR than those in the mid and low tertiles, after adjusting for age, sex, Tanner stage, BMI, and HbA1c (P = 0.02 and P = 0.04). GIR, but not HbA1c, LDL, or systolic blood pressure, was also associated with eGFR after adjusting for sex and Tanner stage (β ± SE: -2.23 ± 0.87; P = 0.02). CONCLUSIONS A significant proportion of adolescents with type 2 diabetes showed evidence of early DN, and insulin sensitivity, rather than HbA1c, blood pressure, or lipid control, was the strongest determinant of renal health.
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Affiliation(s)
- Petter Bjornstad
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - David M Maahs
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - David Z Cherney
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Melanie Cree-Green
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Amy West
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Laura Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Kristen J Nadeau
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Yang GK, Har RLH, Lytvyn Y, Yip P, Cherney DZI. Renal hyperfiltration is associated with glucose-dependent changes in fractional excretion of sodium in patients with uncomplicated type 1 diabetes. Diabetes Care 2014; 37:2774-81. [PMID: 25011944 DOI: 10.2337/dc14-0798] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Renal hyperfiltration is a common abnormality associated with diabetic nephropathy in patients with type 1 diabetes (T1D). In animal models, increased proximal tubular sodium reabsorption results in decreased distal sodium delivery, tubuloglomerular feedback activation, afferent vasodilatation, and hyperfiltration. The role of tubular factors is less well understood in humans. The aim of the current study was therefore to compare the fractional sodium excretion (FENa) in hyperfiltering (T1D-H) versus normofiltering (T1D-N) patients and healthy control (HC) subjects, as well as the role of ambient hyperglycemia on FENa. RESEARCH DESIGN AND METHODS Blood pressure, renal function (inulin for glomerular filtration rate [GFR], and paraaminohippurate for effective renal plasma flow), FENa, and circulating neurohormones were measured in T1D-H (n = 28, GFR ≥135 mL/min/1.73 m(2)), T1D-N (n = 30), and HC (n = 35) subjects during clamped euglycemia. Studies were repeated in a subset of patients during clamped hyperglycemia. RESULTS During clamped euglycemia, T1D-H exhibited lower FENa than T1D-N and HC subjects (0.64 ± 0.06% vs. 0.91 ± 0.12% and 0.90 ± 0.10%, P < 0.05). During clamped hyperglycemia, FENa increased (Δ + 0.88 ± 0.22% vs. Δ + 0.02 ± 0.21%; between-group effect, P = 0.01) significantly in T1D-H, whereas FENa did not change in T1D-N. When treated as continuous variables, elevated GFR values were associated with hyperglycemia-induced increases in FENa (R(2) = 0.20, P = 0.007). CONCLUSIONS Patients with uncomplicated T1D-H exhibit lower FENa under euglycemic conditions, which may help to identify patients with hyperfiltration outside of a controlled laboratory setting. Increased FENa in T1D-H but not T1D-N under clamped hyperglycemic conditions suggests that the mechanisms responsible for increased sodium reabsorption leading to hyperfiltration can be saturated.
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Affiliation(s)
- Gary K Yang
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ronnie L H Har
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Yip
- University Health Network, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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14
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Tsuda A, Ishimura E, Ohno Y, Ichii M, Nakatani S, Mori K, Fukumoto S, Emoto M, Inaba M. Significant association of poor glycemic control with increased resistance in efferent arterioles--study of inulin and para-aminohippuric acid clearance in humans. Diabetes Res Clin Pract 2014; 104:234-40. [PMID: 24598266 DOI: 10.1016/j.diabres.2014.01.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 11/14/2013] [Accepted: 01/28/2014] [Indexed: 02/08/2023]
Abstract
AIMS To examine whether glomerular hemodynamic parameters in humans are associated with glycemic control indices, by simultaneously measuring clearance of inulin (Cin) and para-aminohippuric acid (CPHA). METHODS Thirty-one subjects (age 55.4±14.7 years; 15 men and 16 women; 21 diabetics and 10 non-diabetics) were enrolled. Cin and CPAH were measured simultaneously. Afferent arteriolar resistance (Ra), efferent arteriolar resistance (Re), glomerular hydrostatic pressure (Pglo) and glomerular filtration fraction (FF) were calculated according to Gomez' formula. RESULTS FF correlated significantly and positively with fasting plasma glucose (FPG), hemoglobin A1c (HbA1c) and glycated albumin (GA) (r=0.396, p=0.0303; r=0.587, p=0.0007; r=0.525, p=0.0070, respectively). Pglo correlated significantly and positively with FPG, HbA1c and GA (r=0.572, p=0.0008; r=0.535, p=0.0019; r=0.540, p=0.0053, respectively). Although there was no significant correlation between Ra and glycemic control indices, Re correlated significantly and positively with HbA1c and GA (r=0.499, p=0.0043; r=0.592, p=0.0018, respectively). FF, Pglo and Re were associated significantly with HbA1c and GA after adjustment for age. CONCLUSIONS These results demonstrate, in humans, that poor glycemic control is associated with increased Re, but not Ra. It is suggested that increased Re causes increased Pglo, leading to increased FF. Thus, hemodynamic abnormalities with poor glycemic control may be related to glomerular hypertension in humans.
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Affiliation(s)
- A Tsuda
- Department of Endocrinology, Metabolism and Molecular Medicine, Japan
| | - E Ishimura
- Department of Nephrology, Osaka City University, Graduate School of Medicine, Osaka, Japan.
| | - Y Ohno
- Department of Endocrinology, Metabolism and Molecular Medicine, Japan
| | - M Ichii
- Department of Endocrinology, Metabolism and Molecular Medicine, Japan
| | - S Nakatani
- Department of Endocrinology, Metabolism and Molecular Medicine, Japan
| | - K Mori
- Department of Endocrinology, Metabolism and Molecular Medicine, Japan
| | - S Fukumoto
- Department of Endocrinology, Metabolism and Molecular Medicine, Japan
| | - M Emoto
- Department of Endocrinology, Metabolism and Molecular Medicine, Japan
| | - M Inaba
- Department of Endocrinology, Metabolism and Molecular Medicine, Japan
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16
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Long-term hemodynamic and molecular effects persist after discontinued renin–angiotensin system blockade in patients with type 1 diabetes mellitus. Kidney Int 2013; 84:1246-53. [DOI: 10.1038/ki.2013.221] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/19/2013] [Accepted: 04/25/2013] [Indexed: 01/30/2023]
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Cherney DZI, Montanari A. Gender, clamped hyperglycemia and arterial stiffness in patients with uncomplicated type 1 diabetes mellitus. Clin Exp Hypertens 2013; 36:187-93. [PMID: 24164216 DOI: 10.3109/10641963.2013.804543] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Diabetes mellitus (DM) reduces female gender-mediated protection against the development of renal disease possibly through effects on hyperglycemia. Women with DM also exhibit increased arterial stiffness, which may promote renal disease progression. The mechanisms responsible for increased arterial stiffness in women and the possible role of acute changes in ambient glycemia remain unknown. METHODS Blood pressure, augmentation index (AIx), pulse wave velocity (PWV) and circulating mediators of the renin angiotensin system and nitric oxide (cGMP) were measured in men (n = 22) and women (n = 19) with uncomplicated type 1 DM under clamped euglycemic and hyperglycemic conditions. RESULTS At baseline, men exhibited higher levels of angiotensin II (p = 0.030) and lower cGMP levels (p = 0.004), higher systolic blood pressure (124 ± 2 versus 109 ± 2 mmHg, p < 0.0001) and pulse pressure (42 ± 2 versus 58 ± 2 beats per minute, p < 0.0001). For arterial stiffness, radial (-8.0 ± 2.6% versus +5.4 ± 3.7%, p < 0.0001) and carotid AIx (-4.7 ± 2.9 versus +12.5 ± 3.0, p < 0.0001) were lower in men versus women. In contrast, carotid-femoral PWV was similar in men and women (5.20 ± 0.30 versus 5.13 ± 0.17, respectively, p = 0.853). In response to clamped hyperglycemia, systolic blood pressure increased in women (109 ± 2 to 112 ± 2 mmHg, p = 0.005) but not men. Serum aldosterone increased and cGMP declined in women but not in men. Clamped hyperglycemia did not influence arterial stiffness in either group and radial and carotid AIx remained higher in women. CONCLUSIONS Arterial stiffness is higher in women with type 1 DM. This effect is not dependent on the effects of clamped hyperglycemia or neurohormonal activation.
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Affiliation(s)
- David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto , Canada and
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The effect of sex on endothelial function responses to clamped hyperglycemia in type 1 diabetes. Hypertens Res 2013; 37:220-4. [PMID: 24089261 DOI: 10.1038/hr.2013.136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 07/16/2013] [Accepted: 08/07/2013] [Indexed: 11/08/2022]
Abstract
Although the female sex is associated with renal protection in non-diabetic nephropathy, men and women with type 1 diabetes mellitus (T1D) have a similar risk of developing nephropathy. As hyperglycemia is associated with exaggerated effects on blood pressure and renal hyperfiltration in women versus men with T1D, we examined the influence of clamped hyperglycemia on flow mediated vasodilatation (FMD) to determine if this parameter contributes to sex-related differences in the vascular function. After a controlled diet for seven days, blood pressure, ultrasound derived FMD and circulating renin angiotensin system mediators were measured in men (n=30) and women (n=28) with T1D during clamped euglycemia and hyperglycemia. Men and women were similar in pre-study dietary parameters, age, diabetes duration, body mass index, HbA1c, renal function and proteinuria. The systolic blood pressure (SBP) was higher in men during clamped euglycemia (121±2 vs. 108±2 mm Hg, P<0.0001) and hyperglycemia (121±2 vs. 111±2 mm Hg, P<0.0001), as were the circulating levels of angiotensin II (P<0.05). SBP increased in response to hyperglycemia in women but not in men. Consistently with differences in blood pressure during clamped euglycemia, FMD was higher in women than in men (8.06±0.55 vs. 4.15±0.52%, P<0.0001). In contrast, between-group differences in FMD during clamped hyperglycemia did not reach significance owing to a decline in FMD in women, versus men, in response to clamped hyperglycemia (P=0.040 for between-group change in FMD). Clamped hyperglycemia suppresses FMD in women, but not in men, with uncomplicated T1D, which may contribute to the relative loss of protection against renal disease progression in women with T1D.
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Yang GK, Maahs DM, Perkins BA, Cherney DZI. Renal hyperfiltration and systemic blood pressure in patients with uncomplicated type 1 diabetes mellitus. PLoS One 2013; 8:e68908. [PMID: 23861950 PMCID: PMC3701674 DOI: 10.1371/journal.pone.0068908] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 06/07/2013] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Patients with type 1 diabetes mellitus (DM) and renal hyperfiltration also exhibit systemic microvascular abnormalities, including endothelial dysfunction. The effect of renal hyperfiltration on systemic blood pressure (BP) is less clear. We therefore measured BP, renal hemodynamic function and circulating renin angiotensin aldosterone system (RAAS) mediators in type 1 DM patients with hyperfiltration (n = 36, DM-H, GFR≥135 ml/min/1.73 m(2)) or normofiltration (n = 40, DM-N), and 56 healthy controls (HC). Since renal hyperfiltration represents a state of intrarenal RAAS activation, we hypothesized that hyperfiltration would be associated with higher BP and elevated levels of circulating RAAS mediators. METHODS BP, glomerular filtration rate (GFR - inulin), effective renal plasma flow (paraaminohippurate) and circulating RAAS components were measured in DM-H, DM-N and HC during clamped euglycemia (4-6 mmol/L). Studies were repeated in DM-H and DM-N during clamped hyperglycemia (9-11 mmol/L). RESULTS Baseline GFR was elevated in DM-H vs. DM-N and HC (167±6 vs. 115±2 and 115±2 ml/min/1.73 m(2), p<0.0001). Baseline systolic BP (SBP, 117±2 vs. 111±2 vs. 109±1, p = 0.004) and heart rate (76±1 vs. 67±1 vs. 61±1, p<0.0001) were higher in DM-H vs. DM-N and HC. Despite higher SBP in DM-H, plasma aldosterone was lower in DM-H vs. DM-N and HC (42±5 vs. 86±14 vs. 276±41 ng/dl, p = 0.01). GFR (p<0.0001) and SBP (p<0.0001) increased during hyperglycemia in DM-N but not in DM-H. CONCLUSIONS DM-H was associated with higher heart rate and SBP values and an exaggerated suppression of systemic aldosterone. Future work should focus on the mechanisms that explain this paradox in diabetes of renal hyperfiltration coupled with systemic RAAS suppression.
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Affiliation(s)
- Gary K. Yang
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David M. Maahs
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado, United States of America
| | - Bruce A. Perkins
- Department of Medicine, Division of Endocrinology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Z. I. Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
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Cherney DZI, Scholey JW, Sochett EB. Sex differences in renal responses to hyperglycemia, L-arginine, and L-NMMA in humans with uncomplicated type 1 diabetes. Diabetes Care 2013; 36:1290-6. [PMID: 23250800 PMCID: PMC3631825 DOI: 10.2337/dc12-1305] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Women exhibit exaggerated renal hemodynamic responses to hyperglycemia, which may promote kidney disease progression. Our aim was to determine if increased nitric oxide generation by l-arginine infusion would reverse this deleterious response to clamped hyperglycemia in women with type 1 diabetes mellitus. RESEARCH DESIGN AND METHODS Renal function, blood pressure, and plasma cyclic guanosine monophosphate (cGMP) were measured in 20 men and 15 women with type 1 diabetes mellitus during clamped euglycemia and clamped hyperglycemia. Renal function, blood pressure, and plasma cGMP responses to graded infusions of intravenous l-arginine and N(G)-monomethyl-l-arginine (l-NMMA) were measured during clamped hyperglycemia. RESULTS Subjects were young, normotensive, normoalbuminuric men and women who adhered to a high-sodium, moderate-protein diet. Plasma cGMP levels during euglycemia were generally lower in men compared with women, and systolic blood pressure (SBP) was higher in men. In response to hyperglycemia, cGMP levels did not change in men but did decline in women (Δ-1.10 ± 0.20 vs. Δ+0.05 ± 0.20 pmol/L, between-group effect of hyperglycemia on cGMP; P = 0.012). Hyperglycemia also was associated with an increase in SBP, glomerular filtration rate (GFR) (124 ± 6 to 143 ± 7 mL/min/1.73 m(2); P = 0.003) and filtration fraction (FF) in women, but these parameters did not change in men. In response to l-arginine during hyperglycemia, the increase in cGMP was exaggerated in women versus men and GFR and FF decreased in women only, back toward baseline values observed during clamped euglycemia. l-NMMA infusion did not exaggerate changes in hemodynamic function in response to hyperglycemia. CONCLUSIONS l-Arginine reversed the renal hemodynamic effects of hyperglycemia in women, suggesting that nitric oxide is an important regulator of sex-dependent vascular responses to hyperglycemia in humans.
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Affiliation(s)
- David Z I Cherney
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Goel G, Perkins BA. Can improved glycemic control slow renal function decline at all stages of diabetic nephropathy? Semin Nephrol 2013; 32:423-31. [PMID: 23062982 DOI: 10.1016/j.semnephrol.2012.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Observational studies have shown the strong association between level of glycemic control and the key outcome measure, risk of glomerular filtration rate (GFR) loss rather than subsequent course of albumin excretion, in type 1 diabetes patients at all stages of nephropathy. However, it has not been clear if clinical interventions designed to normalize glycemic control are equally effective at all stages, such as primary prevention in normoalbuminuric patients, secondary prevention in microalbuminuria and macroalbuminuria, or tertiary prevention aimed at slowing or reversing further loss of GFR once impaired. Substantial randomized controlled trial data from the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications exists to support postponement, but not outright prevention, of GFR loss in normoalbuminuric patients. Although secondary and tertiary prevention systematic studies are limited to methodologically insufficient insulin pump and transplantation trials, the reversal of advanced glomerular lesions observed in whole-pancreas transplant recipients who experienced long-term glycemic normalization offers convincing support for further research into glycemic interventions specifically for GFR preservation. In light of existing literature, we encourage the design of secondary and tertiary prevention trials that incorporate biomarker methods for identifying patients at highest risk of GFR loss because interventions to normalize hyperglycemia are resource-intensive and may be applied unnecessarily to clinical populations at low long-term GFR loss risk.
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Affiliation(s)
- Gautam Goel
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Canada
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Zimering MB, Anderson RJ, Ge L, Moritz TE, Duckworth WC. Basic fibroblast growth factor predicts cardiovascular disease occurrence in participants from the veterans affairs diabetes trial. Front Endocrinol (Lausanne) 2013; 4:183. [PMID: 24319441 PMCID: PMC3837222 DOI: 10.3389/fendo.2013.00183] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 11/09/2013] [Indexed: 11/13/2022] Open
Abstract
AIM Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in adults with type 2 diabetes mellitus. The aim of the present study was to test whether plasma basic fibroblast growth factor (bFGF) levels predict future CVD occurrence in adults from the Veterans Affairs Diabetes Trial (VADT). METHODS Nearly 400 veterans, 40 years of age or older having a mean baseline diabetes duration of 11.4 years were recruited from outpatient clinics at six geographically distributed sites in the VADT. Within the VADT, they were randomly assigned to intensive or standard glycemic treatment, with follow-up as much as seven and one-half years. CVD occurrence was examined at baseline in the patient population and during randomized treatment. Plasma bFGF was determined with a sensitive, specific two-site enzyme-linked immunoassay at the baseline study visit in all 399 subjects and repeated at the year 1 study visit in a randomly selected subset of 215 subjects. RESULTS One hundred and five first cardiovascular events occurred in these 399 subjects. The best fit model of risk factors associated with the time to first CVD occurrence (in the study) over a seven and one-half year period had as significant predictors: prior cardiovascular event [hazard ratio (HR) 3.378; 95% confidence intervals (CI) 3.079-3.807; P < 0.0001), baseline plasma bFGF (HR 1.008; 95% CI 1.002-1.014; P = 0.01), age (HR 1.027; 95% CI 1.004-1.051; P = 0.019), baseline plasma triglycerides (HR 1.001; 95% CI 1.000-1.002; P = 0.02), and diabetes duration-treatment interaction (P = 0.03). Intensive glucose-lowering was associated with significantly decreased hazard ratios for CVD occurrence (0.38-0.63) in patients with known diabetes duration of 0-10 years, and non-significantly increased hazard ratios for CVD occurrence (0.82-1.78) in patients with longer diabetes duration. CONCLUSION High level of plasma bFGF is a predictive biomarker of future CVD occurrence in this population of adult type 2 diabetes.
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Affiliation(s)
- Mark B. Zimering
- Medical Service, Department of Veterans Affairs New Jersey Health Care System, Lyons, NJ, USA
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- *Correspondence: Mark B. Zimering, Department of Veterans Affairs New Jersey Health Care System, Medical Service 111, 151 Knollcroft Road, Lyons, NJ 07939, USA e-mail:
| | - Robert J. Anderson
- Hines Cooperative Studies Program Coordinating Center, Veterans Affairs Hospital, Hines, IL, USA
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Ling Ge
- Hines Cooperative Studies Program Coordinating Center, Veterans Affairs Hospital, Hines, IL, USA
| | - Thomas E. Moritz
- Hines Cooperative Studies Program Coordinating Center, Veterans Affairs Hospital, Hines, IL, USA
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23
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Thelwall PE, Taylor R, Marshall SM. Non-invasive investigation of kidney disease in type 1 diabetes by magnetic resonance imaging. Diabetologia 2011; 54:2421-9. [PMID: 21533898 DOI: 10.1007/s00125-011-2163-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 03/23/2011] [Indexed: 12/15/2022]
Abstract
AIMS/HYPOTHESIS Pathophysiological abnormalities in early diabetic nephropathy are poorly understood. We employed MRI to characterise renal perfusion, tissue oxygenation and kidney size in non-diabetic volunteers and type 1 diabetic patients without and with early renal disease. METHODS We studied ten control participants (C; age 40.0 [range 31-54] years), nine longstanding normotensive type 1 diabetic patients (T1Normo; age 40.1 [31-50] years, estimated glomerular filtration rate [eGFR] 83.4 ± 10.6 ml min(-1) 1.73 m(-2)) and eight microalbuminuric type 1 diabetic patients (T1Micro; age 42.4 [33-52] years, eGFR 71.6 ± 13.7 ml min(-1) 1.73 m(-2)). Six microalbuminuric patients were restudied after 4 weeks without renin-angiotensin-aldosterone system inhibitors. Phase contrast angiography and kidney blood oxygen level dependent (BOLD) (R(2)(*)) MRI were performed, before and during water diuresis. Contrast-enhanced MRI was performed at baseline urine flow rate. Renal artery flow, renal vascular resistance (RVR), cortical and medullary volumes, and R(2)(*) were determined. RESULTS Renal cortical and medullary volumes were similar in all groups (cortex: C 108 ± 16, T1Normo 112 ± 21, T1Micro 111 ± 10 cm(3)/1.73 m(2); medulla: C 35 ± 14, T1Normo 29 ± 10, 33 ± 6 cm(3)/1.73 m(2)). RVR increased from control to normoalbuminuric to microalbuminuric type 1 diabetic patients (C 0.061 ± 0.018, T1Normo 0.077 ± 0.014, T1Micro 0.093 ± 0.024 mmHg ml(-1) min(-1) 1.73 m(-2), ANOVA p = 0.012). RVR correlated inversely with eGFR in normoalbuminuric, but not in microalbuminuric diabetic patients. Renal artery flow was lower in the whole diabetes cohort (control 740 ± 205 vs diabetes 591 ± 128 ml min(-1) 1.73 m(-2), p = 0.035). CONCLUSIONS/INTERPRETATION Cortical and medullary volumes remain normal in early diabetic nephropathy. Decreased renal flow in longstanding normoalbuminuric type 1 diabetic patients may reflect intrarenal vascular stiffening, whereas in the microalbuminuric patients it may also reflect increased intraglomerular pressure.
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Affiliation(s)
- P E Thelwall
- Newcastle Magnetic Resonance Centre, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UK.
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24
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Cherney DZI, Sochett EB. Evolution of renal hyperfiltration and arterial stiffness from adolescence into early adulthood in type 1 diabetes. Diabetes Care 2011; 34:1821-6. [PMID: 21636797 PMCID: PMC3142047 DOI: 10.2337/dc11-0167] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine, in a small but carefully physiologically characterized cohort of subjects with uncomplicated type 1 diabetes, the changes in renal hemodynamic function and arterial stiffness that occur over time as the participants transitioned from adolescence into early adulthood. The classical paradigm for type 1 diabetes suggests that glomerular filtration rate (GFR) declines in patients with renal hyperfiltration, but the natural history of peripheral vascular function abnormalities in uncomplicated type 1 diabetes is less well understood, particularly as patients transition from adolescence to early adulthood. RESEARCH DESIGN AND METHODS Renal hemodynamic function (inulin and p-aminohippuric acid clearance), blood pressure, arterial stiffness (radial augmentation index), albumin excretion, and circulating renin-angiotensin system measures were obtained during clamped euglycemia at baseline and at follow-up 6.8 ± 2.5 years later in 10 patients with hyperfiltration (GFR ≥135 mL/min/1.73 m(2)) and in 8 with normofiltration. RESULTS Compared with baseline values, GFR (171 ± 20 to 120 ± 15 mL/min/1.73 m(2)) and filtration fraction (FF, 0.24 ± 0.06 to 0.18 ± 0.03) declined in hyperfilterers (ANOVA P ≤ 0.033), and renal vascular resistance increased (0.0678 ± 0.0135 to 0.0783 ± 0.0121 mmHg/L/min, P = 0.017). GFR and FF did not change in normofiltering subjects. In contrast, the radial augmentation index decreased in hyperfiltering (1.2 ± 11.7 to -11.0 ± 7.8%) and normofiltering (14.3 ± 14.0 to 2.5 ± 14.6%) subjects (within-group changes, ANOVA P ≤ 0.030). The decline in circulating aldosterone levels was similar in both groups. CONCLUSIONS During the transition from adolescence to early adulthood, hyperfiltration is not sustained in subjects with type 1 diabetes, whereas GFR remains stable in normofiltering subjects. Our findings suggest early normofiltration may predict stable renal function. In contrast, arterial stiffness decreased in all patients regardless of filtration status, suggesting that age-related increases in arterial stiffness occur at older ages.
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Yinon Y, Kingdom JC, Odutayo A, Moineddin R, Drewlo S, Lai V, Cherney DZ, Hladunewich MA. Vascular Dysfunction in Women With a History of Preeclampsia and Intrauterine Growth Restriction. Circulation 2010; 122:1846-53. [DOI: 10.1161/circulationaha.110.948455] [Citation(s) in RCA: 182] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background—
Women with a history of placental disease are at increased risk for the future development of vascular disease. It is unknown whether preexisting endothelial dysfunction underlies both the predisposition to placental disease and the later development of vascular disease. The aim of this study was to assess vascular function in postpartum women and to determine whether differences emerged depending on the presentation of placental disease.
Methods and Results—
Women with a history of early-onset preeclampsia (n=15), late-onset preeclampsia (n=9), intrauterine growth restriction without preeclampsia (n=9), and prior normal pregnancy (n=16) were studied 6 to 24 months postpartum. Flow-mediated vasodilatation and flow-independent (glyceryl trinitrate–induced) vasodilatation were studied through the use of high-resolution vascular ultrasound examination of the brachial artery. Arterial stiffness was assessed by pulse-wave analysis (augmentation index). Laboratory assessment included circulating angiogenic factors (vascular endothelial growth factor, soluble fms-like tyrosine kinase 1, placental growth factor, and soluble endoglin). Flow-mediated vasodilatation was significantly reduced in women with previous early-onset preeclampsia and intrauterine growth restriction compared with women with previous late-onset preeclampsia and control subjects (3.2±2.7% and 2.1±1.2% versus 7.9±3.8% and 9.1±3.5%, respectively;
P
<0.0001). Flow-independent vasodilatation was similar among all groups. Similarly, the radial augmentation index was significantly increased among women with previous early-onset preeclampsia and intrauterine growth restriction, but not among late preeclamptic women and control subjects (
P
=0.0105). Circulating angiogenic factors were similar in all groups.
Conclusion—
Only women with a history of early-onset preeclampsia or intrauterine growth restriction without preeclampsia exhibit impaired vascular function, which might explain their predisposition to placental disease and their higher risk of future vascular disease.
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Affiliation(s)
- Yoav Yinon
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital (Y.Y., J.C.P.K.); Samuel Lunenfeld Research Institute (J.C.P.K., S.D.), Department of Family and Community Medicine (R.M.), and Department of Medicine, Division of Nephrology, University Health Network, Mount Sinai Hospital (D.Z.I.C., M.A.H.); and Sunnybrook Health Sciences Centre, University of Toronto (M.A.H., A.O.), Toronto, Ontario, Canada
| | - John C.P. Kingdom
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital (Y.Y., J.C.P.K.); Samuel Lunenfeld Research Institute (J.C.P.K., S.D.), Department of Family and Community Medicine (R.M.), and Department of Medicine, Division of Nephrology, University Health Network, Mount Sinai Hospital (D.Z.I.C., M.A.H.); and Sunnybrook Health Sciences Centre, University of Toronto (M.A.H., A.O.), Toronto, Ontario, Canada
| | - Ayodele Odutayo
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital (Y.Y., J.C.P.K.); Samuel Lunenfeld Research Institute (J.C.P.K., S.D.), Department of Family and Community Medicine (R.M.), and Department of Medicine, Division of Nephrology, University Health Network, Mount Sinai Hospital (D.Z.I.C., M.A.H.); and Sunnybrook Health Sciences Centre, University of Toronto (M.A.H., A.O.), Toronto, Ontario, Canada
| | - Rahim Moineddin
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital (Y.Y., J.C.P.K.); Samuel Lunenfeld Research Institute (J.C.P.K., S.D.), Department of Family and Community Medicine (R.M.), and Department of Medicine, Division of Nephrology, University Health Network, Mount Sinai Hospital (D.Z.I.C., M.A.H.); and Sunnybrook Health Sciences Centre, University of Toronto (M.A.H., A.O.), Toronto, Ontario, Canada
| | - Sascha Drewlo
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital (Y.Y., J.C.P.K.); Samuel Lunenfeld Research Institute (J.C.P.K., S.D.), Department of Family and Community Medicine (R.M.), and Department of Medicine, Division of Nephrology, University Health Network, Mount Sinai Hospital (D.Z.I.C., M.A.H.); and Sunnybrook Health Sciences Centre, University of Toronto (M.A.H., A.O.), Toronto, Ontario, Canada
| | - Vesta Lai
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital (Y.Y., J.C.P.K.); Samuel Lunenfeld Research Institute (J.C.P.K., S.D.), Department of Family and Community Medicine (R.M.), and Department of Medicine, Division of Nephrology, University Health Network, Mount Sinai Hospital (D.Z.I.C., M.A.H.); and Sunnybrook Health Sciences Centre, University of Toronto (M.A.H., A.O.), Toronto, Ontario, Canada
| | - David Z.I. Cherney
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital (Y.Y., J.C.P.K.); Samuel Lunenfeld Research Institute (J.C.P.K., S.D.), Department of Family and Community Medicine (R.M.), and Department of Medicine, Division of Nephrology, University Health Network, Mount Sinai Hospital (D.Z.I.C., M.A.H.); and Sunnybrook Health Sciences Centre, University of Toronto (M.A.H., A.O.), Toronto, Ontario, Canada
| | - Michelle A. Hladunewich
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital (Y.Y., J.C.P.K.); Samuel Lunenfeld Research Institute (J.C.P.K., S.D.), Department of Family and Community Medicine (R.M.), and Department of Medicine, Division of Nephrology, University Health Network, Mount Sinai Hospital (D.Z.I.C., M.A.H.); and Sunnybrook Health Sciences Centre, University of Toronto (M.A.H., A.O.), Toronto, Ontario, Canada
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