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Kang MK, Lee D, Oh MS, Lee JS, Jeong HY, Shin JH, Yoon BW, Park JM. Association of high-estimated glomerular filtration rate with the severity of ischemic stroke during non-vitamin K antagonist oral anticoagulants therapy: a nationwide cohort study. Front Neurol 2023; 14:1277855. [PMID: 38107638 PMCID: PMC10722199 DOI: 10.3389/fneur.2023.1277855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023] Open
Abstract
Aim While the relationship between impaired kidney function and non-vitamin K antagonist oral anticoagulants (NOACs) is well established, there is limited research exploring the association between an elevated estimated glomerular filtration rate (eGFR) and the efficacy of NOACs, especially concerning the outcomes of acute ischemic stroke (AIS). This study aimed to examine the association between higher-than-normal eGFR and the severity of AIS during the use of NOACs using a nationwide multicenter stroke registry in Korea. Material and methods This study utilized data from the Korean Stroke Registry (KSR) database, examining information from 2,379 patients with AIS, who had atrial fibrillation (AF) and a history of utilizing NOACs prior to hospitalization due to incident stroke occurring between 2016 and 2021. Patients with a history involving two or more types of anticoagulants or one or more forms of antiplatelet agents were excluded. Baseline characteristics, medical history, medication usage, CHADS2-VASc score, and the anticoagulation and risk factors in atrial fibrillation (ATRIA) score were evaluated. Renal function was assessed using eGFR levels and calculated with the Cockcroft-Gault equation. The severity of stroke was measured by the National Institutes of Health Stroke Scale as an outcome. For sensitivity analysis, further evaluation was performed using eGFR levels according to the modification of diet in renal disease (MDRD) study equation. Results The mean age of subjects was 76.1 ± 8.9 years. The moderate-to-severe stroke severity group exhibited an elevation in creatinine levels. The eGFR of 60 to 89 mL/min/1.73 m2 group was associated with a decreased risk of moderate-to-severe stroke severity [hazard ratio (HR)] (0.77, 95% confidence interval (CI) [0.61, 0.98], p = 0.031) compared to the eGFR≥90 mL/min/1.73 m2 group. An increment of 10 units in eGFR was marginally associated with an increased risk of moderate-to-severe stroke severity (HR: 1.03, 95% CI [1.00, 1.07], p = 0.054). Conclusion The study revealed that individuals with eGFR ≥ 90 mL/min/1.73 m2 had an association linked to an increased risk of moderate-to-severe stroke severity. Our study suggests that patients taking NOACs with higher-than-normal eGFR levels may have an increased severity of AIS.
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Affiliation(s)
- Min Kyoung Kang
- Department of Neurology, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
- Department of Neurology, Uijeongbu Eulji Medical Center, Gyeonggi, Republic of Korea
| | - Dongwhane Lee
- Department of Neurology, Uijeongbu Eulji Medical Center, Gyeonggi, Republic of Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi, Republic of Korea
| | - Ji-Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Seoul, Republic of Korea
| | - Han-Yeong Jeong
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung Hwan Shin
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Byung-Woo Yoon
- Department of Neurology, Uijeongbu Eulji Medical Center, Gyeonggi, Republic of Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Gyeonggi, Republic of Korea
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Kang MK, Ha HJ, Jung R, Oh Y, Kim DH, Song TJ. Association of high estimated glomerular filtration rate with risk of atrial fibrillation: a nationwide cohort study. Front Med (Lausanne) 2023; 10:1207778. [PMID: 37692776 PMCID: PMC10483117 DOI: 10.3389/fmed.2023.1207778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023] Open
Abstract
Aim While the relationship between impaired kidney function and atrial fibrillation (AF) is well established, there is limited research exploring the association between elevated estimated glomerular filtration rate (eGFR) and AF development. This study aimed to examine the association between higher-than-normal eGFR and AF risk using a nationwide longitudinal study of the general population in Korea. Materials and methods This study utilized the National Health Insurance Service cohort database of Korea, analyzing data from 2,645,042 participants aged 20-79 years who underwent health examinations between 2010 and 2011. Participants with a history of end-stage renal disease, renal transplantation, and AF prior to the index date were excluded. Renal function was assessed using eGFR levels, calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Baseline characteristics were gathered through questionnaires, while comorbidities and AF occurrence outcomes were identified and validated using diagnostic codes and medication histories. The study employed Kaplan-Meier survival curves and Cox proportional hazard models to evaluate the association between eGFR and AF occurrence. Results The mean age of subjects was 48.82 ± 10.08 years. Over a median follow-up of 9.58 years, 27,469 (1.04%) AF cases were identified. The risk for AF increased in the higher-than-normal decile, as demonstrated by Kaplan-Meier survival curves (p < 0.001). The eGFR <30 mL/min/1.73 m2 group was associated with an increased risk of AF [hazard ratio (HR): 1.22, 95% confidence interval (CI) (1.01, 1.46), p = 0.039], while the eGFR >120 mL/min/1.73 m2 group was associated with a decreased risk of AF [HR: 0.88, 95% CI (0.78, 0.98), p = 0.045]. Compared to the 5th decile, the 1st [HR: 1.08, 95% CI (1.03, 1.13), p = 0.010] eGFR decile was significantly associated with an increased risk of AF, while the 10th [HR: 0.77, 95% CI (0.70, 0.85), p < 0.001] eGFR decile was significantly associated with a reduced risk of AF. Conclusion The study revealed that individuals with eGFR>120 mL/min/1.73 m2 or those falling within eGFR 10th decile (>113.41 mL/min/1.73 m2) demonstrated an inverse association linked to a reduced risk of AF. Our study suggests that general population with higher-than-normal eGFR levels may have a lower risk of developing AF.
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Affiliation(s)
- Min Kyoung Kang
- Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Hee-Jung Ha
- Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Raon Jung
- College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - YunSeo Oh
- College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Dong-Hyeok Kim
- Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Tae-Jin Song
- Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
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Rapid Decline of Estimated Glomerular Filtration Rate and its Effect on Mortality Risk of Patients with Hepatocellular Carcinoma. HEPATITIS MONTHLY 2023. [DOI: 10.5812/hepatmon-133853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Background: In patients with Hepatocarcinoma (HCC), the association between the rapid decline of kidney function and clinical outcomes is still unknown, although kidney-liver crosstalk is comprehensively studied. Objectives: We aimed to investigate the prevalence and determinants of the rapid decline of kidney function and its potential prognostic role and influence on mortality in HCC patients treated by percutaneous injection therapy (PEIT). Methods: This prospective cohort included 114 HCC, with 64.9% males and a mean age of 65.17 years. The rapid decline of kidney function was defined according to kidney disease improving global outcome (KDIGO). The cancer of the liver Italian program (CLIP) score was calculated to predict survival. Multivariable logistic regression analysis for rapid estimated glomerular filtration rate (eGFR) decline was performed after evaluating individual covariates. Multivariable Cox regression models for rapid eGFR decline and mortality were analyzed. Results: During a median follow-up of 31 months, 43.85% of patients presented a rapid decline in eGFR. The baseline eGFR was significantly higher in the group with the rapid decline of kidney function: 86.08 ± 19.17 mL/min/1.73m2 vs. 75.53 ± 25.7 mL/min/1.73 m2 (P = 0.001). The CLIP score (hazard ratio [HR] = 2.55, 95% confidence interval [CI]: 1.70 - 3.84, P < 0.001) was independently associated with rapid eGFR decline. In Cox regression, rapid eGFR decline was independently associated with mortality (HR = 3.49, 95%CI: 1.28 - 9.56, P = 0.015). Conclusions: Nearly half of the HCC patients presented a rapid eGFR decline. The HCC severity evaluated by the CLIP score was an independent predictor of the rapid decline of kidney function. The rapid decline in eGFR was associated with a higher mortality risk in HCC patients, independent of other known risk factors.
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Lytvyn Y, Albakr R, Bjornstad P, Lovblom LE, Liu H, Lovshin JA, Boulet G, Farooqi MA, Weisman A, Keenan HA, Brent MH, Paul N, Bril V, Perkins BA, Cherney DZI. Renal hemodynamic dysfunction and neuropathy in longstanding type 1 diabetes: Results from the Canadian study of longevity in type 1 diabetes. J Diabetes Complications 2022; 36:108320. [PMID: 36201892 PMCID: PMC10187942 DOI: 10.1016/j.jdiacomp.2022.108320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 08/29/2022] [Accepted: 09/23/2022] [Indexed: 11/28/2022]
Abstract
AIMS To determine the relationship between renal hemodynamic function and neuropathy in adults with ≥50-years of type 1 diabetes (T1D) compared to nondiabetic controls. METHODS Glomerular filtration rate (GFR, inulin), effective renal plasma flow (ERPF, p-aminohippurate), modified Toronto Clinical Neuropathy Score (mTCNS), corneal confocal microscopy, nerve conduction, and heart rate variability (autonomic function) were measured; afferent (RA) and efferent (RE) arteriolar resistances were estimated using the Gomez equations in 74 participants with T1D and in 75 controls. Diabetic kidney disease (DKD) non-resistors were defined by eGFRMDRD < 60 ml/min/1.73 m2 or 24-h urine albumin excretion >30 mg/day. Linear regression was applied to examine the relationships between renal function (dependent variable) and neuropathy measures (independent variable), adjusted for age, sex, HbA1c, systolic blood pressure, low density lipoprotein cholesterol, and 24-h urine albumin to creatinine ratio. RESULTS Higher mTCNS associated with lower renal blood flow (β ± SE:-9.29 ± 4.20, p = 0.03) and greater RE (β ± SE:32.97 ± 15.43, p = 0.04) in participants with T1D, but not in controls. DKD non-resistors had a higher mTCNS and worse measures of corneal nerve morphology compared to those without DKD. Renal hemodynamic parameters did not associate with autonomic nerve function. CONCLUSIONS Although neurological dysfunction in the presence of diabetes may contribute to impaired renal blood flow resulting in ischemic injury in patients with T1D, early autonomic dysfunction does not appear to be associated with kidney function changes.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rehab Albakr
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Petter Bjornstad
- Department of Pediatrics, Division of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Hongyan Liu
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julie A Lovshin
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Genevieve Boulet
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed A Farooqi
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alanna Weisman
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Michael H Brent
- Department of Ophthalmology and Vision Sciences, Department of Medicine, University of Toronto, Ontario, Canada
| | - Narinder Paul
- Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network, Toronto, Ontario, Canada
| | - Vera Bril
- Division of Neurology, Department of Medicine, University of 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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Lytvyn Y, Kimura K, Peter N, Lai V, Tse J, Cham L, Perkins BA, Soleymanlou N, Cherney DZ. Renal and Vascular Effects of Combined SGLT2 and Angiotensin-Converting Enzyme Inhibition. Circulation 2022; 146:450-462. [PMID: 35862082 PMCID: PMC9354594 DOI: 10.1161/circulationaha.122.059150] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The cardiorenal effects of sodium-glucose cotransporter 2 inhibition (empagliflozin 25 mg QD) combined with angiotensin-converting enzyme inhibition (ramipril 10 mg QD) were assessed in this mechanistic study in patients with type 1 diabetes with potential renal hyperfiltration. METHODS Thirty patients (out of 31 randomized) completed this double-blind, placebo-controlled, crossover trial. Recruitment was stopped early because of an unexpectedly low proportion of patients with hyperfiltration. Measurements were obtained after each of the 6 treatment phases over 19 weeks: (1) baseline without treatment, (2) 4-week run-in with ramipril treatment alone, (3) 4-week combined empagliflozin-ramipril treatment, (4) a 4-week washout, (5) 4-week combined placebo-ramipril treatment, and (6) 1-week follow-up. The primary end point was glomerular filtration rate (GFR) after combination treatment with empagliflozin-ramipril compared with placebo-ramipril. GFR was corrected for ramipril treatment alone before randomization. At the end of study phase, the following outcomes were measured under clamped euglycemia (4 to 6 mmol/L): inulin (GFR) and para-aminohippurate (effective renal plasma flow) clearances, tubular sodium handling, ambulatory blood pressure, arterial stiffness, heart rate variability, noninvasive cardiac output monitoring, plasma and urine biochemistry, markers of the renin-angiotensin-aldosterone system, and oxidative stress. RESULTS Combination treatment with empagliflozin-ramipril resulted in an 8 mL/min/1.73 m2 lower GFR compared with placebo-ramipril treatment (P=0.0061) without significant changes to effective renal plasma flow. GFR decrease was accompanied by a 21.3 mL/min lower absolute proximal fluid reabsorption rate (P=0.0092), a 3.1 mmol/min lower absolute proximal sodium reabsorption rate (P=0.0056), and a 194 ng/mmol creatinine lower urinary 8-isoprostane level (P=0.0084) relative to placebo-ramipril combination treatment. Sodium-glucose cotransporter 2 inhibitor/angiotensin-converting enzyme inhibitor combination treatment resulted in additive blood pressure-lowering effects (clinic systolic blood pressure lower by 4 mm Hg [P=0.0112]; diastolic blood pressure lower by 3 mm Hg [P=0.0032]) in conjunction with a 94.5 dynes × sex/cm5 lower total peripheral resistance (P=0.0368). There were no significant changes observed to ambulatory blood pressure, arterial stiffness, heart rate variability, or cardiac output with the addition of empagliflozin. CONCLUSIONS Adding sodium-glucose cotransporter 2 inhibitor treatment to angiotensin-converting enzyme inhibitor resulted in an expected GFR dip, suppression of oxidative stress markers, additive declines in blood pressure and total peripheral resistance. These changes are consistent with a protective physiologic profile characterized by the lowering of intraglomerular pressure and related cardiorenal risk when adding a sodium-glucose cotransporter 2 inhibitor to conservative therapy. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02632747.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital (Y.L., V.L., J.T., L.C., D.Z.I.C.),Temerty Faculty of Medicine (Y.L.)
| | - Karen Kimura
- Boehringer Ingelheim Canada Ltd/Ltée, Burlington (K.K.)
| | | | - Vesta Lai
- Department of Medicine, Division of Nephrology, Toronto General Hospital (Y.L., V.L., J.T., L.C., D.Z.I.C.)
| | - Josephine Tse
- Department of Medicine, Division of Nephrology, Toronto General Hospital (Y.L., V.L., J.T., L.C., D.Z.I.C.)
| | - Leslie Cham
- Department of Medicine, Division of Nephrology, Toronto General Hospital (Y.L., V.L., J.T., L.C., D.Z.I.C.)
| | - Bruce A. Perkins
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Canada (B.A.P.)
| | | | - David Z.I. Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital (Y.L., V.L., J.T., L.C., D.Z.I.C.)
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Hakala JO, Pahkala K, Juonala M, Salo P, Kähönen M, Hutri-Kähönen N, Lehtimäki T, Laitinen TP, Jokinen E, Taittonen L, Tossavainen P, Viikari JS, Raitakari OT, Rovio SP. Repeatedly Measured Serum Creatinine and Cognitive Performance in Midlife: The Cardiovascular Risk in Young Finns Study. Neurology 2022; 98:e2268-e2281. [PMID: 35410906 DOI: 10.1212/wnl.0000000000200268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 02/08/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Serum creatinine is typically used to assess kidney function. Impaired kidney function and thereby high serum creatinine increases risk of poor cognitive performance. However, serum creatinine might have a non-linear association as low serum creatinine has been linked with cardiovascular risk and impaired cognitive performance. We studied the longitudinal association between serum creatinine and cognitive performance in midlife. METHODS Since 2001, participants from the Cardiovascular Risk in Young Finns Study were followed up for 10 years. Serum creatinine was measured repeatedly in 2001, 2007, and 2011. Sex-specific longitudinal trajectories for serum creatinine among participants without kidney disease were identified using latent class growth mixture modeling. Overall cognitive function and four specific domains such as 1) working memory, 2) episodic memory and associative learning, 3) reaction time, and 4) information processing were assessed using a computerized cognitive test. RESULTS Four serum creatinine trajectory groups all with clinically normal serum creatinine were identified for both men (N=973) and women (N=1,204). After 10 years of follow-up, cognitive testing was performed for 2,026 participants aged 34 to 49 years (mean age 41.8 years). In men and women, consistently low serum creatinine was associated with poor childhood school performance, low adulthood education, low adulthood annual income, low physical activity, and smoking. Compared to the men in the low serum creatinine trajectory group, those in the high serum creatinine group had better overall cognitive performance (β=0.353 SD, 95%CI 0.022-0.684) and working memory (β=0.351 SD, 95%CI 0.034-0.668), while those in the moderate (β=0.247 SD, 95%CI 0.026-0.468) or the normal (β=0.244 SD, 95%CI 0.008-0.481) serum creatinine groups had better episodic memory and associative learning. No associations were found for women. DISCUSSION Our results indicate that, in men, compared to low serum creatinine levels consistently high levels may associate with better memory and learning function in midlife.
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Affiliation(s)
- Juuso O Hakala
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland.,Paavo Nurmi Centre, Sports & Exercise Medicine Unit, Department of Physical Activity and Health, University of Turku, Turku, Finland
| | - Katja Pahkala
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland.,Paavo Nurmi Centre, Sports & Exercise Medicine Unit, Department of Physical Activity and Health, University of Turku, Turku, Finland
| | - Markus Juonala
- Department of Medicine, University of Turku and Division of Medicine, Turku University Hospital, Turku, Finland
| | - Pia Salo
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland
| | - Mika Kähönen
- Department of Clinical Physiology, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Nina Hutri-Kähönen
- Department of Pediatrics, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Terho Lehtimäki
- Department of Clinical Chemistry, Fimlab Laboratories and Finnish Cardiovascular Research Center-Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Tomi P Laitinen
- Department of Clinical Physiology, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Eero Jokinen
- Department of Paediatric Cardiology, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Leena Taittonen
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland.,Department of Pediatrics, PEDEGO Research Unit and Medical Research Center, University of Oulu, and Oulu University Hospital Oulu, Finland
| | - Päivi Tossavainen
- Department of Pediatrics, PEDEGO Research Unit and Medical Research Center, University of Oulu, and Oulu University Hospital Oulu, Finland
| | - Jorma Sa Viikari
- Department of Medicine, University of Turku and Division of Medicine, Turku University Hospital, Turku, Finland
| | - Olli T Raitakari
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland.,Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
| | - Suvi P Rovio
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland
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Wu XR, Wu KM, Deng YT, Huang SY, Yang L, Dong Q, Feng JF, Cheng W, Yu JT. Association of Kidney Function with Risk of Incident Dementia: A Prospective Cohort Study of 275,167 UK Biobank Participants. J Alzheimers Dis 2022; 90:1249-1261. [PMID: 36245378 DOI: 10.3233/jad-220609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Previous studies have reported inconsistent associations between chronic kidney disease (CKD) and dementia. OBJECTIVE To evaluate whether CKD is a risk factor for dementia and compare the performance of different measures of calculating estimated glomerular filtration rate (eGFR). METHODS 275,167 participants from UK Biobank were included and eGFR at baseline was calculated using serum creatinine (eGFRcr), cystatin C (eGFRcys), and creatinine-cystatin C equations (eGFRcr-cys). Restricted cubic splines and Cox regression models were performed to assess the relationship of eGFR with all-cause dementia, Alzheimer's disease (AD), and vascular dementia (VaD). RESULTS We observed a U-shaped relationship between each eGFR and risk of all-cause dementia and VaD, with eGFRcys and eGFRcr-cys showing a closer linkage (peGFRcys <0.0001, peGFRcrhboxcys<0.0001 and peGFRcr = 0.0001). Lower and supranormal eGFR were related to increased risk of all-cause dementia. Compared to the reference category of 90-104 ml/min/1.73 m2, adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of all-cause dementia for eGFRcr-cys 30-59, <30, and ≥105 ml/min/1.73 m2 were 1.26 (95% CI [1.05-1.50], p = 0.012), 2.62 (95% CI [1.54-4.47], p < 0.001), and 1.41 (95% CI [1.17-1.70], p < 0.001). No statistically significant association was observed between eGFR with risk of AD. CONCLUSION This prospective study identified impaired kidney function as a critical risk factor for dementia and noted the application of cystatin C strengthened the relationship between CKD and dementia, underlining the significant value of preserving kidney function to reduce the risk of dementia and considering cystatin C measurement as part of clinical practice.
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Affiliation(s)
- Xin-Rui Wu
- Department of Neurology and National Center for Neurological Disorders, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontier Center for Brain Science, Fudan University, Shanghai, China
| | - Kai-Min Wu
- Department of Neurology and National Center for Neurological Disorders, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontier Center for Brain Science, Fudan University, Shanghai, China
| | - Yue-Ting Deng
- Department of Neurology and National Center for Neurological Disorders, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontier Center for Brain Science, Fudan University, Shanghai, China
| | - Shu-Yi Huang
- Department of Neurology and National Center for Neurological Disorders, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontier Center for Brain Science, Fudan University, Shanghai, China
| | - Liu Yang
- Department of Neurology and National Center for Neurological Disorders, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontier Center for Brain Science, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology and National Center for Neurological Disorders, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontier Center for Brain Science, Fudan University, Shanghai, China
| | - Jian-Feng Feng
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
- Department of Computer Science, University of Warwick, Coventry, UK
| | - Wei Cheng
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
- Department of Computer Science, University of Warwick, Coventry, UK
| | - Jin-Tai Yu
- Department of Neurology and National Center for Neurological Disorders, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontier Center for Brain Science, Fudan University, Shanghai, China
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8
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Lytvyn Y, Bjornstad P, van Raalte DH, Heerspink HL, Cherney DZI. The New Biology of Diabetic Kidney Disease-Mechanisms and Therapeutic Implications. Endocr Rev 2020; 41:5601424. [PMID: 31633153 PMCID: PMC7156849 DOI: 10.1210/endrev/bnz010] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
Diabetic kidney disease remains the most common cause of end-stage kidney disease in the world. Despite reductions in incidence rates of myocardial infarction and stroke in people with diabetes over the past 3 decades, the risk of diabetic kidney disease has remained unchanged, and may even be increasing in younger individuals afflicted with this disease. Accordingly, changes in public health policy have to be implemented to address the root causes of diabetic kidney disease, including the rise of obesity and diabetes, in addition to the use of safe and effective pharmacological agents to prevent cardiorenal complications in people with diabetes. The aim of this article is to review the mechanisms of pathogenesis and therapies that are either in clinical practice or that are emerging in clinical development programs for potential use to treat diabetic kidney disease.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Petter Bjornstad
- Department of Medicine, Division of Nephrology, Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Netherlands
| | - Hiddo L Heerspink
- The George Institute for Global Health, Sydney, Australia.,Department of Clinical Pharmacology, University of Groningen, Groningen, Netherlands
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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9
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Sokolovska J, Dekante A, Baumane L, Pahirko L, Valeinis J, Dislere K, Rovite V, Pirags V, Sjakste N. Nitric oxide metabolism is impaired by type 1 diabetes and diabetic nephropathy. Biomed Rep 2020; 12:251-258. [PMID: 32257188 DOI: 10.3892/br.2020.1288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 12/16/2019] [Indexed: 12/14/2022] Open
Abstract
Diabetes leads to reduced nitric oxide bioavailability, resulting in endothelial dysfunction. However, overproduction of nitric oxide due to hyperglycaemia is associated with oxidative stress and tissue damage. The objective of this study was to characterise nitric oxide production (NO) and added nitrite and nitrate (NO2 -+NO3 -) concentration in the blood and urine of patients with and without diabetic nephropathy. A total of 268 patients with type 1 diabetes and 69 healthy subjects were included. Diabetic nephropathy was defined as macroalbuminuria and/or estimated glomerular filtration rate below 60 ml/min/1.73 cm2. NO2 -+NO3 - concentration was measured by Griess reaction. Production of NO was detected by electron paramagnetic resonance spectroscopy. Blood NO was demonstrated to be higher (P<0.001) and serum NO2 -+NO3 - was lower (P=0.003) in patients with type 1 diabetes and no nephropathy vs. healthy subjects. However, serum NO2 -+NO3 - concentration in patients with diabetes and nephropathy did not differ from the levels observed in healthy controls. Urine excretion of NO2 -+NO3 - was significantly decreased in patients with nephropathy, compared with patients without diabetic kidney disease (P=0.006) and healthy subjects (P=0.010). A significant positive correlation was observed between urine NO2 -+NO3 - and estimated glomerular filtration rate in patients with type 1 diabetes (P=0.002) and healthy subjects (P=0.008). Estimated glomerular filtration rate, albuminuria and diabetic nephropathy status were significant predictors of the whole blood NO and NO2 -+NO3 - in serum and urine in patients with type 1 diabetes, as identified by linear regression models. The present study concludes that NO metabolism is impaired by type 1 diabetes and diabetic nephropathy.
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Affiliation(s)
- Jelizaveta Sokolovska
- Laboratory for Personalized Medicine, Faculty of Medicine, University of Latvia, LV-1004 Riga, Latvia
| | - Alise Dekante
- Laboratory for Personalized Medicine, Faculty of Medicine, University of Latvia, LV-1004 Riga, Latvia.,Internal Medicine Clinic, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia
| | - Larisa Baumane
- Biochemistry Team, Latvian Institute of Organic Synthesis, LV-1006 Riga, Latvia
| | - Leonora Pahirko
- Laboratory for Statistics Research and Data Analysis, Faculty of Physics, Mathematics and Optometry, University of Latvia, LV-1004 Riga, Latvia
| | - Janis Valeinis
- Laboratory for Statistics Research and Data Analysis, Faculty of Physics, Mathematics and Optometry, University of Latvia, LV-1004 Riga, Latvia
| | - Kristine Dislere
- Laboratory of Genomics and Bioinformatics, Institute of Biology, University of Latvia, LV-1004 Riga, Latvia
| | - Vita Rovite
- Database of Latvian Population, Latvian Biomedical Research and Study Centre, LV-1067 Riga, Latvia
| | - Valdis Pirags
- Laboratory for Personalized Medicine, Faculty of Medicine, University of Latvia, LV-1004 Riga, Latvia.,Internal Medicine Clinic, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia.,Database of Latvian Population, Latvian Biomedical Research and Study Centre, LV-1067 Riga, Latvia
| | - Nikolajs Sjakste
- Department of Medical Biochemistry, Faculty of Medicine, University of Latvia, LV-1004 Riga, Latvia
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10
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Kang MW, Park S, Lee S, Lee Y, Cho S, Han K, Cho H, Kim Y, Kim YC, Han SS, Lee H, Lee JP, Joo KW, Lim CS, Kim YS, Kim DK. Glomerular hyperfiltration is associated with dementia: A nationwide population-based study. PLoS One 2020; 15:e0228361. [PMID: 31990949 PMCID: PMC6986766 DOI: 10.1371/journal.pone.0228361] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/13/2020] [Indexed: 01/06/2023] Open
Abstract
Background Glomerular hyperfiltration may be a clinical phenotype of endothelial dysfunction. Endothelial dysfunction may cause vascular dementia through the deterioration of cerebral blood flow. We aimed to identify the risk of dementia in people with glomerular hyperfiltration. Methods Using the Korean National Health Information Database, we included subjects aged ≥45 years who underwent national health screening examinations between 2012 and 2015 and who had no previous history of end-stage renal disease or dementia (n = 2,244,582). The primary exposure was glomerular hyperfiltration. We divided the subjects into groups by sex and five-year age intervals and categorized each group into 8 intervals according to estimated glomerular filtration (eGFR). The subjects with an eGFR ≥95th percentile in each group were defined as the hyperfiltration group. The outcomes were development of all types of dementia, Alzheimer's dementia and vascular dementia. Multivariable Cox proportional hazards models were used to analyze the hazard ratios (HRs) for outcomes. Results The Hyperfiltration group showed a higher risk for the development of all types of dementia [adjusted HR 1.09 (95% CI, 1.03–1.15)] and vascular dementia [adjusted HR 1.33 (95% CI, 1.14–1.55)] than the reference group. However, the association between hyperfiltration and Alzheimer's dementia was not statistically significant. Conclusions Glomerular hyperfiltration may be associated with dementia. In this respect, subjects with glomerular hyperfiltration should be monitored more closely for signs and symptoms of dementia.
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Affiliation(s)
- Min Woo Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sehoon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Soojin Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yeonhee Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Semin Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyungdo Han
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Hanna Cho
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yaerim Kim
- Department of Internal Medicine, Keimyung School of Medicine, Seoul, Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Soo Lim
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea
- * E-mail:
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11
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Kanbay M, Ertuglu LA, Afsar B, Ozdogan E, Kucuksumer ZS, Ortiz A, Covic A, Kuwabara M, Cherney DZI, van Raalte DH, de Zeeuw D. Renal hyperfiltration defined by high estimated glomerular filtration rate: A risk factor for cardiovascular disease and mortality. Diabetes Obes Metab 2019; 21:2368-2383. [PMID: 31297976 DOI: 10.1111/dom.13831] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/30/2019] [Accepted: 07/08/2019] [Indexed: 12/22/2022]
Abstract
Renal hyperfiltration, defined as an increased glomerular filtration rate above normal values, is associated with early phases of kidney disease in the setting of various conditions such as obesity and diabetes. Although it is recognized that glomerular hyperfiltration, that is, increased filtration per nephron unit (usually studied at low glomerular filtration levels and often referred to as single nephron hyperfiltration), is a risk factor for the progression of chronic kidney disease, the implications of having renal hyperfiltration for cardiovascular disease and mortality risk are incompletely understood. Recent evidence from diverse populations, including healthy individuals and patients with diabetes or established cardiovascular disease, suggests that renal hyperfiltration is associated with a higher risk of cardiovascular disease and all-cause mortality. In this review, we critically summarize the existing studies, discuss possible mechanisms, and describe the remaining gaps in our knowledge regarding the association of renal hyperfiltration with cardiovascular disease and mortality risk.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koç University School of Medicine, Istanbul, Turkey
| | - Lale A Ertuglu
- Department of Medicine, School of Medicine, Koç University, Istanbul, Turkey
| | - Baris Afsar
- Department of Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Elif Ozdogan
- Department of Medicine, School of Medicine, Koç University, Istanbul, Turkey
| | - Zeynep S Kucuksumer
- Department of Medicine, School of Medicine, Koç University, Istanbul, Turkey
| | - Alberto Ortiz
- Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | | | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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12
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Kidokoro K, Cherney DZ, Bozovic A, Nagasu H, Satoh M, Kanda E, Sasaki T, Kashihara N. Evaluation of Glomerular Hemodynamic Function by Empagliflozin in Diabetic Mice Using In Vivo Imaging. Circulation 2019; 140:303-315. [DOI: 10.1161/circulationaha.118.037418] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Kengo Kidokoro
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Okayama, Japan (K.K., H.N., M.S., E.K., T.S., N.K.)
| | - David Z.I. Cherney
- Division of Nephrology, Department of Medicine (D.Z.I.C.), University Health Network, University of Toronto, Canada
| | - Andrea Bozovic
- Department of Laboratory Medicine and Pathology (A.B.), University Health Network, University of Toronto, Canada
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Okayama, Japan (K.K., H.N., M.S., E.K., T.S., N.K.)
| | - Minoru Satoh
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Okayama, Japan (K.K., H.N., M.S., E.K., T.S., N.K.)
| | - Eiichiro Kanda
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Okayama, Japan (K.K., H.N., M.S., E.K., T.S., N.K.)
| | - Tamaki Sasaki
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Okayama, Japan (K.K., H.N., M.S., E.K., T.S., N.K.)
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Okayama, Japan (K.K., H.N., M.S., E.K., T.S., N.K.)
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13
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Lytvyn Y, Bjornstad P, Lovshin JA, Singh SK, 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. Association between uric acid, renal haemodynamics and arterial stiffness over the natural history of type 1 diabetes. Diabetes Obes Metab 2019; 21:1388-1398. [PMID: 30761725 PMCID: PMC6504604 DOI: 10.1111/dom.13665] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 02/03/2019] [Accepted: 02/10/2019] [Indexed: 12/11/2022]
Abstract
AIMS To examine the relationship between normal plasma uric acid (PUA) levels, renal haemodynamic function, arterial stiffness and plasma renin and aldosterone over a wide range of type 1 diabetes (T1D) durations in adolescents, young adults and older adults. MATERIALS AND METHODS PUA, glomerular filtration rate (GFR), effective renal plasma flow (ERPF), vascular stiffness parameters (aortic augmentation index [AIx], carotid AIx, carotid femoral pulse wave velocity [cfPWV]), and plasma renin and aldosterone were measured during a euglycaemic clamp in people with T1D: 27 adolescents (mean ± SD age 16.8 ± 1.9 years), 52 young adults (mean ± SD age 25.6 ± 5.5 years) and 66 older adults (mean ± SD age 65.7 ± 7.5 years). RESULTS PUA was highest in patients with the longest T1D duration: 197 ± 44 μmol/L in adolescents versus 264 ± 82 μmol/L in older adults (P < 0.001). Higher PUA correlated with lower GFR only in older adults, even after correcting for age, glycated haemoglobin and sex (β = -2.12 ± 0.56; P = 0.0003), but not in adolescents or young adults. Higher PUA correlated with lower carotid AIx (β = -1.90, P = 0.02) in adolescents. In contrast, PUA correlated with higher cfPWV (P = 0.02) and higher plasma renin (P = 0.01) in older adults with T1D. CONCLUSIONS The relationship between higher PUA with lower GFR, increased arterial stiffness and renin angiotensin aldosterone system (RAAS) activation was observed only in older adults with longstanding T1D. T1D duration may modify the association between PUA, renal haemodynamic function and RAAS activation, leading to renal vasoconstriction and ischaemia. Further work must determine whether pharmacological PUA-lowering prevents or reverses injurious haemodynamic and neurohormonal sequelae of longstanding T1D, thereby improving clinical outcomes.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Petter Bjornstad
- Department of Pediatrics, Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julie A. Lovshin
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sunita K. Singh
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Genevieve Boulet
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed A. Farooqi
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vesta Lai
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Josephine Tse
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Leslie Cham
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Leif E. Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alanna Weisman
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, 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, 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, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada and the 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, Toronto, Ontario, Canada
| | - Etienne Sochett
- Division of Pediatric Endocrinology, Department of Pediatrics, University of 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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14
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Ekinci EI, Barr ELM, Barzi F, Hughes JT, Lawton PD, Jones GRD, Hoy W, Cass A, Thomas M, Sinha A, Jerums G, O'Dea K, MacIsaac RJ, Maple-Brown LJ. Is hyperfiltration associated with higher urine albumin-to-creatinine ratio at follow up among Indigenous Australians? The eGFR follow-up study. J Diabetes Complications 2019; 33:343-349. [PMID: 30904420 DOI: 10.1016/j.jdiacomp.2019.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/13/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Glomerular hyperfiltration is not able to be detected in clinical practice. We assessed whether hyperfiltration is associated with albuminuria progression among Indigenous Australians at high risk of diabetes and kidney disease to determine its role in kidney disease progression. METHODS Longitudinal observational study of Indigenous Australians aged ≥18 years recruited from >20 sites, across diabetes and/or kidney function strata. At baseline, iohexol clearance was used to measure glomerular filtration rate (mGFR) and hyperfiltration was defined as (i) a mGFR of ≥125 mL/min/1.73 m2, and (ii) an age-adjusted definition, with the top 10% of the mGFR for each 10 year age group at baseline. Baseline and follow-up urine albumin-to-creatinine ratio (uACR) was collected, and linear regression was used to assess the associations of hyperfiltration and uACR at follow up. RESULTS 407 individuals (33% men, mean age 47 years) were followed-up for a median of 3 years. At baseline, 234 had normoalbuminuria and 173 had albuminuria. Among participants with normoalbuminuria, those with mGFR ≥125 mL/min/1.73 m2 had 32% higher uACR at follow-up (p = 0.08), and those with age-adjusted hyperfiltration had 60% higher uACR (p = 0.037) compared to those who had normofiltration. These associations were independent of uACR at baseline, but attenuated by HbA1c. Associations were stronger among those without than those with albuminuria at baseline. CONCLUSIONS Although not available for assessment in current clinical practice, hyperfiltration may represent a marker of subsequent albuminuria progression among individuals who have not yet developed albuminuria.
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Affiliation(s)
- Elif I Ekinci
- Menzies School of Health Research, Charles Darwin University, Australia; The University of Melbourne, Department of Medicine at Austin Health, Melbourne, Australia; Department of Endocrinology, Austin Health, Melbourne, Australia
| | - Elizabeth L M Barr
- Menzies School of Health Research, Charles Darwin University, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Federica Barzi
- Menzies School of Health Research, Charles Darwin University, Australia
| | - Jaquelyne T Hughes
- Menzies School of Health Research, Charles Darwin University, Australia; Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Paul D Lawton
- Menzies School of Health Research, Charles Darwin University, Australia
| | - Graham R D Jones
- SydPath, St Vincent's Hospital, Sydney, Australia; University of New South Wales Sydney, Sydney, Australia
| | - Wendy Hoy
- The University of Queensland Centre for Chronic Disease, Queensland, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Australia
| | | | - Ashim Sinha
- Diabetes and Endocrinology, Cairns Base Hospital, Cairns, Australia
| | - George Jerums
- Menzies School of Health Research, Charles Darwin University, Australia; The University of Melbourne, Department of Medicine at Austin Health, Melbourne, Australia
| | - Kerin O'Dea
- The University of Melbourne, Department of Medicine at Austin Health, Melbourne, Australia; School of Population Health, University of South Australia, Australia
| | - Richard J MacIsaac
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne and the University of Melbourne, Melbourne, Australia
| | - Louise J Maple-Brown
- Menzies School of Health Research, Charles Darwin University, Australia; Division of Medicine, Royal Darwin Hospital, Darwin, Australia.
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15
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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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16
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León Jiménez D, López Chozas JM, Espino Montoro A, Rico Corral MÁ, Castilla Guerra L, Miramontes González JP. Could renin-angiotensin-aldosterone system activation explain the amputations associated with canagliflozin? The nitric oxide hypothesis. Diabetes Res Clin Pract 2019; 148:10-13. [PMID: 30583037 DOI: 10.1016/j.diabres.2018.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 11/21/2018] [Accepted: 12/17/2018] [Indexed: 12/12/2022]
Affiliation(s)
- David León Jiménez
- Unidad Riesgo Vascular, Medicina Interna, Hospital Universitario Virgen Macarena, Seville, Spain.
| | - José Manuel López Chozas
- Unidad Gestión Clínica Medicina Interna, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Antonio Espino Montoro
- Unidad Gestión Clínica Medicina Interna, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Miguel Ángel Rico Corral
- Unidad Riesgo Vascular, Medicina Interna, Hospital Universitario Virgen Macarena, Seville, Spain.
| | - Luis Castilla Guerra
- Unidad Riesgo Vascular, Medicina Interna, Hospital Universitario Virgen Macarena, Seville, Spain
| | - José Pablo Miramontes González
- Medicina Interna, Instituto de Investigación Biomédica de Salamanca (IBSAL), Hospital Universitario de Salamanca, Salamanca, Spain.
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17
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Stehouwer CDA. Microvascular Dysfunction and Hyperglycemia: A Vicious Cycle With Widespread Consequences. Diabetes 2018; 67:1729-1741. [PMID: 30135134 DOI: 10.2337/dbi17-0044] [Citation(s) in RCA: 176] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/18/2018] [Indexed: 11/13/2022]
Abstract
Microvascular and metabolic physiology are tightly linked. This Perspective reviews evidence that 1) the relationship between hyperglycemia and microvascular dysfunction (MVD) is bidirectional and constitutes a vicious cycle; 2) MVD in diabetes affects many, if not all, organs, which may play a role in diabetes-associated comorbidities such as depression and cognitive impairment; and 3) MVD precedes, and contributes to, hyperglycemia in type 2 diabetes (T2D) through impairment of insulin-mediated glucose disposal and, possibly, insulin secretion. Obesity and adverse early-life exposures are important drivers of MVD. MVD can be improved through weight loss (in obesity) and through exercise. Pharmacological interventions to improve MVD are an active area of investigation.
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Affiliation(s)
- Coen D A Stehouwer
- Department of Internal Medicine and CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre+, Maastricht, the Netherlands
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18
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Low S, Zhang X, Wang J, Yeoh LY, Liu YL, Ang KKL, Tang WE, Kwan PY, Tavintharan S, Sum CF, Lim SC. Long-term prospective observation suggests that glomerular hyperfiltration is associated with rapid decline in renal filtration function: A multiethnic study. Diab Vasc Dis Res 2018; 15:417-423. [PMID: 29807475 DOI: 10.1177/1479164118776465] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
AIM Glomerular hyperfiltration usually occurs early in development of kidney complications in diabetes. To understand hyperfiltration as a marker of renal disease progression in type 2 diabetes mellitus, we aimed to examine association between glomerular hyperfiltration (estimated glomerular filtration rate ⩾ 120 mL/min/1.73 m2) and rapid renal decline (annual estimated glomerular filtration rate loss ⩾ 3 mL/min/1.73 m2). METHODS This was a prospective cohort comprising 1014 patients with type 2 diabetes mellitus attending a Diabetes Centre of a regional hospital in 2002-2014. A separate prospective cohort, comprising 491 patients who attended Diabetes Centre or primary-care polyclinics, was used for validation. We performed binary mediation analysis to examine role of hyperfiltration on relationship between baseline haemoglobin A1c and rapid renal decline. RESULTS Among patients in discovery cohort, 5.2% had baseline hyperfiltration. Over mean follow-up of 6 years, 22.9% had rapid glomerular filtration rate decline. Baseline hyperfiltration was significantly associated with greater odds of rapid renal decline after adjusting for demographics, diabetes duration and clinical covariates (odds ratio: 2.57; 95% confidence interval: 1.21-5.46; p = 0.014). Similar finding was found in validation cohort (odds ratio: 2.98; 95% confidence interval: 1.06-8.42; p = 0.034). Hyperfiltration significantly accounted for 35.3% of association between increasing baseline haemoglobin A1c and rapid renal decline. CONCLUSION Glomerular hyperfiltration is an independent risk factor of rapid renal decline. It mediates the association between increasing haemoglobin A1c and rapid renal decline.
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Affiliation(s)
- Serena Low
- 1 Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - Xiao Zhang
- 1 Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - Jiexun Wang
- 1 Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - Lee Ying Yeoh
- 2 Department of General Medicine, Khoo Teck Puat Hospital, Singapore
| | - Yan Lun Liu
- 2 Department of General Medicine, Khoo Teck Puat Hospital, Singapore
| | | | - Wern Ee Tang
- 3 National Healthcare Group Polyclinics, Singapore
| | - Pek Yee Kwan
- 3 National Healthcare Group Polyclinics, Singapore
| | | | - Chee Fang Sum
- 4 Diabetes Clinic, Khoo Teck Puat Hospital, Singapore
| | - Su Chi Lim
- 1 Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
- 4 Diabetes Clinic, Khoo Teck Puat Hospital, Singapore
- 5 Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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19
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Aroor AR, Das NA, Carpenter AJ, Habibi J, Jia G, Ramirez-Perez FI, Martinez-Lemus L, Manrique-Acevedo CM, Hayden MR, Duta C, Nistala R, Mayoux E, Padilla J, Chandrasekar B, DeMarco VG. Glycemic control by the SGLT2 inhibitor empagliflozin decreases aortic stiffness, renal resistivity index and kidney injury. Cardiovasc Diabetol 2018; 17:108. [PMID: 30060748 PMCID: PMC6065158 DOI: 10.1186/s12933-018-0750-8] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/23/2018] [Indexed: 02/06/2023] Open
Abstract
Background Arterial stiffness is emerging as an independent risk factor for the development of chronic kidney disease. The sodium glucose co-transporter 2 (SGLT2) inhibitors, which lower serum glucose by inhibiting SGLT2-mediated glucose reabsorption in renal proximal tubules, have shown promise in reducing arterial stiffness and the risk of cardiovascular and kidney disease in individuals with type 2 diabetes mellitus. Since hyperglycemia contributes to arterial stiffness, we hypothesized that the SGLT2 inhibitor empagliflozin (EMPA) would improve endothelial function, reduce aortic stiffness, and attenuate kidney disease by lowering hyperglycemia in type 2 diabetic female mice (db/db). Materials/methods Ten-week-old female wild-type control (C57BLKS/J) and db/db (BKS.Cg-Dock7m+/+Leprdb/J) mice were divided into three groups: lean untreated controls (CkC, n = 17), untreated db/db (DbC, n = 19) and EMPA-treated db/db mice (DbE, n = 19). EMPA was mixed with normal mouse chow at a concentration to deliver 10 mg kg−1 day−1, and fed for 5 weeks, initiated at 11 weeks of age. Results Compared to CkC, DbC showed increased glucose levels, blood pressure, aortic and endothelial cell stiffness, and impaired endothelium-dependent vasorelaxation. Furthermore, DbC exhibited impaired activation of endothelial nitric oxide synthase, increased renal resistivity and pulsatility indexes, enhanced renal expression of advanced glycation end products, and periarterial and tubulointerstitial fibrosis. EMPA promoted glycosuria and blunted these vascular and renal impairments, without affecting increases in blood pressure. In addition, expression of “reversion inducing cysteine rich protein with Kazal motifs” (RECK), an anti-fibrotic mediator, was significantly suppressed in DbC kidneys and partially restored by EMPA. Confirming the in vivo data, EMPA reversed high glucose-induced RECK suppression in human proximal tubule cells. Conclusions Empagliflozin ameliorates kidney injury in type 2 diabetic female mice by promoting glycosuria, and possibly by reducing systemic and renal artery stiffness, and reversing RECK suppression.
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Affiliation(s)
- Annayya R Aroor
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA.,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri, Columbia, MO, USA.,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA
| | - Nitin A Das
- Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, San Antonio, TX, USA
| | - Andrea J Carpenter
- Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, San Antonio, TX, USA
| | - Javad Habibi
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA.,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri, Columbia, MO, USA.,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA
| | - Guanghong Jia
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA.,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri, Columbia, MO, USA.,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA
| | | | - Luis Martinez-Lemus
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, USA.,Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA
| | - Camila M Manrique-Acevedo
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA.,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri, Columbia, MO, USA.,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA
| | - Melvin R Hayden
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA.,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri, Columbia, MO, USA
| | - Cornel Duta
- Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA.,Division of Nephrology, Department of Medicine, University of Missouri, Columbia, MO, USA
| | - Ravi Nistala
- Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA.,Division of Nephrology, Department of Medicine, University of Missouri, Columbia, MO, USA
| | - Eric Mayoux
- Boehringer Ingelheim, Biberach an der Riss, Germany
| | - Jaume Padilla
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA.,Department of Child Health, University of Missouri, Columbia, MO, USA.,Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, USA
| | - Bysani Chandrasekar
- Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA.,Division of Cardiology, Department of Medicine, University of Missouri, Columbia, MO, USA.,Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, USA.,Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA
| | - Vincent G DeMarco
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA. .,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri, Columbia, MO, USA. .,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA. .,Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA. .,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri-Columbia School of Medicine, D110, DC043.0, One Hospital Dr, Columbia, MO, 65212, USA.
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20
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Solini A, Giannini L, Seghieri M, Vitolo E, Taddei S, Ghiadoni L, Bruno RM. Dapagliflozin acutely improves endothelial dysfunction, reduces aortic stiffness and renal resistive index in type 2 diabetic patients: a pilot study. Cardiovasc Diabetol 2017; 16:138. [PMID: 29061124 PMCID: PMC5654086 DOI: 10.1186/s12933-017-0621-8] [Citation(s) in RCA: 253] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/15/2017] [Indexed: 12/22/2022] Open
Abstract
Background Sodium-glucose cotransporter-2 inhibitors reduce blood pressure (BP) and renal and cardiovascular events in patients with type 2 diabetes through not fully elucidated mechanisms. Aim of this study was to investigate whether dapagliflozin is able to acutely modify systemic and renal vascular function, as well as putative mechanisms. Methods Neuro-hormonal and vascular variables, together with 24 h diuresis, urinary sodium, glucose, isoprostanes and free-water clearance were assessed before and after a 2-day treatment with dapagliflozin 10 mg QD in sixteen type 2 diabetic patients; data were compared with those obtained in ten patients treated with hydrochlorothiazide 12.5 mg QD. Brachial artery endothelium-dependent and independent vasodilation (by flow-mediated dilation) and pulse wave velocity were assessed. Renal resistive index was obtained at rest and after glyceryl trinitrate administration. Differences were analysed by repeated measures ANOVA, considering treatment as between factor and time as within factor; Bonferroni post hoc comparison test was also used. Results Dapagliflozin decreased systolic BP and induced an increase in 24 h diuresis to a similar extent of hydrochlorothiazide; 24 h urinary glucose and serum magnesium were also increased. 24 h urinary sodium and fasting blood glucose were unchanged. Oxidative stress was reduced, as by a decline in urinary isoprostanes. Flow-mediated dilation was significantly increased (2.8 ± 2.2 to 4.0 ± 2.1%, p < 0.05), and pulse-wave-velocity was reduced (10.1 ± 1.6 to 8.9 ± 1.6 m/s, p < 0.05), even after correction for mean BP. Renal resistive index was reduced (0.62 ± 0.04 to 0.59 ± 0.05, p < 0.05). These vascular modifications were not observed in hydrochlorothiazide-treated individuals. Conclusions An acute treatment with dapagliflozin significantly improves systemic endothelial function, arterial stiffness and renal resistive index; this effect is independent of changes in BP and occurs in the presence of stable natriuresis, suggesting a fast, direct beneficial effect on the vasculature, possibly mediated by oxidative stress reduction.
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Affiliation(s)
- Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, I-56126, Pisa, Italy.
| | - Livia Giannini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marta Seghieri
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Edoardo Vitolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Lorenzo Ghiadoni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rosa Maria Bruno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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21
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Lovshin JA, Rajasekeran H, Lytvyn Y, Lovblom LE, Khan S, Alemu R, Locke A, Lai V, He H, Hittle L, Wang W, Drucker DJ, Cherney DZI. Dipeptidyl Peptidase 4 Inhibition Stimulates Distal Tubular Natriuresis and Increases in Circulating SDF-1α 1-67 in Patients With Type 2 Diabetes. Diabetes Care 2017; 40:1073-1081. [PMID: 28550195 DOI: 10.2337/dc17-0061] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 05/03/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Antihyperglycemic agents, such as empagliflozin, stimulate proximal tubular natriuresis and improve cardiovascular and renal outcomes in patients with type 2 diabetes. Because dipeptidyl peptidase 4 (DPP-4) inhibitors are used in combination with sodium-glucose cotransporter 2 (SGLT2) inhibitors, we examined whether and how sitagliptin modulates fractional sodium excretion and renal and systemic hemodynamic function. RESEARCH DESIGN AND METHODS We studied 32 patients with type 2 diabetes in a prospective, double-blind, randomized, placebo-controlled trial. Measurements of renal tubular function and renal and systemic hemodynamics were obtained at baseline, then hourly after one dose of sitagliptin or placebo, and repeated at 1 month. Fractional excretion of sodium and lithium and renal hemodynamic function were measured during clamped euglycemia. Systemic hemodynamics were measured using noninvasive cardiac output monitoring, and plasma levels of intact versus cleaved stromal cell-derived factor (SDF)-1α were quantified using immunoaffinity and tandem mass spectrometry. RESULTS Sitagliptin did not change fractional lithium excretion but significantly increased total fractional sodium excretion (1.32 ± 0.5 to 1.80 ± 0.01% vs. 2.15 ± 0.6 vs. 2.02 ± 1.0%, P = 0.012) compared with placebo after 1 month of treatment. Moreover, sitagliptin robustly increased intact plasma SDF-1α1-67 and decreased truncated plasma SDF-1α3-67. Renal hemodynamic function, systemic blood pressure, cardiac output, stroke volume, and total peripheral resistance were not adversely affected by sitagliptin. CONCLUSIONS DPP-4 inhibition promotes a distal tubular natriuresis in conjunction with increased levels of intact SDF-1α1-67. Because of the distal location of the natriuretic effect, DPP-4 inhibition does not affect tubuloglomerular feedback or impair renal hemodynamic function, findings relevant to using DPP-4 inhibitors for treating type 2 diabetes.
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Affiliation(s)
- Julie A Lovshin
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada .,Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Harindra Rajasekeran
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Yulyia Lytvyn
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Leif E Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shajiha Khan
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robel Alemu
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Amy Locke
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Vesta Lai
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Huaibing He
- Pharmacokinetic Pharmacodynamics and Drug Metabolism, Merck and Co., Inc., Rahway, NJ
| | - Lucinda Hittle
- Pharmacokinetic Pharmacodynamics and Drug Metabolism, Merck and Co., Inc., Rahway, NJ
| | - Weixun Wang
- Pharmacokinetic Pharmacodynamics and Drug Metabolism, Merck and Co., Inc., Rahway, NJ
| | - Daniel J Drucker
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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22
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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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23
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Montanari A, Lazzeroni D, Pelà G, Crocamo A, Lytvyn Y, Musiari L, Cabassi A, Cherney DZI. Calcium channel blockade blunts the renal effects of acute nitric oxide synthase inhibition in healthy humans. Am J Physiol Renal Physiol 2017; 312:F870-F878. [DOI: 10.1152/ajprenal.00568.2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 02/01/2017] [Accepted: 02/06/2017] [Indexed: 01/25/2023] Open
Abstract
Our aim was to investigate whether blockade of calcium channels (CCs) or angiotensin II type 1 receptors (AT1R) modulates renal responses to nitric oxide synthesis inhibition (NOSI) in humans. Fourteen sodium-replete, healthy volunteers underwent 90-min infusions of 3.0 μg·kg−1·min−1 NG-nitro-l-arginine methyl ester (l-NAME) on 3 occasions, preceded by 3 days of either placebo (PL), 10 mg of manidipine (MANI), or 50 mg of losartan (LOS). At each phase, mean arterial pressure (MAP), glomerular filtration rate (GFR; inulin), renal blood flow (RBF; p-aminohippurate), urinary sodium (UNaV), and 8-isoprostane (U8-iso-PGF2αV; an oxidative stress marker) were measured. With PL + l -NAME, the following changes were observed: +6% MAP ( P < 0.005 vs. baseline), −10% GFR, −20% RBF, −49% UNaV ( P < 0.001), and +120% U8-iso-PGF2αV ( P < 0.01). In contrast, MAP did not increase during LOS + l-NAME or MANI + l-NAME ( P > 0.05 vs. baseline), whereas renal changes were the same during LOS + l-NAME vs. PL + l-NAME (ANOVA, P > 0.05). However, during MANI + l-NAME, changes vs. baseline in GFR (−6%), RBF (−12%), and UNaV (−34%) were blunted vs. PL + l-NAME and LOS + l-NAME ( P < 0.005), and the rise in U8-iso-PGF2αV was almost abolished (+37%, P > 0.05 vs. baseline; P < 0.01 vs. PL + l-NAME or LOS + l-NAME). We conclude that, since MANI blunted l-NAME-induced renal hemodynamic changes, CCs participate in the renal responses to NOSI in healthy, sodium-replete humans independent of changes in MAP and without the apparent contribution of the AT1R. Because the rise in U8-iso-PGF2αV was essentially prevented during MANI + l-NAME, CC blockade may oppose the renal effects of NOSI in part by counteracting oxidative stress responses to acutely impaired renal NO bioavailability.
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Affiliation(s)
- Alberto Montanari
- Department of Clinical and Experimental Medicine, University of Parma Medical School, Parma, Italy
| | - Davide Lazzeroni
- Prevention and Rehabilitation Unit at the Don Gnocchi Foundation and Department of Clinical and Experimental Medicine, University of Parma Medical School, Parma, Italy; and
| | - Giovanna Pelà
- Department of Clinical and Experimental Medicine, University of Parma Medical School, Parma, Italy
| | - Antonio Crocamo
- Department of Clinical and Experimental Medicine, University of Parma Medical School, Parma, Italy
| | - Yuliya Lytvyn
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Luisa Musiari
- Department of Clinical and Experimental Medicine, University of Parma Medical School, Parma, Italy
| | - Aderville Cabassi
- Department of Clinical and Experimental Medicine, University of Parma Medical School, Parma, Italy
| | - David Z. I. Cherney
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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24
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Škrtić M, Lytvyn Y, Bjornstad P, Reich HN, Scholey JW, Yip P, Sochett EB, Perkins B, Cherney DZI. Influence of sex on hyperfiltration in patients with uncomplicated type 1 diabetes. Am J Physiol Renal Physiol 2016; 312:F599-F606. [PMID: 28031170 DOI: 10.1152/ajprenal.00357.2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 11/28/2016] [Accepted: 12/21/2016] [Indexed: 01/26/2023] Open
Abstract
The aim of this analysis was to examine sex-based differences in renal segmental resistances in healthy controls (HCs) and patients with type 1 diabetes (T1D). We hypothesized that hyperfiltration-an early hemodynamic abnormality associated with diabetic nephropathy-would disproportionately affect women with T1D, thereby attenuating protection against the development of renal complications. Glomerular hemodynamic parameters were evaluated in HC (n = 30) and in normotensive, normoalbuminuric patients with T1D and either baseline normofiltration [n = 36, T1D-N, glomerular filtration rate (GFR) 90-134 ml·min-1·1.73 m2] or hyperfiltration (n = 32, T1D-H, GFR ≥ 135 ml·min-1·1.73 m2) during euglycemic conditions (4-6 mmol/l). Gomez's equations were used to derive efferent (RE) and afferent (RA) arteriolar resistances, glomerular hydrostatic pressure (PGLO) from inulin (GFR) and paraaminohippurate [effective renal plasma flow (ERPF)] clearances, plasma protein and estimated ultrafiltration coefficients (KFG). Female patients with T1D with hyperfiltration (T1D-H) had higher RE (1,985 ± 487 vs. 1,381 ± 296 dyne·sec-1·cm-5, P < 0.001) and filtration fraction (FF, 0.20 ± 0.047 vs. 0.16 ± 0.03 P < 0.05) and lower ERPF (876 ± 245 vs. 1,111 ± 298 134 ml·min-1·1.73 m2P < 0.05) compared with male T1D-H patients. Overall, T1D-H patients had higher PGLO and lower RA vs. HC subjects, although there were no sex-based differences. In conclusion, female T1D-H patients had higher RE and FF and lower ERPF than their male counterparts with no associated sex differences in RA Prospective intervention studies should consider sex as a modifier of renal hemodynamic responses to renal protective therapies.
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Affiliation(s)
- Marko Škrtić
- 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.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Petter Bjornstad
- Department of Pediatric Endocrinology, Barbara Davis Center for Diabetes University of Colorado School of Medicine, Aurora, CO
| | - Heather N Reich
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James W Scholey
- 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
| | - Etienne B Sochett
- Department of Pediatrics, Division of Endocrinology, Sickkids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Perkins
- Department of Medicine, Division of Endocrinology, 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; .,Department of Medicine, Division of Endocrinology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada; and.,Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
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Andrianesis V, Glykofridi S, Doupis J. The renal effects of SGLT2 inhibitors and a mini-review of the literature. Ther Adv Endocrinol Metab 2016; 7:212-228. [PMID: 28203358 PMCID: PMC5298360 DOI: 10.1177/2042018816676239] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Sodium-glucose linked transporter 2 (SGLT2) inhibitors are a new and promising class of antidiabetic agents which target renal tubular glucose reabsorption. Their action is based on the blockage of SGLT2 sodium-glucose cotransporters that are located at the luminal membrane of tubular cells of the proximal convoluted tubule, inducing glucosuria. It has been proven that they significantly reduce glycated hemoglobin (HbA1c), along with fasting and postprandial plasma glucose in patients with type 2 diabetes mellitus (T2DM). The glucosuria-induced caloric loss as well as the osmotic diuresis significantly decrease body weight and blood pressure, respectively. Given that SGLT2 inhibitors do not interfere with insulin action and secretion, their efficacy is sustained despite the progressive β-cell failure in T2DM. They are well tolerated, with a low risk of hypoglycemia. Their most frequent adverse events are minor: genital and urinal tract infections. Recently, it was demonstrated that empagliflozin presents a significant cardioprotective effect. Although the SGLT2 inhibitors' efficacy is affected by renal function, new data have been presented that some SGLT2 inhibitors, even in mild and moderate renal impairment, induce significant HbA1c reduction. Moreover, recent data indicate that SGLT2 inhibition has a beneficial renoprotective effect. The role of this review paper is to explore the current evidence on the renal effects of SGLT2 inhibitors.
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Bjornstad P, Škrtić M, Lytvyn Y, Maahs DM, Johnson RJ, Cherney DZI. The Gomez' equations and renal hemodynamic function in kidney disease research. Am J Physiol Renal Physiol 2016; 311:F967-F975. [PMID: 27605583 PMCID: PMC6347069 DOI: 10.1152/ajprenal.00415.2016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/02/2016] [Indexed: 12/16/2022] Open
Abstract
Diabetic kidney disease (DKD) remains the leading cause of end-stage renal disease. A major challenge in preventing DKD is the difficulty in identifying high-risk patients at an early, pre-clinical stage. Albuminuria and eGFR as measures of renal function in DKD research and clinical practice are limited by regression of one-third of patients with microalbuminuria to normoalbuminuria and eGFR is biased and imprecise in the normal-elevated range. Moreover, existing methods that are used to assess renal function do not give detailed insight into the location of the renal hemodynamic effects of pharmacological agents at the segmental level. To gain additional information about the intrarenal circulation in-vivo in humans, mathematical equations were developed by Gomez et al in the 1950s. These equations used measurements of GFR, renal blood flow (RBF), effective renal plasma flow (ERPF), renal vascular resistance (RVR), hematocrit and serum protein to calculate afferent and efferent arteriolar resistances, glomerular hydrostatic pressure and filtration pressure. Although indirect and based on physiological assumptions, these techniques have the potential to improve researchers' ability to identify early pre-clinical changes in renal hemodynamic function in patients with a variety of conditions including DKD, thereby offering tremendous potential in mechanistic human research studies. In this review, we focus on the application of Gomez' equations and summarize the potential and limitations of this technique in DKD research. We also summarize illustrative data derived from Gomez' equations in patients with type 1 (T1D) and type 2 diabetes (T2D) and hypertension.
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Fujii N, Dervis S, Sigal RJ, Kenny GP. Type 1 diabetes modulates cyclooxygenase- and nitric oxide-dependent mechanisms governing sweating but not cutaneous vasodilation during exercise in the heat. Am J Physiol Regul Integr Comp Physiol 2016; 311:R1076-R1084. [PMID: 27733388 DOI: 10.1152/ajpregu.00376.2016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 09/30/2016] [Accepted: 10/11/2016] [Indexed: 01/09/2023]
Abstract
Both cyclooxygenase (COX) and nitric oxide synthase (NOS) contribute to sweating, whereas NOS alone contributes to cutaneous vasodilation during exercise in the heat. Here, we evaluated if Type 1 diabetes mellitus (T1DM) modulates these responses. Adults with (n = 11, 25 ± 5 yr) and without (n = 12, 24 ± 4 yr) T1DM performed two bouts of 30-min cycling at a fixed rate of heat production of 400 W in the heat (35°C); each followed by a 20- and 40-min recovery period, respectively. Sweat rate and cutaneous vascular conductance (CVC) were measured at four intradermal microdialysis sites treated with either 1) lactated Ringer (vehicle control site), 2) 10 mM ketorolac (nonselective COX inhibitor), 3) 10 mM NG-nitro-l-arginine methyl ester (nonselective NOS inhibitor), or 4) a combination of both inhibitors. In nondiabetic adults, separate and combined inhibition of COX and NOS reduced exercise sweat rate (P ≤ 0.05), and the magnitude of reductions were similar across sites. In individuals with T1DM, inhibition of COX resulted in an increase in sweat rate of 0.10 ± 0.09 and 0.09 ± 0.08 mg ·: min-1 ·: cm-2 for the first and second exercise bouts, respectively, relative to vehicle control site (P ≤ 0.05), whereas NOS inhibition had no effect on sweating. In both groups, NOS inhibition reduced CVC during exercise (P ≤ 0.05), although the magnitude of reduction did not differ between the nondiabetic and T1DM groups (exercise 1: -28 ± 10 vs. -23 ± 8% max, P = 0.51; exercise 2: -31 ± 12 vs. -24 ± 10% max, P = 0.38). We show that in individuals with T1DM performing moderate intensity exercise in the heat, NOS-dependent sweating but not cutaneous vasodilation is attenuated, whereas COX inhibition increases sweating.
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Affiliation(s)
- Naoto Fujii
- Human and Environmental Physiology Research Unit, School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada
| | - Sheila Dervis
- Human and Environmental Physiology Research Unit, School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada
| | - Ronald J Sigal
- Human and Environmental Physiology Research Unit, School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada.,Departments of Medicine, Cardiac Sciences and Community Health Sciences, Faculties of Medicine and Kinesiology, University of Calgary, Calgary, Alberta Canada; and.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Glen P Kenny
- Human and Environmental Physiology Research Unit, School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada; .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Lytvyn Y, Škrtić M, Yang GK, Lai V, Scholey JW, Yip PM, Perkins BA, Cherney DZI. Plasma uric acid effects on glomerular haemodynamic profile of patients with uncomplicated Type 1 diabetes mellitus. Diabet Med 2016; 33:1102-11. [PMID: 26670339 DOI: 10.1111/dme.13051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2015] [Indexed: 12/30/2022]
Abstract
AIMS Increased plasma uric acid (PUA) levels are associated with impaired renal function in patients with Type 1 diabetes, but the mechanisms are not well understood. Our aim was to evaluate whether higher PUA levels are associated with increased afferent arteriolar resistance in patients with Type 1 diabetes vs. healthy controls, thereby influencing renal function. METHODS PUA, GFR (inulin) and effective renal plasma flow (ERPF; para-aminohippurate) were measured in 70 otherwise healthy patients with Type 1 diabetes and 60 healthy controls. Gomez's equations were used to estimate afferent (RA ) and efferent (RE ) arteriolar resistances, glomerular hydrostatic pressure (PGLO ) and filtration pressure (ΔPF ). The relationships between PUA and glomerular haemodynamic parameters were evaluated by univariable linear regression correlation coefficients. RESULTS In patients with Type 1 diabetes, higher PUA correlated with lower PGLO (P = 0.002) and ΔPF (P = 0.0007), with higher RA (P = 0.001), but not with RE (P = 0.55). These associations were accompanied by correlations between higher PUA with lower GFR (P = 0.0007), ERPF (P = 0.008), RBF (P = 0.047) and higher RVR (P = 0.021). There were no significant correlations between PUA and renal haemodynamic parameters in the healthy controls. CONCLUSIONS The association between higher PUA with lower GFR and lower ERPF in patients with Type 1 diabetes is driven by alterations in the estimated RA . PUA-mediated RA may be caused by increased tone or thickening of the afferent renal arteriole, which might potentiate renal injury by causing ischaemia to the renal microcirculation.
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Affiliation(s)
- Y 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
| | - M Škrtić
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - G K Yang
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - V Lai
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - J W Scholey
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - P M Yip
- University Health Network, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - B A Perkins
- Department of Medicine, Division of Endocrinology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Hassouneh R, Nasrallah R, Zimpelmann J, Gutsol A, Eckert D, Ghossein J, Burns KD, Hébert RL. PGE2 receptor EP3 inhibits water reabsorption and contributes to polyuria and kidney injury in a streptozotocin-induced mouse model of diabetes. Diabetologia 2016; 59:1318-28. [PMID: 26995650 DOI: 10.1007/s00125-016-3916-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 02/19/2016] [Indexed: 10/22/2022]
Abstract
AIMS/HYPOTHESIS The first clinical manifestation of diabetes is polyuria. The prostaglandin E2 (PGE2) receptor EP3 antagonises arginine vasopressin (AVP)-mediated water reabsorption and its expression is increased in the diabetic kidney. The purpose of this work was to study the contribution of EP3 to diabetic polyuria and renal injury. METHODS Male Ep 3 (-/-) (also known as Ptger3 (-/-)) mice were treated with streptozotocin (STZ) to generate a mouse model of diabetes and renal function was evaluated after 12 weeks. Isolated collecting ducts (CDs) were microperfused to study the contribution of EP3 to AVP-mediated fluid reabsorption. RESULTS Ep 3 (-/-)-STZ mice exhibited attenuated polyuria and increased urine osmolality compared with wild-type STZ (WT-STZ) mice, suggesting enhanced water reabsorption. Compared with WT-STZ mice, Ep 3 (-/-)-STZ mice also had increased protein expression of aquaporin-1, aquaporin-2, and urea transporter A1, and reduced urinary AVP excretion, but increased medullary V2 receptors. In vitro microperfusion studies indicated that Ep 3 (-/-) and WT-STZ CDs responded to AVP stimulation similarly to those of wild-type mice, with a 60% increase in fluid reabsorption. In WT non-injected and WT-STZ mice, EP3 activation with sulprostone (PGE2 analogue) abrogated AVP-mediated water reabsorption; this effect was absent in mice lacking EP3. A major finding of this work is that Ep 3 (-/-)-STZ mice showed blunted renal cyclooxygenase-2 protein expression, reduced renal hypertrophy, reduced hyperfiltration and reduced albuminuria, as well as diminished tubular dilation and nuclear cysts. CONCLUSIONS/INTERPRETATION Taken together, the data suggest that EP3 contributes to diabetic polyuria by inhibiting expression of aquaporins and that it promotes renal injury during diabetes. EP3 may prove to be a promising target for more selective management of diabetic kidney disease.
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Affiliation(s)
- Ramzi Hassouneh
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room 2514, Ottawa, ON, Canada, K1H 8M5
| | - Rania Nasrallah
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room 2514, Ottawa, ON, Canada, K1H 8M5
| | - Joe Zimpelmann
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Alex Gutsol
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - David Eckert
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room 2514, Ottawa, ON, Canada, K1H 8M5
| | - Jamie Ghossein
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room 2514, Ottawa, ON, Canada, K1H 8M5
| | - Kevin D Burns
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room 2514, Ottawa, ON, Canada, K1H 8M5
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Richard L Hébert
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room 2514, Ottawa, ON, Canada, K1H 8M5.
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Blood pressure-independent renoprotection in diabetic rats treated with AT1 receptor-neprilysin inhibition compared with AT1 receptor blockade alone. Clin Sci (Lond) 2016; 130:1209-20. [PMID: 27129187 DOI: 10.1042/cs20160197] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 04/18/2016] [Indexed: 11/17/2022]
Abstract
ARNI [dual AT1 (angiotensin II type 1) receptor-neprilysin inhibition] exerts beneficial effects on blood pressure and kidney function in heart failure, compared with ARB (AT1 receptor blockade) alone. We hypothesized that ARNI improves cardiac and kidney parameters in diabetic TGR(mREN2)27 rats, an angiotensin II-dependent hypertension model. Rats were made diabetic with streptozotocin for 5 or 12 weeks. In the final 3 weeks, rats were treated with vehicle, irbesartan (ARB) or irbesartan+thiorphan (ARNI). Blood pressure, measured by telemetry in the 5-week group, was lowered identically by ARB and ARNI. The heart weight/tibia length ratio in 12-week diabetic animals was lower after ARNI compared with after ARB. Proteinuria and albuminuria were observed from 8 weeks of diabetes onwards. ARNI reduced proteinuria more strongly than ARB, and a similar trend was seen for albuminuria. Kidneys of ARNI-treated animals showed less severe segmental glomerulosclerosis than those of ARB-treated animals. After 12 weeks, no differences between ARNI- and ARB-treated animals were found regarding diuresis, natriuresis, plasma endothelin-1, vascular reactivity (acetylcholine response) or kidney sodium transporters. Only ARNI-treated rats displayed endothelin type B receptor-mediated vasodilation. In conclusion, ARNI reduces proteinuria, glomerulosclerosis and heart weight in diabetic TGR(mREN2)27 rats more strongly than does ARB, and this occurs independently of blood pressure.
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Lytvyn Y, Mahmud FH, Daneman D, Deda L, Dunger DB, Deanfield J, Dalton RN, Elia Y, Har R, Bradley TJ, Slorach C, Hui W, Moineddin R, Reich HN, Scholey JW, Mertens L, Sochett E, Cherney DZI. Association Between Plasma Uric Acid Levels and Cardiorenal Function in Adolescents With Type 1 Diabetes. Diabetes Care 2016; 39:611-6. [PMID: 26895883 DOI: 10.2337/dc15-2345] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/13/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The relationship between plasma uric acid (PUA) and renal and cardiovascular parameters in adolescents with type 1 diabetes (T1D) is not well understood. Our aims in this exploratory analysis were to study the association between PUA and estimated glomerular filtration rate (eGFR), urinary albumin-to-creatinine ratio (ACR), blood pressure, endothelial function, and arterial stiffness in T1D adolescents. These associations were also studied in healthy control (HC) subjects. RESEARCH DESIGN AND METHODS We studied 188 T1D subjects recruited to the Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT) and 65 HC subjects. Baseline PUA, eGFRcystatin C, ACR, blood pressure, flow-mediated dilation (FMD), and carotid-femoral pulse wave velocity (PWV) were measured. RESULTS PUA was lower in T1D vs. HC subjects (242 ± 55 vs. 306 ± 74 μmol/L, respectively; P < 0.0001). Higher PUA was inversely associated with eGFR in T1D subjects (r = -0.48, P < 0.0001) even after correction for baseline clinical demographic characteristics. PUA was not associated with ACR in T1D after adjustment for potential confounders such as eGFR. For cardiovascular parameters, PUA levels did not associate with systolic blood pressure, FMD, or PWV in T1D or HC subjects. CONCLUSIONS Even within the physiological range, PUA levels were significantly lower in T1D adolescent patients compared with HC subjects. There was an inverse relationship between PUA and eGFR in T1D, likely reflecting an increase in clearance. There were no associations observed with ACR, blood pressure, arterial stiffness, or endothelial function. Thus, in contrast with adults, PUA may not yet be associated with cardiorenal abnormalities in adolescents with T1D.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada Division of Nephrology, Department of Medicine, The University Health Network, University of Toronto, Toronto, Canada
| | - Farid H Mahmud
- Division of Endocrinology, Department of Paediatrics and JDRF Canadian Clinical Trial Network SickKids Multicenter Clinical Trial Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Denis Daneman
- Division of Endocrinology, Department of Paediatrics and JDRF Canadian Clinical Trial Network SickKids Multicenter Clinical Trial Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Livia Deda
- Division of Endocrinology, Department of Paediatrics and JDRF Canadian Clinical Trial Network SickKids Multicenter Clinical Trial Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - David B Dunger
- Department of Pediatrics, University of Cambridge, Cambridge, U.K
| | | | - R Neil Dalton
- WellChild Laboratory, Evelina London Children's Hospital, St Thomas' Hospital, London, U.K
| | - Yesmino Elia
- Division of Endocrinology, Department of Paediatrics and JDRF Canadian Clinical Trial Network SickKids Multicenter Clinical Trial Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Ronnie Har
- Division of Nephrology, Department of Medicine, The University Health Network, University of Toronto, Toronto, Canada
| | - Timothy J Bradley
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Cameron Slorach
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Wei Hui
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Rahim Moineddin
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Heather N Reich
- Division of Nephrology, Department of Medicine, The University Health Network, University of Toronto, Toronto, Canada
| | - James W Scholey
- Division of Nephrology, Department of Medicine, The University Health Network, University of Toronto, Toronto, Canada
| | - Luc Mertens
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Etienne Sochett
- Division of Endocrinology, Department of Paediatrics and JDRF Canadian Clinical Trial Network SickKids Multicenter Clinical Trial Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, The University Health Network, University of Toronto, Toronto, Canada
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Bradley TJ, Slorach C, Mahmud FH, Dunger DB, Deanfield J, Deda L, Elia Y, Har RLH, Hui W, Moineddin R, Reich HN, Scholey JW, Mertens L, Sochett E, Cherney DZI. Early changes in cardiovascular structure and function in adolescents with type 1 diabetes. Cardiovasc Diabetol 2016; 15:31. [PMID: 26879273 PMCID: PMC4754808 DOI: 10.1186/s12933-016-0351-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/05/2016] [Indexed: 01/24/2023] Open
Abstract
Background Children with type 1 diabetes (T1D) are at higher risk of early adult-onset cardiovascular disease. We assessed cardiovascular structure and function in adolescents with T1D compared with healthy controls and the relationships between peripheral vascular function and myocardial parameters. Methods and results 199 T1D [14.4 ± 1.6 years, diabetes duration 6.2 (2.0–12.8) years] and 178 controls (14.4 ± 2.1 years) completed endothelial function by flow mediated vasodilatation (FMD), arterial stiffness using pulse wave velocity (PWV) along with M-mode, pulse wave and tissue Doppler, and myocardial deformation echocardiographic imaging. Systolic (113 ± 10 vs. 110 ± 9 mmHg; p = 0.0005) and diastolic (62 ± 7 vs. 58 ± 7 mmHg; p < 0.0001) blood pressures, carotid femoral PWV and endothelial dysfunction measurements were increased in T1D compared with controls. Systolic and diastolic left ventricular dimensions and function by M-mode and pulse wave Doppler assessment were not significantly different. Mitral valve lateral e’ (17.6 ± 2.6 vs. 18.6 ± 2.6 cm/s; p < 0.001) and a’ (5.4 ± 1.1 vs. 5.9 ± 1.1 cm/s; p < 0.001) myocardial velocities were decreased and E/e’ (7.3 ± 1.2 vs. 6.7 ± 1.3; p = 0.0003) increased in T1D. Left ventricular mid circumferential strain (−20.4 ± 2.3 vs. −19.5 ± 1.7 %; p < 0.001) was higher, whereas global longitudinal strain was lower (−19.0 ± 1.9 vs. −19.8 ± 1.5 % p < 0.001) in T1D. Conclusions Adolescents with T1D exhibit early changes in blood pressure, peripheral vascular function and left ventricular myocardial deformation indices with a shift from longitudinal to circumferential shortening. Longitudinal follow-up of these changes in ongoing prospective trials may allow detection of those most at risk for cardiovascular abnormalities including hypertension that could preferentially benefit from early therapeutic interventions.
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Affiliation(s)
- Timothy J Bradley
- Department of Paediatrics, Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Cameron Slorach
- Department of Paediatrics, Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Farid H Mahmud
- Department of Paediatrics, Division of Endocrinology, JDRF-Canadian Clinical Trial Network (JDRF-CCTN) Sick Kids Multicenter Clinical Trial Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - David B Dunger
- Department of Pediatrics, University of Cambridge, Cambridge, UK.
| | - John Deanfield
- University College Hospital, London, UK. .,Heart Hospital and Great Ormond Street Hospital, London, UK.
| | - Livia Deda
- Department of Paediatrics, Division of Endocrinology, JDRF-Canadian Clinical Trial Network (JDRF-CCTN) Sick Kids Multicenter Clinical Trial Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Yesmino Elia
- Department of Paediatrics, Division of Endocrinology, JDRF-Canadian Clinical Trial Network (JDRF-CCTN) Sick Kids Multicenter Clinical Trial Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Ronnie L H Har
- Department of Paediatrics, Division of Endocrinology, JDRF-Canadian Clinical Trial Network (JDRF-CCTN) Sick Kids Multicenter Clinical Trial Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Wei Hui
- Department of Paediatrics, Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
| | - Heather N Reich
- Department of Medicine, Division of Nephrology, University Health Network, Toronto General Hospital, University of Toronto, 585 University Avenue, 8 N-845, Toronto, ON, M5G 2N2, Canada.
| | - James W Scholey
- Department of Medicine, Division of Nephrology, University Health Network, Toronto General Hospital, University of Toronto, 585 University Avenue, 8 N-845, Toronto, ON, M5G 2N2, Canada.
| | - Luc Mertens
- Department of Paediatrics, Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Etienne Sochett
- Department of Paediatrics, Division of Endocrinology, JDRF-Canadian Clinical Trial Network (JDRF-CCTN) Sick Kids Multicenter Clinical Trial Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, Toronto General Hospital, University of Toronto, 585 University Avenue, 8 N-845, Toronto, ON, M5G 2N2, Canada.
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Xiang L, Mittwede PN, Clemmer JS. Glucose Homeostasis and Cardiovascular Alterations in Diabetes. Compr Physiol 2015; 5:1815-39. [DOI: 10.1002/cphy.c150001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Nasrallah R, Hassouneh R, Hébert RL. PGE2, Kidney Disease, and Cardiovascular Risk: Beyond Hypertension and Diabetes. J Am Soc Nephrol 2015; 27:666-76. [PMID: 26319242 DOI: 10.1681/asn.2015050528] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
An important measure of cardiovascular health is obtained by evaluating the global cardiovascular risk, which comprises a number of factors, including hypertension and type 2 diabetes, the leading causes of illness and death in the world, as well as the metabolic syndrome. Altered immunity, inflammation, and oxidative stress underlie many of the changes associated with cardiovascular disease, diabetes, and the metabolic syndrome, and recent efforts have begun to elucidate the contribution of PGE2 in these events. This review summarizes the role of PGE2 in kidney disease outcomes that accelerate cardiovascular disease, highlights the role of cyclooxygenase-2/microsomal PGE synthase 1/PGE2 signaling in hypertension and diabetes, and outlines the contribution of PGE2 to other aspects of the metabolic syndrome, particularly abdominal adiposity, dyslipidemia, and atherogenesis. A clearer understanding of the role of PGE2 could lead to new avenues to improve therapeutic options and disease management strategies.
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Affiliation(s)
- Rania Nasrallah
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ramzi Hassouneh
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard L Hébert
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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35
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Sodium-glucose cotransporter-2 inhibition and the potential for renal protection in diabetic nephropathy. Curr Opin Nephrol Hypertens 2015; 24:96-103. [PMID: 25470017 DOI: 10.1097/mnh.0000000000000084] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Renal hyperfiltration has been used as a surrogate marker for increased intraglomerular pressure in patients with diabetes mellitus. Previous human investigation examining the pathogenesis of hyperfiltration has focused on the role of neurohormones such as the renin-angiotensin-aldosterone system (RAAS). Unfortunately, RAAS blockade does not completely attenuate hyperfiltration or diabetic kidney injury. More recent work has therefore investigated the contribution of renal tubular factors, including the sodium-glucose cotransporter, to the hyperfiltration state, which is the topic of this review. RECENT FINDINGS Novel sodium-glucose cotransporter-2 (SGLT2) inhibitors reduce proximal tubular sodium reabsorption, thereby increasing distal sodium delivery to the macula densa, causing tubuloglomerular feedback, afferent vasoconstriction and decreased hyperfiltration in animals. In humans, SGLT2 inhibition was recently shown to reduce hyperfiltration in normotensive, normoalbuminuric patients with type 1 diabetes. In clinical trials of type 2 diabetes, SGLT2 is associated with significant renal effects, including modest, acute declines in estimated glomerular filtration rate followed by the maintenance of stable renal function, and reduced albuminuria. SUMMARY Existing data are supportive of a potential renal-protective role for SGLT2 inhibition in patients with diabetes. Dedicated renal outcome trials are ongoing and have the potential to change the clinical practice.
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Škrtić M, Lytvyn Y, Yang GK, Yip P, Lai V, Silverman M, Cherney DZI. Glomerular haemodynamic profile of patients with Type 1 diabetes compared with healthy control subjects. Diabet Med 2015; 32:972-9. [PMID: 25662770 DOI: 10.1111/dme.12717] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2015] [Indexed: 11/28/2022]
Abstract
AIMS To evaluate the glomerular haemodynamic profile of patients with Type 1 diabetes with either renal hyperfiltration (GFR ≥ 135 ml/min/1.73 m2 ) or renal normofiltration (GFR 90-134 ml/min/1.73 m2 ) during euglycaemic and hyperglycaemic conditions, and to compare this profile with that of a similar group of healthy control subjects. METHODS Gomez's equations were used to derive afferent and efferent arteriolar resistances, glomerular hydrostatic pressure and filtration pressure. RESULTS At baseline, during clamped euglycaemia, patients with Type 1 diabetes and hyperfiltration had lower mean ± sd afferent arteriolar resistance than both those with Type 1 diabetes and normofiltration (914 ± 494 vs. 2065 ± 597 dyne/s/cm5 ; P < 0.001) and healthy control subjects (1676 ± 707 dyne/s/cm(5) ; p < 0.001). By contrast, efferent arteriolar resistance was similar in the three groups. Patients with Type 1 diabetes and hyperfiltration also had higher mean ± sd glomerular hydrostatic pressure than both healthy control subjects and patients with Type 1 diabetes and normofiltration (66 ± 6 vs. 60 ± 3 vs. 55 ± 3 mmHg; P < 0.05). Similar findings for afferent arteriolar resistance, efferent arteriolar resistance, glomerular hydrostatic pressure and filtration pressure were observed during clamped hyperglycaemia. CONCLUSION Hyperfiltration in Type 1 diabetes is primarily driven by alterations in afferent arteriolar resistance rather than efferent arteriolar resistance. Renal protective therapies should focus on afferent renal arteriolar mechanisms through the use of pharmacological agents that target tubuloglomerular feedback, including sodium-glucose cotransporter 2 inhibitors and incretins.
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Affiliation(s)
- M Škrtić
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Y Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - G K Yang
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - P Yip
- University Health Network, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - V Lai
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - M Silverman
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Bjornstad P, Cherney DZ, Snell-Bergeon JK, Pyle L, Rewers M, Johnson RJ, Maahs DM. Rapid GFR decline is associated with renal hyperfiltration and impaired GFR in adults with Type 1 diabetes. Nephrol Dial Transplant 2015; 30:1706-11. [PMID: 26050268 DOI: 10.1093/ndt/gfv121] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/27/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Rapid glomerular filtration rate (GFR) decline (>3 mL/min/1.73 m(2)) is an increasingly recognized high-risk diabetic nephropathy (DN) phenotype in Type 1 diabetes. Rapid GFR decline is a recognized predictor of impaired GFR (<60 mL/min/1.73 m(2)). However, the association between rapid GFR decline and renal hyperfiltration is not well described in Type 1 diabetes. We hypothesized that renal hyperfiltration (estimated glomerular filtration rate, eGFR ≥ 120 mL/min/1.73 m(2)) would predict rapid GFR decline over 6 years and that rapid GFR decline would predict impaired GFR at 6 years in adults with Type 1 diabetes. METHODS GFR was calculated by chronic kidney disease epidemiology (CKD-EPI) creatinine in 646 adults with Type 1 diabetes in the coronary artery calcification in Type 1 diabetes study. Logistic multivariable models were employed to investigate the relationships between renal hyperfiltration and rapid GFR decline, and rapid GFR decline and incident impaired GFR over 6 years. RESULTS Renal hyperfiltration predicted greater odds of rapid GFR decline over 6 years [odds ratio (OR): 5.00, 95% confidence interval (CI): 3.03-8.25, P < 0.0001] adjusting for hemoglobin A1c (HbA1c), systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), sex, duration, log of albumin/creatinine ratio and estimated insulin sensitivity. Furthermore, rapid GFR decline predicted greater odds of incident impaired eGFR (OR: 15.99, 95% CI 2.34-114.37, P = 0.006) in a similarly adjusted model. Sensitivity analyses with GFR calculated by CKD-EPI combined creatinine and cystatin C, and renal hyperfiltration defined as ≥135 mL/min/1.73 m(2) yielded similar results. CONCLUSIONS In adults with Type 1 diabetes, rapid GFR decline over 6 years was associated with baseline renal hyperfiltration and incident GFR impairment. These observations may suggest an intermediate and predictive role of rapid GFR decline in the progression of DN.
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Affiliation(s)
- Petter Bjornstad
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - David Z Cherney
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Janet K Snell-Bergeon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Laura Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Marian Rewers
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard J Johnson
- Division of Nephrology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - David M Maahs
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA Division of Nephrology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Bjornstad P, Pyle L, Nguyen N, Snell-Bergeon JK, Bishop FK, Wadwa RP, Maahs DM. Achieving International Society for Pediatric and Adolescent Diabetes and American Diabetes Association clinical guidelines offers cardiorenal protection for youth with type 1 diabetes. Pediatr Diabetes 2015; 16:22-30. [PMID: 25604668 PMCID: PMC5426809 DOI: 10.1111/pedi.12252] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 11/24/2014] [Accepted: 12/12/2014] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Most youth with type 1 diabetes do not meet the American Diabetes Association (ADA) and International Society for Pediatric and Adolescent Diabetes (ISPAD) targets for hemoglobin A1c (HbA1c), blood pressure (BP), lipids, and body mass index (BMI). We hypothesized that ISPAD/ADA goal achievement at baseline would be associated with cardiorenal risk factors at baseline and 2 yr follow-up in adolescents with type 1 diabetes. METHODS We assessed the cross-sectional and longitudinal relationships between ISPAD/ADA goal achievement at baseline and cardiorenal health at baseline and 2-yr follow-up (n = 297; 15.4 ± 2.1 yr at baseline) in adolescents with type 1 diabetes. Goal achievement was defined as HbA1c < 7.5%, BP < 90th percentile for age, sex, and height, low density lipoprotein-cholesterol (LDL-C) <100 mg/dL, high density lipoprotein-cholesterol (HDL-C) >35 mg/dL, triglycerides (TG) <150 mg/dL and BMI <85th percentile for age and sex. Cardiorenal outcomes included pulse-wave velocity (PWV), brachial distensibility (BrachD), augmentation index (AIx), and epidermal growth factor receptor (eGFR) continuously and categorically as hyperfiltration (eGFR ≥ 135 mL/min/1.73 m(2)). RESULTS Adolescents with type 1 diabetes who met 1-3 goals, had significantly greater (P < 0.05) baseline PWV (5.1 ± 0.1 vs. 5.4 ± 0.1 m/s), follow-up PWV (5.5 ± 0.1 vs. 5.7 ± 0.1 m/s), greater follow-up eGFR (104 ± 2 vs. 116 ± 3 mL/min/1.73 m(2)), and greater odds of renal hyperfiltration at follow-up (odds ratio (OR): 20.0, 95% confidence interval (CI): 3.8-105.2) compared to those who met 4-6 goals after adjusting for Tanner stage, sex, age, and diabetes duration. No statistically significant differences in the cardiorenal outcomes were observed between adolescents with type 1 diabetes who met 4-6 goals and non-diabetic controls (n = 96). CONCLUSIONS In adolescents with type 1 diabetes, baseline ADA/ISPAD goal achievement was associated with cardiorenal protection at baseline and 2-yr follow-up.
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Affiliation(s)
- Petter Bjornstad
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Laura Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Nhung Nguyen
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Janet K. Snell-Bergeon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO,Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Franziska K. Bishop
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - R. Paul Wadwa
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO,Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - David M. Maahs
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO,Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
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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: 14] [Impact Index Per Article: 1.6] [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, Wan J, Lai V, Cohen P, Cherney DZI. The effect of sex on humanin levels in healthy adults and patients with uncomplicated type 1 diabetes mellitus. Can J Physiol Pharmacol 2014; 93:239-43. [PMID: 25615723 DOI: 10.1139/cjpp-2014-0401] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Diabetes mellitus (DM) is associated with a loss of renal and vascular protection in women compared with men, but the responsible mechanisms are unclear. Recent experimental work implicated humanin (HN) as a novel cytoprotective hormone in DM. Our goal was to measure sex-related differences in HN levels in uncomplicated type 1 DM patients (T1D) and healthy controls (HC), as well as the interaction between HN, circulating neurohormones, and vascular function. Plasma HN, cGMP and aldosterone, blood pressure (BP), glomerular filtration rate, and effective renal plasma flow (inulin and para-aminohippurate) were measured in HC (11 men, 10 women) and T1D (23 men and 18 women) during clamped euglycemia (4-6 mmol·L(-1)). Plasma HN levels were generally lower in HC men by comparison with the women, but the differences were not statistically significant. In contrast, levels in the T1D men were higher compared with the T1D women (p = 0.026) and HC men (p < 0.0001). In the HC men, but not the women, HN correlated negatively with BP, but not with renal function, cGMP, or aldosterone. In the T1D men, HN negatively correlated with plasma cGMP. In the T1D women, HN did not correlate with neurohormones or vascular function. Future work should determine the role of HN in the pathogenesis of sex-related vascular function differences in DM.
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Affiliation(s)
- Yuliya Lytvyn
- Division of Nephrology, University Health Network, University of Toronto, Toronto General Hospital, 585 University Avenue, Toronto, ON M5G 2N2, Canada., Department of Pharmacology and Toxicology, Faculty of Medicine University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada
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The impact of hyperfiltration on the diabetic kidney. DIABETES & METABOLISM 2014; 41:5-17. [PMID: 25457474 DOI: 10.1016/j.diabet.2014.10.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 10/02/2014] [Accepted: 10/02/2014] [Indexed: 02/07/2023]
Abstract
More than two decades ago, hyperfiltration (HF) in diabetes was postulated to be a maladaptive response observed early in the course of diabetic kidney disease (DKD), which may eventually predispose to irreversible damage to nephrons and development of progressive renal disease. Despite this, the potential mechanisms leading to renal HF in diabetes are not fully understood, although several hypotheses have been proposed, including alterations in glomerular haemodynamic function and tubulo-glomerular feedback. Furthermore, the role of HF as a causative factor in renal disease progression is still unclear and warrants further prospective longer-term studies. Although HF has been entrenched as the first stage in the classic albuminuric pathway to end-stage renal disease in DKD, and HF has been shown to predict the progression of albuminuria in many, but not all studies, the concept that HF predisposes to the development of chronic kidney disease (CKD) stage 3, that is, glomerular filtration rate (GFR) decline to<60mL/min/1.73m(2), remains to be proved. Further long-term studies of GFR gradients therefore are required to establish whether HF ultimately leads to decreased kidney function, after adjustment for glycaemic control and other confounders. Whether reversal of HF with therapeutic agents is protective against reducing the risk of development of albuminuria and renal impairment is also worth investigating in prospective randomized trials.
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Har RLH, Reich HN, Scholey JW, Daneman D, Dunger DB, Moineddin R, Dalton RN, Motran L, Elia Y, Deda L, Ostrovsky M, Sochett EB, Mahmud FH, Cherney DZI. The urinary cytokine/chemokine signature of renal hyperfiltration in adolescents with type 1 diabetes. PLoS One 2014; 9:e111131. [PMID: 25392936 PMCID: PMC4230911 DOI: 10.1371/journal.pone.0111131] [Citation(s) in RCA: 16] [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: 07/17/2014] [Accepted: 09/20/2014] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Urinary cytokine/chemokine levels are elevated in adults with type 1 diabetes (T1D) exhibiting renal hyperfiltration. Whether this observation extends to adolescents with T1D remains unknown. Our first objective was to determine the relationship between hyperfiltration and urinary cytokines/chemokines in normotensive, normoalbuminuric adolescents with T1D using GFR(cystatin). Our second aim was to determine the relationship between urine and plasma levels of inflammatory biomarkers, to clarify the origin of these factors. METHODS Urine and serum cytokines/chemokines (Luminex platform) and GFR(cystatin) were measured in normofiltering (n = 111, T1D-N, GFR<135 ml/min/1.73 m(2)) and hyperfiltering (n = 31, T1D-H, GFR ≥ 135 ml/min/1.73 m(2)) adolescents with T1D (ages 10-16), and in age and sex matched healthy control subjects (HC, n = 59). RESULTS We noted significant step-wise increases in urinary cytokine/chemokine excretion according to filtration status with highest levels in T1D-H, with parallel trends in serum analyte concentrations. After adjusting for serum glucose at the time of sampling, differences in urinary cytokine excretion were not statistically significant. Only serum IL-2 significantly differed between HC and T1D (p = 0.0076). CONCLUSIONS Hyperfiltration is associated with increased urinary cytokine/chemokine excretion in T1D adolescents, and parallel trends in serum cytokine concentration. The GFR-associated trends in cytokine excretion may be driven by the effects of ambient hyperglycemia. The relationship between hyperfiltration, glycemia, and variations in serum and urine cytokine expression and their impact on future renal and systemic vascular complications requires further study.
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Affiliation(s)
- Ron L. H. Har
- Division of Nephrology, University Health Network - Toronto General Hospital, Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
| | - Heather N. Reich
- Division of Nephrology, University Health Network - Toronto General Hospital, Toronto, Ontario, Canada
| | - James W. Scholey
- Division of Nephrology, University Health Network - Toronto General Hospital, Toronto, Ontario, Canada
| | - Denis Daneman
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - David B. Dunger
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Rahim Moineddin
- Family and Community Medicine, University of Toronto Toronto, Ontario, Canada
| | - R. Neil Dalton
- WellChild Laboratory, Evelina Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - Laura Motran
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yesmino Elia
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Livia Deda
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Masha Ostrovsky
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Etienne B. Sochett
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Farid H. Mahmud
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - David Z. I. Cherney
- Division of Nephrology, University Health Network - Toronto General Hospital, Banting and Best Diabetes Centre, 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: 37] [Impact Index Per Article: 3.7] [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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45
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Zaltzman JS, Lai V, Schulz MZ, Moon KH, Cherney DZ. A randomized cross-over comparison of short-term exposure of once-daily extended release tacrolimus and twice-daily tacrolimus on renal function in healthy volunteers. Transpl Int 2014; 27:1294-302. [PMID: 25160518 PMCID: PMC4497360 DOI: 10.1111/tri.12435] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 07/13/2014] [Accepted: 08/20/2014] [Indexed: 11/26/2022]
Abstract
Calcineurin inhibitor nephrotoxicity remains an issue for transplant recipients. The pharmacokinetic profile (PK) of the once-daily tacrolimus extended release (Tac-ER) includes equivalent exposure [AUC(0-24 h) ] but lower Cmax versus twice-daily tacrolimus immediate release (Tac-IR). We hypothesized that the unique PK profiles would result in pharmacodynamic differences in renal function. Nineteen healthy male subjects were allocated to once-daily Tac-ER and twice-daily Tac-IR in a prospective, randomized, two period, cross-over study. Tacrolimus was titrated to achieve trough levels of 8-12 ng/ml. Twenty four hours ERPF and GFR estimated by para-aminohippurate and sinistrin clearance were performed at baseline and at the end of each 10-day dosing period. Mean Tac C0 was 11.0 ± 2.2 and 11.3 ± 1.8 ng/ml for Tac-ER and Tac-IR, respectively. The mean Effective 24 h renal plasma flow (ERPF) was significantly higher with Tac-ER compared with Tac-IR (658 ± 127 vs. 610 ± 93 ml/min/1.73 m(2) , P = 0.046). There was a trend to a greater mean GFR over 24 h for Tac-ER at 114.5 ± 13.6 ml/min/1.73 m(2) compared with 108.9 ± 9.7 ml/min/1.73 m(2) for Tac-IR, P = 0.116. Under controlled physiological conditions, ERPF was significantly improved with Tac-ER compared with Tac-IR, likely owing to the differing PKs of these tacrolimus preparations (ClinicalTrials.gov Identifier: NCT01681134).
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Affiliation(s)
- Jeffrey S Zaltzman
- Renal Transplant Program, Department of Medicine, Li Ka Shing Institute St. Michael's University of Toronto, Toronto, ON, Canada
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46
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Nasrallah R, Hassouneh R, Hébert RL. Chronic kidney disease: targeting prostaglandin E2 receptors. Am J Physiol Renal Physiol 2014; 307:F243-50. [PMID: 24966087 DOI: 10.1152/ajprenal.00224.2014] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Chronic kidney disease is a leading cause of morbidity and mortality in the world. A better understanding of disease mechanisms has been gained in recent years, but the current management strategies are ineffective at preventing disease progression. A widespread focus of research is placed on elucidating the specific processes implicated to find more effective therapeutic options. PGE2, acting on its four EP receptors, regulates many renal disease processes; thus EP receptors could prove to be important targets for kidney disease intervention strategies. This review summarizes the major pathogenic mechanisms contributing to initiation and progression of chronic kidney disease, emphasizing the role of hyperglycemia, hypertension, inflammation, and oxidative stress. We have long recognized the multifaceted role of PGs in both the initiation and progression of chronic kidney disease, yet studies are only now seriously contemplating specific EP receptors as targets for therapy. Given the plethora of renal complications attributed to PG involvement in the kidney, this review highlights these pathogenic events and emphasizes the PGE2 receptor targets as options available to complement current therapeutic strategies.
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Affiliation(s)
- Rania Nasrallah
- Department of Cellular and Molecular Medicine, and Kidney Research Centre, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ramzi Hassouneh
- Department of Cellular and Molecular Medicine, and Kidney Research Centre, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard L Hébert
- Department of Cellular and Molecular Medicine, and Kidney Research Centre, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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47
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Cherney DZI, Xiao F, Zimpelmann J, Har RLH, Lai V, Scholey JW, Reich HN, Burns KD. Urinary ACE2 in healthy adults and patients with uncomplicated type 1 diabetes. Can J Physiol Pharmacol 2014; 92:703-6. [PMID: 24920267 DOI: 10.1139/cjpp-2014-0065] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Angiotensin-converting enzyme 2 (ACE2) is expressed in the kidney and may be renoprotective. We determined whether urinary ACE2 enzyme activity and protein levels (ELISA), as well as angiotensinogen and ACE, are elevated during clamped euglycemia (4-6 mmol·L(-1)) in patients with uncomplicated type 1 diabetes (T1D, n = 58) compared with normoglycemic controls (n = 21). We also measured the effect of clamped hyperglycemia (9-11 mmol·L(-1)) on each urinary factor in T1D patients. Urinary ACE2 activity and protein levels were higher during clamped euglycemia in T1D compared with the controls (p < 0.0001). In contrast, urinary angiotensinogen levels (p = 0.27) and ACE excretion (p = 0.68) did not differ. In response to clamped hyperglycemia in T1D, urinary ACE2 protein decreased (p < 0.0001), whereas urinary ACE2 activity as well as angiotensinogen and ACE levels remained unchanged. Urinary ACE2 activity and protein expression are increased in T1D patients prior to the onset of clinical complications. Further work is required to determine the functional role of urinary ACE2 in early T1D.
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Affiliation(s)
- David Z I Cherney
- a Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
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48
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Green DJ, Dawson EA, Groenewoud HM, Jones H, Thijssen DH. Is Flow-Mediated Dilation Nitric Oxide Mediated? Hypertension 2014; 63:376-82. [DOI: 10.1161/hypertensionaha.113.02044] [Citation(s) in RCA: 230] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Flow-mediated dilation (FMD) is a noninvasive index of endothelial function and vascular health in humans. Studies examining the role of nitric oxide (NO) are not conclusive. In this article, we quantified the contribution of NO in FMD of conduit arteries and explored the effect of the protocol (ie, distal cuff, ≈5-minute ischemia) and method of analysis (ie, automated and continuous edge detection) on the NO dependency of this test. A systematic review and 3-stage meta-analysis of published crossover studies that measured FMD under local infusion of saline or the NO synthase blocker
N
G
monomethyl-L-arginine (L-NMMA) was undertaken. Twenty studies met the inclusion criteria for stage 1 (374 individual comparisons). The meta-analyzed outcome was the difference in FMD between infusion of saline (ie, FMD
saline
) and NO synthase blocker (ie, FMD
L-NMMA
). Overall, FMD
saline
was 8.2% (95% confidence interval [CI], 6.8%–9.6%) compared with FMD
L-NMMA
of 3.7% (95% CI, 3.1%–4.3%;
P
<0.001). Stage 2 analysis focused on studies that used the most commonly adopted approach in healthy volunteers (ie, distal cuff placement, ≈5-minute occlusion), which similarly revealed a significant NO contribution to FMD (FMD
saline
, 6.5% [95% CI, 5.7%–7.3%]; FMD
L-NMMA
, 0.9% [95% CI, 0.5%–1.3%];
P
<0.001). Stage 3 meta-analyzed the studies that adopted the commonly adopted approach and automated, continuous method of analysis, which also revealed a significant contribution of NO to the FMD (FMD
saline
, 6.9% [95% CI, 6.0%–7.8%]; FMD
L-NMMA
, 2.4% [95% CI, 1.1%–3.7%];
P
<0.001). This comprehensive analysis demonstrates that FMD of conduit arteries in humans is, at least in part, mediated by NO.
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Affiliation(s)
- Daniel J. Green
- From the Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom (D.J.G., E.A.D., H.J., D.H.J.T.); School of Sports Science, Exercise and Health, The University of Western Australia, Crawley Perth, Western Australia (D.J.G.); and Departments of Health Evidence (H.M.M.G.) and Physiology (D.H.J.T.), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ellen A. Dawson
- From the Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom (D.J.G., E.A.D., H.J., D.H.J.T.); School of Sports Science, Exercise and Health, The University of Western Australia, Crawley Perth, Western Australia (D.J.G.); and Departments of Health Evidence (H.M.M.G.) and Physiology (D.H.J.T.), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hans M.M. Groenewoud
- From the Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom (D.J.G., E.A.D., H.J., D.H.J.T.); School of Sports Science, Exercise and Health, The University of Western Australia, Crawley Perth, Western Australia (D.J.G.); and Departments of Health Evidence (H.M.M.G.) and Physiology (D.H.J.T.), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Helen Jones
- From the Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom (D.J.G., E.A.D., H.J., D.H.J.T.); School of Sports Science, Exercise and Health, The University of Western Australia, Crawley Perth, Western Australia (D.J.G.); and Departments of Health Evidence (H.M.M.G.) and Physiology (D.H.J.T.), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dick H.J. Thijssen
- From the Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom (D.J.G., E.A.D., H.J., D.H.J.T.); School of Sports Science, Exercise and Health, The University of Western Australia, Crawley Perth, Western Australia (D.J.G.); and Departments of Health Evidence (H.M.M.G.) and Physiology (D.H.J.T.), Radboud University Medical Center, Nijmegen, The Netherlands
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Guberina H, Baumann M, Bruck H, Feldkamp T, Nürnberger J, Kribben A, Philipp T, Witzke O, Sotiropoulos G, Mitchell A. Associations of smoking with alterations in renal hemodynamics may depend on sex--investigations in potential kidney donors. Kidney Blood Press Res 2013; 37:611-21. [PMID: 24356551 DOI: 10.1159/000355741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Cigarette smoking is a risk factor for renal damage, but little is known about subclinical effects of smoking on renal hemodynamics and parameters of renal function in humans. We examined the associations of smoking with systemic and renal hemodynamics and renal function parameters in healthy individuals. METHODS Data from 196 potential living kidney donors were analysed retrospectively. Mean arterial blood pressure (MAP), effective renal plasma flow (ERPF) and creatinine clearance had been measured. We additionally calculated parameters of renal hemodynamics. Data were analyzed for the effects of smoking and sex dependent on age and MAP. RESULTS Systemic and renal hemodynamic parameters did not differ between smokers and non-smokers. In non-smokers of both sexes MAP was negatively correlated with ERPF, and higher MAP was associated with increased renal vascular resistance and with afferent arteriolar resistance, with glomerular pressure (PG) remaining constant. However, in male, but not in female smokers, ERPF and PG increased with MAP. A correlation of age with a steeper decline in ERPF in male smokers was lost in multiple regression analysis. CONCLUSIONS As compared to women, smoking men may exhibit an increased glomerular hydrostatic pressure, which is a known promoter of kidney damage.
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Affiliation(s)
- Hana Guberina
- Department of Nephrology, Essen University Hospital, Essen, Germany
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50
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Cherney DZI, Perkins BA, Soleymanlou N, Maione M, Lai V, Lee A, Fagan NM, Woerle HJ, Johansen OE, Broedl UC, von Eynatten M. Renal hemodynamic effect of sodium-glucose cotransporter 2 inhibition in patients with type 1 diabetes mellitus. Circulation 2013; 129:587-97. [PMID: 24334175 DOI: 10.1161/circulationaha.113.005081] [Citation(s) in RCA: 926] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The primary objective of this mechanistic open-label, stratified clinical trial was to determine the effect of 8 weeks' sodium glucose cotransporter 2 inhibition with empagliflozin 25 mg QD on renal hyperfiltration in subjects with type 1 diabetes mellitus (T1D). METHODS AND RESULTS Inulin (glomerular filtration rate; GFR) and paraaminohippurate (effective renal plasma flow) clearances were measured in individuals stratified based on having hyperfiltration (T1D-H, GFR ≥ 135 mL/min/1.73m(2), n=27) or normal GFR (T1D-N, GFR 90-134 mL/min/1.73m(2), n=13) at baseline. Renal function and circulating levels of renin-angiotensin-aldosterone system mediators and NO were measured under clamped euglycemic (4-6 mmol/L) and hyperglycemic (9-11 mmol/L) conditions at baseline and end of treatment. During clamped euglycemia, hyperfiltration was attenuated by -33 mL/min/1.73m(2) with empagliflozin in T1D-H, (GFR 172±23-139±25 mL/min/1.73 m(2), P<0.01). This effect was accompanied by declines in plasma NO and effective renal plasma flow and an increase in renal vascular resistance (all P<0.01). Similar significant effects on GFR and renal function parameters were observed during clamped hyperglycemia. In T1D-N, GFR, other renal function parameters, and plasma NO were not altered by empagliflozin. Empagliflozin reduced hemoglobin A1c significantly in both groups, despite lower insulin doses in each group (P≤0.04). CONCLUSIONS In conclusion, short-term treatment with the sodium glucose cotransporter 2 inhibitor empagliflozin attenuated renal hyperfiltration in subjects with T1D, likely by affecting tubular-glomerular feedback mechanisms. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01392560.
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Affiliation(s)
- David Z I Cherney
- Department of Medicine, Division of Nephrology (D.Z.I.C., M.M., V.L., A.L.) and the Department of Medicine, Division of Endocrinology (B.A.P.), Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Boehringer Ingelheim Canada Ltd./Ltée, Burlington, Ontario, Canada (N.S.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (N.M.F., M.v.E.); and Boehringer Ingelheim Pharma GmbH & Co.KG, Ingelheim, Germany (H.J.W., O.E.J., U.C.B.)
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