Individual and Combined Relationship between Reduced eGFR and/or Increased Urinary Albumin Excretion Rate with Mortality Risk among Insulin-Treated Patients with Type 2 Diabetes in Routine Practice

The drivers of non-adherence to albuminuria testing guidelines and the clinical and economic impact of not identifying chronic kidney disease

BACKGROUND

Regular monitoring is required to ensure that patients who have, or are at risk of, chronic kidney disease (CKD) receive appropriate management. Guidelines recommend regular testing of estimated glomerular filtration rate (GFR) and albuminuria. However, evidence suggests that albuminuria testing rates, specifically urine albumin-to-creatinine ratio (UACR), are suboptimal.

AIM

To assess published evidence relating to the drivers of non-adherence to albuminuria testing guidelines and the impact of not identifying CKD across the course of progression.

MATERIALS AND METHODS

A systematic review of five bibliographic databases was conducted, supplemented by hand searches of relevant conference abstracts.

RESULTS

One study was identified that reported drivers of non-adherence to albuminuria testing guidelines. The largest barrier was the perception that testing does not impact patient management. Thirteen studies were identified that evaluated the impact of not identifying CKD patients. All included studies analyzed the effect of not identifying worsening CKD severity leading to late referral (LR). 12/13 studies reported only on clinical impact, and 1/13 reported on clinical and economic impact. LR led to higher costs and worse outcomes than early referral, including higher rates of mortality and worsened kidney replacement therapy preparation.

CONCLUSION

This systematic review demonstrates a gap in evidence exploring the drivers of non-adherence to albuminuria testing guidelines and the impact of not identifying patients in the early stages of CKD. Guideline-recommended testing allows timely identification, referral, and treatment for patients with, or at risk of, CKD, providing the best chance of avoiding the worsened outcomes identified in this review.

Association of estimated glomerular filtration rate and all-cause mortality in acute pancreatitis: a retrospective analysis

BACKGROUND

Our primary objective was to explore the association between estimated glomerular filtration rate (eGFR) and all-cause mortality in acute pancreatitis (AP) admission to intensive care units.

METHODS

This study is a retrospective cohort analysis based on the Medical Information Mart for Intensive Care III database. The eGFR was calculated based on Chronic Kidney Disease Epidemiology Collaboration equation. Cox models with restricted cubic spline functions were used to evaluated the association of eGFR with all-cause mortality.

RESULTS

The mean eGFR was 65.93 ± 38.56 ml/min/1.73 m² in 493 eligible patients. 28-day mortality was 11.97% (59/ 493), which decreased by 15% with every 10 ml/min/1.73 m² increase in eGFR. The adjusted hazard ratio (95% confidence interval) was 0.85 (0.76-0.96). A non-linear association was proved between eGFR and all-cause mortality. When eGFR < 57 ml/min/1.73 m², there was a negative correlation between eGFR and 28-day mortality, hazard ratio (95% CI) was 0.97 (0.95, 0.99). The eGFR was also negatively correlated with in-hospital and in-ICU mortality. Subgroup analysis confirmed that the association between eGFR and 28-day mortality in different characteristics was stable.

CONCLUSIONS

The eGFR was negatively correlated with all-cause mortality in AP when eGFR is less than the threshold inflection point.

Effect of Urinary Albumin Creatinine Ratio on Cardiovascular Morbidity and Mortality in Diabetes Patients with Atherosclerotic Disease

BACKGROUND

Diabetes mellitus (DM) patients with increased urinary albumin creatinine ratio (uACR) have higher risk of mortality, while it is unclear in DM patients with atherosclerotic cardiovascular disease (ASCVD).

METHODS

We analysed 2832 DM patients with ASCVD in this multi-center registry cohort study Cardiorenal ImprovemeNt II (CIN-II) in 5 Chinese tertiary hospitals from 2007 to 2020. Patients were divided into 3 groups according to their uACR level (normal group: uACR <30mg/g, moderately increased group: 30mg/g≤ uACR <300mg/g, severely increased group: 300mg/g≤ uACR). The main outcome of the study was cardiovascular mortality and all-cause mortality.

RESULTS

During a median follow-up of 2.1 years, among 2832 patients (mean age: 63.3 ± 9.9 years, 29.1% women), 434 patients (15.3%) had moderately increased uACR, and 203 patients (7.2%) had severely increased uACR. Compared to patients in normal group, patients had higher cardiovascular mortality in moderately increased group and severely increased group (2.5% vs 9.9% vs 16.7%, P < 0.001), as well as all-cause mortality. After adjusting confounders, the risk of cardiovascular mortality remained higher in moderately increased group (adjusted hazard ratio [aHR]: 3.13; 95% confidence interval [CI]: 2.04-4.81) and severely increased group (aHR: 4.54; 95% CI: 2.58-8.01) than in normal group, as well as all-cause mortality.

CONCLUSION

In our study, we found nearly a quarter of DM patients with ASCVD had increased uACR, and they have over 2- or 3-fold risk of cardiovascular mortality than those with normal uACR. UACR is a helpful indicator for risk stratification and treatment target for DM patients with ASCVD.

Cardiovascular autonomic neuropathy and the impact on progression of diabetic kidney disease in type 1 diabetes

INTRODUCTION

We investigated the association between cardiovascular autonomic neuropathy (CAN) and decline in kidney function in type 1 diabetes.

RESEARCH DESIGN AND METHODS

We included 329 persons with type 1 diabetes. CAN was assessed by cardiovascular reflex tests (CARTs): heart rate response to deep breathing (E/I ratio), to standing (30/15 ratio) and to the Valsalva maneuvre. Two or more pathological CARTs defined CAN diagnosis. Outcomes were yearly change in albuminuria or yearly change in estimated glomerular filtration rate (eGFR). An endpoint of eGFR decline >30%, development of end-stage kidney disease (ESKD) or death was examined.Associations were assessed by linear and Cox regression.

RESULTS

Participants were aged 55.2 (9.4) years, 52% were male, with a diabetes duration of 40.1 (8.9) years, HbA_1c of 7.9% (62.5 mmol/mol), eGFR 77.9 (27.7) mL/min/1.73 m², urinary albumin excretion rate of 14.5 (7-58) mg/24 hours, and 31% were diagnosed with CAN.CAN was associated with a 7.8% higher albuminuria increase per year (95% CI: 0.50% to 15.63%, p=0.036) versus no CAN. The endpoint of ESKD, all-cause mortality and ≥30% decline in eGFR was associated with CAN (HR=2.497, p=0.0254).

CONCLUSION

CAN and sympathetic dysfunction were associated with increase in albuminuria in individuals with type 1 diabetes suggesting its role as a potential marker of diabetic kidney disease progression.

A Phase IIb Randomized Controlled Trial Investigating the Effects of Tocotrienol-Rich Vitamin E on Diabetic Kidney Disease

Diabetic kidney disease (DKD) is a debilitating complication of diabetes, which develops in 40% of the diabetic population and is responsible for up to 50% of end-stage renal disease (ESRD). Tocotrienols have shown to be a potent antioxidant, anti-inflammatory, and antifibrotic agent in animal and clinical studies. This study evaluated the effects of 400 mg tocotrienol-rich vitamin E supplementation daily on 59 DKD patients over a 12-month period. Patients with stage 3 chronic kidney disease (CKD) or positive urine microalbuminuria (urine to albumin creatinine ratio; UACR > 20–200 mg/mmol) were recruited into a randomized, double-blind, placebo-controlled trial. Patients were randomized into either intervention group (n = 31) which received tocotrienol-rich vitamin E (Tocovid SupraBio^TM; Hovid Berhad, Ipoh, Malaysia) 400 mg daily or a placebo group which received placebo capsules (n = 28) for 12 months. HbA1c, renal parameters (i.e., serum creatinine, eGFR, and UACR), and serum biomarkers were collected at intervals of two months. Tocovid supplementation significantly reduced serum creatinine levels (MD: −4.28 ± 14.92 vs. 9.18 ± 24.96), p = 0.029, and significantly improved eGFR (MD: 1.90 ± 5.76 vs. −3.29 ± 9.24), p = 0.011 after eight months. Subgroup analysis of 37 patients with stage 3 CKD demonstrated persistent renoprotective effects over 12 months; Tocovid improved eGFR (MD: 4.83 ± 6.78 vs. −1.45 ± 9.18), p = 0.022 and serum creatinine (MD: −7.85(20.75) vs. 0.84(26.03), p = 0.042) but not UACR. After six months post washout, there was no improvement in serum creatinine and eGFR. There were no significant changes in the serum biomarkers, TGF-β1 and VEGF-A. Our findings verified the results from the pilot phase study where tocotrienol-rich vitamin E supplementation at two and three months improved kidney function as assessed by serum creatinine and eGFR but not UACR.

Renal Evaluation and Protection

Diabetes and diabetic nephropathy have become more prevalent in the elderly population. Diabetic nephropathy has become increasingly prevalent in the elderly population. The presence of this disease in an age group suffering multiple comorbidities has altered the pathophysiology and leading cause of mortality. Mortality has become linked more often to cardiovascular events rather than progression of end-stage-renal-disease, which explains the recent shift of focus of trials to improving cardiovascular-outcomes in patients with diabetes. In this chapter, we emphasize the difference in treatment modalities and goals of therapy in elderly versus young. In addition, we discuss results from recent outcome trials with regards to renal benefits of sodium-glucose co-transporter-2-inhibitors and glucagon-like peptide-1-receptor-agonists.