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Culshaw GJ, Costello HM, Binnie D, Stewart KR, Czopek A, Dhaun N, Hadoke PWF, Webb DJ, Bailey MA. Impaired pressure natriuresis and non-dipping blood pressure in rats with early type 1 diabetes mellitus. J Physiol 2019; 597:767-780. [PMID: 30537108 PMCID: PMC6355628 DOI: 10.1113/jp277332] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 11/28/2018] [Indexed: 01/26/2023] Open
Abstract
KEY POINTS Type 1 diabetes mellitus increases cardiovascular risk; hypertension amplifies this risk, while pressure natriuresis regulates long-term blood pressure. We induced type 1 diabetes in rats by streptozotocin injection and demonstrated a substantial impairment of pressure natriuresis: acute increases in blood pressure did not increase renal medullary blood flow, tubular sodium reabsorption was not downregulated, and proximal tubule sodium reabsorption, measured by lithium clearance, was unaffected. Insulin reduced blood glucose in diabetic rats, and rescued the pressure natriuresis response without influencing lithium clearance, but did not restore medullary blood flow. Radiotelemetry showed that diastolic blood pressure was increased in diabetic rats, and its diurnal variation was reduced. Increases in medullary blood flow and decreases in distal tubule sodium reabsorption that offset acute rises in BP are impaired in early type 1 diabetes, and this impairment could be a target for preventing hypertension in type 1 diabetes. ABSTRACT Type 1 diabetes mellitus (T1DM) substantially increases cardiovascular risk, and hypertension amplifies this risk. Blood pressure (BP) and body sodium homeostasis are linked. T1DM patients have increased total exchangeable sodium, correlating directly with BP. Pressure natriuresis is an important physiological regulator of BP. We hypothesised that pressure natriuresis would be impaired, and BP increased, in the early phase of T1DM. Male Sprague-Dawley rats were injected with streptozotocin (30-45 mg/kg) or citrate vehicle. After 3 weeks, pressure natriuresis was induced by serial arterial ligation. In non-diabetic controls, this increased fractional excretion of sodium from ∼1% to ∼25% of the filtered load (P < 0.01); in T1DM rats, the response was significantly blunted, peaking at only ∼3% (P < 0.01). Mechanistically, normal lithium clearance suggested that distal tubule sodium reabsorption was not downregulated with increased BP in T1DM rats. The pressure dependence of renal medullary perfusion, considered a key factor in the integrated response, was abolished. Insulin therapy rescued the natriuretic response in diabetic rats, restoring normal downregulation of tubular sodium reabsorption when BP was increased. However, the pressure dependence of medullary perfusion was not restored, suggesting persistent vascular dysfunction despite glycaemic control. Radiotelemetry showed that T1DM did not affect systolic BP, but mean diastolic BP was ∼5 mmHg higher than in non-diabetic controls (P < 0.01), and normal diurnal variation was reduced. In conclusion, functional impairment of renal sodium and BP homeostasis is an early manifestation of T1DM, preceding hypertension and nephropathy. Early intervention to restore pressure natriuresis in T1DM may complement reductions in cardiovascular risk achieved with glycaemic control.
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Affiliation(s)
- Geoffrey J. Culshaw
- The British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research InstituteThe University of Edinburgh47 Little France CrescentEdinburghEH16 4TJUK
| | - Hannah M. Costello
- The British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research InstituteThe University of Edinburgh47 Little France CrescentEdinburghEH16 4TJUK
| | - David Binnie
- The British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research InstituteThe University of Edinburgh47 Little France CrescentEdinburghEH16 4TJUK
| | - Kevin R. Stewart
- The British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research InstituteThe University of Edinburgh47 Little France CrescentEdinburghEH16 4TJUK
| | - Alicja Czopek
- The British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research InstituteThe University of Edinburgh47 Little France CrescentEdinburghEH16 4TJUK
| | - Neeraj Dhaun
- The British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research InstituteThe University of Edinburgh47 Little France CrescentEdinburghEH16 4TJUK
| | - Patrick W. F. Hadoke
- The British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research InstituteThe University of Edinburgh47 Little France CrescentEdinburghEH16 4TJUK
| | - David J. Webb
- The British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research InstituteThe University of Edinburgh47 Little France CrescentEdinburghEH16 4TJUK
| | - Matthew A. Bailey
- The British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research InstituteThe University of Edinburgh47 Little France CrescentEdinburghEH16 4TJUK
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Koye DN, Shaw JE, Reid CM, Atkins RC, Reutens AT, Magliano DJ. Incidence of chronic kidney disease among people with diabetes: a systematic review of observational studies. Diabet Med 2017; 34:887-901. [PMID: 28164387 DOI: 10.1111/dme.13324] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2017] [Indexed: 12/26/2022]
Abstract
AIMS The aim was to systematically review published articles that reported the incidence of chronic kidney disease among people with diabetes. METHODS A systematic literature search was performed using MEDLINE, Embase and CINAHL databases. The titles and abstracts of all publications identified by the search were reviewed and 10 047 studies were retrieved. RESULTS A total of 71 studies from 30 different countries with sample sizes ranging from 505 to 211 132 met the inclusion criteria. The annual incidence of microalbuminuria and albuminuria ranged from 1.3% to 3.8% for Type 1 diabetes. For Type 2 diabetes and studies combining both diabetes types, the range was from 3.8% to 12.7%, with four of six studies reporting annual rates between 7.4% and 8.6%. In studies reporting the incidence of eGFR < 60 ml/min/1.73 m2 using the Modification of Diet on Renal Disease (MDRD) equation, apart from one study which reported an annual incidence of 8.9%, the annual incidence ranged from 1.9% to 4.3%. The annual incidence of end-stage renal disease ranged from 0.04% to 1.8%. CONCLUSIONS The annual incidence of microalbuminuria and albuminuria is ~ 2-3% in Type 1 diabetes, and ~ 8% in Type 2 diabetes or mixed diabetes type. The incidence of developing eGFR < 60 ml/min/1.73 m2 is ~ 2-4% per year. Despite the wide variation in methods and study design, within a particular category of kidney disease, there was only modest variation in incidence rates. These findings may be useful in clinical settings to help understand the risk of developing kidney disease among those with diabetes.
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Affiliation(s)
- D N Koye
- Department of Clinical Diabetes and Epidemiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - J E Shaw
- Department of Clinical Diabetes and Epidemiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - C M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- School of Public Health, Curtin University, Perth, Australia
| | - R C Atkins
- Department of Clinical Diabetes and Epidemiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - A T Reutens
- Department of Clinical Diabetes and Epidemiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - D J Magliano
- Department of Clinical Diabetes and Epidemiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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Ku E, McCulloch CE, Mauer M, Gitelman SE, Grimes BA, Hsu CY. Association Between Blood Pressure and Adverse Renal Events in Type 1 Diabetes. Diabetes Care 2016; 39:2218-2224. [PMID: 27872156 PMCID: PMC5127223 DOI: 10.2337/dc16-0857] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 08/08/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare different blood pressure (BP) levels in their association with the risk of renal outcomes in type 1 diabetes and to determine whether an intensive glycemic control strategy modifies this association. RESEARCH DESIGN AND METHODS We included 1,441 participants with type 1 diabetes between the ages of 13 and 39 years who had previously been randomized to receive intensive versus conventional glycemic control in the Diabetes Control and Complications Trial (DCCT). The exposures of interest were time-updated systolic BP (SBP) and diastolic BP (DBP) categories. Outcomes included macroalbuminuria (>300 mg/24 h) or stage III chronic kidney disease (CKD) (sustained estimated glomerular filtration rate <60 mL/min/1.73 m2). RESULTS During a median follow-up time of 24 years, there were 84 cases of stage III CKD and 169 cases of macroalbuminuria. In adjusted models, SBP in the <120 mmHg range was associated with a 0.59 times higher risk of macroalbuminuria (95% CI 0.37-0.95) and a 0.32 times higher risk of stage III CKD (95% CI 0.14-0.75) compared with SBPs between 130 and 140 mmHg. DBP in the <70 mmHg range were associated with a 0.73 times higher risk of macroalbuminuria (95% CI 0.44-1.18) and a 0.47 times higher risk of stage III CKD (95% CI 0.21-1.05) compared with DBPs between 80 and 90 mmHg. No interaction was noted between BP and prior DCCT-assigned glycemic control strategy (all P > 0.05). CONCLUSIONS A lower BP (<120/70 mmHg) was associated with a substantially lower risk of adverse renal outcomes, regardless of the prior assigned glycemic control strategy. Interventional trials may be useful to help determine whether the currently recommended BP target of 140/90 mmHg may be too high for optimal renal protection in type 1 diabetes.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Michael Mauer
- Division of Pediatric Nephrology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Stephen E Gitelman
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Barbara A Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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Maahs DM, Daniels SR, de Ferranti SD, Dichek HL, Flynn J, Goldstein BI, Kelly AS, Nadeau KJ, Martyn-Nemeth P, Osganian SK, Quinn L, Shah AS, Urbina E. Cardiovascular disease risk factors in youth with diabetes mellitus: a scientific statement from the American Heart Association. Circulation 2014; 130:1532-58. [PMID: 25170098 DOI: 10.1161/cir.0000000000000094] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Pathogenesis and novel treatment from the mouse model of type 2 diabetic nephropathy. ScientificWorldJournal 2013; 2013:928197. [PMID: 23737732 PMCID: PMC3655660 DOI: 10.1155/2013/928197] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 04/04/2013] [Indexed: 01/13/2023] Open
Abstract
Diabetic nephropathy (DN) is the leading cause of end-stage kidney disease worldwide. However, current treatments remain suboptimal. Many factors, such as genetic and nongenetic promoters, hypertension, hyperglycemia, the accumulation of advanced glycation end products (AGEs), dyslipidemia, and albuminuria/proteinuria itself, influence the progression of this disease. It is important to determine the molecular mechanisms and treatment of this disease. The development of diabetes results in the formation of AGEs, oxidative stress, and the activation of the renin-angiotensin-aldosterone system (RAAS) within the kidney, which promotes progressive inflammation and fibrosis, leading to DN and declining renal function. A number of novel therapies have also been tested in the experimental diabetic model, including exercise, inhibitors of the RAAS (angiotensin type 1 receptor blockers (ARB), angiotensin-converting enzyme (ACE) inhibitors), inhibitors of AGE (pyridoxamine), peroxisome proliferator-activated receptor (PPAR) γ agonists (pioglitazone), inhibitors of lipid accumulation (statins and eicosapentaenoic acid (EPA)), and the vitamin D analogues. This review summarizes the advances in knowledge gained from our studies and therapeutic interventions that may prevent this disease.
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Abstract
The number of people with diabetic kidney disease continues to increase worldwide despite current treatments. Of the pathophysiologic mechanisms that have been identified in the development and progression of diabetic nephropathy, oxidative stress (more accurately described as increased levels of reactive oxygen species; ROS) is of major importance. The increase in ROS is due to both increased production and to decreased and/or inadequate antioxidant function. To date, human clinical trials with antioxidants have not been shown to be effective. This is likely due, at least in part, to the lack of specificity of current agents. Recent research has determined both major sources of high glucose-induced cellular ROS production as well as high glucose-induced changes in antioxidant function. Treatments targeted at one or more of the specific diabetes-induced alterations in the regulation of ROS levels will likely lead to effective treatments that prevent the development and progression of diabetic kidney disease.
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Affiliation(s)
- Robert C Stanton
- Harvard Medical School, Joslin Diabetes Center, One Joslin Place, Boston, MA 02215, USA.
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Abstract
Blood pressure (BP) in the prehypertensive range is associated with an increased risk for cardiovascular (CV) disease. Patients with co-morbidities are at greater risk for chronic kidney disease (CKD) development in the presence of prehypertension. Lifestyle changes can alter the natural history of prehypertension; however, long-term adherence is rare and thus, their impact on outcomes is limited. Pharmacological therapy in patients with prehypertension and demonstrable target organ damage with blockers of the renin-angiotensin system has demonstrated benefits on markers of CKD outcomes such as microalbuminuria. There are no data, however, on 'hard end points' such as doubling of creatinine or need for renal replacement therapy. In patients with diabetes, monitoring changes in albuminuria, along with assessment of BP in the prehypertensive range, is important to optimize early management and impact the attenuation of CKD progression. Data from natural history studies in patients with type 1 diabetes indicate that increases within the microalbuminuria range antedate increases in BP within the prehypertensive range. Even within the microalbuminuria range, however, systolic BP increases above 125 mm Hg are predictive of nephropathy. Thus, nephrologists need to ensure that their colleagues appreciate the importance of not only early BP intervention but also of monitoring albuminuria changes in order to have maximal impact on CKD prevention.
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Krishnan S, Short KR. Prevalence and significance of cardiometabolic risk factors in children with type 1 diabetes. ACTA ACUST UNITED AC 2009; 4:50-6. [PMID: 19245517 DOI: 10.1111/j.1559-4572.2008.00034.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Type 1 diabetes (T1D) is a common disease of childhood with a current prevalence of almost 2 cases per 1000 adolescents, according to the third National Health and Nutrition Examination Survey. Modern insulin treatment has resulted in improved quality of life for children with this chronic disorder. However, T1D continues to carry a long-term burden of increased microvascular and macrovascular complications and mortality risk. Compared to the nondiabetic population, patients with T1D are more likely to have >or=1 cardiovascular risk factor and often at an earlier age. Since the prevalence of cardiovascular risk factors increases with age in young persons with T1D, there is a clear need for early screening and counseling to prevent their occurrence and manage long-term health ramifications. The purpose of this review is to describe how traditional risk factors for cardiovascular disease such as an abnormal lipid profile, hypertension, obesity, and insulin resistance contribute to the accelerated atherosclerosis seen in young persons with T1D. A summary is given of the guidelines and recommendations published for clinical care for these patients.
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Affiliation(s)
- Sowmya Krishnan
- Section of Diabetes & Endocrinology, Department of Pediatrics, CMRI Diabetes and Metabolic Research Program, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Krishnan S, Short KR. Prevalence and significance of cardiometabolic risk factors in children with type 1 diabetes. JOURNAL OF THE CARDIOMETABOLIC SYNDROME 2009. [PMID: 19245517 DOI: 10.1111/j.1559-4572.2008.00034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Type 1 diabetes (T1D) is a common disease of childhood with a current prevalence of almost 2 cases per 1000 adolescents, according to the third National Health and Nutrition Examination Survey. Modern insulin treatment has resulted in improved quality of life for children with this chronic disorder. However, T1D continues to carry a long-term burden of increased microvascular and macrovascular complications and mortality risk. Compared to the nondiabetic population, patients with T1D are more likely to have >or=1 cardiovascular risk factor and often at an earlier age. Since the prevalence of cardiovascular risk factors increases with age in young persons with T1D, there is a clear need for early screening and counseling to prevent their occurrence and manage long-term health ramifications. The purpose of this review is to describe how traditional risk factors for cardiovascular disease such as an abnormal lipid profile, hypertension, obesity, and insulin resistance contribute to the accelerated atherosclerosis seen in young persons with T1D. A summary is given of the guidelines and recommendations published for clinical care for these patients.
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Affiliation(s)
- Sowmya Krishnan
- Section of Diabetes & Endocrinology, Department of Pediatrics, CMRI Diabetes and Metabolic Research Program, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Maia AL, Hwang SJ, Levy D, Larson MG, Larsen PR, Fox CS. Lack of association between the type 2 deiodinase A/G polymorphism and hypertensive traits: the Framingham Heart Study. Hypertension 2008; 51:e22-3. [PMID: 18285610 PMCID: PMC3014057 DOI: 10.1161/hypertensionaha.107.109454] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Alzahrani AS. Management of hypertension in diabetes mellitus. Expert Rev Endocrinol Metab 2007; 2:341-357. [PMID: 30743805 DOI: 10.1586/17446651.2.3.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Overall, approximately 40% of diabetic patients have hypertension at the time of diagnosis of diabetes and a similar percentage may develop hypertension during their follow-up. Factors contributing to this high prevalance of hypertension in diabetes include obesity, old age, insulin resistance, increased extracelluar volume, diabetic nephropathy and increased arterial stiffness. Well-conducted clinical trials that have been completed in the last decade demonstrated a major impact of hypertension on the micro- and macrovascular complications of diabetes and remarkable benefits of its control. Based on this large trial database, the currently accepted level of blood pressure used in diabetes for definition and target of therapy is 130/80 mmHg. Dietary and behavioral lifestyle modifications should be an intergral part of any management regimen. These include weight reduction, low sodium diet, exercise, moderate alcohol intake and smoking cessation. Effective control of blood pressure to target levels is more important than the drug(s) used. Combination drug therapy is needed frequently to achieve a target blood pressure. Although blockers of the renin-angiotensin-aldosterone system seem to have a favorable effect in diabetes, high-level evidence suggests that low-dose thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and calcium channel blockers are all good choices, both as initial and add-on therapy. Frequently, more than one drug is needed, and a low-dose thiazide diuretic combined with an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker is a commonly used effective combination. Other drugs that can be added include calcium channel blockers and β-blockers. In certain clinical situations, specific drug classes are indicated. These include angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in the case of diabetic nephropathy, β-blockers in the case of ischemic heart disease, and calcium channel blockers and loop diuretics in the case of advanced renal insufficiency, where the use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers carries a significant risk of hyperkalemia.
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Affiliation(s)
- Ali S Alzahrani
- a Consultant Endocrinologist, King Faisal Specialist Hospital & Research Center, Department of Medicine, MBC-46, PO Box 3354, Riyadh 11211, Saudi Arabia.
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