Modification of the Relationship Between Blood Pressure and Renal Albumin Permeability by Impaired Excretory Function and Diabetes

Mild cognitive impairment in type 2 diabetes is associated with fibrinogen-to-albumin ratios

Background

Cognitive impairment is the main manifestation of diabetes central neuropathy. Currently, there is no effective dementia treatment; early diagnosis and treatment are particularly crucial. Inflammation index fibrinogen-to-albumin ratio (FAR) has been shown to predict complications of type 2 diabetes (diabetic kidney disease and diabetes-related arteriosclerosis), but its relationship with mild cognitive impairment (MCI) in type 2 diabetes (T2D) is undetermined. In this study, we examined the association between the FAR and mild cognitive impairment in type 2 diabetes.

Methods

This is a retrospective and cross-sectional study. From January 2022 to December 2022, we have retrieved 328 inpatient medical records for T2D patients hospitalized at the First Hospital of Harbin Medical University from the hospital's electronic system. Subjects' cognitive function was assessed and grouped by the MoCA scales. Subjects' demographic and various laboratory indicators were collected. Using Spearman's bivariate correlation analysis, the FAR and other clinical variables were analyzed for association strength. A multiple linear regression analysis was conducted to determine the independent relationship between FAR and MoCA scores. Multivariate logistic regression was used to analyze the independent relationship between FAR and MCI. The capacity of the FAR to detect MCI was carried using receiver operating characteristic (ROC) analysis.

Results

The included participants' (n = 328; 61.9% male) mean age was 52.62 ± 10.92 years. MoCA scores and MCI prevalence significantly differed (p < 0.05) between the four subgroups of FAR quartiles. The FAR and the MoCA score were significantly negatively correlated in the entire population (p < 0.05). Based on the multiple linear regression analysis, lnFAR and lnMoCA are significantly correlated (β = -0.449, t = -8.21, p < 0.05, R2 = 0.469). In multivariate logistic regression analysis, FAR and MCI were independently correlated after adjusting for covariates (OR 95% CI 34.70 [13.90-86.66]). Finally, the analysis of receptor working characteristics shows that the optimal FAR cut-off value was 0.08 (sensitivity: 95.81%, specificity: 84.47%) for detecting MCI in type 2 diabetes.

Conclusion

In type 2 diabetes, the FAR was positive associations with MCI and negative associations with MoCA score. The high FAR was associated with an increased risk of MCI. FAR maybe a appropriate indicator of MCI risk for type 2 diabetes.

Intestinal microbiome diversity of diabetic and non-diabetic kidney disease: Current status and future perspective

A significant portion of the health burden of diabetic kidney disease (DKD) is caused by both type 1 and type 2 diabetes which leads to morbidity and mortality globally. It is one of the most common diabetic complications characterized by loss of renal function with high prevalence, often leading to acute kidney disease (AKD). Inflammation triggered by gut microbiota is commonly associated with the development of DKD. Interactions between the gut microbiota and the host are correlated in maintaining metabolic and inflammatory homeostasis. However, the fundamental processes through which the gut microbiota affects the onset and progression of DKD are mainly unknown. In this narrative review, we summarised the potential role of the gut microbiome, their pathogenicity between diabetic and non-diabetic kidney disease (NDKD), and their impact on host immunity. A well-established association has already been seen between gut microbiota, diabetes and kidney disease. The gut-kidney interrelationship is confirmed by mounting evidence linking gut dysbiosis to DKD, however, it is still unclear what is the real cause of gut dysbiosis, the development of DKD, and its progression. In addition, we also try to distinguish novel biomarkers for early detection of DKD and the possible therapies that can be used to regulate the gut microbiota and improve the host immune response. This early detection and new therapies will help clinicians for better management of the disease and help improve patient outcomes.

Intraoperative alteration in the vital signs of diabetic patients during cataract surgery with local anesthesia

Purpose

Diabetic patients often have systemic circulation diseases which may cause serious systemic complications during ophthalmic surgeries with local anesthesia. The purpose of this study is to evaluate the intraoperative alteration of the vital signs in diabetic patients during cataract surgery with local anesthesia.

Methods

Clinical records of 428 patients who underwent cataract surgeries with local anesthesia were reviewed. The parameters measured were systolic/diastolic blood pressures and pulse rates at pre-operation, 5, 10 and 15 minutes during the surgeries. The factors were compared between non-diabetic patients (n = 325) and diabetic patients (n = 103).

Results

Diabetic patients had significantly higher fasting blood sugar and preoperative pulse rate. Diabetic patients showed significantly higher systolic blood pressure compared to non-diabetic patients at 5 and 10 minutes from the beginning of surgery (p = 0.0093 and 0.0075, respectively). In the non-diabetic patients, the pulse rate was significantly decreased at 5 minutes from the beginning of surgery (p = 4.74 x 10⁻⁸) which was maintained during the surgery, but no change was observed in the pulse rate of the diabetic patients.

Conclusions

Diabetic patients showed higher systolic blood pressure and pulse rate during cataract surgeries with local anesthesia, which should be monitored carefully by the physicians to avoid possible systemic complications.

Contribution of Predictive and Prognostic Biomarkers to Clinical Research on Chronic Kidney Disease

Chronic kidney disease (CKD), defined as the presence of albuminuria and/or reduction in estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2, is considered a growing public health problem, with its prevalence and incidence having almost doubled in the past three decades. The implementation of novel biomarkers in clinical practice is crucial, since it could allow earlier diagnosis and lead to an improvement in CKD outcomes. Nevertheless, a clear guidance on how to develop biomarkers in the setting of CKD is not yet available. The aim of this review is to report the framework for implementing biomarkers in observational and intervention studies. Biomarkers are classified as either prognostic or predictive; the first type is used to identify the likelihood of a patient to develop an endpoint regardless of treatment, whereas the second type is used to determine whether the patient is likely to benefit from a specific treatment. Many single assays and complex biomarkers were shown to improve the prediction of cardiovascular and kidney outcomes in CKD patients on top of the traditional risk factors. Biomarkers were also shown to improve clinical trial designs. Understanding the correct ways to validate and implement novel biomarkers in CKD will help to mitigate the global burden of CKD and to improve the individual prognosis of these high-risk patients.

Amplified Association Between Blood Pressure and Albuminuria in Overweight Patients With Biopsy-Proven Hypertensive Nephrosclerosis

BACKGROUND

An overweight person is at high risk for hypertensive renal damage. The effect of weight on the association between systolic blood pressure (SBP) and albuminuria remains unknown in patients with histologically diagnosed hypertensive nephrosclerosis.

METHODS

A total of 97 patients with biopsy-confirmed hypertensive nephrosclerosis were recruited from 13 centers throughout Japan. We examined the relationship between SBP and proteinuria among those who were overweight, which is defined as a body mass index ≥25 kg/m2, and those who were not. We examined the interaction of weight and SBP with albuminuria at baseline and with the changes in estimated glomerular filtration rate (eGFR) during the observational period.

RESULTS

Our results included mean age (54 years old), blood pressure (138/80), eGFR (53 ml/min/1.73 m2), and urine albumin levels (0.2 g/day). SBP was significantly correlated with log-transformed urine albumin levels (r = 0.4, P = 0.01) in patients who were overweight (n = 38) compared with patients who were not overweight (n = 59). Multiple regression analysis revealed that the interaction between being overweight and SBP with respect to albuminuria was significantly correlated with the log-transformed urine albumin level (β = 0.39, P = 0.047) and was independent of age, sex, and potential confounding factors. The interaction between weight and SBP ≥140 mm Hg was significantly associated with a greater decrease in eGFR in the following 3 years.

CONCLUSIONS

Being overweight may enhance susceptibility to hypertensive glomerular damage and may eventually lead to renal progression in patients with hypertensive nephrosclerosis.

Mineralocorticoid receptor blockade suppresses dietary salt-induced ACEI/ARB-resistant albuminuria in non-diabetic hypertension: a sub-analysis of evaluate study

Excessive dietary salt intake can counteract the renoprotective effects of renin-angiotensin system (RAS) blockade in hypertensive patients with chronic kidney disease (CKD). In rodents, salt loading induces hypertension and renal damage by activating the mineralocorticoid receptor (MR) independently of plasma aldosterone levels. Thus, high salt-induced resistance to RAS blockade may be mediated by MR activation. To test this, a post hoc analysis of the Eplerenone Combination Versus Conventional Agents to Lower Blood Pressure on Urinary Antialbuminuric Treatment Effect (EVALUATE) trial was conducted. Thus, 304 non-diabetic hypertensive patients on RAS-blocking therapy were divided into tertiles according to salt intake (estimated 24-h urinary sodium excretion at baseline) and compared in terms of percent reduction in urinary albumin-to-creatinine ratio (UACR) at 52 weeks relative to baseline. The eplerenone-treated patients in the highest sodium excretion tertile exhibited significantly greater reduction in UACR than the placebo subjects in the same tertile (-22.5% vs. +21.8%, p = 0.02). This disparity was not observed in the lowest (-10.2% vs. -0.84%, p = 0.65) or middle (-19.5% vs. +9.5%, p = 0.22) tertiles. Similar systolic blood pressure changes were observed. In the whole cohort, reduction in UACR correlated positively with reduction in systolic blood pressure (r² = 0.04, p = 0.02). These results support the hypothesis that excessive salt intake can enhance resistance to RAS blockade by activating MR. They also suggest that eplerenone plus RAS blockade may be effective for CKD in hypertensive patients, especially those with excessive salt intake.

The clinical efficacy of angiotensin II type1 receptor blockers on inflammatory markers in patients with hypertension: a multicenter randomized-controlled trial; MUSCAT-3 study

Purpose: The purpose of present study was to evaluate the clinical efficacy of irbesartan on the anti-inflammatory and anti-oxidative stress effect in patients with hypertension compared to other ARBs. Further, we assessed the effect of the ARBs on kidney function and urinary albumin excretion. Methods: Eighty-five outpatients with hypertension who took an ARB except irbesartan more than 3 months were assigned into two groups, one continued the same ARB and the other switched the ARB to irbesartan for 6 months. Results: Although blood pressures were equally controlled (continue group: 148 ± 2/79 ± 2 mmHg to 131 ± 2/74 ± 2 mmHg; switch group: 152 ± 2/81 ± 2 mmHg to 132 ± 2/74 ± 2 mmHg; p < 0.001 each), the inflammatory markers (hsCRP, PTX3, MCP-1) and oxidative stress marker (MDA-LDL) did not change after 6 months in both groups. Urinary albumin excretion was significantly reduced only in the switch group without renal function deterioration (switch group 292.4 ± 857.9 mg/gCr to 250.6 ± 906.5 mg/gCr, p = 0.012). Conclusion: These results provide knowledge of the characteristics of irbesartan, suggesting appropriate choice of ARBs in the treatment for hypertension should be considered.

Augmented Association Between Blood Pressure and Proteinuria in Hyperuricemic Patients With Nonnephrotic Chronic Kidney Disease

BACKGROUND

Hyperuricemia (HU) may enhance susceptibility to hypertensive renal damage via disrupted autoregulation of glomerular hemodynamics. The effect of HU on the association between blood pressure (BP) and proteinuria remains unknown in patients with chronic kidney disease (CKD).

METHODS

In total, 109 patients with nonnephrotic CKD (55 men and 54 females) who underwent renal biopsy were recruited. Arteriolar hyalinosis was semiquantitatively assessed via arteriole grading. Correlation between BP and urine protein (UP) level was examined based on the presence of HU, which was defined as the use of urate-lowering drugs or serum uric acid levels of ≥7 and ≥5 mg/dl in males and females, respectively, which were associated with increased risks of hyalinosis in our previous study.

RESULTS

Median age, BP, estimated glomerular filtration rate, and UP level were 38 years, 124/74 mm Hg, 82 ml/min/1.73 m2, and 0.8 g/gCr, respectively. In patients with HU (n = 59), log-transformed systolic BP (SBP) was significantly correlated with log-transformed UP level (r = 0.49, P < 0.0001); this was not observed in patients without HU (n = 50). Multiple regression analysis (R2 = 0.21, P = 0.0001) revealed that the interaction between HU and log-transformed SBP with respect to proteinuria was significantly correlated with log-transformed UP level (β = 7.0, P = 0.03), independent of age, sex, and potential confounding factors; however, this statistical significance was completely eliminated after adjustment for the arteriolar hyalinosis index.

CONCLUSIONS

HU potentiates susceptibility to hypertensive glomerular damage via disrupted autoregulation in patients with nonnephrotic CKD.

Modification of the impact of hypertension on proteinuria by renal arteriolar hyalinosis in nonnephrotic chronic kidney disease

OBJECTIVE

Morphological analysis suggests that afferent arteriole hyalinosis reflects disturbed autoregulation of glomerular hemodynamics. However, the effect of arteriolar hyalinosis on the correlation between blood pressure (BP) levels and proteinuria is unknown in patients with chronic kidney disease (CKD). Therefore, we conducted a cross-sectional study to determine this correlation.

METHODS

A total of 109 patients with nonnephrotic CKD (55 men and 54 women) who underwent renal biopsy were recruited. Arteriolar hyalinosis was semiquantitatively assessed via arteriole grading. We examined the correlation between BP and urine protein levels (g/gCr) according to the presence of arteriolar hyalinosis.

RESULT

Patients had a mean age, BP, estimated glomerular filtration rate, and urine protein level of 40 years, 126/75 mmHg, 86 ml/min per 1.73 m, and 1.3 g/gCr, respectively. Patients with hyalinosis (n = 59) exhibited significant increases in median proteinuria (g/gCr) because the SBP increased (<130, 130-140, and ≥140 mmHg: 1.0, 1.3, and 2.3, respectively; P = 0.045); however, median proteinuria was comparable in patients without hyalinosis (n = 50), regardless of SBP. Multiple logistic analysis revealed that combined high BP and hyalinosis were significantly associated with increased proteinuria, defined as equal to or greater than the median value (odds ratio: 5.99, 95% confidence interval: 1.13-31.70, P < 0.05 vs. high BP-/hyalinosis-). Moreover, this combination was associated with the largest glomerular diameter.

CONCLUSION

Renal arteriolar hyalinosis may potentiate susceptibility to BP-related glomerular damage in patients with nonnephrotic CKD. Dysregulated afferent arteriolar resistance via arteriolar sclerosis may affect hypertensive renal damage.

Progression of Chronic Kidney Disease After Acute Kidney Injury: Role of Self-Perpetuating Versus Hemodynamic-Induced Fibrosis

The relative contribution of self-perpetuating versus hemodynamic-induced fibrosis to the progression of chronic kidney disease (CKD) after acute kidney injury (AKI) is unclear. In the present study, male Sprague-Dawley rats underwent right uninephrectomy and were instrumented with a blood pressure radiotelemeter. Two weeks later, separate groups of rats were subjected to 40 minutes renal ischemia-reperfusion or sham surgery and followed up for 4 or 16 weeks to determine the extent to which glomerulosclerosis and tubulointerstitial fibrosis as a result of the AKI-CKD transition (ie, at 4 weeks post AKI) change over time during the progression of CKD (ie, at 16 weeks post AKI). On average, tubulointerstitial fibrosis was ≈3-fold lower (P<0.05), whereas glomerulosclerosis was ≈6-fold higher (P<0.05) at 16 versus 4 weeks post AKI. At 16 weeks post AKI, marked tubulointerstitial fibrosis was only observed in rats exhibiting marked glomerulosclerosis, proteinuria, and kidney hypertrophy consistent with a hemodynamic pathogenesis of renal injury. Moreover, quantitative analysis between blood pressure and renal injury revealed a clear and modest blood pressure threshold (average 16-week systolic blood pressure of ≈127 mm Hg) for the development of glomerulosclerosis. In summary, modest levels of blood pressure may be playing a substantial role in the progression of renal disease after AKI in settings of preexisting CKD associated with 50% loss of renal mass. In contrast, these data do not support a major role of self-perpetuating tubulointerstitial fibrosis in the progression CKD after AKI in such settings.

Pirfenidone exhibits cardioprotective effects by regulating myocardial fibrosis and vascular permeability in pressure-overloaded hearts

Although cardiac fibrosis causes heart failure, its molecular mechanisms remain elusive. In this study, we investigated the mechanisms of cardiac fibrosis and examined the effects of the antifibrotic drug pirfenidone (PFD) on chronic heart failure. To understand the responsible mechanisms, we generated an in vivo pressure-overloaded heart failure model via transverse aortic constriction (TAC) and examined the effects of PFD on chronic-phase cardiac fibrosis and function. In the vehicle group, contractile dysfunction and left ventricle fibrosis progressed further from 4 to 8 wk after TAC but were prevented by PFD treatment beginning 4 wk after TAC. We isolated cardiac fibroblasts and vascular endothelial cells from the left ventricles of adult male mice and investigated the cell-type-specific effects of PFD. Transforming growth factor-β induced upregulated collagen 1 expression via p38 phosphorylation and downregulated claudin 5 (Cldn5) expression in cardiac fibroblasts and endothelial cells, respectively; both processes were inhibited by PFD. Moreover, PFD inhibited changes in the collagen 1 and Cldn5 expression levels, resulting in reduced fibrosis and serum albumin leakage into the interstitial space during the chronic phase in TAC hearts. In conclusion, PFD inhibited cardiac fibrosis by suppressing both collagen expression and the increased vascular permeability induced by pressure overload.