Pharmacotherapy to delay the progression of diabetic kidney disease in people with type 2 diabetes: past, present and future

The Mechanism of Plantaginis Semen in the Treatment of Diabetic Nephropathy based on Network Pharmacology and Molecular Docking Technology

BACKGROUND

Diabetic nephropathy (DN) is one of the common complications of diabetes. Plantaginis Semen (PS) has a variety of therapeutic effects, however its mechanism on DN is unclear.

OBJECTIVE

This paper aims to find the ingredients, the key targets, and the action pathways of PS on DN from the perspective of network pharmacology.

METHODS

The databases of network pharmacology, such as Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform (TCMSP), Pharmmapper, OMIM, DrugBank, Gene- Cards, TTD, Disgenet, STRING, and Cytoscape software, were used to find the main ingredients and targets. Gene Ontology (GO) function and Kyoto Encyclopedia of Genome and Genomes (KEGG) pathway enrichment analysis were used to reveal the potential pathways of the PS on DN. The GEO database was used to find the targets of DN based on valid experimental research. The molecular docking technology was used to evaluate the combination between ingredients of PS and the targets.

RESULTS

A total of 9 active ingredients and 216 potential therapeutic targets were obtained for PS on DN. Hub targets were discovered by the Cytoscape software analysis. CASP3 was screened by Venn diagram by making intersection between GSE30529 and hub genes. Moreover, CASP3 was combined with one of the nine active ingredients, quercetin, by molecular docking analysis. The KEGG pathways were mainly involved in diabetic nephropathy, and were simultaneously associated with CASP3 as followed: AGE-RAGE signaling pathway in diabetic complications, apoptosis, lipid and atherosclerosis, MAPK signaling pathway, TNF signaling pathway, IL-17 signaling pathway, and p53 signaling pathway.

CONCLUSION

PS can have the treatment on DN through CASP3. Quercetin, as one of the nine active ingredients, can be bounded to CASP3 to inhibit apoptosis in DN. PS can also take action on DN probably through many pathways. The role of PS on DN through other pathways still needs to be further elaborated.

Targeting DNA methylation in diabetic kidney disease: A new perspective

Diabetic kidney disease (DKD) is a leading diabetic complication causing significant mortality among people around the globe. People with poor glycemic control accompanied by hyperinsulinemia, dyslipidemia, hypertension, and obesity develop diabetic complications. These diabetic patients develop epigenetic changes and suffer from diabetic kidney complications even after subsequent glucose control, the phenomenon that is recognized as metabolic memory. DNA methylation is an essential epigenetic modification that contributes to the development and progression of several diabetic complications, including DKD. The aberrant DNA methylation pattern at CpGs sites within several genes, such as mTOR, RPTOR, IRS2, GRK5, SLC27A3, LCAT, and SLC1A5, associated with the accompanying risk factors exacerbate the DKD progression. Although drugs such as azacytidine and decitabine have been approved to target DNA methylation for diseases such as hematological malignancies, none have been approved for the treatment of DKD. More importantly, no DNA hypomethylation-targeting drugs have been approved for any disease conditions. Understanding the alteration in DNA methylation and its association with the disease risk factors is essential to target DKD effectively. This review has discussed the abnormal DNA methylation pattern and the kidney tissue-specific expression of critical genes involved in DKD onset and progression. Moreover, we also discuss the new possible therapeutic approach that can be exploited for treating DNA methylation aberrancy in a site-specific manner against DKD.

Antihypertensive and Lipid-Lowering Medication Adherence in Young Adults With Youth-Onset Type 2 Diabetes

Importance

Youth-onset type 2 diabetes is associated with early development of chronic complications. Treatment of elevated blood pressure (BP), nephropathy, and dyslipidemia are critical to reduce morbidity. Data are needed on adherence to BP- and lipid-lowering medications in young adults with youth-onset diabetes.

Objective

To assess adherence and factors associated with adherence to BP- and lipid-lowering medications in young adults with youth-onset type 2 diabetes and diagnoses of hypertension, nephropathy, or dyslipidemia.

Design, Setting, and Participants

This cohort study measured medication adherence with 3 monthly unannounced pill counts at 2 time points 1 year apart during iCount, conducted during the last years (2017-2019) of the observational phase of the Treatment Options for Type 2 Diabetes in Adolescents and Youth study. Psychosocial factors associated with medication adherence were examined. Participants included individuals with youth-onset type 2 diabetes with hypertension, nephropathy, or dyslipidemia receiving diabetes care in their communities. Data were analyzed from September 2022 to September 2023.

Main Outcomes and Measures

The main outcome was BP- and lipid-lowering medication adherence, with low adherence defined as using less than 80% of pills and high adherence, at least 80% of pills. Psychosocial factors were measured using the Beliefs about Medicines Questionnaire and Material Needs Insecurities Survey.

Results

Of 381 participants in iCount, 243 participants (mean [SD] age, 26.12 [2.51] years; 159 [65.43%] women) with hypertension, nephropathy, or dyslipidemia were included in analysis. Among 196 participants with hypertension or nephropathy, 157 (80.1%) had low adherence. Participants with low adherence, compared with those with high adherence, were younger (mean [SD] age, 25.99 [2.41] vs 27.26 [2.41] years; P = .005), had higher glycated hemoglobin A1c (mean [SD], 10.33% [2.66 percentage points] vs 8.85% [2.39 percentage points]; P = .001), shorter diabetes duration (mean [SD], 12.32 [1.49] vs 12.90 [1.46] years; P = .03), and less education (eg, 17 participants [10.83%] vs 0 participants with no high school diploma; P = .004). Of 146 participants with dyslipidemia, 137 (93.8%) had low adherence and only 9 participants (6.2%) had high adherence. Of 103 participants with low adherence to BP-lowering medications and using oral hypoglycemic agents, 83 (80.58%) had low adherence to oral hypoglycemic agents. Beliefs that medications are necessary were higher for participants with high adherence to BP-lowering medications than those with low adherence in unadjusted analyses (mean [SD] necessity score, 16.87 [6.78] vs 13.89 [9.15]; P = .03). In adjusted multivariable analyses of participants with hypertension or nephropathy, having at least 1 unmet social need (odds ratio [OR], 0.20; 95% CI, 0.05-0.65; P = .04) and medication concerns (OR, 0.63; 95% CI, 0.40-0.96; P = .01) were associated with worse medication adherence 1 year follow-up. Diabetes distress, self-efficacy, depressive and anxiety symptoms, and self-management support were not associated with 1-year medication adherence.

Conclusions and Relevance

These findings suggest that adherence to BP- and lipid-lowering medications was very poor in this cohort. To improve medication adherence and prevent early vascular events, approaches that identify and address medication concerns and unmet social needs are needed.

Treatment patterns of antidiabetic and kidney protective therapies among patients with type 2 diabetes mellitus and chronic kidney disease in Colombia. The KDICO descriptive study

BACKGROUND

Type 2 diabetes mellitus is one of the most common causes of chronic kidney disease (CKD) worldwide and prevalence of 1.75 per 100 inhabitants in Colombia. The aim of this study was to describe the treatment patterns of a group of patients with type 2 diabetes mellitus and CKD in an outpatient setting from Colombia.

METHODS

A cross-sectional study in adult patients with type 2 diabetes mellitus and CKD identified in the Audifarma S.A. administrative healthcare database between April 2019 and March 2020 was performed. Sociodemographic, clinical and pharmacological variables were considered and analyzed.

RESULTS

A total of 14,722 patients with type 2 diabetes mellitus and CKD were identified, predominantly male (51%), with a mean age of 74.7 years. The most common treatment patterns of type 2 diabetes mellitus included the use of metformin monotherapy (20.5%), followed by the combination of metformin + dipeptidyl peptidase-4 inhibitor (13.4%). Regarding the use of drugs with nephroprotective properties, the most prescribed treatments were angiotensin receptor blockers (67.2%), angiotensin converting enzyme inhibitors (15.8%), sodium glucose cotransporter 2 inhibitors (SGLT2i) (17.0%) and glucagon-like peptide-1 analogs (GLP1a) (5.2%).

CONCLUSION

In Colombia, the majority of patients with type 2 diabetes mellitus and CKD identified in this study were treated with antidiabetic and protective medications to ensure adequate metabolic, cardiovascular, and renal control. The management of type 2 diabetes mellitus and CKD may be improved if the beneficial properties of new groups of antidiabetics (SGLT2i, GLP1a), as well as novel mineralocorticoid receptor antagonists, are considered.

Canagliflozin on top of dual renin-angiotensin system blockade in a woman with partial acquired lipodystrophy, type 2 diabetes and severely proteinuric chronic kidney disease: a case report

Sodium glucose cotransporter 2 inhibitors have proven strong efficacy in reducing end-stage renal disease in patients with type 2 diabetes. We are presenting here the case of a 40-year-old woman with acquired partial lipodystrophy, type 2 diabetes and essential hypertension complicated by chronic kidney disease and proteinuria in the nephrotic range. She first came to our attention in 2012; estimated glomerular filtration rate (eGFR) was 41.5 ml/min/1.73 m² and total proteinuria was 375 mg/24h; she was treated with dual renin angiotensin system blocking. Proteinuria significantly increased during the following years, reaching a nephrotic range (>5 g/day). A kidney biopsy revealed a tubule-interstitial involvement compatible with type 2 diabetes. Leptin replacement therapy, started in 2018, improved glycaemic control and lipid profile, also determining a reduction in insulin total daily dose. In 2019, after the publication of the CREDENCE study, canagliflozin was started on top of losartan and ramipril. After an initial, expected eGFR drop, kidney function stabilized, and albuminuria significantly reduced (from 4120 to 984 mg/24h), while serum potassium showed only minimal increase. At last follow-up (2022) total proteinuria was still reducing (510 mg/24h), while kidney function was substantially unchanged (eGFR 40 ml/min/1.73 m²). This case report suggests that, despite not recommended in international guidelines, the use of SGLT2i in combination with dual renin angiotensin system blockade should be considered in specific conditions and under close clinical monitoring.

Up-Date on Diabetic Nephropathy

Diabetes is one of the leading causes of kidney disease. Diabetic kidney disease (DKD) is a major cause of end-stage kidney disease (ESKD) worldwide, and it is linked to an increase in cardiovascular (CV) risk. Diabetic nephropathy (DN) increases morbidity and mortality among people living with diabetes. Risk factors for DN are chronic hyperglycemia and high blood pressure; the renin-angiotensin-aldosterone system blockade improves glomerular function and CV risk in these patients. Recently, new antidiabetic drugs, including sodium-glucose transport protein 2 inhibitors and glucagon-like peptide-1 agonists, have demonstrated additional contribution in delaying the progression of kidney disease and enhancing CV outcomes. The therapeutic goal is regression of albuminuria, but an atypical form of non-proteinuric diabetic nephropathy (NP-DN) is also described. In this review, we provide a state-of-the-art evaluation of current treatment strategies and promising emerging treatments.

Hypertriglyceridemia and Other Risk Factors of Chronic Kidney Disease in Type 2 Diabetes: A Hospital-Based Clinic Population in Greece

Aims/Introduction: Several reports indicate an increasing prevalence of chronic kidney disease (CKD) in type 2 diabetes mellitus (T2DM). Hyperglycemia and hypertension are the main risk factors for CKD development and progression. However, despite the achievement of recommended targets for blood glucose and blood pressure (BP), the residual risk of diabetic chronic kidney disease (DCKD) remains relatively high. The aim of this study is to examine dyslipidemia and other major risk factors to provide support for the prevention and treatment of DCKD. Materials and Methods: Participants are from the Redit-2-Diag study that examines 1759 subjects within a period of 6 months. DCKD severity is staged according to KDIGO criteria. Results: An increase in hemoglobin A_1c (1 unit) and systolic blood pressure (1 mm Hg) increases the probability of being classified into a higher CKD stage by 14% and 26%, respectively. Moreover, an increase of triglycerides by 88.5 mg/dL increases the risk of classification to a worse CKD stage by 24%. Conclusions: Elevated triglycerides, systolic blood pressure, and poor glycemic control increase the risk of CKD in T2DM and should be addressed in the treatment strategies.

Adaptation and Psychometric Evidence of the ARABIC Version of the Diabetes Self-Management Questionnaire (A-DSMQ)

(1) Background: Diabetic patients must engage in self-care practices in order to maintain optimal glycemic control, hence reducing the likelihood of developing complications, and enhance the overall quality of their lives. The Diabetes Self-care Management Questionnaire (DSMQ) is a tool for assessing self-management habits that may be used to predict glycemic control in people with diabetes. However, no Arabic language version of the instrument has been found. Therefore, we adapted an Arabic language version of the instrument in Tunisia. The purpose of the current research aimed to assess the psychometric features of the Tunisian version of the DSMQ in patients with type 2 diabetes. (2) Method: Two samples including both genders, one exploratory (n = 208, mean age 53.2 ± 8.3) and one confirmatory (n = 441, mean age 53.4 ± 7.4), completed an adapted Arabic language version of the DSMQ, a sociodemographic questionnaire and information about their HbA1C levels. (3) Results: The exploratory factor analysis revealed that the 15 items of the A-DSMQ fit well with the data. Likewise, the alpha coefficients for the A-DSMQ factors were above 0.80: for “Glucose Management” (GM), “Dietary Control” (DC), “Physical Activity” (PA), and “Heath-Care Use” (HU). The fit indices for the CFA were good, and the four-factor solution was confirmed. The Average Variance Extracted values and Fornell–Larcker criterion established the convergent and discriminant validity, respectively. The concurrent validity of the tool was established through the statistically significant negative relationships between the A-DSMQ factors and HbA1C, in addition to its positive association with the practice of physical activity measured by the IPAQ. (4) Conclusions: Given the high EFA factor loadings, the CFA fit indices, the correlation matrix, the sensitivity analysis, the convergent validity, and the excellent internal consistency of the A-DSMQ, it can be concluded that the A-DSMQ is an effective psychometric tool for diabetes self-management in Tunisia.

A systematic review and meta-analysis of gut microbiota in diabetic kidney disease: Comparisons with diabetes mellitus, non-diabetic kidney disease, and healthy individuals

BACKGROUND

Gut microbiota has been reported to play an important role in diabetic kidney disease (DKD), however, the alterations of gut bacteria have not been determined.

METHODS

Studies comparing the differences of gut microbiome between patients with DKD and non-DKD individuals using high-throughput sequencing technology, were systematically searched and reviewed. Outcomes were set as gut bacterial diversity, microbial composition, and correlation with clinical parameters of DKD. Qualitative data were summarized and compared through a funnel R script, and quantitative data were estimated by meta-analysis.

RESULTS

A total of 15 studies and 1640 participants were included, the comparisons were conducted between DKD, diabetes mellitus (DM), non-diabetic kidney disease (NDKD), and healthy controls. There were no significant differences of α-diversity between DKD and DM, and between DKD and NDKD, however, significant lower microbial richness was found in DKD compared to healthy controls. Different bacterial compositions were found between DKD and non-DKD subjects. The phylum Actinobacteria were found to be enriched in DKD compared to healthy controls. At the genus level, we found the enrichment of Hungatella, Bilophila, and Escherichia in DKD compared to DM, patients with DKD showed lower abundances of Faecalibacterium compared to those with NDKD. The genera Butyricicoccus, Faecalibacterium, and Lachnospira were depleted in DKD compared to healthy controls, whereas Hungatella, Escherichia, and lactobacillus were significantly enriched. The genus Ruminococcus torques group was demonstrated to be inversely correlated with estimated glomerular filtration rate of DKD.

CONCLUSIONS

Gut bacterial alterations was demonstrated in DKD, characterized by the enrichment of the genera Hungatella and Escherichia, and the depletion of butyrate-producing bacteria, which might be associated with the occurrence and development of DKD. Further studies are still needed to validate these findings, due to substantial heterogeneity.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42022340870.