Optimal Early Diagnosis and Monitoring of Diabetic Kidney Disease in Type 2 Diabetes Mellitus: Addressing the Barriers to Albuminuria Testing

Prevalence and characteristics of chronic kidney disease in people with type 2 diabetes mellitus in the Autonomous Community of Aragon

AIMS

The main objective in this study was to determine the prevalence of Chronic Kidney Disease (CKD) in people with Type 2 Diabetes Mellitus (T2DM) in the Autonomous Community (AC) of Aragon (Spain) and to detect whether or not there is under-registration in the patient's history. As a secundary objetive, it was proposed to study the most relevant demographic and clinical characteristics of people with CKD.

METHODS

Observational and retrospective real world data study of the population over 18 years of age with a diagnosis of T2DM, between January 2017 and December 2021. A descriptive analysis of qualitative and quantitative variables, and a comparison using the parametric Student's t-test or the non-parametric Mann-Whitney U-test between both groups was performed.

RESULTS

The prevalence of T2DM was 8.07 % and that of CKD 31.4 %, with an under-reporting of 47 %. The main risk factor associated with CKD was arterial hypertension (p<0.001), followed by dyslipidemia (p<0.001). The main treatment used for diabetes control was metformin, both in patients with and without CKD (p<0.001). A total of 56.81 % of people with T2DM and CKD did not undergo annual monitoring of their renal function (glomerular filtration rate) or determination of albuminuria.

CONCLUSIONS

The prevalence of CKD increases in patients with T2DM (31.4 %), and in almost half of patients the diagnosis is not registered (47 %). This under-reporting delays the implementation of measures needed to prevent CKD progression.

The impact of population ageing on the burden of chronic kidney disease

The burden of chronic kidney disease (CKD) and its risk factors are projected to rise in parallel with the rapidly ageing global population. By 2050, the prevalence of CKD category G3-G5 may exceed 10% in some regions, resulting in substantial health and economic burdens that will disproportionately affect lower-income countries. The extent to which the CKD epidemic can be mitigated depends largely on the uptake of prevention efforts to address modifiable risk factors, the implementation of cost-effective screening programmes for early detection of CKD in high-risk individuals and widespread access and affordability of new-generation kidney-protective drugs to prevent the development and delay the progression of CKD. Older patients require a multidisciplinary integrated approach to manage their multimorbidity, polypharmacy, high rates of adverse outcomes, mental health, fatigue and other age-related symptoms. In those who progress to kidney failure, comprehensive conservative management should be offered as a viable option during the shared decision-making process to collaboratively determine a treatment approach that respects the values and wishes of the patient. Interventions that maintain or improve quality of life, including pain management and palliative care services when appropriate, should also be made available.

E-waste: mechanisms of toxicity and safety testing

Currently, information on the toxicity profile of the majority of the identified e-waste chemicals, while extensive and growing, is admittedly fragmentary, particularly at the cellular and molecular levels. Furthermore, the toxicity of the chemical mixtures likely to be encountered by humans during and after informal e-waste recycling, as well as their underlying mechanisms of action, is largely unknown. This review paper summarizes state-of-the-art knowledge of the potential underlying toxicity mechanisms associated with e-waste exposures, with a focus on toxic responses connected to specific organs, organ systems, and overall effects on the organism. To overcome the complexities associated with assessing the possible adverse outcomes from exposure to chemicals, a growing number of new approach methodologies have emerged in recent years, with the long-term objective of providing a human-based and animal-free system that is scientifically superior to animal testing, more effective, and acceptable. This encompasses a variety of techniques, typically regarded as alternative approaches for determining chemical-induced toxicities and holds greater promise for a better understanding of key events in the metabolic pathways that mediate known adverse health outcomes in e-waste exposure scenarios. This is crucial to establishing accurate scientific knowledge on mixed e-waste chemical exposures in shorter time frames and with greater efficacy, as well as supporting the need for safe management of hazardous chemicals. The present review paper discusses important gaps in knowledge and shows promising directions for mechanistically anchored effect-based monitoring strategies that will contribute to the advancement of the methods currently used in characterizing and monitoring e-waste-impacted ecosystems.

Effects of Once-Weekly Semaglutide on Kidney Disease Outcomes by KDIGO Risk Category in the SUSTAIN 6 Trial

Introduction

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are recommended by Kidney Disease: Improving Global Outcomes (KDIGO) as risk-based treatment for hyperglycemia, weight management, and cardiovascular (CV) risk reduction in people with type 2 diabetes (T2D) and chronic kidney disease (CKD). The aim of this post hoc analysis was to assess treatment effects of once weekly semaglutide on kidney disease outcomes by KDIGO risk category and on changes in KDIGO risk category, compared with placebo.

Methods

Participants with T2D and established CV disease or at high CV risk treated with once weekly semaglutide or placebo in SUSTAIN 6 (NCT01720446) were stratified by baseline KDIGO risk category (low [n = 1596], moderate [n = 831], high [n = 445], very high [n = 366]). Treatment effect was analyzed for a kidney disease composite end point (macroalbuminuria, serum creatinine doubling and estimated glomerular filtration rate [eGFR] < 45 ml/min per 1.73 m2, kidney replacement therapy, or death due to kidney disease) from baseline to 2 years.

Results

The treatment effect of semaglutide versus placebo was consistent across KDIGO categories for the kidney disease composite end point (hazard ratio [95% confidence interval (CI)]: 0.35 [0.07-1.72], 0.42 [0.25-0.72], 0.87 [0.45-1.71], and 0.72 [0.42-1.23] for low, moderate, high, and very high risk categories, respectively; P interaction = 0.28). Participants receiving semaglutide were more likely to move to a lower KDIGO risk category (odds ratio: 1.69; 95% CI: [1.32-2.16]) and less likely to move to a higher KDIGO risk category versus placebo (odds ratio: 0.71; 95% CI: [0.59-0.86]).

Conclusion

Once weekly semaglutide versus placebo reduced risks of kidney disease end points and improved risk categories irrespective of baseline KDIGO risk.

Effects of a Patient Portal Intervention to Address Diabetes Care Gaps: Protocol for a Pragmatic Randomized Controlled Trial

BACKGROUND

Despite the potential to significantly reduce complications, many patients do not consistently receive diabetes preventive care. Our research team recently applied user-centered design sprint methodology to develop a patient portal intervention empowering patients to address selected diabetes care gaps (eg, no diabetes eye examination in last 12 months).

OBJECTIVE

This study aims to evaluate the effect of our novel diabetes care gap intervention on completion of selected evidence-based diabetes preventive care services and secondary outcomes.

METHODS

We are conducting a pragmatic randomized controlled trial of the effect of the intervention on diabetes care gaps. Adult patients with diabetes mellitus (DM) are recruited from primary care clinics affiliated with Vanderbilt University Medical Center. Participants are eligible if they have type 1 or 2 DM, can read in English, are aged 18-75 years, have a current patient portal account, and have reliable access to a mobile device with internet access. We exclude patients with medical conditions that prevent them from using a mobile device, severe difficulty seeing, pregnant women or women who plan to become pregnant during the study period, and patients on dialysis. Participants will be randomly assigned to the intervention or usual care. The primary outcome measure will be the number of diabetes care gaps among 4 DM preventive care services (diabetes eye examination, pneumococcal vaccination, hemoglobin A1c, and urine microalbumin) at 12 months after randomization. Secondary outcomes will include diabetes self-efficacy, confidence managing diabetes in general, understanding of diabetes preventive care, diabetes distress, patient portal satisfaction, and patient-initiated orders at baseline, 3 months, 6 months, and 12 months after randomization. An ordinal logistic regression model will be used to quantify the effect of the intervention on the number of diabetes care gaps at the 12-month follow-up. For dichotomous secondary outcomes, a logistic regression model will be used with random effects for the clinic and provider variables as needed. For continuous secondary outcomes, a regression model will be used.

RESULTS

This study is ongoing. Recruitment was closed in February 2022; a total of 433 patients were randomized. Of those randomized, most (n=288, 66.5%) were non-Hispanic White, 33.5% (n=145) were racial or ethnic minorities, 33.9% (n=147) were aged 65 years or older, and 30.7% (n=133) indicated limited health literacy.

CONCLUSIONS

The study directly tests the hypothesis that a patient portal intervention-alerting patients about selected diabetes care gaps, fostering understanding of their significance, and allowing patients to initiate care-will reduce diabetes care gaps compared with usual care. The insights gained from this study may have broad implications for developing future interventions to address various care gaps, such as gaps in cancer screening, and contribute to the development of effective, scalable, and sustainable approaches to engage patients in chronic disease management and prevention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04894903; https://classic.clinicaltrials.gov/ct2/show/NCT04894903.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56123.

Predicting the Progression of Chronic Kidney Disease: A Systematic Review of Artificial Intelligence and Machine Learning Approaches

Chronic kidney disease (CKD) is a progressive condition characterized by gradual loss of kidney function, necessitating timely monitoring and interventions. This systematic review comprehensively evaluates the application of artificial intelligence (AI) and machine learning (ML) techniques for predicting CKD progression. A rigorous literature search identified 13 relevant studies employing diverse AI/ML algorithms, including logistic regression, support vector machines, random forests, neural networks, and deep learning approaches. These studies primarily aimed to predict CKD progression to end-stage renal disease (ESRD) or the need for renal replacement therapy, with some focusing on diabetic kidney disease progression, proteinuria, or estimated glomerular filtration rate (GFR) decline. The findings highlight the promising predictive performance of AI/ML models, with several achieving high accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve scores. Key factors contributing to enhanced prediction included incorporating longitudinal data, baseline characteristics, and specific biomarkers such as estimated GFR, proteinuria, serum albumin, and hemoglobin levels. Integration of these predictive models with electronic health records and clinical decision support systems offers opportunities for timely risk identification, early interventions, and personalized management strategies. While challenges related to data quality, bias, and ethical considerations exist, the reviewed studies underscore the potential of AI/ML techniques to facilitate early detection, risk stratification, and targeted interventions for CKD patients. Ongoing research, external validation, and careful implementation are crucial to leveraging these advanced analytical approaches in clinical practice, ultimately improving outcomes and reducing the burden of CKD.

Metabolic dysfunction-associated fatty liver disease in the elderly with diabetic foot ulcers: A longitudinal cohort study

This study aimed to explore the association between metabolic-associated fatty liver disease (MAFLD) and ulcer recurrence risk in patients with diabetic foot ulcers (DFUs) through an ambispective longitudinal cohort. From December 2013 to December 2022, a total of 482 inpatients with DFUs (PEDIS grade 3 and above with a severe infection) were eligible for inclusion in this study. This was an ambispective longitudinal cohort study. All participants were followed up every 6 months for 9 years with a median of 36 months. According to whether having MAFLD or not, all subjects were placed into two groups: non-MAFLD (n = 351) and MAFLD (n = 131). The association between MAFLD and ulcer recurrence in patients with DFUs was then evaluated through multivariate Cox regression analysis, stratified analyses and Kaplan-Meier survival analysis. Throughout the follow-up period, out of 482 subjects with DFUs, 68 had ulcer recurrence (14.1%). Three Cox regression models were established for data analyses. In the model I (unadjusted), MAFLD was significantly associated with the ulcer recurrence rate in patients with DFUs (HR = 1.79; 95% CI = 1.097-2.92; p = 0.02). Model II (adjusted model I with gender and age) (HR = 1.781; 95% CI = 1.09-2.912; p = 0.021) and model III (adjusted model II with CVD, duration of diabetes and Cr.) (HR = 1.743; 95% CI = 1.065-2.855; p = 0.027) also showed that MAFLD was significantly related to the ulcer recurrence risk in patients with DFUs, respectively. Stratified analysis indicated that subjects aged ≥60 had a greater risk of ulcer recurrence in MAFLD than in non-MAFLD (HR = 2.31; 95% CI = 1.268-4.206; p = 0.006). Kaplan-Meier survival curve analysis showed that ulcer recurrence rate had a significant association with MAFLD (log-rank, p = 0.018). This study indicated a close association between ulcer recurrence risk and MAFLD in patients with DFUs, especially in the elderly (aged ≥60). Therefore, special attention should be paid to the elderly with both DFUs and MAFLD because they have a higher ulcer recurrence rate than other general populations in routine clinical practice.

Patient-Centric Quantitative Microsampling for Accurate Determination of Urine Albumin to Creatinine Ratio (UACR) in a Clinical Setting

BACKGROUND

Developing and implementing new patient-centric strategies for drug trials lowers the barrier to participation for some patients by reducing the need to travel to research sites. In early chronic kidney disease (CKD) trials, albuminuria is the key measure for determining treatment effect prior to pivotal kidney outcome trials.

METHODS

To facilitate albuminuria sample collection outside of a clinical research site, we developed 2 quantitative microsampling methods to determine the urinary albumin to creatinine ratio (UACR). Readout was performed by LC-MS/MS.

RESULTS

For the Mitra device the within-batch precision (CV%) was 2.8% to 4.6% and the between-batch precision was 5.3% to 6.1%. Corresponding data for the Capitainer device were 4.0% to 8.6% and 6.7% to 9.0%, respectively. The storage stability at room temperature for 3 weeks was 98% to 103% for both devices. The recovery for the Mitra and Capitainer devices was 104% (SD 7.0%) and 95 (SD 7.4%), respectively. The inter-assay comparison of UACR assessment generated results that were indistinguishable regardless of microsampling technique. The accuracy based on LC-MS/MS vs analysis of neat urine using a clinical chemistry analyzer was assessed in a clinical setting, resulting in 102 ± 8.0% for the Mitra device and 95 ± 10.0% for the Capitainer device.

CONCLUSIONS

Both UACR microsampling measurements exhibit excellent accuracy and precision compared to a clinical chemistry analyzer using neat urine. We applied our patient-centric sampling strategy to subjects with heart failure in a clinical setting. Precise UACR measurements using quantitative microsampling at home would be beneficial in clinical drug development for kidney therapies.

Effects of Qidan Tangshen Granule on diabetic kidney disease in patients with type 2 diabetes

BACKGROUND

This study aimed to conduct a prospective, randomized, controlled clinical trial using, Qidan Tangshen Granule, a traditional Chinese medicine (TCM), as an antioxidant, to treat diabetic kidney disease (DKD) patients.

METHODS

A total of 355 patients were enrolled, and after exclusions, 219 patients were divided into an intervention group (n = 109) receiving Qidan Tangshen Granule treatment and a control group (n = 110) receiving conventional treatment. Demographic and physiological parameters were evaluated at baseline and 3 months and 12 months of follow-up. The levels of serum oxidants including 8-hydroxy-2'-deoxyguanosine (8-OHdG) and 3-nitrotyrosine (3-NT), and the enzymic anti-oxidant, superoxide dismutase (SOD), were evaluated using enzyme-linked immunosorbent assays.

RESULTS

Qidan Tangshen Granule treatment significantly reduced hemoglobin A1c (HbA1c) and albumin-to-creatinine ratio (UACR) levels, improved renal function, and exerted antioxidative effects in DKD patients. Compared to the control group, the intervention group showed increased levels of SOD and decreased levels of 8-OHdG and 3-NT, indicating reduced oxidative stress. Furthermore, the intervention group demonstrated a significant decrease in HbA1c and UACR levels and an improvement in glomerular filtration rate compared to the control group.

CONCLUSIONS

Qidan Tangshen Granule may be a potential therapeutic option for the treatment of DKD, offering improved clinical outcomes for patients.

Peter WL, Shubrook JH. Type 2 Diabetes and Chronic Kidney Disease: An Opportunity for Pharmacists to Improve Outcomes

Chronic kidney disease (CKD) is an important contributor to end-stage kidney disease, cardiovascular disease, and death in people with type 2 diabetes (T2D), but current evidence suggests that diagnosis and treatment are often not optimized. This review examines gaps in care for patients with CKD and how pharmacist interventions can mitigate these gaps. We conducted a PubMed search for published articles reporting on real-world CKD management practice and compared the findings with current recommendations. We find that adherence to guidelines on screening for CKD in patients with T2D is poor with particularly low rates of testing for albuminuria. When CKD is diagnosed, the prescription of recommended heart-kidney protective therapies is underutilized, possibly due to issues around treatment complexity and safety concerns. Cost and access are barriers to the prescription of newer therapies and treatment is dependent on racial, ethnic, and socioeconomic factors. Rates of nephrologist referrals for difficult cases are low in part due to limitations of information and communication between specialties. We believe that pharmacists can play a vital role in improving outcomes for patients with CKD and T2D and support the cost-effective use of healthcare resources through the provision of comprehensive medication management as part of a multidisciplinary team. The Advancing Kidney Health through Optimal Medication Management initiative supports the involvement of pharmacists across healthcare systems to ensure that comprehensive medication management can be optimally implemented.

A Prospective, Multicentered, Randomized, Double-Blind, Placebo-Controlled Clinical Trial of Keluoxin Capsules in the Treatment of Microalbuminuria in Patients with Type 2 Early Diabetic Kidney Disease

Background: To evaluate the efficacy and safety of Keluoxin (KLX) capsules and provide validated evidence for the application of KLX in the treatment of diabetic kidney disease (DKD). Methods: A multicenter, randomized, double-blind, placebo-controlled trial design was used to screen 129 patients with DKD (urinary albumin-to-creatinine ratio [UACR]: male, 2.5-30 mg/mmol; female, 3.5-30 mg/mmol) and with Qi and Yin deficiency and blood stasis symptoms. Written informed consent was obtained from all patients. The patients were randomly divided into KLX and control groups. The KLX group was orally administered KLX (6 g/day) and irbesartan tablets (150 mg/day), whereas the control group was administered KLX placebo (6 g/day) and irbesartan tablets (150 mg/day). Patients were observed for 24 weeks to evaluate the natural logarithm of the UACR (log-UACR), the odds ratio (OR) for a sustained increase in the UACR of at least 30% and 40%, estimated glomerular filtration rate (eGFR), changes in symptoms and quality-of-life scores, and adverse events. Results: The changes of the natural log-UACR during the 24 weeks compared with baseline in the KLX group were better than those in the control group (LS mean ± standard error, -0.26 ± 0.10 vs. 0.01 ± 0.09, p = 0.0292). The incidence of a sustained increase in the UACR of at least 30% and 40% was found to be significantly lower in the KLX group (OR, 0.26; 95% confidence interval [CI], 0.09-0.75; OR, 0.29; 95% CI, 0.10-0.82). Changes in symptoms and quality-of-life scores in the KLX group were better than those in the control group. There was no statistically significant difference in eGFR or the incidence of adverse events between the groups. Conclusions: Overall, these results suggest that KLX capsules combined with irbesartan can reduce microalbuminuria, relieve the symptoms, and improve the quality of life for patients with type 2 early DKD compared with the use of irbesartan alone. Trial registration: Chinese Clinical Trial Registry, registration number: ChiCTR2100052764.

Novel model predicts diastolic cardiac dysfunction in type 2 diabetes

OBJECTIVE

Diabetes mellitus complicated with heart failure has high mortality and morbidity, but no reliable diagnoses and treatments are available. This study aimed to develop and verify a new model nomogram based on clinical parameters to predict diastolic cardiac dysfunction in patients with Type 2 diabetes mellitus (T2DM).

METHODS

3030 patients with T2DM underwent Doppler echocardiography at the First Affiliated Hospital of Shenzhen University between January 2014 and December 2021. The patients were divided into the training dataset (n = 1701) and the verification dataset (n = 1329). In this study, a predictive diastolic cardiac dysfunction nomogram is developed using multivariable logical regression analysis, which contains the candidates selected in a minor absolute shrinkage and selection operator regression model. Discrimination in the prediction model was assessed using the area under the receiver operating characteristic curve (AUC-ROC). The calibration curve was applied to evaluate the calibration of the alignment nomogram, and the clinical decision curve was used to determine the clinical practicability of the alignment map. The verification dataset was used to evaluate the prediction model's performance.

RESULTS

A multivariable model that included age, body mass index (BMI), triglyceride (TG), creatine phosphokinase isoenzyme (CK-MB), serum sodium (Na), and urinary albumin/creatinine ratio (UACR) was presented as the nomogram. We obtained the model for estimating diastolic cardiac dysfunction in patients with T2DM. The AUC-ROC of the training dataset in our model was 0.8307, with 95% CI of 0.8109-0.8505. Similar to the results obtained with the training dataset, the AUC-ROC of the verification dataset in our model was 0.8083, with 95% CI of 0.7843-0.8324, thus demonstrating robust. The function of the predictive model was as follows: Diastolic Dysfunction = -4.41303 + 0.14100*Age(year)+0.10491*BMI (kg/m2) +0.12902*TG (mmol/L) +0.03970*CK-MB (ng/mL) -0.03988*Na(mmol/L) +0.65395 * (UACR > 30 mg/g) + 1.10837 * (UACR > 300 mg/g). The calibration plot diagram of predicted probabilities against observed DCM rates indicated excellent concordance. Decision curve analysis demonstrated that the novel nomogram was clinically useful.

CONCLUSION

Diastolic cardiac dysfunction in patients with T2DM can be predicted by clinical parameters. Our prediction model may represent an effective tool for large-scale epidemiological study of diastolic cardiac dysfunction in T2DM patients and provide a reliable method for early screening of T2DM patients with cardiac complications.KEY MESSAGESThis study used clinical parameters to predict diastolic cardiac dysfunction in patients with T2DM. This study established a nomogram for predicting diastolic cardiac dysfunction by multivariate logical regression analysis. Our predictive model can be used as an effective tool for large-scale epidemiological study of diastolic cardiac dysfunction in patients with T2DM and provides a reliable method for early screening of cardiac complications in patients with T2DM.

Sex Difference in the Association Between Serum Versican and Albuminuria in Patients with Type 2 Diabetes Mellitus

Introduction

Diabetic kidney disease (DKD) is one of the major microvascular complications of diabetes. DKD is associated with oxidative stress and inflammation. Versican (VCAN), a chondroitin sulphate proteoglycan, has been proven to participate in oxidative stress and inflammation. This study aimed to explore the overall and sex-based relationship between serum VCAN levels and albuminuria in patients with type 2 diabetes mellitus (T2DM).

Methods

428 patients with T2DM and 84 healthy individuals were enrolled. Patients with diabetes were separated into normal albuminuria, microalbuminuria, and macroalbuminuria groups, according to their urinary albumin/creatinine ratio (UACR). Serum VCAN levels were tested using an enzyme-linked immunosorbent assay.

Results

Compared with males, female patients were older, and had higher total cholesterol and high-density lipoprotein cholesterol, but lower body mass index, diastolic blood pressure, glycated hemoglobin A1, alanine aminotransferase, urinary albumin (UA), and serum creatinine (SCr) (P < 0.05). The VCAN levels in male patients with T2DM were significantly higher than those in the healthy individuals. Male patients with T2DM with albuminuria (micro and macro) had higher levels of VCAN than in patients with normal albuminuria; the highest level was seen in patients with macroalbuminuria (P < 0.05). In male patients with T2DM, serum VCAN correlated positively with systolic blood pressure, blood urea nitrogen, UA, SCr, and UACR, but correlated negatively with the estimated glomerular filtration rate. The area under the receiver operating characteristic curve of serum VCAN to diagnose albuminuria was 0.702, with a corresponding cut-off value of 0.399 ng/mL (P < 0.001). However, the association between serum VCAN and UACR was not observed in female patients with T2DM.

Conclusion

Serum VCAN levels correlated positively with the severity of albuminuria in male patients with T2DM.

Improving the identification and management of diabetic nephropathy in patients with diabetes in primary care

BACKGROUND

Diabetic nephropathy is the leading cause of renal failure in the United States. Screening for albuminuria in individuals with diabetes is critical to identify the early stages of DKD. Prompt identification and management of DKD improves patient outcomes, increases life expectancy, and decreases health care costs.

LOCAL PROBLEM

The DKD screening rate for patients ≥18 years of age with diabetes at the project site was 29%, below the national benchmark of 90%. Patients diagnosed with DKD were not receiving appropriate management. This quality-improvement project used a standardized protocol consisting of a checklist and educational initiatives to improve DKD identification and management.

METHODS

The Knowledge-to-Action Framework was used for this project at a primary care practice in the southeastern United States. Data collection included demographic data, DKD screening with urine albumin-to-creatine ratio, diagnosis rates, DKD treatment with angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB), and a sodium-glucose cotransporter-2 inhibitor (SGLT2i) reviewed 6 months before and after intervention.

INTERVENTIONS

Evidence-based interventions included a DKD educational in-service for clinical staff, creation of a standardized protocol through a checklist for screening and appropriate management of DKD, and implementation of patient educational handouts.

RESULTS

Diabetic kidney disease screening rates increased by 100%, patients diagnosed with DKD decreased by 8%, patients with DKD on ACEi/ARB increased by 39%, and patients with DKD on SGLT2i increased by 15%.

CONCLUSION

Implementation of a standardized protocol through a checklist and providing patient education on DKD can improve DKD identification/management.

Empowering patients to address diabetes care gaps: formative usability testing of a novel patient portal intervention

Objective

The aim of this study was to design and assess the formative usability of a novel patient portal intervention designed to empower patients with diabetes to initiate orders for diabetes-related monitoring and preventive services.

Materials and Methods

We used a user-centered Design Sprint methodology to create our intervention prototype and assess its usability with 3 rounds of iterative testing. Participants (5/round) were presented with the prototype and asked to perform common, standardized tasks using think-aloud procedures. A facilitator rated task performance using a scale: (1) completed with ease, (2) completed with difficulty, and (3) failed. Participants completed the System Usability Scale (SUS) scored 0-worst to 100-best. All testing occurred remotely via Zoom.

Results

We identified 3 main categories of usability issues: distrust about the automated system, content concerns, and layout difficulties. Changes included improving clarity about the ordering process and simplifying language; however, design constraints inherent to the electronic health record system limited our ability to respond to all usability issues (eg, could not modify fixed elements in layout). Percent of tasks completed with ease across each round were 67%, 60%, and 80%, respectively. Average SUS scores were 87, 74, and 93, respectively. Across rounds, participants found the intervention valuable and appreciated the concept of patient-initiated ordering.

Conclusions

Through iterative user-centered design and testing, we improved the usability of the patient portal intervention. A tool that empowers patients to initiate orders for disease-specific services as part of their existing patient portal account has potential to enhance the completion of recommended health services and improve clinical outcomes.

Consensus Statements from the Diabetologists & Endocrinologists Alliance for the Management of People with Hypertension and Type 2 Diabetes Mellitus

Hypertension and type 2 diabetes mellitus (T2DM) are important, intertwined public health issues. People with both conditions face significantly elevated risks of cardiovascular (CV) and renal complications. To optimize patient care, a multidisciplinary expert panel met to review recent evidence on optimal blood pressure (BP) targets, implications of albuminuria, and treatment regimens for hypertensive patients with T2DM, with the aim of providing recommendations for physicians in Hong Kong. The panel reviewed the relevant literature, obtained by searching PubMed for the publication period from January 2015 to June 2021, to address five discussion areas: (i) BP targets based on CV/renal benefits; (ii) management of isolated systolic or diastolic hypertension; (iii) roles of angiotensin II receptor blockers; (iv) implications of albuminuria for CV/renal events and treatment choices; and (v) roles and tools of screening for microalbuminuria. The panel held three virtual meetings using a modified Delphi method to address the discussion areas. After each meeting, consensus statements were derived and anonymously voted on by every panelist. A total of 17 consensus statements were formulated based on recent evidence and expert insights regarding cardioprotection and renoprotection for hypertensive patients with T2DM.

Potential of electronic devices for detection of health problems in older adults at home: A systematic review and meta-analysis

OBJECTIVE

The aim of this review was to evaluate the overall diagnostic performance of e-devices for detection of health problems in older adults at home.

METHODS

A systematic review was conducted following the PRISMA-DTA guidelines.

RESULTS

31 studies were included with 24 studies included in meta-analysis. The included studies were divided into four categories according to the signals detected: physical activity (PA), vital signs (VS), electrocardiography (ECG) and other. The meta-analysis showed the pooled estimates of sensitivity and specificity were 0.94 and 0.98 respectively in the 'VS' group. The pooled sensitivity and specificity were 0.97 and 0.98 respectively in the 'ECG' group.

CONCLUSIONS

All kinds of e-devices perform well in diagnosing the common health problems. While ECG-based health problems detection system is more reliable than VS-based ones. For sole signal detection system has limitation in diagnosing specific health problems, more researches should focus on developing new systems combined of multiple signals.

Management of Type 2 Diabetic Kidney Disease in 2022: A Narrative Review for Specialists and Primary Care

Purpose of review

Kidney disease is present in almost half of Canadian patients with type 2 diabetes (T2D), and it is also the most common first cardiorenal manifestation of T2D. Despite clear guidelines for testing, opportunities are being missed to identify kidney diseases, and many Canadians are therefore not receiving the best available treatments. This has become even more important given recent clinical trials demonstrating improvements in both kidney and cardiovascular (CV) endpoints with sodium-glucose cotransporter 2 (SGLT2) inhibitors and a nonsteroidal mineralocorticoid receptor antagonist, finerenone. The goal of this document is to provide a narrative review of the current evidence for the treatment of diabetic kidney disease (DKD) that supports this new standard of care and to provide practice points.

Sources of information

An expert panel of Canadian clinicians was assembled, including 9 nephrologists, an endocrinologist, and a primary care practitioner. The information the authors used for this review consisted of published clinical trials and guidelines, selected by the authors based on their assessment of their relevance to the questions being answered.

Methods

Panelists met virtually to discuss potential questions to be answered in the review and agreed on 10 key questions. Two panel members volunteered as co-leads to write the summaries and practice points for each of the identified questions. Summaries and practice points were distributed to the entire author list by email. Through 2 rounds of online voting, a second virtual meeting, and subsequent email correspondence, the authors reached consensus on the contents of the review, including all the practice points.

Key findings

It is critical that DKD be identified as early as possible in the course of the disease to optimally prevent disease progression and associated complications. Patients with diabetes should be routinely screened for DKD with assessments of both urinary albumin and kidney function. Treatment decisions should be individualized based on the risks and benefits, patients' needs and preferences, medication access and cost, and the degree of glucose lowering needed. Patients with DKD should be treated to achieve targets for A1C and blood pressure. Renin-angiotensin-aldosterone system blockade and treatment with SGLT2 inhibitors are also key components of the standard of care to reduce the risk of kidney and CV events for these patients. Finerenone should also be considered to further reduce the risk of CV events and chronic kidney disease progression. Education of patients with diabetes prescribed SGLT2 inhibitors and/or finerenone is an important component of treatment.

Limitations

No formal guideline process was used. The practice points are not graded and are not intended to be viewed as having the weight of a clinical practice guideline or formal consensus statement. However, most practice points are well aligned with current clinical practice guidelines.

Predictors of microalbuminuria and its relationship with glycemic control among Type 2 diabetic patients of Jazan Armed Forces Hospital, southwestern Saudi Arabia

BACKGROUND AND PURPOSE

Diabetic kidney disease (DKD) is highly prevalent among patients with diabetes mellitus. It affects approximately 20% of diabetic patients, who are believed to be more than 400 million individuals. The objectives of the present work were to assess patterns of albuminuria and determine microalbuminuria predictors among patients living with type 2 diabetes (T2D) who attended the family medicine department of Jazan Armed Forces Hospital.

METHODS

A case-control design was used and included two groups (n, 202/group), one with microalbuminuria and the other with a normal urine albumin/creatinine ratio (ACR). Data regarding patient history, glycosylated hemoglobin (HbA1c), lipid profile, renal function tests, ACR, ASCVD (atherosclerotic cardiovascular disease) risk, etc., were collected.

RESULTS

The prevalence rates of microalbuminuria and macroalbuminuria were 26.4% and 3.9%, respectively. HbA1c was significantly higher in patients with microalbuminuria (9.3 ± 2.2; P˂0.001) and macroalbuminuria (10.5 ± 2.3; P˂0.001) than in those with normal ACR (8.3 ± 1.9%). The predictors of microalbuminuria were poor glycemic control with HbA1c ≥ 7% {OR, 2.5 (95% C. I, 1.5-4.2)}; hypertension {(OR, 1.8 (95% C. I, 1.2-2.8)}; estimated glomerular filtration rate (eGFR) of ˂90 mL/min/1.73 m2 {OR, 2.2 (95% C. I, 1.4-3.6}; smoking {OR, 1.3 (95% C. I, 0.7-2.6}; and body mass index {OR, 1.05 (95% C. I, 1.01-1.09}.

CONCLUSION

Microalbuminuria is highly prevalent among patients with type 2 diabetes and is associated with poor glycemic control and hypertension, necessitating aggressive and timely screening and treatment.

RSSDI Guidelines for the management of hypertension in patients with diabetes mellitus

Hypertension and diabetes mellitus (DM) are two of the leading lifestyle diseases in the Indian and South Asian populations that often co-exist due to overlapping pathophysiological factors. Obesity, insulin resistance, inflammation, and oxidative stress are thought to be some common pathways. Up to 50% of hypertensive cases in India are diagnosed with type 2 diabetes mellitus (T2DM), which defines the need for a comprehensive guideline for managing hypertension in diabetic patients. These RSSDI guidelines have been formulated based on consultation with expert endocrinologists in India and Southeast Asia, acknowledging the needs of the Indian population. Ambulatory blood pressure monitoring and office and home-based blood pressure (BP) monitoring are recommended for the early analysis of risks. Cardiovascular risks, end-organ damage, and renal disorders are the primary complications associated with diabetic hypertension that needs to be managed with the help of non-pharmacological and pharmacological interventions. The non-pharmacological interventions include the nutrition education of the patient to reduce the intake of salt, sodium, and trans fats and increase the consumption of nuts, fresh fruits, vegetables, and potassium-rich foods. It is also recommended to initiate 50 to 60 min of exercise three to four times a week since physical activity has shown to be more beneficial for hypertension control in Indian patients than dietary modulation. For the pharmacological management of hypertension in patients with T2DM, angiotensin II receptor blockers (ARBs) are recommended as the first line of therapy, demonstrating their superiority over other antihypertensive agents such as ACEi. However, most of the global hypertension guidelines recommend initiation with combination therapy to achieve better BP control in most patients and to reduce the risk of adverse events. For combination therapy, calcium channel blockers (CCBs) are recommended to be administered along with ARBs instead of beta-blockers or diuretics to avoid the risk of cardiovascular events and hyperglycaemia. Among the CCBs, novel molecules (e.g. cilnidipine) are recommended in combination with ARBs for better cardiovascular and reno-protection in diabetic hypertensive patients.

Making an impact on kidney disease in people with type 2 diabetes: the importance of screening for albuminuria

Albuminuria is useful for early screening and diagnosis of kidney impairment, especially in people with pre-diabetes or type 2 diabetes (T2D), which is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease (ESKD), associated with increased mortality, poor cardiovascular outcomes, and high economic burden. Identifying patients with CKD who are most likely to progress to ESKD permits timely implementation of appropriate interventions. The early stages of CKD are asymptomatic, which means identification of CKD relies on routine assessment of kidney damage and function. Both albuminuria and estimated glomerular filtration rate are measures of kidney function. This review discusses albuminuria as a marker of kidney damage and cardiorenal risk, highlights the importance of early screening and routine testing for albuminuria in people with T2D, and provides new insights on the optimum management of CKD in T2D using albuminuria as a target in a proposed algorithm. Elevated urine albumin can be used to detect CKD in people with T2D and monitor its progression; however, obstacles preventing early detection exist, including lack of awareness of CKD in the general population, poor adherence to clinical guidelines, and country-level variations in screening and treatment incentives. With albuminuria being used as an entry criterion and a surrogate endpoint for kidney failure in clinical trials, and with novel treatment interventions available to prevent CKD progression, there is an urgent need for early screening and diagnosis of kidney function decline in people with T2D or pre-diabetes.

Nomogram Prediction for the Risk of Diabetic Foot in Patients With Type 2 Diabetes Mellitus

AIMS

To develop and validate a nomogram prediction model for the risk of diabetic foot in patients with type 2 diabetes mellitus (T2DM) and evaluate its clinical application value.

METHODS

We retrospectively collected clinical data from 1,950 patients with T2DM from the Second Affiliated Hospital of Xi'an Jiaotong University between January 2012 and June 2021. The patients were divided into training cohort and validation cohort according to the random number table method at a ratio of 7:3. The independent risk factors for diabetic foot among patients with T2DM were identified by multivariate logistic regression analysis. Then, a nomogram prediction model was developed using the independent risk factors. The model performances were evaluated by the area under the receiver operating characteristic curve (AUC), calibration plot, Hosmer-Lemeshow test, and the decision curve analysis (DCA).

RESULTS

Multivariate logistic regression analysis indicated that age, hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), total cholesterol (TC), smoke, and drink were independent risk factors for diabetic foot among patients with T2DM (P < 0.05). The AUCs of training cohort and validation cohort were 0.806 (95% CI: 0.775∼0.837) and 0.857 (95% CI: 0.814∼0.899), respectively, suggesting good discrimination of the model. Calibration curves of training cohort and validation cohort showed a favorable consistency between the predicted probability and the actual probability. In addition, the P values of Hosmer-Lemeshow test for training cohort and validation cohort were 0.826 and 0.480, respectively, suggesting a high calibration of the model. When the threshold probability was set as 11.6% in the DCA curve, the clinical net benefits of training cohort and validation cohort were 58% and 65%, respectively, indicating good clinical usefulness of the model.

CONCLUSION

We developed and validated a user-friendly nomogram prediction model for the risk of diabetic foot in patients with T2DM. Nomograms may help clinicians early screen and identify patients at high risk of diabetic foot.

Management of chronic kidney disease in type 2 diabetes: screening, diagnosis and treatment goals, and recommendations

Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) are at high risk of CKD progression and cardiovascular (CV) disease. Prevalence of CKD in patients with T2D is currently around 40% and continues to grow. The increasing number of people with CKD and T2D will ultimately have a significant impact upon health resource use and costs of care for people with T2D. Management of CKD in patients with T2D aims to preserve kidney function to reduce the risk of end-stage kidney disease, CV events, and mortality. Evidence-based recommendations for the treatment of patients with CKD and T2D are provided by several international and national organizations and recommend several lifestyle and pharmacological approaches to help prevent or delay the progression of CKD in patients with T2D. Guidelines include regular screening of patients with T2D for CKD using spot urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (at least annually and at least twice a year if UACR >300 mg/g). Additionally, assessment of vascular complications, together with interventions designed to improve glycemic control and lipid levels, maintain healthy body weight, and optimize blood pressure should be performed. Medications shown to slow progression of CKD include renin-angiotensin system inhibitors, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists, and, more recently, selective, non-steroidal mineralocorticoid receptor antagonists. This review highlights the ongoing challenges facing primary care providers in the management of CKD in patients with T2D including the consideration of comorbidities, adoption of new treatment options, and implementation of individualized care. Achieving consensus for optimal treatment of this disease is critical in providing consistent and appropriate care for all patients. Strategies to improve outcomes should also include use of clear referral criteria, use of a multi-disciplinary approach, and patient education.

Novel glucose-responsive nanoparticles based on p-hydroxyphenethyl anisate and 3-acrylamidophenylboronic acid reduce blood glucose and ameliorate diabetic nephropathy

An insulin delivery system that self-regulates blood sugar levels, mimicking the human pancreas, can improve hyperglycaemia. At present, a glucose-responsive insulin delivery system combining AAPBA with long-acting slow release biomaterials has been developed. However, the safety of sustained-release materials and the challenges of preventing diabetic complications remain. In this study, we developed a novel polymer slow release material using a plant extract—p-hydroxyphenylethyl anisate (HPA). After block copolymerisation with AAPBA, the prepared nanoparticles had good pH sensitivity, glucose sensitivity, insulin loading rate and stability under physiological conditions and had high biocompatibility. The analysis of streptozotocin-induced diabetic nephropathy (DN) mouse model showed that the insulin-loaded injection of nanoparticles stably regulated the blood glucose levels of DN mice within 48 ​h. Importantly, with the degradation of the slow release material HPA in vivo, the renal function improved, the inflammatory response reduced, and antioxidation levels in DN mice improved. This new type of nanoparticles provides a new idea for hypoglycaemic nano-drug delivery system and may have potential in the prevention and treatment of diabetic complications.

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We established a new glucose-responsive intelligent system with HPA.

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p(AAPBA-b-HPA) shows good pH and glucose sensitivity.

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p(AAPBA-b-HPA) nanoparticles can slowly release HPA and insulin.

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This system can be used to regulate blood glucose.

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p(AAPBA-b-HPA) nanoparticles can aid in diabetic nephropathy prevention and treatment.

The risk factors and predictive nomogram of human albumin infusion during the perioperative period of posterior lumbar interbody fusion: a study based on 2015-2020 data from a local hospital

BACKGROUND

Perioperative hypoalbuminemia of the posterior lumbar interbody fusion (PLIF) can increase the risk of infection of the incision site, and it is challenging to accurately predict perioperative hypoproteinemia. The objective of this study was to create a clinical predictive nomogram and validate its accuracy by finding the independent risk factors for perioperative hypoalbuminemia of PLIF.

METHODS

The patients who underwent PLIF at the Affiliated Hospital of Qingdao University between January 2015 and December 2020 were selected in this study. Besides, variables such as age, gender, BMI, current and past medical history, indications for surgery, surgery-related information, and results of preoperative blood routine tests were also collected from each patient. These patients were divided into injection group and non-injection group according to whether they were injected with human albumin. And they were also divided into training group and validation group, with the ratio of 4:1. Univariate and multivariate logistic regression analyses were performed in the training group to find the independent risk factors. The nomogram was developed based on these independent predictors. In addition, the area under the curve (AUC), the calibration curve and the decision curve analysis (DCA) were drawn in the training and validation groups to evaluate the prediction, calibration and clinical validity of the model. Finally, the nomograms in the training and validation groups and the receiver operating characteristic (ROC) curves of each independent risk factor were drawn to analyze the performance of this model.

RESULTS

A total of 2482 patients who met our criteria were recruited in this study and 256 (10.31%) patients were injected with human albumin perioperatively. There were 1985 people in the training group and 497 in the validation group. Multivariate logistic regression analysis revealed 5 independent risk factors, including old age, accompanying T2DM, level of preoperative albumin, amount of intraoperative blood loss and fusion stage. We drew nomograms. The AUC of the nomograms in the training group and the validation group were 0.807, 95% CI 0.774-0.840 and 0.859, 95% CI 0.797-0.920, respectively. The calibration curve shows consistency between the prediction and observation results. DCA showed a high net benefit from using nomograms to predict the risk of perioperative injection of human albumin. The AUCs of nomograms in the training and the validation groups were significantly higher than those of five independent risk factors mentioned above (P < 0.001), suggesting that the model is strongly predictive.

CONCLUSION

Preoperative low protein, operative stage ≥ 3, a relatively large amount of intraoperative blood loss, old age and history of diabetes were independent predictors of albumin infusion after PLIF. A predictive model for the risk of albumin injection during the perioperative period of PLIF was created using the above 5 predictors, and then validated. The model can be used to assess the risk of albumin injection in patients during the perioperative period of PLIF. The model is highly predictive, so it can be clinically applied to reduce the incidence of perioperative hypoalbuminemia.