Chronic kidney disease in the type 2 diabetic patients: prevalence and associated variables in a random sample of 2642 patients of a Mediterranean area

The relationship between kidney function and cardiometabolic risk factors, anthropometric indices, and dietary inflammatory index in the Iranian general population: a cross-sectional study

BACKGROUND

The prevalence of chronic kidney disease (CKD) is estimated to be about 13.4% worldwide. Studies have shown that CKD accounts for up to 2% of the health cost burden. Various factors, such as genetic polymorphisms, metabolic disorders, and unhealthy lifestyles, can contribute to the occurrence of CKD. Therefore, the present study aimed to investigate the relationship between renal function and cardiometabolic risk factors, anthropometric characteristics, and the dietary inflammatory index (DII) in an Iranian population.

METHODS

This study was conducted on 2472 male and female employees of Shiraz University of Medical Sciences (SUMS), selected through census between 2018 and 2019. In this cross-sectional study, renal function was evaluated using serum creatinine (sCr), blood urea nitrogen (BUN), and estimated glomerular filtration rate (eGFR). Biochemical indices including sCr, BUN, fasting blood sugar (FBS), total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglyceride (TG) were measured using standard laboratory methods. eGFR was calculated using the Modification of Diet in Renal Disease formula. Systolic (SBP) and diastolic (DBP) blood pressure as well as anthropometric indices such as height (Ht), weight (Wt), hip circumference (HC), waist circumference (WC), body mass index (BMI), conicity index (C-Index), visceral adiposity index (VAI), abdominal volume index (AVI), body adiposity index (BAI), and body shape index (ABSI) were measured and calculated using standard methods and formulas. Diet was evaluated through a 113-item food frequency questionnaire, and the DII was calculated according to its specific instructions. To predict the factors influencing renal function and to remove the impact of confounders, multivariable linear regression was employed using the backward elimination method.

RESULTS

There was a significant direct relationship between sCr and FBS, TG, HDL, DBP, Wt, and BAI as well as between BUN and age, TG, HDL, and BAI. In addition, there was a significant inverse relationship between eGFR and SBP, Wt, BAI, and VAI. In women compared to men, sCr and BUN values were significantly lower, while eGFR levels were significantly higher.

CONCLUSIONS

It seems that age, gender, lipid profile, glycemic status, BP, BAI, VAI, and Wt can be considered factors associated with renal function.

Prevalence of nephropathy among diabetic patients in North American region: A systematic review and meta-analysis

BACKGROUND

Nephropathy is one of the most common microvascular impediments of diabetes mellitus. In this study, we aimed to estimate the prevalence of nephropathy in diabetic patients across the North American region.

METHODS

Eligible studies were screened out from 3 electronic databases, for example, PubMed, Google Scholar, and ScienceDirect using specific search keywords based on the eligibility criteria. Extracting the data from the included studies publication bias, quality assessment, outlier investigation, and meta-analysis was done followed by the subgroup analysis. A total of 11 studies met the study inclusion criteria. Meta-analysis was performed with the extracted data.

RESULTS

Pooled prevalence of 28.2% (95% confidence interval [CI]: 19.7-36.7) with a high rate of heterogeneity (I2 = 100%) was identified. The pooled prevalence of nephropathy among diabetic patients in the United States of America, Canada, and Mexico was 24.2% (95% CI: 13.8-34.5), 31.2% (95% CI: 25.8-36.5), and 31.1% (95% CI: 20.8-41.5), respectively.

CONCLUSION

The prevalence of nephropathy among diabetic patients was found lower in the United States of America as compared to Canada and Mexico. Besides, the pooled prevalence of the North American region was found to be lower as compared to the African, European, and Asian regions. Minimizing the pathogenic factors, sufficient diagnostic, healthcare facilities, and awareness are recommended to improve the situation.

Gender Differences in the Incidence of Nephropathy and Changes in Renal Function in Patients with Type 2 Diabetes Mellitus: A Retrospective Cohort Study

Purpose

This research aims to examine and scrutinize gender variations in the incidence of diabetic nephropathy (DN) and the trajectory of renal function in type 2 diabetes mellitus (T2DM) patients.

Patients and Methods

We conducted a retrospective cohort study that enrolled 1549 patients diagnosed with T2DM from May 2015 to July 2023. We separately compared the clinical characteristics of male and female participants with and without DN. We utilized the Kaplan-Meier method to examine the cumulative incidence of DN among T2DM patients of varying genders. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using univariable and multivariable Cox proportional hazards regression analysis to evaluate the correlation between various factors and the risk of DN incidence. Multiple linear regression was utilized to investigate the relationship between ΔeGFR% and each factor. Logistic regression with cubic spline function and smooth curve fitting was employed to analyze the nonlinear link between ΔeGFR% and the risk of DN among participants of different genders.

Results

The prevalence of DN was higher in female participants (17.31%) than in male participants (12.62%), with a significant cumulative risk ratio (1.33 [1.02-1.73], P = 0.034). Multiple linear regression analysis revealed that creatinine, female gender, blood urea nitrogen, alkaline phosphatase, and total cholesterol had a significant impact on ΔeGFR% in T2DM patients, with standardized β coefficients of -0.325, -0.219, -0.164, -0.084, and 0.071, respectively. The restricted cubic spline analysis demonstrated a strong negative association between ΔeGFR% and the risk of developing DN (P < 0.001).

Conclusion

Both male and female patients with T2DM had a higher prevalence of DN over the 5-year follow-up period. However, women had a greater risk of developing DN and a faster decline in renal function compared to men.

Out of sight: chronic kidney diseases among diabetic patients attending care and follow up. Findings from pastoralist health facilities of Southern Ethiopia

Background

In Ethiopia, the prevalence of chronic kidney disease (CKD) among the adult population ranges to 19.1%. The disease's impact has increased in low-resource settings due to a lack of knowledge about the condition and its risk factors. Diabetes is one of the numerous causes of CKD. Despite this, little was known in Ethiopia, particularly in the study area. This study aimed to identify the determinants of CKD among diabetic patients enrolled in care and follow up at pastoralist health facility of Jinka General Hospital (JGH), Southern Ethiopia, 2023.

Methods

An institutional-based cross-sectional study design was conducted among 626 diabetic patients recruited through a systematic random sampling. Data was collected using a structured interviewer-administered questionnaire and entered into Epi data version 7.2 and then exported to the Statistical Package for Social Sciences (SPSS) version 25 for further analysis. Bivariate and multivariate logistic regression analyses were conducted to find eligible variables for the later analysis. Variables with p < 0.25 at bivariate logistic regression were selected for multivariate logistic regression analysis. The variables with p < 0.05 at the multivariate analysis were taken as statically significant in the final model.

Results

The prevalence of CKD was 2.7% (95% CI: 1.12-6.01%). Place of residence (AOR: 4.84; 95% CI: 1.51-15.40), presence of hypertension (AOR: 5.69; 95% CI: 1.58-20.51) and family history of CKD (AOR: 6.20; 95% CI: 1.40-15.49) were factors associated with CKD among diabetes patients.

Conclusion

The prevalence found in this study was low when compared with the local studies. Provision of health education to diabetic patients on preventative measures such as physical exercise is cost-effective approach. Factors associated with CKD among diabetics can be significantly mitigated by strengthening the existing NCDs prevention packages in the study area particularly and in Ethiopia generally.

Risk of rapid progression to dialysis in patients with type 2 diabetes mellitus with and without diabetes-related complications at diagnosis

Many adults with diabetes mellitus are unaware worldwide. The study objectives aimed to evaluate the risk of dialysis within 5 years of diagnosis between patients with newly diagnosed diabetes with and without diabetes-related complications. A retrospective longitudinal nationwide cohort study was conducted. Patients diagnosed with diabetes between 2005 and 2013 were followed up until 2018. They were categorized based on the presence or absence of complications, the number of complications, and the diabetes complications severity index (DCSI) scores. Dialysis outcomes were determined through the Registry of Catastrophic Illness from the National Health Insurance Research Database. Among the analyzed patients, 25.38% had complications at diagnosis. Patients with complications at diagnosis had a significantly higher risk of dialysis within 5 years (adjusted hazard ratio: 9.55, 95% confidence interval CI 9.02-10.11). Increasing DCSI scores and the number of complications were associated with higher dialysis risks. Patients with one complication had a 7.26-times higher risk (95% CI 6.83-7.71), while those with ≥ 3 complications had a 36.12-times higher risk (95% CI 32.28-40.41). In conclusion, newly diagnosed diabetes patients with complications face an increased risk of dialysis within 5 years. The severity and number of complications are directly linked to the risk of dialysis within this timeframe.

Sex differences in risk factors for end-stage kidney disease and death in type 2 diabetes: A retrospective cohort study

BACKGROUND

This study investigated the sex differences in the risk of end-stage kidney disease (ESKD) and mortality, as well as the effect modification of sex on associated factors in patients with type 2 diabetes.

METHODS

This multicenter observational cohort study included 4328 patients with type 2 diabetes. Hazard ratios (HRs) with 95% confidence intervals (CIs) of sex for ESKD and death were estimated using Cox proportional regression with adjustment for baseline covariates. For assessing risk modification, HRs and incidence rates for ESKD and death were compared between sexes across patient characteristics using Cox proportional and Poisson regression models.

RESULTS

During a median follow-up of 7 years, 276 patients (70% men) developed ESKD, and 241 patients (68% men) died. Men had higher risks of ESKD (HR 1.34; 95% CI 1.02-1.75; p = .034) and death (HR 1.64; 95% CI 1.24-2.16; p = .001) versus women after adjusting for multiple covariates. Among patients with microalbuminuria, men had a substantially higher risk of ESKD versus women, compared to those with normo- and macroalbuminuria (p for interaction .04). Incidence rates were also increased in men versus women with albuminuria of around 300 mg/g. No differences were detected in the association of sex and death across baseline patient subgroups.

CONCLUSIONS

In type 2 diabetes, men had an increased risk of ESKD and death versus women. Moderately increased albuminuria was strongly associated with sex difference in developing ESKD.

Chronic Kidney Disease and Associated Factors among Diabetic Patients at the Diabetic Clinic in a Police Hospital, Addis Ababa

Background

Diabetes mellitus remains the leading cause of end-stage renal disease in most countries in the world. In Ethiopia, renal complications of diabetes may remain unrecognized due to limited diagnostic resources. As a result, the prevalence of chronic kidney disease among adult diabetics in Ethiopia has not been well described. Hence, this study was aimed at assessing the prevalence of chronic kidney disease and associated factors among diabetic patients who attended the federal police hospital diabetic clinic in Addis Ababa.

Methods

A cross-sectional study was conducted among 362 Diabetes Mellitus. Data were collected using face-to-face interviewing questionnaires and analyzed using SPSS version 21.0. Binary logistic regression analyses were performed to identify predictors.

Results

The prevalence of chronic kidney disease diagnosed by Cockcroft-Gault equation and Modification of Diet in Renal Disease equation was 14.6% and 7.7% respectively. This finding shows the prevalence of chronic kidney disease among Diabetic patients was low. Age 50-59 years [(AOR= 4.0; 95% CI:(1.2, 13)] by Cockroft-Gault equation (CG), age 60-69 years [(AOR=5.8 95% CI:(1.5,21.0)] by Modification of Diet in Renal Disease (MDRD) and (AOR;22.9 95%CI:7.1,74.2) by CG, age 70 years and above (AOR=4.7; 95 CI: 1.1, 19.7) by MDRD and (AOR= 22.9; 95%CI:7.1,74.2) by CG, BMI (AOR=0.2; 95% CI:0.1,0.4) by CG, and previous kidney disease (AOR=6.2 95%CI:2.0,8.4) by MDRD and (AOR;4.6 95%CI:1.9,10.8) C-G equation have a significant association with chronic kidney disease after an adjustment done.

Conclusion

The prevalence of chronic kidney disease among Diabetic patients in this study was lower. Age, BMI, and previous recurrent kidney disease were associated with chronic kidney disease. Preventive measures like giving health education and screening of patients with risk factors should get more attention.

Cost of Type 2 Diabetes Patients with Chronic Kidney Disease Based on Real-World Data: An Observational Population-Based Study in Spain

This study analyzed the prevalence, costs and economic impact of chronic kidney disease CKD in patients with T2D in a Spanish Health District using real-world data. Observational cross-sectional study in adult patients with T2D was through data extracted from the information systems of the Valencia Clínico–La Malvarrosa Health District in the year 2015. Patients were stratified with the KDIGO classification for CKD. Additionally, patients were assigned to Clinical Risk Groups (CRGs) according to multimorbidity. Direct costs of primary and specialized care, and medication were estimated. The prevalence of T2D in the database population (n = 28,345) was 10.8% (mean age (SD) = 67.8 years (13.9); 51.5% male). Up to 14.935 patients (52.6%) had data on kidney function. According to the KDIGO classification, 66.2% of the patients were at low risk of CKD, 20.6% at moderately increased risk, 7.9% at high risk, and 5.2% at very high risk. The average healthcare costs associated with these four risk groups were EUR 3437, EUR 4936, EUR 5899 and EUR 7389, respectively. The large number of T2D patients with CKD in the early stages of the disease generated a significant increase in direct healthcare costs. The economic impact could be mitigated by early and comprehensive therapeutic approaches.

Burden of chronic kidney disease and rapid decline in renal function among adults attending a hospital-based diabetes center in Northern Europe

Introduction

This study aimed to determine the prevalence of diabetic kidney disease (DKD) and rapid renal function decline and to identify indices associated with this decline among adults attending a diabetes center in Northern Europe.

Research design and methods

This is a retrospective cohort study of 4606 patients who attended a diabetes center in Ireland between June 2012 and December 2016. Definition/staging of chronic kidney disease used the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 classification based on data from the most recently attended appointment. Relevant longitudinal trends and variabilities were derived from serial records prior to index visit. Rapid renal function decline was defined based on per cent and absolute rates of estimated glomerular filtration rate (eGFR) change. Multiple linear regression was used to explore the relationships between explanatory variables and per cent eGFR change.

Results

42.0% (total), 23.4% (type 1 diabetes), 47.9% (type 2 diabetes) and 32.6% (other diabetes) had DKD. Rapid decline based on per cent change was more frequent in type 2 than in type 1 diabetes (32.8% vs 14.0%, p<0.001). Indices independently associated with rapid eGFR decline included older age, greater number of antihypertensives, higher log-normalized urine albumin to creatinine ratio (LNuACR), serum alkaline phosphatase, thyroid stimulating hormone, variability in systolic blood pressure and variability in LNuACR, lower glycated hemoglobin, high-density lipoprotein cholesterol and diastolic blood pressure, and lack of ACE inhibitor/angiotensin receptor blocker prescription.

Conclusions

DKD (using the KDIGO 2012 classification) and rapid eGFR decline were highly prevalent among adults attending a hospital-based diabetes clinic in a predominantly Caucasian Northern European country. The burden was greater for adults with type 2 diabetes. Expected as well as potentially novel clinical predictors were identified.

Chronic kidney disease prevalence and cardiovascular risk in a cohort of patients with type 2 diabetes followed for 10 years in Badajoz (Spain). An observational study

AIMS

To estimate the prevalence of chronic kidney disease (CKD), their risk factors the incidence of cardiovascular and coronary events and total and cardiovascular mortality in a cohort of type 2 diabetes (T2DM) patients observed for 10 years in primary care practices in Badajoz, Spain.

METHODS

Observational, longitudinal study. A total of 643 patients with T2DM (mean age 64.0 years, 55.7% women), without evidence of cardiovascular disease, were studied. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² at the beginning of the study, by applying the simplified Modification of Diet in Renal Disease (MDRD) Study formula.

RESULTS

The prevalence rate of CKD was 24.3%. Patients with CKD had higher percentages of coronary, cerebrovascular and cardiovascular events and higher rates of cardiovascular mortality (18.6 vs. 6.0%, p < 0.001) and total mortality (42.3 vs. 23.4%, p < 0.01), compared to patients without CKD. The Cox proportional hazards model, adjusted for age, systolic blood pressure levels, glycated haemoglobin, total cholesterol, obesity and smoking, revealed that patients with CKD had an increased risk of coronary events (HR:2.18; 95% CI:1.13-4.22, p < 0.05).

CONCLUSIONS

Our study confirms a high prevalence of CKD in patients with T2DM and its relationship with the presence of cardiovascular disease.

Sex difference in the incidence of microvascular complications in patients with type 2 diabetes mellitus: a prospective cohort study

AIMS

Type 2 diabetes mellitus is a major cause of death and disability due to its long-term macro- and microvascular diseases. Although women with type 2 diabetes have more macrovascular diseases, it is unclear whether there are sex differences in the occurrence of microvascular disease. The aim of our study was to investigate sex differences in the incidence of microvascular complications in type 2 diabetes.

METHODS

Analyses were performed in the DiaGene study, a prospective cohort study for complications of type 2 diabetes, collected in the city of Eindhoven, the Netherlands (n = 1886, mean follow-up time = 6.93 years). Cox proportional hazard models adjusted for risk factors for complications (age, smoking, hypertension, dyslipidemia, HbA1c and duration of type 2 diabetes) were used to analyze the incidence of microvascular complications in men and women.

RESULTS

The incidence of microalbuminuria was significantly higher in men (HR microalbuminuria 1.64 [CI 1.21-2.24], p = 0.002). Additionally, men are more likely to develop two or three microvascular complications compared to women (OR 2.42 [CI 1.69-3.45], p < 0.001).

CONCLUSIONS

This study shows that men with type 2 diabetes are more likely to develop microvascular complications, especially microalbuminuria. Furthermore, men seem to have a higher chance of developing multiple microvascular complications. Our results highlight that men and women may not benefit to a similar extent from current treatment approaches to prevent diabetes-related microvascular diseases.

Prevalence and awareness of chronic kidney disease among adult diabetic outpatients in Northeast Ethiopia

Background

Chronic kidney disease (CKD) is a serious complication of diabetes associated with adverse outcomes of renal failure, cardiovascular disease and mortality. Despite this, data regarding the burden and awareness of CKD among adults with diabetes in Sub-Saharan Africa countries are lacking. The aim of this study was, therefore to determine the prevalence and awareness of CKD among diabetic outpatients attending a hospital in Northeast Ethiopia.

Methods

We conducted a cross-sectional study on 323 diabetic adults at the diabetes clinic of a hospital in Northeast Ethiopia, from February 1 to July 30, 2016. Each patient provided a blood sample for serum creatinine and urine for albuminuria. Glomerular filtration rate (eGFR) was estimated using the Modification of Diet in Renal Disease (MDRD) equation. CKD was defined as eGFR < 60 ml/min/1.73 m² and/or albuminuria. Awareness was defined as a positive response to “Has a doctor or other health care professional ever told you that you had kidney disease?”

Results

Of the 323 patients, 85 (26.3%) had Stage 1–5 CKD, 42 (13.0%) had eGFR < 60 ml/min/1.73m² and 58 (18.0%) had albuminuria. In patients with eGFR < 60 ml/min/1.73m² (stage 3–5 CKD), serum creatinine was abnormal (> 1.5 mg/dl) in 23.5% and albuminuria was absent in 31.8%. Of the patients with CKD, only 10.6% of them were aware of their CKD. The proportion of patients who were aware of their disease increased with worsening of CKD stages, from 3.4% of with stage 1 to 75.0% with stage 4. Awareness for all individuals with advanced stages of CKD was only 11.9%. Having albuminuria, high serum creatinine, a family history of kidney disease and being obese were significantly associated with CKD awareness.

Conclusion

A high prevalence but low awareness of CKD was found in diabetic outpatients attending our clinic in Northeast Ethiopia. Our results highlight the need for more diagnostic strategies for CKD screening among diabetic adults and primary care education on the impact of detecting CKD in the early stage to prevent adverse outcomes and improve diabetes care.

Prevalence of Chronic Kidney Disease and Associated Factors among Patients with Diabetes in Northwest Ethiopia: A Hospital-Based Cross-Sectional Study

BACKGROUND

Chronic kidney disease (CKD) is increasingly recognized as a global health issue and it affects 10% to 15% of the world population. Diabetes mellitus is the leading cause of end-stage renal disease. More than 422 million adults in the world populations are living with diabetes mellitus, 40% of whom will develop CKD. CKD in diabetes increases the risk of early death and cardiovascular morbidity and mortality. There is a paucity of published data on the prevalence of CKD and its associated factors among patients with diabetes in northwest Ethiopia.

OBJECTIVE

The aim of this study is to determine the prevalence and factors associated with CKD among patients with diabetes at University of Gondar Hospital, Northwest Ethiopia.

METHODS

A hospital-based cross-sectional study was conducted from April 2 to July 31, 2018. Using convenience sampling, a total of 272 consecutive patients with diabetes were recruited for the study. Data regarding the patients' sociodemographic information, clinical characteristics, and laboratory parameters were collected using patient interview and review of medical records. Serum creatinine was measured and used to calculate estimated glomerular filtration rate using modification of diet in renal disease and chronic kidney disease epidemiology equations. Data were analyzed using SPSS version 20. Bivariate and multivariate logistic regression analyses were used to identify predictors of CKD in patients with diabetes.

RESULT

The prevalence of CKD, defined by estimated glomerular filtration rate <60 mL/min/1.73 m2, was found to be 17.3% and 14.3% by modification of diet in renal disease and chronic kidney disease epidemiology equations, respectively. The proportion of stage 3 CKD by modification of diet in renal disease equation was 14.7%, whereas the proportions of stage 4 and stage 5 CKD were 2.2% and 0.4%, respectively. Among those who were diagnosed with CKD, 85.1% had pre-existing hypertension. Multivariate logistic regression analysis revealed that the presence of retinopathy (adjusted odds ratio = 14; 95% CI, 4-36; p < 0.001), pre-existing hypertension (adjusted odds ratio = 8.2; 95% CI, 2-23; P < 0.001), current systolic blood pressure >140 mm Hg (adjusted odds ratio = 6; 95% CI, 4-22; P = 0.001), and duration of diabetes >10 years (adjusted odds ratio = 3.2; 95% CI, 2-7; P = 0.004) were significantly associated with CKD in patients with diabetes.

CONCLUSIONS

The prevalence of CKD in patients with diabetes is high and comparable with previous studies from low- and middle-income countries. Pre-existing hypertension, current systolic blood pressure >140 mm Hg, duration of diabetes >10 years, and presence of retinopathy were significantly associated with CKD. Regular screening for CKD, retinopathy, and optimal blood pressure management should be practiced.

Prevalence of diabetic nephropathy among Chinese patients with type 2 diabetes mellitus and different categories of their estimated glomerular filtration rate based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in primary care in Hong Kong: a cross-sectional study

Purpose

To evaluate the prevalence of diabetic nephropathy and different categories of estimated glomerular filtration rate (eGFR) as calculated by the CKD-EPI equation among Chinese patients with type 2 diabetes in primary care in Hong Kong. The associated factors of diabetic nephropathy were also analyzed.

Methods

A cross-sectional study was conducted in 35,109 Chinese patients with type 2 diabetes followed up in all General Outpatient Clinics in a Hospital Authority cluster and had undergone comprehensive diabetic complication assessment from April 2013 to March 2016. The GFR was estimated by the CKD-EPI equation. Logistic regression was used to analyze the associated factors of diabetic nephropathy.

Results

The prevalence of diabetic nephropathy (with either or both albuminuria and impaired eGFR), impaired eGFR (with or without albuminuria) and albuminuria (with or without impaired eGFR) was 31.6%, 16.9% and 22.0% respectively. The prevalence of eGFR categories 1, 2, 3, 4 and 5 was 36.0%, 47.1%, 15.7%, 1.1% and 0.1% respectively. The comorbidity with hypertension or presence of other diabetic microvascular or macrovascular complications including diabetic retinopathy, peripheral neuropathy, peripheral vascular disease, history of stroke and history of ischemic heart disease had strong association with diabetic nephropathy. Obesity, smoking, suboptimal control of blood pressure, hemoglobin A1c and non-high density lipoprotein cholesterol were also significantly associated with diabetic nephropathy.

Conclusions

Diabetic nephropathy was common among Chinese patients with type 2 diabetes in primary care in Hong Kong. Early identification and control of the modifiable risk factors are of upmost importance in preventing the complication.

Safety and Effectiveness of Bexagliflozin in Patients With Type 2 Diabetes Mellitus and Stage 3a/3b CKD

RATIONALE & OBJECTIVE

Hyperglycemia exacerbates the progression of chronic kidney disease (CKD), but most glucose-lowering therapies do not address morbidities associated with CKD. Sodium/glucose cotransporter 2 (SGLT2) inhibitors offer potential benefits to patients with diabetes and CKD, but their effectiveness may be diminished with decreased kidney function. We aimed to evaluate the safety and effectiveness of bexagliflozin, a novel SGLT2 inhibitor, in patients with type 2 diabetes and CKD.

STUDY DESIGN

Phase 3, double-blind, placebo-controlled, multicenter, multinational, randomized trial.

SETTING & PARTICIPANTS

54 sites across 4 countries. Patients with CKD stage 3a or 3b, type 2 diabetes mellitus, and hemoglobin A_1c level of 7.0% to 10.5% and estimated glomerular filtration rate (eGFR) of 30 to 59mL/min/1.73m² who were taking oral hypoglycemic agents for 8 weeks.

INTERVENTIONS

Bexagliflozin, 20mg, daily versus placebo for 24 weeks.

OUTCOMES

Primary outcome was change in percent hemoglobin A_1c from baseline to week 24. Secondary end points included changes in body weight, systolic blood pressure, albuminuria, and hemoglobin A_1c level stratified by CKD stage.

RESULTS

312 patients across 54 sites were analyzed. Bexagliflozin lowered hemoglobin A_1c levels by 0.37% (95% CI, 0.20%-0.54%); P<0.001 compared to placebo. Patients with CKD stages 3a (eGFR, 45-<60mL/min/1.73m²) and 3b (eGFR, 30-<45mL/min/1.73m²) experienced reductions in hemoglobin A_1c levels of 0.31% (P=0.007) and 0.43% (P=0.002), respectively. Bexagliflozin decreased body weight (1.61kg; P<0.001), systolic blood pressure (3.8mm Hg; P=0.02), fasting plasma glucose level (0.76mmol/L; P=0.003), and albuminuria (geometric mean ratio reduction of 20.1%; P=0.03). Urinary tract infection and genital mycotic infections were more common in the bexagliflozin group; otherwise, frequencies of adverse events were comparable between groups.

LIMITATIONS

Not designed to evaluate the impact of treatment on long-term kidney disease and cardiovascular outcomes.

CONCLUSIONS

Bexagliflozin reduces hemoglobin A_1c levels in patients with diabetes and stage 3a/3b CKD and appears to be well tolerated. Additional observed benefits included reductions in body weight, systolic blood pressure, and albuminuria.

FUNDING

Trial was sponsored by Theracos Sub, LLC.

Albuminuric and non-albuminuric patterns of chronic kidney disease in type 2 diabetes

A growing body of evidence supports a shift in the natural history of chronic kidney disease (CKD) in subjects with diabetes. Specifically, normoalbuminuric chronic kidney disease (NA-CKD), which is characterized by a decline in the glomerular filtration rate in the absence of a preceding or accompanying elevation of albuminuria, has become a widely prevalent variant of renal impairment in diabetes. Diabetic women and nonsmoking individuals with better glycemic control have a better chance of preserving normoalbuminuria, even in the case of declining renal function. The wide use of renin-angiotensin system blockers, advances in antihyperglycemic, antihypertensive, and hypolipidemic therapy, and smoking cessation are suspected to be responsible for an increasing proportion of NA-CKD among diabetic subjects with renal impairment. Significant differences in the sets of risk factors, renal morphology, comorbidity, and outcomes were found between the albuminuric and normoalbuminuric CKD patterns. NA-CKD, even if a more favorable option in terms of the risk of end-stage renal disease, is clearly associated with cardiovascular disease and its risk factors. The presence of NA-CKD in patients with diabetes increases the risk of myocardial infarction, stroke, and cardiovascular death. The study of the molecular pathways, clinical course, and outcomes of NA-CKD in diabetic subjects and the search for more specific diagnostic and treatment options are challenges for future research.

Chronic Kidney Disease and Associated Risk Factors Assessment among Diabetes Mellitus Patients at A Tertiary Hospital, Northwest Ethiopia

BACKGROUND

The prevalence of chronic kidney disease, particularly in diabetic patients, is increasing rapidly throughout the world. Nowadays, many individuals in developing nations are suffering from diabetes which is one of the primary risk factors of chronic kidney disease.

METHODS

Institution based cross-sectional study was conducted at the University of Gondar Hospital from February to April 2016. A total of 229 study participants were selected using systematic random sampling technique. Urine sample was collected for albumin determination by dipstick. The Simplified Modification of Diet in Renal Disease study equation was used to estimate glomerular filtration rate. Binary logistic regression model was used to identify risk factors.

RESULTS

Of the total 229 study participants, 50.2% were females and the mean age was 47±15.7 years. Among study participants, the prevalence of chronic kidney disease (CKD) was found to be 21.8% (95% CI: 16% - 27%). Of all study participants, 9(3.9%) had renal impairment (eGFR < 60 ml/min/ 1.73 m2) and 46 (20.1%) had albuminuria. Older age (AOR: 5.239, 95% CI: 2.255-12.175), systolic blood pressure ≥140mmHg (AOR: 3.633, 95% CI: 1.597-8.265), type 2 diabetes mellitus (AOR: 3.751, 95% CI: 1.507-9.336) and longer duration of diabetes (AOR: 3.380, 95% CI: 1.393-8.197) were independent risk factors of CKD.

CONCLUSIONS

The study identified high prevalence (21.8%) of CKD among diabetic adults. CKD was significantly associated with older age, systolic blood pressure, type 2 DM and longer duration of DM. Thus, DM patients should be diagnosed for chronic kidney disease and then managed accordingly.

Opening of mitoKATP improves cardiac function and inhibits apoptosis via the AKT-Foxo1 signaling pathway in diabetic cardiomyopathy

Decreasing phosphorylation of AKT-Foxo1 is closely associated with the onset of insulin resistance and apoptosis during diabetic cardiomyopathy (DCM). Opening of mitochondrial ATP-sensitive potassium channels (mitoK_ATP) increases the expression of p-AKT in the process of reperfusion injury. It was therefore hypothesized that opening of mitoK_ATP may regulate the AKT-Foxo1 signaling pathway and improve cardiac function in DCM. In the present study, opening of mitoK_ATP by diazoxide (DZX) was found to improve cardiac function and attenuate cardiomyocyte apoptosis in db/db mice. DZX also significantly increased the expression of p-AKT and p-Foxo1. Similarly, DZX decreased the expression of the heart failure marker NT-proBNP, increased mitochondrial membrane potential, inhibited apoptosis, and increased the expression of p-AKT and p-Foxo1 when mimicking insulin resistance in cultured cardiomyocytes. Moreover, the protective effects of DZX were completely blocked by the specific AKT inhibitor MK-2206. These data suggest that the regulation of the AKT-Foxo1 signaling pathway by mitoK_ATP plays an important role in improving cardiac function and inhibiting apoptosis in DCM, and may therefore be a new potential therapeutic target for DCM.

Prevalence of kidney dysfunction in diabetes mellitus and associated risk factors among productive age Indonesian

Background

The prevalence of diabetes mellitus is increasing in Indonesia due to population growth, urbanization, and lifestyle. Diabetes mellitus (DM) is the leading cause of chronic kidney disease that escalates mortality rate, but not all DM develop into chronic kidney disease.

Aims

To estimate the prevalence of kidney dysfunction (KD) in DM and the associated dominant risk factors among productive age Indonesian based on the National Health Survey (Riskesdas) 2013.

Methods

The statistical data consisted of 15,791 females and 10,349 males, aged 20 to 54, who lived in rural and urban areas. The data was obtained from National Institute of Health Research and Development (NIHRD), Ministry of Health. Data were collected from 33 provinces using cross sectional method. The variables data analyzed were sociodemographic, lifestyle, anthropometric, blood pressure, blood lipid, blood glucose, and creatinine. Kidney dysfunction was defined according to Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Multivariable logistic regression was used to analyze the dominant associated risk factors.

Results

The prevalence of KD in DM was 4% (CI 95% 3.1-5.1) and only 0.6% had been diagnosed. Many associated risk factors could affect DM leading to KD such as age, sex, rural, economic status, sugary food/drinks, salty food, coffee, hypertension, hypercholesterolemia, low HDL, high LDL, and hypertriglyceridemia. The dominant associated risk factors were age, sex, economic status, sugary food/drinks, and low HDL.

Conclusion

The prevalence of KD in DM among productive age Indonesian was 4% and only 0.6% had been diagnosed. Early detection of identification of KD in DM is needed in order to slow progression and complications. The dominant associated risk factors of KD in DM were age, sex, economic status, sugary food/drinks, and low HDL. Controlling of risk factors in DM should be done in order to prevent diabetic kidney disease.

The Global Epidemiology of Diabetes and Kidney Disease

The prevalence of diabetes is increasing worldwide, with the greatest increases occurring in low- and middle-income countries. In most developed countries, type 2 diabetes is presently the leading cause of end-stage renal disease and also contributes substantially to cardiovascular disease. In countries with weaker economies type 2 diabetes is rapidly replacing communicable diseases as a leading cause of kidney disease and is increasingly competing for scarce health care resources. Here, we present a narrative review of the prevalence and incidence of diabetes-related kidney disease worldwide. Mortality among those with diabetes and kidney disease will also be explored. Given the high morbidity and mortality associated with chronic kidney disease, we will also examine the level of awareness of this disease among people who have it.

Chronic renal disease in spain: prevalence and related factors in persons with diabetes mellitus older than 64 years

INTRODUCTION

Type 2 diabetes mellitus and chronic kidney disease (CKD) are conditions which have a high prevalence in individuals ≥ 65 years of age and represent a major public health problem.

OBJECTIVES

To determine the prevalence of CKD, its categories and its relationship with various demographic and clinical factors in elderly patients with type 2 diabetes mellitus in Spain.

METHODS

Observational, cross-sectional, multicenter, Spanish epidemiological study. Patients with known type 2 diabetes mellitus, age ≥ 65 years of age treated in Primary Care were included. We collected demographic, anthropometric and analytical variables from the previous 12 months, including the albumin-to-creatinine ratio and estimated glomerular filtration rate to evaluate renal function.

RESULTS

The prevalence of CKD was 37.2% (95% CI, 34.1-40.3%), renal failure was 29.7% (95% CI, 26.8-32.6%) and increased albuminuria was 20.6% (95% CI, 17.3-23.9%), moderately increased albuminuria was 17.8% (95% CI, 14.7-20.9%) and severely increased albuminuria was 2.8% (95% CI, 1.4-4.2%). In turn, the prevalence of CKD categories were: G1 1.3% (95% CI, 0.6-2%), G2 6.2% (95% CI, 4.6-7.8%), G3a 17.2% (95% CI, 14.8-19.6%), G3b 9.8% (95% CI, 7.9-11.7%), G4 2% (95% CI, 1.1-2.9%) and G5 0.7% (95% CI, 0.2-1.2%). In the multivariate analysis, after adjusting for the remaining variables, CKD was associated with elderly age (OR 5.13, 95% CI, 3.15-8.35), high comorbidity (OR 3.36. 95% CI, 2.2-5.12) and presence of antihypertensive treatment (OR 2.43. 95% CI, 1.48-4.02).

CONCLUSIONS

CKD is frequent in the diabetic population ≥ 65 years of age and is associated with elderly age, high comorbidity and with treated hypertension. No relationship has been found with gender and time in years since onset of diabetes.

The impact of the quality of care and other factors on progression of chronic kidney disease in Thai patients with Type 2 Diabetes Mellitus: A nationwide cohort study

Objective

The present study investigates the impact of quality of care (QoC) and other factors on chronic kidney disease (CKD) stage progression among Type 2 Diabetes Mellitus (T2DM) patients.

Methods

This study employed a retrospective cohort from a nationwide Diabetes and Hypertension study involving 595 Thai hospitals. T2DM patients who were observed at least 2 times in the 3 years follow-up (between 2011–2013) were included in our study. Ordinal logistic mixed effect regression modeling was used to investigate the association between the QoC and other factors with CKD stage progression.

Results

After adjusting for covariates, we found that the achievement of the HbA1c clinical targets (≤7%) was the only QoC indicator protective against the CKD stage progression (adjusted OR = 0.76; 95%CI = 0.59–0.98; p<0.05). In terms of other covariates, age, occupation, type of health insurance, region of residence, HDL-C, triglyceride, hypertension and insulin sensitizer were also strongly associated with CKD stage progression.

Conclusions

This cohort study demonstrates the achievement of the HbA1c clinical target (≤7%) is the only QoC indicator protective against progression of CKD stage. Neither of the other clinical targets (BP and LDL-C) nor any process of care targets could be shown to be associated with CKD stage progression. Therefore, close monitoring of blood sugar control is important to slow CKD progression, but long-term prospective cohorts are needed to gain better insights into the impact of QoC indicators on CKD progression.

Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis †

Diabetic foot is a severe public health issue, yet rare studies investigated its global epidemiology. Here we performed a systematic review and meta-analysis through searching PubMed, EMBASE, ISI Web of science, and Cochrane database. We found that that global diabetic foot ulcer prevalence was 6.3% (95%CI: 5.4-7.3%), which was higher in males (4.5%, 95%CI: 3.7-5.2%) than in females (3.5%, 95%CI: 2.8-4.2%), and higher in type 2 diabetic patients (6.4%, 95%CI: 4.6-8.1%) than in type 1 diabetics (5.5%, 95%CI: 3.2-7.7%). North America had the highest prevalence (13.0%, 95%CI: 10.0-15.9%), Oceania had the lowest (3.0%, 95% CI: 0.9-5.0%), and the prevalence in Asia, Europe, and Africa were 5.5% (95%CI: 4.6-6.4%), 5.1% (95%CI: 4.1-6.0%), and 7.2% (95%CI: 5.1-9.3%), respectively. Australia has the lowest (1.5%, 95%CI: 0.7-2.4%) and Belgium has the highest prevalence (16.6%, 95%CI: 10.7-22.4%), followed by Canada (14.8%, 95%CI: 9.4-20.1%) and USA (13.0%, 95%CI: 8.3-17.7%). The patients with diabetic foot ulcer were older, had a lower body mass index, longer diabetic duration, and had more hypertension, diabetic retinopathy, and smoking history than patients without diabetic foot ulceration. Our results provide suggestions for policy makers in deciding preventing strategy of diabetic foot ulceration in the future. Key messages Global prevalence of diabetic foot is 6.3% (95%CI: 5.4-7.3%), and the prevalence in North America, Asia, Europe, Africa and Oceania was 13.0% (95%CI: 10.0-15.9%), 5.5% (95%CI: 4.6-6.4%), 5.1% (95%CI: 4.1-6.0%), 7.2% (95%CI: 5.1-9.3%), and 3.0% (95% CI: 0.9-5.0%). Diabetic foot was more prevalent in males than in females, and more prevalent in type 2 diabetic foot patients than in type 1 diabetic foot patients. The patients with diabetic foot were older, had a lower body mass index, longer diabetic duration, and had more hypertension, diabetic retinopathy, and smoking history than patients without diabetic foot.

Diferencias entre MDRD-4 y CG en la prevalencia de la insuficiencia renal y sus variables asociadas en pacientes diabéticos tipo 2

Objetivo

Estimar la prevalencia de insuficiencia renal (IR) oculta en DM2, comparando 2 fórmulas de estimación de filtrado glomerular (EFG): Modification of Diet in Renal Disease 4 (MDRD-4) y Crockcoft-Gault (CG) y las variables clínicas asociadas.

Diseño Analítico transversal multicéntrico.

Emplazamiento

Dos áreas básicas de atención primaria a Terres de l’Ebre.

Participantes

Un total de 493 DM2 con médico asignado en las áreas incluidas y edad > 18 años. Pérdidas de 9 y 11 casos en cada fórmula debido a falta de variables necesarias para EFG.

Mediciones principales

Estimación del filtrado glomerular mediante las 2 fórmulas, valores de creatinina plasmática, clasificación de pacientes con IR establecida, IR oculta y sin IR, posibles variables clinicopatológicas asociadas a la IR.

Resultados

Un 45,2% fueron hombres, con una media de edad 70,4 años y un tiempo de evolución de diabetes de 7,5 años. La prevalencia de IR oculta con MDRD-4 fue del 18%, y del 22,6% con CG. Los casos detectados por CG y no por MDRD-4 fueron mayores y con peso menor. En ambas fórmulas, los pacientes con IR oculta presentaron más patologías crónicas, hipertensión y eventos cardiovasculares (CV) que los sin IR. Los factores de riesgo asociados a IR oculta fueron el ser mujer y el incremento de la edad y del colesterol LDL.

Conclusiones

La prevalencia de IR oculta fue del 20% en DM2 e, independientemente de la fórmula, se observó un peor control de factores CV, lo que les hace ser un grupo de mayor riesgo de sufrir un evento.

The Role of the Kidney and SGLT2 Inhibitors in Type 2 Diabetes

Effective glycemic control reduces the risk for diabetes-related complications. However, the majority of patients with type 2 diabetes still do not achieve glycemic targets. Beyond metformin therapy, current practice guidelines for the management of type 2 diabetes recommend individualized treatment based on patient and agent characteristics. The sodium glucose cotransporter type 2 (SGLT2) inhibitors represent a novel treatment strategy, independent of impaired beta-cell function and insulin resistance. SGLT2 inhibitors decrease renal glucose reabsorption, thereby increasing urinary glucose excretion with subsequent reduction in plasma glucose levels and glycosylated hemoglobin concentrations. Current evidence suggests that they are effective as monotherapy or as add-ons to metformin either alone, or in combination with other oral glucose-lowering agents or insulin. They are generally well tolerated, though rates of lower urinary tract and genital mycotic infections are slightly increased. The advantages of this class include modest reductions in body weight and blood pressure, and low risk for hypoglycemia. Long-term safety data and results of ongoing cardiovascular outcome studies are awaited so we can fully understand the role that SGLT2 inhibitors will play in the comprehensive management of type 2 diabetes.

Blood pressure and proteinuria control remains a challenge in patients with type 2 diabetes mellitus and chronic kidney disease: experience from the prospective observational ALICE-PROTECT study

BACKGROUND

Type 2 diabetes (T2DM) is the leading cause of chronic kidney disease (CKD) in western countries. The combination of both increases the risk of end stage renal disease (ESRD), cardiovascular events and all-cause mortality. Early control of blood pressure (BP) and proteinuria (Pu) is crucial to slow down the progression of the CKD and prevent cardiovascular events and mortality. The primary objective of the study was to assess BP and Pu control after a 2-year follow-up in T2DM patients with CKD.

METHODS

Prospective, multicenter, observational study. Overall, 153 French nephrologists included 986 T2DM patients with Pu (≥0.5 g/day) and an eGFR >15 ml/min/1.73 m². Data from 729 patients were available after a 2-year follow-up. BP and Pu control were respectively defined as less than 140/90 mmHg and 0.5 g/day. We also looked at renal and cardiovascular events.

RESULTS

At baseline, 74 % of the patients were male, mean age was 70 years. The mean T2DM duration was 17 years with a mean HbA1c of 7.4 %. All were treated for hypertension and 33 % had a controlled BP; 81 % had dyslipidemia and LDLc was <1 g/L for 54 %; 44 % had retinopathy, 40 % macrovascular complications and 12 % heart failure. Mean Pu was 2 g/day and eGFR 40 ± 20 mL/min/1.73 m², with 13, 18, 32 and 37 % of the patients in respectively stage 2, 3a, 3b and 4 CKD. After two years, 21 % reached the Pu target and 39 % the BP target. The mean eGFR of 40 ± 20.3 ml/min/1.73 m² at baseline dropped to 33.9 ± 22.6 ml/min/1.73 m² by year two (p < 0.001). This corresponded to a mean annual eGFR reduction of 3.2 ml/min/1.73 m². 118 patients presented a renal event (16.2 %): doubling of serum creatinine for 86 patients (11.8 %) and start of dialysis for 72 (9.9 %); 176 patients (24.1 %) developed at least one cardiovascular complication (mainly coronary events and acute heart failure) during the follow-up period, and among these, 50 had also developed renal complications. Sixty patients died, i.e., 8.2 %, 26 patients from cardiovascular causes.

CONCLUSION

Our study highlights that achieving BP and Pu targets remains a major challenge in patients with T2DM and nephropathy. Renal failure emerges as a more frequent event than death.

Prevalence of chronic kidney disease and associated factors in Chinese individuals with type 2 diabetes: Cross-sectional study

AIMS

This cross-sectional study aimed to determine the prevalence and associated risk factors of chronic kidney disease (CKD) in Chinese type 2 diabetic patients.

METHODS

A total of 3301 patients with type 2 diabetes were included in this study. Anthropometric parameters and biochemical indices were measured. The main outcome measures were detection of CKD, albuminuria and estimated glomerular filtration rate (eGFR).

RESULTS

The prevalence of CKD and albuminuria in Shanghai Chinese type 2 diabetic patients was 27.1% and 25.2%. The prevalence of mildly decreased renal function or worse (eGFR<60/mL/min/1.73m(2)) was 6%. The prevalence of glomerular hyperfiltration was 12.2%. The prevalence of diabetic kidney disease (DKD) according to the newest NKF's KDOQI classification was 12.03%. Risk factors associated with DKD were SBP, retinopathy, neuropathy, TG, LDL, anemia and HbA1c. Clinical factors associated with both albuminuria and low eGFR (≥60/<60) were SBP, retinopathy, TC, TG and anemia.

CONCLUSION

In conclusion, CKD and DKD were common in the Shanghai Chinese patients with T2DM and were similar to that in Western patients. Prevention and control of diabetes should be a high priority in reducing the CKD burden in China.

Sex Differences in the Renal Function Decline of Patients with Type 2 Diabetes

Aims. We aimed to investigate the sex differences in the renal function decline among patients with type 2 diabetic mellitus (T2DM), focusing on the differences in the risk factors at early stage of renal dysfunction. Methods. A clinic-based retrospective longitudinal study (follow-up duration: 8.1 ± 1.4 years) was conducted to assess the sex differences in the annual estimated glomerular filtration rate (eGFR) change in 344 (247 male and 97 female) Japanese T2DM patients. The sex differences in the risk factors of annual eGFR decline were subjected to linear regression analyses. Results. The mean annual eGFR change was -3.5 ± 2.7%/year in females and -2.0 ± 2.2%/year in males (P < 0.001). Baseline retinopathy and proteinuria were significantly associated with a larger eGFR decline, irrespective of sex, while HbA1c and LDL-cholesterol levels were significantly associated with an eGFR decline in females only. Interactive effects were observed between sex and the HbA1c, LDL-cholesterol, retinopathy, or proteinuria levels on the annual eGFR decline. Conclusions. The increased susceptibility to poor metabolic control seemed to contribute to a higher risk of renal dysfunction in females with T2DM. Our study highlights the importance of aggressive therapeutic intervention to improve metabolic profiles at early stage, especially in females.

Comparing the effect of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on renal function decline in diabetes

AIM

To compare effectiveness of angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs) for protecting Type 2 diabetes mellitus (DM2) patients from renal function decline in a real-world setting.

METHODS

Retrospective cohort study of new ACEi/ARB users in 2007-2012 in an unselected primary care DM2 population. Outcome is decline in renal function stage (combining estimated glomerular filtration rate and albuminuria). Patients were matched on a propensity score. Extended Cox models with time-varying covariates were used to estimate hazard ratios of outcome.

RESULTS

The time to renal function decline for ARB users was slightly, but not significantly longer than for ACEi users (hazard ratio: 0.80; 95% CI: 0.58-1.10; p = 0.166).

CONCLUSION

This study did not show significant differences between the classes in preventing renal function decline in DM2 patients in primary care.

Differential pharmacology and clinical utility of empagliflozin in type 2 diabetes

With rates of obesity and diabetes rising across the world, effective therapies to treat hyperglycemia and its associated comorbidities continue to be in demand. Empagliflozin is a highly selective sodium glucose transporter-2 inhibitor that improves serum glucose levels by inducing glucosuria. Taken orally, it is rapidly absorbed with linear pharmacokinetics consistent in Asian and Caucasian populations. Empagliflozin treatment demonstrates consistent reductions in hemoglobin A1c, fasting plasma glucose, body weight, and blood pressure in individuals with type 2 diabetes. Improvements in glycemic control and metabolic end points are evident with empagliflozin monotherapy, as add-on to oral hypoglycemics or add-on to insulin. The nonglycemic effects of empagliflozin with consistent improvements in blood pressure, body weight, and waist circumference provide additional rationale for use in patients with type 2 diabetes. Moreover, treatment with empagliflozin has recently shown significant reductions in both microvascular and macrovascular complications of diabetes.

Cardiovascular and all-cause mortality in patients with type 2 diabetes mellitus in the MADIABETES Cohort Study: Association with chronic kidney disease

AIMS

To assess the prevalence of stage 3-5 chronic kidney disease (CKD) at baseline and to identify associated risk factors. To determine the effect of CKD and CKD stage according to estimated glomerular filtration rate (eGFR) and albuminuria categories on all-cause and cardiovascular mortality after a 5-year follow-up.

METHODS

Prospective cohort study of 3443 outpatients with type 2 diabetes mellitus.

RESULTS

The prevalence of CKD was 28.32% (95% CI, 26.84-29.86); and variables most strongly associated were: age >74 years (OR, 19.88; 95% CI, 12.89-30.68) and albuminuria (OR, 2.27; 95% CI, 1.72-3.00). During follow-up, 221 CKD patients (22.90%) died compared with 203 non-CKD patients (8.31%) (p<0.01). The adjusted HR of CKD for cardiovascular and all-cause mortality was 1.82 (95% CI, 1.36-2.44) and 2.11 (95% CI, 1.61-2.76) for those with LDL cholesterol =135 mg/dl, respectively. The adjusted HR of very-high-risk CKD for all-cause mortality was 4.44 (95% CI, 2.31-8.53) in aged <75 years and 1.80 (95% CI, 1.19-2.72) in aged ≥75 years.

CONCLUSIONS

CKD at baseline is an independent risk factor for all-cause and cardiovascular mortality in the overall cohort, men and women, or in primary and secondary prevention of coronary heart disease. Albuminuria is an independent risk factor for all-cause and cardiovascular mortality only in primary prevention.

Overview of Data Concerning the Safe Use of Antihyperglycemic Medications in Type 2 Diabetes Mellitus and Chronic Kidney Disease

INTRODUCTION

It can be a challenge to manage glycemic control in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD), due to both patient and medication issues. Although most antihyperglycemic medications can be used in mild kidney disease, many medications are either not advised or require dose adjustments in more advanced CKD. This review summarizes product label information, pharmacokinetic and clinical studies, and clinical guidelines relevant to use of antihyperglycemic medications in CKD.

METHODS

Product labels and guidelines from North America and Europe, as well as pharmacokinetic and clinical studies of diabetes medication use in CKD were identified through Medline and PubMed searches, up to February 2015. Available data are summarized and correlations between treatment recommendations and available research are discussed, as are glycemic targets for patients with CKD.

RESULTS

Newer medications have significantly more data available than older medications regarding use in CKD, although larger clinical studies are still lacking for some drugs. As CKD advances, dose adjustment is needed for many medications [numerous dipeptidyl peptidase-4 inhibitors, some insulins, sodium glucose co-transporter 2 (SGLT2) inhibitors], although not for others (thiazolidinediones, meglitinides). Some medications are not recommended for use in more advanced CKD (metformin, SGLT2 inhibitors, some glucagon-like protein-1 receptor agonists) for safety or efficacy reasons. There is not always good alignment between label recommendations, pharmacokinetic or clinical studies, and guideline recommendations for use of these drugs in CKD. In particular, controversy remains about the use of metformin in moderate CKD and appropriate use of liraglutide and sulfonylureas in advanced CKD.

CONCLUSION

Considerable variability exists with respect to recommendations and clinical data for the many antihyperglycemic drugs used in patients with T2DM and CKD.

FUNDING

Eli Lilly and Company.

Prevalence of Chronic Kidney Disease in Adults with Type 2 Diabetes Mellitus

Introduction: Diabetes mellitus (DM) is a major cause of chronic kidney disease (CKD). The epidemiology of CKD secondary to type 2 DM (T2DM) (i.e. diabetic nephropathy (DN)) has not been well studied in Singapore, a multi-ethnic Asian population. We aimed to determine the prevalence of CKD in adult patients with T2DM. Materials and Methods: We conducted a cross-sectional study on patients (n = 1861) aged 21 to 89 years with T2DM who had attended the DM centre of a single acute care public hospital or a primary care polyclinic between August 2011 and November 2013. Demographic and clinical data were obtained from patients using a standard questionnaire. Spot urine and fasting blood samples were sent to an accredited hospital laboratory for urinary albumin, serum creatinine, HbA1c and lipid measurement. CKD was defi ned and classified using the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines and classification. Results: The distribution by risk of adverse CKD outcomes was: low risk, 47%; moderate risk, 27.2%; high risk, 12.8%; and very high risk, 13%. The prevalence of CKD in patients with T2DM was 53%. Variables significantly associated with CKD include neuropathy, blood pressure ≥140/80 mmHg, triglycerides ≥1.7 mmol, body mass index, duration of diabetes, HbA1c ≥8%, age, cardiovascular disease, and proliferative retinopathy. Conclusion: CKD was highly prevalent among patients with T2DM in Singapore. Several risk factors for CKD are well recognised and amenable to intervention. Routine rigorous screening for DN and enhanced programme for global risk factors reduction will be critical to stem the tide of DN. Key words: Albuminuria, Renal impairment, Risk factors

Sodium-glucose linked transporter-2 inhibitors in chronic kidney disease

SGLT2 inhibitors are new antihyperglycaemic agents whose ability to lower glucose is directly proportional to GFR. Therefore, in chronic kidney disease (CKD) the blood glucose lowering effect is reduced. Unlike many current therapies, the mechanism of action of SGLT2 inhibitors is independent of insulin action or beta-cell function. In addition, the mechanism of action of SGLT2 inhibitors is complementary and not alternative to other antidiabetic agents. SGLT2 inhibitors could be potentially effective in attenuating renal hyperfiltration and, consequently, the progression of CKD. Moreover, the reductions in intraglomerular pressure, systemic blood pressure, and uric acid levels induced by SGLT inhibition may potentially be of benefit in CKD subjects without diabetes. However, at present, only few clinical studies were designed to evaluate the effects of SGLT2 inhibitors in CKD. Consequently, safety and potential efficacy beyond blood glucose lowering should be better clarified in CKD. In this paper we provide an updated review of the use of SGLT2 inhibitors in clinical practice, with particular attention on subjects with CKD.

Chronic kidney disease screening methods and its implication for Malaysia: an in depth review

Chronic Kidney Disease has become a public health problem, imposing heath, social and human cost on societies worldwide. Chronic Kidney Disease remains asymptomatic till late stage when intervention cannot stop the progression of the disease. Therefore, there is an urgent need to detect the disease early. Despite the high prevalence of Chronic Kidney Disease in Malaysia, screening is still lacking behind. This review discusses the strengths and limitations of current screening methods for Chronic Kidney Disease from a Malaysian point of view. Diabetic Kidney Disease was chosen as focal point as Diabetes is the leading cause of Chronic Kidney Disease in Malaysia. Screening for Chronic Kidney Disease in Malaysia includes a urine test for albuminuria and a blood test for serum creatinine. Recent literature indicates that albuminuria is not always present in Diabetic Kidney Disease patients and serum creatinine is only raised after substantial kidney damage has occurred.  Recently, cystatin C was proposed as a potential marker for kidney disease but this has not been studied thoroughly in Malaysia.  Glomerular Filtration Rate is the best method for measuring kidney function and is widely estimated using the Modification of Diet for Renal Disease equation. Another equation, the Chronic Kidney Disease Epidemiology Collaboration Creatinine equation was introduced in 2009. The new equation retained the precision and accuracy of the Modification of Diet for Renal Disease equation at GFR < 60ml/min/1.73m2, showed less bias and improved precision at GFR>60ml/min/1.73m2. In Asian countries, adding an ethnic coefficient to the equation enhanced its performance. In Malaysia, a multi-ethnic Asian population, the Chronic Kidney Disease Epidemiology Collaboration equation should be validated and the Glomerular Filtration Rate should be reported whenever serum creatinine is ordered. Reporting estimated Glomerular Filtration Rate will help diagnose patients who would have been otherwise missed if only albuminuria and serum creatinine are measured.

Efficacy and safety of empagliflozin added to existing antidiabetes treatment in patients with type 2 diabetes and chronic kidney disease: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Diabetes is a leading cause of chronic kidney disease (CKD) worldwide. Optimum glycaemic control in patients with type 2 diabetes is important to minimise the risk of microvascular and macrovascular complications and to slow the progression of CKD. We assessed the efficacy and safety of empagliflozin as an add-on treatment in patients with type 2 diabetes and CKD.

METHODS

We did a phase 3, randomised, double-blind, parallel-group, placebo-controlled trial at 127 centres in 15 countries. Patients with HbA1c of 7% or greater to 10% or less were eligible for inclusion. Patients with stage 2 CKD (estimated glomerular filtration rate [eGFR] ≥60 to <90 mL/min per 1·73 m(2); n=290) were randomly assigned (1:1:1) to receive empagliflozin 10 mg or 25 mg or placebo once daily for 52 weeks. Patients with stage 3 CKD (eGFR ≥30 to <60 mL/min per 1·73 m(2); n=374) were randomly assigned (1:1) to receive empagliflozin 25 mg or placebo for 52 weeks. Randomisation was done with a computer-generated random sequence and stratified by renal impairment, HbA1c, and background antidiabetes medication. Treatment assignment was masked from patients and investigators. The primary endpoint was change from baseline in HbA1c at week 24 by ANCOVA in the full analysis set. This study is registered with ClinicalTrials.gov, number NCT01164501.

FINDINGS

In patients with stage 2 CKD, adjusted mean treatment differences versus placebo in changes from baseline in HbA1c at week 24 were -0·52% (95% CI -0·72 to -0·32) for empagliflozin 10 mg and -0·68% (-0·88 to -0·49) for empagliflozin 25 mg (both p<0·0001). In patients with stage 3 CKD, adjusted mean treatment difference versus placebo in change from baseline in HbA1c at week 24 was -0·42% (-0·56 to -0·28) for empagliflozin 25 mg (p<0·0001). In patients with stage 2 CKD, adverse events were reported over 52 weeks by 83 patients (87%) on placebo (15 severe [16%] and 11 serious [12%]), 86 (88%) on empagliflozin 10 mg (six severe [6%] and six serious [6%]) and 78 (80%) on empagliflozin 25 mg (eight severe [8%] and seven serious [7%]). In patients with stage 3 CKD, adverse events were reported over 52 weeks by 156 patients (83%) on placebo (15 severe [8%] and 23 serious [12%]) and 156 (83%) on empagliflozin 25 mg (18 severe [10%] and 22 serious [12%]).

INTERPRETATION

In patients with type 2 diabetes and stage 2 or 3 CKD, empagliflozin reduced HbA1c and was well tolerated. However, our findings might not be applicable to the general population of patients with type 2 diabetes and renal impairment.

FUNDING

Boehringer Ingelheim, Eli Lilly.

Pharmacokinetics, pharmacodynamics and safety of empagliflozin, a sodium glucose cotransporter 2 (SGLT2) inhibitor, in subjects with renal impairment

AIMS

Empagliflozin is a selective sodium glucose cotransporter 2 (SGLT2) inhibitor that inhibits renal glucose reabsorption and is being investigated for the treatment of type 2 diabetes mellitus (T2DM).

METHODS

In this open-label study, the effect of renal impairment on the pharmacokinetics, pharmacodynamics and safety of a 50 mg dose of empagliflozin was investigated in 40 subjects, grouped according to estimated glomerular filtration rate (eGFR).

RESULTS

Maximum empagliflozin plasma concentrations were similar in subjects with normal renal function and renal impairment. Area under the empagliflozin concentration-time curve (AUC0 -∞ ) values increased by approximately 18, 20, 66 and 48% in subjects with mild, moderate, severe renal impairment and renal failure/end stage renal disease (ESRD), respectively, in comparison to healthy subjects. This was attributed to decreased renal clearance (CLR ). Urinary glucose excretion (UGE) decreased with increasing renal impairment and correlated with decreased eGFR and CLR . Empagliflozin was well tolerated, with no increase in adverse events associated with renal impairment.

CONCLUSIONS

Renal insufficiency resulted in decreased CLR of empagliflozin, moderately increased systemic exposure and decreased UGE. A single 50 mg dose of empagliflozin was well tolerated in subjects with normal renal function and any degree of renal impairment. The pharmacokinetic results of this study indicate that no dose adjustment of empagliflozin is required in patients with renal impairment.

SOD2 gene Val16Ala polymorphism is associated with macroalbuminuria in Mexican type 2 diabetes patients: a comparative study and meta-analysis

Background

Several studies in type 2 diabetes patients have shown significant associations between the SOD2 gene Val16Ala polymorphism and albuminuria, but this association has not been explored in the Mexican population.

Methods

We evaluated the association between the SOD2 gene Val16Ala polymorphism (rs4880) and macroalbuminuria in a sample of 994 unrelated Mexican type 2 diabetes patients. The study included 119 subjects with urinary albumin >300 mg/dL and 875 subjects with urinary albumin ≤ 30 mg/dL. Genotyping of the SOD2 gene Val16Ala SNP was carried out with Real-Time Polymerase Chain Reaction (RT-PCR).

Results

The frequency of the TT genotype was 6.7% higher in participants with macroalbuminuria than in the normoalbuminuria group (16.8% vs. 10.1%). Using a logistic regression analysis, we observed that individuals with the CC genotype had significantly lower risks of macroalbuminuria than those with the TT genotype (OR=0.42, p=0.034). We carried out a meta-analysis combining our data with data from four previous studies and estimated an odds ratio (95% CI) for the C allele (with respect to the reference T allele) of 0.65 (0.52-0.80, p<0.001).

Conclusions

A significant association was found between the SOD2 Val16Ala polymorphism and macroalbuminuria in a sample of Mexican type 2 diabetes patients.

Inconsistency in albuminuria predictors in type 2 diabetes: a comparison between neural network and conditional logistic regression

Albuminuria is a sensitive marker to predict future cardiovascular events in patients with type 2 diabetes mellitus. However, current studies only use conventional regression models to discover predictors of albuminuria. We have used 2 different statistical models to predict albuminuria in type 2 diabetes mellitus: a multilayer perception neural network and a conditional logistic regression. Neural network models were used to predict the level of albuminuria in patients with type 2 diabetes mellitus, which include a matched case-control study for the population. For each case, we randomly selected 1 control matched by age and body mass index (BMI). The input variables were sex, duration of diabetes, systolic and diastolic blood pressure, glomerular filtration rate, high-density lipoprotein, low-density lipoprotein, triglyceride, high-density lipoprotein/triglyceride ratio, cholesterol, fasting blood sugar, and glycated hemoglobin. Age and BMI were included only in the neural network model. This model included 4 hidden layers and 1 bias. Relative error of predictions was 0.38% in the training group, 0.52% in the testing group, and 1.20% in the holdout group. The most robust predictors of albuminuria were high-density lipoprotein (21%), cholesterol (14.4%), and systolic blood pressure (9.7%). Using the conditional logistic regression model, glomerular filtration rate, time of onset to diabetes, and sex were significant indicators in the onset of albuminuria. Using a neural network model, we show that high-density lipoprotein is the most important factor in predicting albuminuria in type 2 diabetes mellitus. Our neural network model complements the current risk factor models to improve the care of patients with diabetes.

Prevalence of chronic kidney disease in patients with type 2 diabetes in Spain: PERCEDIME2 study

BACKGROUND

The objective of this study was to determinate the prevalence of chronic kidney disease (CKD) and the different stages of CKD in patients with type 2 diabetes mellitus (DM2) treated in primary care consults in Spain.

METHODS

A national cross-sectional study was performed in primary care consults. The following data were collected: demographic and anthropometric information; list of present cardiovascular risk factors (CVRF); previous macrovascular and microvascular disease history; physical examination and analytical data from the previous 12 months, including the urine albumin-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) to evaluate renal function.

RESULTS

With regard to the patients, 27.9% presented some degree of CKD as follows: 3.5% with stage 1; 6.4% with stage 2; 16.8% with stage 3 (11.6% with stage 3A and 5.2% with stage 3B); and 1.2% with stages 4 and 5. The prevalence of patients with UACR ≥ 30 mg/g was 15.4% (13% microalbuminuria and 2.4% macroalbuminuria). Renal impairment (RI) was found in 206 patients (18%) of whom 133 patients (64.6%) was stage 3A, 60 patients (29.1%) was stage 3B and 13 patients (6.3%) stages 4 and 5. Among patients with RI, 143 patients (69.4%) had normoalbuminuria. The following variables were significantly associated with CKD: age; sex (women); systolic arterial blood pressure (SABP) ≥ 150 mmHg; and a previous history of cardiovascular disease.

CONCLUSIONS

The results showed that the prevalence for any type of CKD was 27.9%. A systematic determination of UACR and eGFR may contribute to an early diagnosis, thus allowing intervention during the initial stages of the disease when treatment is more efficient.

Association of serum uric acid with proteinuria in type 2 diabetic patients

BACKGROUND

Various findings suggest that uric acid is an inflammatory factor and may have a role in endothelial dysfunction and act as a mediator of diabetic nephropathy. The objective of this study was to evaluate the relationships between serum uric acid level and level of proteinuria in type 2 diabetic (T2D) patients.

MATERIALS AND METHODS

A cross-sectional analytical study was conducted in 60 patients with T2D without a history of gout. None was treated with allopurinol. Venous blood samples were obtained in fasting state for determinations of serum creatinine, uric acid, and hemoglobin A1c (HbA1c) (reference range 3.8-5.5%); 24-h urine proteinuria was also measured.

RESULTS

Mean age of the patients was 57 ± 8.3 years. Mean ± standard error (SE) of serum creatinine was 0.98 ± 0.028 mg/dL, mean ± SE of serum uric acid was 4.5 ± 0.15 mg/dL, and mean ± SE of proteinuria was 388 ± 28.7 mg/day (median = 303.5 mg/day). There was no significant difference in serum uric acid, HbA1c, and creatinine level between males and females (P > 0.05). There was a significant positive association between body mass index (BMI) and serum uric acid levels (r = 0.428, P = 0.001). After adjustment for weight, a significant positive association of serum uric acid with level of proteinuria was seen (r = 0.47, P < 0.001).

CONCLUSION

Serum uric acid had a significant positive association with diabetic nephropathy. It might be hypothesized that serum uric acid plays a role in diabetic nephropathy in T2D.