Joint relationship between renal function and proteinuria on mortality of patients with type 2 diabetes: the Taichung Diabetes Study

Derivation and validation of 10-year all-cause and cardiovascular disease mortality prediction model for middle-aged and elderly community-dwelling adults in Taiwan

Prediction model mainly focused on specific diseases, such as diabetes, hypertension, cardiovascular disease, or patients with cancer, or populations of Europe and America, thereby limiting its generalization. This study aimed to develop and validate a 10-year mortality risk score by using data from a population-representative sample of adults. Data were collected from 2,221 Taichung Community Health study participants aged ≥40 years. The baseline period of the study was 2004, and all participants were followed up until death or in 2016. Cox’s proportional hazards regression analyses were used to develop the prediction model. A total of 262 deaths were ascertained during the 10-year follow-up. The all-cause mortality prediction model calculated the significant risk factors, namely, age, sex, marital status, physical activity, tobacco use, estimated glomerular filtration rate, and albumin-to-creatinine ratio, among the baseline risk factors. The expanded cardiovascular disease (CVD) mortality prediction model consisted of six variables: age, sex, body mass index, heart disease plus heart disease medication use, stroke plus medication use, and ankle–brachial index. The areas under receiver operating curves of the 3-, 5- and 10-year predictive models varied between 0.97, 0.96, and 0.88 for all-cause mortality, and between 0.97, 0.98, and 0.84 for expanded CVD mortality. These mortality prediction models are valid and can be used as tools to identify the increased risk for mortality.

Changes in Proteinuria on the Risk of All-Cause Mortality in People with Diabetes or Prediabetes: A Prospective Cohort Study

BACKGROUND

Proteinuria has been related to all-cause mortality, showing regression or progression. However, few studies have focused on the relationship between proteinuria changes and all-cause mortality. The main purpose of this paper is to examine the associations between proteinuria changes and all-cause mortality in people with diabetes or prediabetes.

METHODS

Dipstick proteinuria at baseline and a 2-year follow-up were determined in the participants attending the Kailuan prospective cohort study. Participants were then divided into three categories: elevated proteinuria, stable proteinuria, and reduced proteinuria. Four Cox proportional hazard models were built to access the relations of proteinuria changes to all-cause mortality, adjusting for other confounding covariates.

RESULTS

A total of 17,878 participants were finally included in this study. There were 1193 deaths after a median follow-up of 6.69 years. After adjusting for major covariates and proteinuria at baseline, mortality risk was significantly associated with elevated proteinuria (hazard ratio (HR): 1.54, 95% confidence interval (CI): 1.33-1.79) and reduced proteinuria (HR: 0.70, 95% CI: 0.55-0.89), compared to those with stable proteinuria.

CONCLUSION

Proteinuria changes were independently associated with mortality risk in either diabetic or prediabetic population.

Prevention of renal failure in Chinese patients with newly diagnosed type 2 diabetes: A cost-effectiveness analysis

Aims/Introduction

Diabetic kidney disease (DKD) is the second leading cause (16.4%) of end‐stage renal disease in China. The current study assessed the cost‐effectiveness of preventing DKD in patients with newly diagnosed type 2 diabetes from the Chinese healthcare perspective.

Materials and Methods

A lifetime Markov decision model was developed according to the disease course of DKD. Patients with newly diagnosed type 2 diabetes might receive treatment according to one of the following three strategies: (i) “do nothing” strategy (control strategy); (ii) treatment with angiotensin‐converting enzyme inhibitors and angiotensin II receptor blockers (universal strategy); (iii) or screening for microalbuminuria followed by angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker treatment (screening strategy). Clinical and utility data were obtained from the published literature. Direct medical costs and resource utilization in the Chinese healthcare setting were considered. Sensitivity analyses were undertaken to test the impact of a range of variables and assumptions on the results.

Results

Compared with the control strategy, both the screening and universal strategies were cost‐saving options that showed lower costs and better health benefits. The incremental cost‐effectiveness ratio of the universal strategy over the screening strategy was US $30,087 per quality‐adjusted life‐year, which was higher than the cost‐effectiveness threshold of China. The sensitivity analyses showed robust results, except for the probability of developing macroalbuminuria from microalbuminuria.

Conclusions

Screening for microalbuminuria could be a cost‐saving option for the prevention of DKD in the Chinese setting.

High Blood Pressure and All-Cause and Cardiovascular Disease Mortalities in Community-Dwelling Older Adults

Although hypertension is common among older adults, the optimal blood pressure (BP) for survival in older adults remains unclear. We attempt to use a large cohort to assess the relationship between BP and mortality and to gain insight into what level of BP is required for optimal survival in older adults.A total of 77,389 community-dwelling adults, aged ≥65 years, were followed between 2006 and 2010. Mortality was determined using matching cohort identifications with national death files. Cox proportional hazards regression models were used to evaluate the relationship of BP with all-cause, cardiovascular disease (CVD), and expanded-CVD mortalities.The mortality risks of the stage 2-3 hypertension group were substantial (all-cause mortality: hazard ratio [HR]: 1.23; 95% confidence interval [CI]: 1.10-1.37; CVDs mortality: HR: 1.31; 95% CI: 1.05-1.64; expanded-CVDs mortality: HR: 1.40; 95% CI: 1.15-1.71). The cardiovascular and expanded-cardiovascular mortality risks were lowest when systolic blood pressures were 120 to 129 mm Hg, and increased significantly when systolic blood pressures (SBPs) were ≥160 mm Hg or diastolic BPs were ≥90 mm Hg. A J-curve phenomenon for SBP on CVD and expanded-CVD mortality was observed. The impacts of stage 2-3 hypertension on mortality risks were significantly increased among women. The mortality risks of hypertension were not attenuated with older age.This study provides insight for identifying the optimal BP for survival in older adults, and extends the knowledge of the impacts of hypertension on mortality risks among women and the older adults.

Cardiovascular events and all-cause mortality in a cohort of 57,946 patients with type 2 diabetes: associations with renal function and cardiovascular risk factors

Background

Diabetes and chronic kidney disease (CKD) are independent predictors of death and cardiovascular events and their concomitant prevalence has increased in recent years. The aim of this study was to characterize the effect of the estimated glomerular filtration rate (eGFR) and other factors on the risk of death and cardiovascular events in patients with type 2 diabetes.

Methods

A cohort of 57,946 patients with type 2 diabetes who were aged 20–89 years in 2000–2005 was identified from The Health Improvement Network, a UK primary care database. Incidence rates of death, myocardial infarction (MI), and ischemic stroke or transient ischemic attack (IS/TIA) were calculated overall and by eGFR category at baseline. eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) study equation. Death, MI and IS/TIA cases were detected using an automatic computer search and IS/TIA cases were further ascertained by manual review of medical records. Hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) for death, MI, and IS/TIA associated with eGFR category and other factors were estimated using Cox regression models adjusted for potential confounders.

Results

Overall incidence rates of death (mean follow-up time of 6.76 years), MI (6.64 years) and IS/TIA (6.56 years) were 43.65, 9.26 and 10.39 cases per 1000 person-years, respectively. A low eGFR (15–29 mL/min) was associated with an increased risk of death (HR: 2.79; 95% CI: 2.57–3.03), MI (HR: 2.33; 95% CI: 1.89–2.87) and IS/TIA (HR: 1.77; 95% CI: 1.43–2.18) relative to eGFR ≥ 60 mL/min. Other predictors of death, MI and IS/TIA included age, longer duration of diabetes, poor control of diabetes, hyperlipidemia, smoking and a history of cardiovascular events.

Conclusions

In patients with type 2 diabetes, management of cardiovascular risk factors and careful monitoring of eGFR may represent opportunities to reduce the risks of death, MI and IS/TIA.

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-015-0204-5) contains supplementary material, which is available to authorized users.

Proteinuria and its relation to cardiovascular disease

Chronic kidney disease (CKD) and its associated morbidity pose a worldwide health problem. As well as risk of endstage renal disease requiring renal replacement therapy, cardiovascular disease is the leading cause of premature death among the CKD population. Proteinuria is a marker of renal injury that can often be detected earlier than any tangible decline in glomerular filtration rate. As well as being a risk marker for decline in renal function, proteinuria is now widely accepted as an independent risk factor for cardiovascular morbidity and mortality. This review will address the prognostic implications of proteinuria in the general population as well as other specific disease states including diabetes, hypertension and heart failure. A variety of pathophysiological mechanisms that may underlie the relationship between renal and cardiovascular disease have been proposed, including insulin resistance, inflammation, and endothelial dysfunction. As proteinuria has evolved into a therapeutic target for cardiovascular risk reduction in the clinical setting we will also review therapeutic strategies that should be considered for patients with persistent proteinuria.

Metabolic syndrome and abdominal fat are associated with inflammation, but not with clinical outcomes, in peritoneal dialysis patients

Background

In the general population, metabolic syndrome (MetS) is correlated with visceral fat and a risk factor for cardiovascular disease (CVD); however, little is known about the significance of abdominal fat and its association with inflammation and medication use in peritoneal dialysis (PD) patients. We investigated the relationship of visceral fat area (VFA) with C-reactive protein (CRP) levels and medication use in PD patients and followed their clinical outcomes.

Methods

In a prospective study from February 2009 to February 2012, we assessed diabetes mellitus (DM) status, clinical and PD-associated characteristics, medication use, CRP levels, components of MetS, and VFA in 183 PD patients. These patients were categorized into 3 groups based on MetS and DM status: non-MetS (group 1, n = 73), MetS (group 2, n = 65), and DM (group 3, n = 45). VFA was evaluated by computed tomography (CT) and corrected for body mass index (BMI).

Results

Patients in group 1 had smaller VFAs than patients in groups 2 and 3 (3.2 ± 1.8, 4.6 ± 1.9, and 4.9 ± 2.0 cm²/[kg/m²], respectively, P < 0.05) and lower CRP levels (0.97 ± 2.31, 1.27 ± 2.57, and 1.11 ± 1.35 mg/dL, respectively, P < 0.05). VFA increased with the number of criteria met for MetS. After adjusting for age, body weight, and sex, CRP and albumin levels functioned as independent positive predictors of VFA; on other hand, the use of renin-angiotensin system blockers was inversely correlated with VFA in PD patients without DM. In the survival analysis, DM patients (group 3) had the poorest survival among the 3 groups, but no significant differences were found between groups 1 and 2.

Conclusion

This study showed that VFA and MetS are associated with CRP levels but cannot predict survival in PD patients without DM. The complex relationship of nutritional parameters to VFA and MetS may explain these results. The type of antihypertensive medication used was also associated with the VFA. The mechanisms behind these findings warrant further investigation.

Is the risk and nature of CVD the same in type 1 and type 2 diabetes?

The incidence of both type 1 and type 2 diabetes is increasing globally, most likely explained by environmental changes, such as changing exposures to foods, viruses, and toxins, and by increasing obesity. While cardiovascular disease (CVD) mortality has been declining recently, this global epidemic of diabetes threatens to stall this trend. CVD is the leading cause of death in both type 1 and type 2 diabetes, with at least a two- to fourfold increased risk in patients with diabetes. In this review, the risk factors for CVD are discussed in the context of type 1 and type 2 diabetes. While traditional risk factors such as dyslipidemia, hypertension, and obesity are greater in type 2 patients than in type 1 diabetes, they explain only about half of the increased CVD risk. The role for diabetes-specific risk factors, including hyperglycemia and kidney complications, is discussed in the context of new study findings.

Glomerular filtration rate and albuminuria predict mortality independently from coronary artery calcified plaque in the Diabetes Heart Study

Background

Risk stratification in individuals with type 2 diabetes (T2D) remains an important priority in the management of associated morbidity and mortality, including from cardiovascular disease (CVD). The current investigation examined whether estimated glomerular filtration rate (eGFR) and urine albumin:creatinine ratio (UACR) were independent predictors of CVD-mortality in European Americans (EAs) with T2D after accounting for subclinical CVD.

Methods

The family-based Diabetes Heart Study (DHS) cohort (n=1,220) had baseline measures of serum creatinine, eGFR, UACR and coronary artery calcified plaque (CAC) assessed by non-contrast computed tomography scan. Cox proportional hazards regression was performed to determine risk for all-cause mortality and CVD-mortality associated with indices of kidney disease after accounting for traditional CVD risk factors and CAC as a measure of subclinical CVD.

Results

Participants were followed for 8.2±2.6 years (mean±SD) during which time 247 (20.9%) were deceased, 107 (9.1%) from CVD. Univariate analyses revealed positive associations between serum creatinine (HR:1.56; 95% CI:1.37–1.80; p<0.0001) and UACR (1.59; 1.43–1.77; p>0.0001) and negative associations between serum albumin (0.74; 0.65–0.84; p<0.0001) and eGFR (0.66; 0.58–0.76; p<0.0001) with all-cause mortality. Associations remained significant after adjustment for traditional CVD risk factors, as well as for CAC. Similar trends were noted when predicting risk for CVD-mortality.

Conclusions

The DHS reveals that kidney function and albuminuria are independent risk factors for all-cause mortality and CVD-mortality in EAs with T2D, even after accounting for CAC.