Low-grade albuminuria is associated with early but not late carotid atherosclerotic lesions in community-based patients with type 2 diabetes

High-normal serum bilirubin is a useful indicator to assess the risk of diabetic retinopathy in type 2 diabetes: A real-world study

Background

To investigate the association of serum bilirubin within normal range, especially unconjugated bilirubin (UCB), with diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM).

Methods

In this cross-sectional, real-world study, 7617 T2DM patients were stratified into quartiles based on serum UCB levels. DR was determined by digital fundus photography and further classified into non-proliferative diabetic retinopathy (NPDR) and PDR. The associations of serum bilirubin levels and UCB quartiles with DR were investigated by logistic regression analysis.

Results

After controlling for age, sex, and diabetes duration, the DR prevalence was significantly decreased across the serum UCB quartiles (40.4 %, 33.4 %, 29.7 %, 26.6 % for each quartile, respectively, p < 0.001 for trend). The subjects with DR had lower serum total bilirubin (TB) and UCB, rather than conjugated bilirubin (CB), compared with those without DR (p = 0.003 for TB, p < 0.001 for UCB, and p = 0.528 for CB, respectively), while all three types of serum bilirubin in the subjects with PDR were obviously lower than those with NPDR (p = 0.006 for TB, and p < 0.001 for UCB and CB, respectively). After adjustment for confounding factors, logistic regression demonstrated negative associations of serum TB and UCB levels, rather than CB, with the presence of DR (OR: 0.844, 95%CI: 0.774-0.920, p < 0.001 for TB; OR: 0.828, 95%CI: 0.763-0.899, p < 0.001 for UCB; and OR: 0.984, 95%CI: 0.900-1.074, p = 0.713 for CB, respectively). Additionally, a fully-adjusted analysis revealed a negative correlation between UCB quartiles and DR (p < 0.001).

Conclusion

High-normal serum TB and UCB were closely associated with the decreased odds of DR, while all types of serum bilirubin were negatively correlated with the severity of DR in T2DM patients. Serum bilirubin may be used as a potential indicator to assess the risk and severity of DR in T2DM.

An elevated urinary albumin-to-creatinine ratio increases the risk of incident cardia-cerebrovascular disease in individuals with type 2 diabetes

AIMS

We aimed to explore the associations between urine albumin-to-creatinine ratio (uACR) and cardia-cerebrovascular disease (CVD) in Chinese population with type 2 diabetes(T2D).

METHODS

We included 8975 participants with T2D but free of prevalent CVD (including myocardial infarction, ischemic and hemorrhagic stroke) at baseline from Kailuan study who were assessed with uACR between 2014 and 2016. The participants were divided into three groups based on their baseline uACR: normal (< 3 mg/mmol), microalbuminuria (3-30 mg/mmol), and macroalbuminuria (≥ 30 mg/mmol). Cox regression models and restricted cubic spline were used to evaluate the hazard ratios (HRs) and 95% confidence intervals (CIs) of incident CVD. The area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to see if incorporating uACR into existing models could improve performance.

RESULTS

During a median follow-up of 4.05 years, 560 participants developed first CVD event (6.24%). After adjustment for potential confounders, participants with microalbuminuria had higher risks of CVD compared with normal uACR, with HRs of 1.57(95% CI 1.04-2.37) for myocardial infarction, 1.24(95% CI 1.00-1.54) for ischemic stroke,1.62(95% CI 0.73-3.61) for hemorrhagic stroke, and 1.30(95% CI 1.07-1.57) for total CVD. The risks gradually attenuated with uACR increase, with HRs of 2.86(95% CI 1.63-5.00) for myocardial infarction, 2.46(95% CI 1.83-3.30) for ischemic stroke, 4.69(95% CI 1.72-12.78) for hemorrhagic stroke, and 2.42(95% CI 1.85-3.15) for total CVD in macroalbuminuria. The addition of uACR to established CVD risk models improved the CVD risk prediction efficacy.

CONCLUSIONS

Increasing uACR, even below the normal range, is an independent risk factor for new-onset CVD in T2D population. Furthermore, uACR could improve the risk prediction for CVD among community based T2D patients.

Association of high-normal albuminuria and vascular aging: Hanzhong adolescent hypertension study

Normoalbuminuria has recently been associated with increased cardiovascular risk, and vascular aging is proposed as the early manifestation of cardiovascular disease. Here, the authors aimed to examine the association of high-normal albuminuria and vascular aging in a Chinese cohort. From our previously established cohort, 1942 participants with estimated glomerular filtration rate ≥60 mL/min/1.73 m2 or urinary albumin-creatinine ratio (UACR) <30 mg/g were enrolled. Brachial-ankle pulse wave velocity (baPWV) ≥1400 cm/s and/or carotid intima-media thickness (CIMT) ≥0.9 mm were used as indicators of vascular aging. Multivariate regression and receiving operating characteristic curve analysis were performed to examine the relationship between continuous and categorical UACR with vascular aging. We found an average UACR value of 8.08 (5.45-12.52) mg/g in this study. BaPWV and CIMT demonstrated positive correlations with lg-UACR (p < .05). High-normal albuminuria (10-29 mg/g) was significantly associated with the presence of vascular aging after adjusting for multiple cardiovascular confounders (OR = 1.540, 95% CI = 1.203-1.972, p = .001). In addition, a lg-UACR cutoff point of 0.918 lg(mg/g) (equal to UACR of 8.285 mg/g) was significantly associated with the presence of vascular aging and its components for all participants and those without hypertension or diabetes and without medication (p < .05). Briefly, high-normal albuminuria was significantly associated with vascular aging in this sample of Chinese adults. These findings implied the warning of elevated UACR even within normal range in clinical practice and the importance of UACR screening in normoalbuminuria for early detection and prevention of cardiovascular disease in otherwise healthy participants.

[Albuminuria as a marker of atherosclerosis burden and a possible predictor of adverse events in patients with polyvascular disease]

BACKGROUND

The role of albuminuria as a marker of the atherosclerosis burden and a predictor of prognosis in patients with polyvascular disease (PD) has been little studied.

AIM

To evaluate the prevalence, association with atherosclerosis burden, and prognostic value of albuminuria in relation to cardiovascular and bleeding complications in patients with PD.

MATERIALS AND METHODS

The data was obtained from the prospective registry REGATA-1 (NCT04347200). Seventy four patients (75.7% males, median age 67 [61-69] years) with PD (CAD and peripheral arterial disease) were enrolled. All patients received aspirin and rivaroxaban 2.5 mg. The albumin-creatinine ratio in a single morning urine sample, estimated glomerular filtration rate (eGFR), and von Willebrand factor levels were determined.

RESULTS

Mild albuminuria (10-29 mg/g) was detected in 45.9% of patients, moderate and severe (≥30 mg/g) - in 29.7%; eGFR<60 ml/min - in 21.7%, chronic kidney disease (CKD) according to the full KDIGO criteria (eGFR and/or albuminuria ≥30 mg/g) - twice as often (39.2%). The frequency of nephroprotective therapy prescription was insufficient. The level of albuminuria did not correlate with von Willebrand factor (endothelial dysfunction marker), but was associated with affecting of 4-5 vascular beds (ROC AUC 0.775; p=0.011). During the follow-up (12 [8-18] months) 3 patients developed MACE, 11 - BARC 2-3 bleedings. Neither albuminuria nor eGFR were predictors of MACE, bleeding, or net clinical benefit. CKD (KDIGO) was also not associated with bleedings. CKD (KDIGO) was independent predictor of MACE (in significant multiple regression model beta - coefficient for CKD was 0.097; p=0.042), however, the small number of end points allows us to speak only of a hypothesis-generating trend. The implementation of CKD (KDIGO) has increased the predictive value of the REACH score.

CONCLUSION

Albuminuria is highly prevalent in patients with PD. It is a marker of atherosclerosis burden. CKD, diagnosed taking into account the level of albuminuria, can be used in a comprehensive assessment of cardiovascular risk in this category of patients.

Low-grade albuminuria and its relationship with cardiovascular disease risk in hypertensive and diabetic patients in primary health care

OBJECTIVE

To evaluate the presence of LGA and the relationship with the 10-year risk of a cardiovascular event in hypertensive and diabetic patients in Primary Health Care.

STUDY DESIGN

The study design used is cross-sectional.

METHODS

This study was based on the application of questionnaires, anthropometric measurements, and laboratory tests carried out from August 2017 to April 2018. Logistic regression was used to evaluate the odds ratio of the explanatory variables in relation to the highest tercile of LGA. The Framingham risk score was used to assess the 10-year risk of cardiovascular event. The comparison of this score with the LGA terciles was analyzed using ANOVA.

RESULTS

An increase in the 10-year risk of cardiovascular event score was observed with an increasing LGA tercile, and this pattern prevailed after adjusting for confounding variables.

CONCLUSION

An association between LGA and the 10-year risk of cardiovascular event was observed in a representative sample of hypertensive and diabetic patients.

Are Any Changes in Carotid Intima–Media Thickness Associated with Cardiometabolic Risk Among Adult Bantu Central African Hypertensive Patients from Monkole and Biamba Marie Mutombo Hospitals?

Background

Several classic/traditional risk factors are associated with intima–media thickness (IMT), a novel risk of cardio metabolic risk (CMR) in the literature but not in Kinshasa, a megacity prone to CMR. Thus, the objective of this study was to evaluate potential correlations between inflammation, kidney function, psychological stress, hemodynamics, and changes in IMT.

Methods

This cross-sectional study was carried out between 2018 and 2021 within Monkole and Biamba Marie Mutombo Hospitals, respectively, and randomly selected from 10 health structures from East and West of Kinshasa, Capital of Democratic Republic Congo (DRC). A random sample of adult hypertensive Bantu Central Africans was examined after bivariate correlations and multiple linear regression.

Results

Out of 280 patients with 140 men and 140 women aged 62 ± 11 years, the mean carotid intima–media thickness (CIMT) was 1.06 ± 0.5 mm and 73% (n = 204) patients had uncontrolled hypertension. After controlling for confounders, 52.9% variations (R2) of CIMT were independently and significantly (P = 0.037) predicted by CRP, 24-hour proteinuria, urinary albumin/creatinine ratio, duration of hypertension, heart rate, hip circumference, and psychological stress with Equation Y = 0.717 + 0.87 × CRP + 0.02 × 24 H – proteinuria + 0.005 × urinary albumin/creatinine ratio + 0.05 × duration of hypertension + 0.001 × heart rate + 0.006 × hip circumference + 0.017 × psychological stress.

Conclusion

There is an urgent need to control inflammation, impaired renal function, cardiac rhythm, peripheral obesity, longer duration of hypertension management, and stress, which are emerging as specific novel determinants of the subclinical atherosclerosis for those Bantu Central African hypertensive patients.

Serum metabolomic profiles associated with subclinical and clinical cardiovascular phenotypes in people with type 2 diabetes

BACKGROUND

Atherosclerotic cardiovascular diseases (CVD) is the leading cause of death in diabetes, but the full range of biomarkers reflecting atherosclerotic burden and CVD risk in people with diabetes is unknown. Metabolomics may help identify novel biomarkers potentially involved in development of atherosclerosis. We investigated the serum metabolomic profile of subclinical atherosclerosis, measured using ankle brachial index (ABI), in people with type 2 diabetes, compared with the profile for symptomatic CVD in the same population.

METHODS

The Edinburgh Type 2 Diabetes Study is a cohort of 1,066 individuals with type 2 diabetes. ABI was measured at baseline, years 4 and 10, with cardiovascular events assessed at baseline and during 10 years of follow-up. A panel of 228 metabolites was measured at baseline using nuclear magnetic resonance spectrometry, and their association with both ABI and prevalent CVD was explored using univariate regression models and least absolute shrinkage and selection operator (LASSO). Metabolites associated with baseline ABI were further explored for association with follow-up ABI and incident CVD.

RESULTS

Mean (standard deviation, SD) ABI at baseline was 0.97 (0.18, N = 1025), and prevalence of CVD was 35.0%. During 10-year follow-up, mean (SD) change in ABI was + 0.006 (0.178, n = 436), and 257 CVD events occurred. Lactate, glycerol, creatinine and glycoprotein acetyls levels were associated with baseline ABI in both univariate regression [βs (95% confidence interval, CI) ranged from - 0.025 (- 0.036, - 0.015) to - 0.023 (- 0.034, - 0.013), all p < 0.0002] and LASSO analysis. The associations remained nominally significant after adjustment for major vascular risk factors. In prospective analyses, lactate was nominally associated with ABI measured at years 4 and 10 after adjustment for baseline ABI. The four ABI-associated metabolites were all positively associated with prevalent CVD [odds ratios (ORs) ranged from 1.29 (1.13, 1.47) to 1.49 (1.29, 1.74), all p < 0.0002], and they were also positively associated with incident CVD [ORs (95% CI) ranged from 1.19 (1.02, 1.39) to 1.35 (1.17, 1.56), all p < 0.05].

CONCLUSIONS

Serum metabolites relating to glycolysis, fluid balance and inflammation were independently associated with both a marker of subclinical atherosclerosis and with symptomatic CVD in people with type 2 diabetes. Additional investigation is warranted to determine their roles as possible etiological and/or predictive biomarkers for atherosclerotic CVD.

Albuminuria but not low eGFR is closely associated with atherosclerosis in patients with type 2 diabetes: an observational study

BACKGROUND

There is still controversy regarding the associations of urinary albumin excretion (UAE) and estimated glomerular filtration rate (eGFR) with atherosclerosis in patients with type 2 diabetes mellitus (T2DM). Therefore, it is necessary to explore the correlation between them in T2DM patients.

METHODS

We conducted a survey involving 2565 T2DM patients from a single center. The study cohort was classified into three groups based on the levels of albuminuria: normal UAE (UAE < 30 mg/24 h), moderate UAE (UAE between 30 and 299 mg/24 h) and high UAE (UAE ≥ 300 mg/24 h). Additionally, the patients were divided into three separate groups according to eGFR levels, including low eGFR (eGFR < 60 ml/min/1.73 m²), intermediate eGFR (eGFR 60-89 ml/min/1.73 m²) and normal eGFR (eGFR ≥ 90 ml/min/1.73 m²) groups. Atherosclerotic lesions were compared among the three UAE and eGFR groups. Regression analyses were used to assess the associations of atherosclerotic lesions with UAE and eGFR in T2DM.

RESULTS

After controlling for age, sex and diabetes duration, the prevalence of atherosclerotic plaque and stenosis were significantly increased from the normal to high UAE groups (plaque: 72.2%, 78.6% and 87.3%, respectively, p = 0.016 for trend; stenosis: 14.0%, 25.5% and 37.3%, respectively, p < 0.001 for trend). Likewise, the values of carotid intima-media thickness (CIMT) and femoral intima-media thickness (FIMT) were also obviously increased from the normal to high UAE groups (CIMT: p < 0.001 for trend; FIMT: p = 0.001 for trend). Conversely, only the FIMT value was clearly increased from the low to normal eGFR groups (p = 0.001 for trend). Fully adjusted regression analyses revealed that UAE was closely associated with the presence of atherosclerotic plaque (OR 1.20, 95% CI 1.03-1.40, p = 0.020) and stenosis (OR 1.17, 95% CI 1.01-1.35, p = 0.036), and with the values of CIMT (β 0.05, 95% CI 0.01-0.10, p = 0.029) and FIMT (β 0.07, 95% CI 0.03-0.11, p = 0.001) in T2DM patients. However, there was no significant association between eGFR levels and atherosclerotic lesions in T2DM after adjustment for multiple confounding factors.

CONCLUSIONS

Overall, albuminuria rather than low eGFR is closely associated with atherosclerotic lesions in T2DM patients. Albuminuria is an independent risk factor for carotid and femoral atherosclerotic lesions in T2DM. Therefore, albuminuria may be a potential early marker to predict the development of atherosclerosis in patients with T2DM.

Visceral adiposity index is closely associated with urinary albumin-creatinine ratio in the Chinese population with prediabetes

AIMS

Visceral obesity is a major health issue and is a risk factor for an atherogenic state. Visceral obesity has been reported to be a crucial link between albuminuria and cardiovascular diseases (CVD). This study attempted to explore the association between visceral obesity and albuminuria in prediabetic individuals.

METHODS

This cross-sectional study included 24871 prediabetic participants over 40 years of age from seven centres across China (REACTION study). The visceral adiposity index (VAI) was determined based on the measurements of anthropometric indices and lipid parameters. Increased albuminuria was defined as a urinary albumin-creatinine ratio (UACR) ≥30 mg/g, indicating kidney damage. Propensity score matching was used to reduce bias, and a multiple logistic regression model was performed to evaluate the association between visceral obesity and albuminuria in the population with prediabetes.

RESULTS

Participants with increased UACR exhibited increased VAI, age, blood pressure, triglycerides, poor glycaemic control, CVD events, and decreased estimated glomerular filtration rate (eGFR). Multiple logistic regression analysis demonstrated that VAI quartiles were positively associated with an increased risk of albuminuria (Q2: odds rate [OR]: 1.10, 95% confidence intervals [CI] 0.96-1.25; Q3: OR: 1.16, 95% CI 1.01-1.32; Q4: OR: 1.26, 95% CI 1.10-1.44, p for trend = 0.001). Stratified analysis revealed that the association of VAI level with increased albuminuria risk also occurred in people who were young, women, overweight or obese, with poor control of blood pressure, and eGFR ≥90 ml/min per 1.73 m² .

CONCLUSIONS

Visceral obesity assessed by VAI is significantly associated with increased UACR in a Chinese population with prediabetes.

Prevalence of Microalbuminuria and Its Association with Subclinical Carotid Atherosclerosis in Middle Aged, Nondiabetic, Low to Moderate Cardiovascular Risk Individuals with or without Hypertension

Microalbuminuria is closely associated with the risk of cardiovascular disease and all-cause mortality in the general population. Less is known about its relationship with subclinical atherosclerosis. We aimed to assess the prevalence of microalbuminuria and its relationship with subclinical atherosclerosis in middle-aged, nondiabetic, apparently healthy individuals (N = 187; 40.1% men, 59.9% women; aged 35–55 years) as well as to evaluate its potential associations with established risk modifiers, especially with the presence of carotid plaque. Clinical and laboratory parameters, the estimated 10-year fatal cardiovascular risk (SCORE), as well as circulating, functional (flow mediated vasodilation, ankle-brachial index, augmentation index, and pulse wave velocity), and morphological markers (mean carotid intima–media thickness, and carotid plaque) of subclinical atherosclerosis were analysed in group with vs. without microalbuminuria. Microalbuminuria was present in 3.8% of individuals with SCORE risk 0.43 ± 0.79%. Functional markers predominated in both groups. Carotid intima–media thickness (mean ± SD) in both groups was in range: 0.5–0.55 ± 0.09–0.14 mm. Carotid plaque was more frequent in group with (14.3%) vs. without (4.4%) microalbuminuria. Microalbuminuria had no statistically significant effect on most markers of subclinical atherosclerosis, but the increasing value of microalbuminuria was significantly associated with the occurrence of carotid plaque (p = 0.035; OR = 1.035; 95% CI = 1.002–1.07). Additional multiple logistic regression analysis, where variables belonged to microalbuminuria, number of risk factors, and family history, finally showed only two variables: microalbuminuria (p = 0.034; OR = 1.04; 95%CI = 1.003–1.09) and the number of risk factors (p = 0.006; OR = 2.15; 95% CI = 1.24–3.73) with independent and significant impact on the occurrence of carotid plaque. Our results may indicate an association of microalbuminuria with the presence of carotid atherosclerotic plaque; in addition, microalbuminuria and the number of risk factors appear to be possible predictors of the carotid plaque occurrence. Monitoring microalbuminuria may improve the personalized cardiovascular risk assessment in nondiabetic, low-to-moderate cardiovascular risk individuals with or without hypertension.

Low-grade albuminuria is associated with high cardiovascular risk in CVD-free and normoalbuminuric Chinese adults: Results from the REACTION study

BACKGROUND

Data are limited with regard to the association between low-grade albuminuria (below the threshold of microalbuminuria) and high cardiovascular risk in normoalbuminuric Chinese adults free of cardiovascular disease (CVD).

METHODS

A total of 32 650 participants aged over 40 years from seven regional centers in China were included in this study. The single-void first morning urine sample was collected to measure the urinary albumin to creatinine ratio (UACR) and the data were divided into sex-specific quartiles. The Framingham Risk Score (FRS) was used to identify participants at high risk of developing coronary heart disease (CHD) over the next 10 years and the association between low-grade albuminuria and high 10-year Framingham risk for CHD (FRS ≥20%) was investigated.

RESULTS

Among males and females, the prevalence of cardiometabolic risk factors (diabetes, hypertension, and dyslipidemia) increased markedly with the elevation of UACR quartiles. Logistic regression analysis showed that the odds ratios (ORs) for high 10-year risk of CHD increased significantly from the second quartile in males (UACR: 4.78 ~ 7.53 mg/g, OR = 1.21, 95% confidence interval [CI]: 1.05-1.40) and the third quartile in females (UACR: 9.13 ~ 15.04 mg/g, OR = 3.07, 95% CI: 1.75-5.40). Stratified analysis showed that in males, the association was especially pronounced in elderly, overweight/obese participants and those without diabetes and hypertension whereas in females, the association was especially pronounced in elderly, overweight/obese participants and those without diabetes and with hypertension.

CONCLUSIONS

Low-grade albuminuria was significantly associated with high 10-year cardiovascular risk among CVD-free and normoalbuminuric Chinese adults.

How Clinically Relevant Is C-Reactive Protein for Blacks with Metabolic Syndrome to Predict Microalbuminuria?

Background: The metabolic syndrome (MetS) is associated with elevated urinary albumin (UA) excretion and C-reactive protein (CRP). However, potential differences in CRP levels on the association between individual components of the MetS and microalbuminuria (MA; 30-300 μg/mL) and/or UA (0-300 μg/mL) by race/ethnicity is unknown. Methods: We analyzed National Health and Nutrition Examination Surveys (NHANES) data, (1999-2010) for adults (≥20 years of age) with the MetS (N = 5700). The Sobel-Goodman mediation test examined the influence of CRP on the association between individual MetS components and both MA and UA by race/ethnicity. We applied machine learning models to predict UA. Results: CRP mediated the association between waist circumference (WC) and MA in Whites and Hispanics but not in Blacks. However, in general, the proportion of the total effect of MetS components on UA, mediated by CRP, was: 11% for high-density lipoprotein cholesterol (HDL-C) and 40% for WC (P < 0.001). In contrast to MA, the mediation effect of CRP for WC and UA was highest for Blacks (94%) compared with Whites (55%) or Hispanics (18%), P < 0.05. The prediction of an elevated UA concentration was increased in Blacks (∼51%) with the MetS when CRP was added to the random forest model. Conclusions: CRP mediates the association between UA and both HDL-C and WC in Whites and Blacks and between UA and WC in Hispanics. Moreover, the machine learning approach suggests that the incorporation of CRP may improve model prediction of UA in Blacks. These findings may favor screening for CRP in persons with the MetS, particularly in Blacks.

Insulin Therapy Is Associated With an Increased Risk of Carotid Plaque in Type 2 Diabetes: A Real-World Study

Background: Controversies concerning the association between insulin therapy and atherosclerotic lesions in type 2 diabetes mellitus (T2DM) remain to exist. The purpose of this study was to investigate whether insulin therapy in T2DM patients is linked with the increased risk of carotid atherosclerosis in real-world settings. Methods: We retrospectively enrolled 2,356 hospitalized patients with T2DM, including 1,716 subjects receiving insulin therapy and 640 subjects without receiving insulin therapy. Carotid atherosclerotic lesions including carotid intima-media thickness (CIMT), carotid plaque and carotid stenosis were assessed by Doppler ultrasonography and were compared between T2DM patients treated with and without insulin. Results: After adjusting for age and duration of diabetes, there was a significant increase in the prevalence of carotid plaque in both men (52.0 vs. 41.7%, p = 0.007) and women (49.6 vs. 39.7%, p = 0.003) receiving insulin therapy than in those without receiving insulin therapy. After further controlling for other confounding factors, compared with the patients without receiving insulin therapy, the risk of carotid plaque was still significantly increased not only in women treated with insulin (OR: 1.810; 95% CI: 1.155-2.837, p = 0.010), but also in men treated with insulin (OR: 1.867; 95% CI: 1.307-2.666; p = 0.001). Additionally, HOMA2-B% was higher in both women and men without receiving insulin therapy compared with those receiving insulin therapy (p < 0.001 in both men and women), but HOMA-IR was significantly higher in patients treated with insulin than in those without receiving insulin therapy (p < 0.001 in both men and women). Conclusions: Insulin therapy is associated with markedly increased risk of carotid atherosclerotic lesions in type 2 diabetes, which partly attribute to the more serious insulin resistance in T2DM patients receiving insulin therapy.

Independent associations of urinary albumin-to-creatinine ratio and serum cystatin C with carotid intima-media thickness in community-living Taiwanese adults

Background

Renal function is a key factor of cardiovascular disease. Carotid intima-media thickness (IMT) has been widely used as a marker of early subclinical atherosclerosis. The determinants of cystatin C, a novel marker of renal function, have not been extensively studied in the Asian population. This study aimed to assess the determinants of cystatin C and explore whether carotid thickening was associated with urinary albumin-creatinine ratio and cystatin C in community-living Taiwanese adults.

Methods

A cross-sectional study was conducted on participants from Taichung City, Taiwan. All the participants underwent carotid ultrasonography. Carotid IMT-mean and IMT-maximum were derived. Kidney biomarkers were measured on the basis of urinary albumin-to-creatinine ratio (ACR) and cystatin C. Multiple linear regression analysis was used.

Results

A total of 1032 individuals were recruited, and 469 (45.44%) of them were men. An increased cystatin C level was significantly associated with older age, male gender, lack of physical activity, low HDL cholesterol, abdominal obesity, high hs-CRP, and high ACR. The multivariate-adjusted mean carotid IMT-mean and IMT-maximum values significantly increased by 80.49 and 195.23 μm for every one unit of increase in cystatin C level and by 0.07 and 0.14 μm for every one unit of increase in ACR, respectively (all p < 0.001 except ACR on IMT-maximum with p < 0.01). Lack of physical activity, low HDL, abdominal obesity, high hs-CRP, and high ACR were the determinants of cystatin C.

Conclusion

Cystatin C and ACR were strongly and linearly associated with carotid thickening, a marker of subclinical atherosclerosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-020-02123-x.

Subclinical Atherosclerosis Markers of Carotid Intima-Media Thickness, Carotid Plaques, Carotid Stenosis, and Mortality in Community-Dwelling Adults

Carotid intima–media thickness (IMT), plaque, and stenosis are widely used as early surrogate markers of subclinical atherosclerosis and strong predictors of future deaths and cardiovascular events. Albuminuria is an indicator of generalized endothelial dysfunction that speeds up atherosclerosis. However, previous studies reporting these associations cannot rule out the confounding effect of albuminuria. We aimed to examine the independent and joint relationships between IMT markers and 10-year mortality in community-dwelling Taiwanese adults. This work was a community-based prospective cohort study consisting of 2956 adults aged at least 30 years recruited in 2007 and followed up through 2019. Cox proportional hazard regression models were used to examine associations of these subclinical atherosclerosis markers with mortality. During an average of 9.41 years of follow up, 242 deaths occurred. The mortality rate was 8.70 per 1000 person-years. Compared with those with carotid IMT less than 1.0 mm, persons with severely increased carotid IMT (≥2.0 mm) had an increased risk for death (hazard ratio (HR): 1.79; 95% confidence interval (CI): 1.07, 3.00). Compared with those without carotid plaque, persons with carotid plaque were more likely to have an increased risk for death (1.65; 1.21–2.32). Compared with those with carotid stenosis less than 25%, persons with carotid stenosis of 25–36% had a significant increased risk for death (1.57; 1.12–2.22). Considering these three IMT markers along with the traditional risk factors (c-statistic: 0.85) significantly increased their predictive ability of mortality compared with any individual variable’s predictive ability (all p-values < 0.001 for comparisons of c-statistic values). Carotid IMT measures, including IMT thickness, carotid plaque, and carotid stenosis were significant independent predictors of mortality. Our study supports evidence of blood pressure-related media thickening markers to assess future mortality risks in Chinese adults of general population.

Association between kidney disease measures and intracranial atherosclerosis: The ARIC study

OBJECTIVE

To test the association between reduced kidney function (assessed by estimated glomerular filtration rate [eGFR] and cystatin C [CysC]) and kidney damage (assessed by urinary albumin-to-creatinine ratio [ACR]) and intracranial atherosclerotic disease (ICAD) by high-resolution vessel wall MRI (VWMRI) in the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS).

METHODS

We conducted a cross-sectional analysis of ARIC participants with data on kidney measures and VWMRI in 2011 to 2013. The main outcomes were presence of intracranial plaques and luminal stenosis. Multivariable models were adjusted for demographics, cardiovascular risk factors, and use of antithrombotic medications.

RESULTS

A total of 1,762 participants (mean ± SD age, 76.3 ± 5.3) were included. eGFR based on CysC (eGFRcysc) <60 mL/min/1.73 m2 (vs ≥60 mL/min/1.73 m2) was associated with plaque presence (adjusted odds ratio [OR] 1.29, 95% confidence interval [CI] 1.04-1.60), any detectable stenosis (adjusted OR 1.31, 95% CI 1.04-1.63), and >70% stenosis or occlusion (adjusted OR 2.15, 95% CI 1.32-3.50). Neither ACR nor CysC showed statistically significant associations with ICAD features in adjusted models. In adjusted multinomial models, participants with eGFRcysc <60 mL/min/1.73 m2 (vs ≥60 mL/min/1.73 m2) had an increased OR of 1.41 (95% CI 1.06-1.87) for having 1 plaque (vs none) but no significant increase for multiple plaques; ACR ≥30 was associated with moderate (50%-70%) stenosis (OR 2.01, 95% CI 1.14-3.55) vs absent or less than 50% stenosis.

CONCLUSION

In community-dwelling older adults, reduced kidney function or elevated kidney damage was associated with ICAD measured by VWMRI. This finding may help to better identify a population at high risk for ICAD.

Low-Grade Albuminuria Is Associated with Left Ventricular Hypertrophy and Diastolic Dysfunction in Patients with Hypertension

INTRODUCTION

Microalbuminuria is a risk factor for cardiovascular morbidity and mortality in hypertensive patients. However, the relationship between low-grade albuminuria, a higher level of albuminuria below microalbuminuria threshold, and hypertension-related organ damage is unclear. Left ventricular (LV) hypertrophy (LVH) is well recognized to be a subclinical organ damage of hypertension, and LV diastolic dysfunction is also reported to be an early functional cardiac change of hypertension that predicts heart failure. The present study aimed to investigate the association of low-grade albuminuria with LVH and LV diastolic dysfunction in hypertensive patients.

METHODS

This cross-sectional observational clinical study was retrospectively performed in 870 hypertensive patients admitted to our hospital. Urinary albumin to creatinine ratio (UACR) was calculated to assess the levels of albuminuria: macroalbuminuria (≥300 mg/g), microalbuminuria (≥30 mg/g, but <300 mg/g), and normal albuminuria (<30 mg/g). Low-grade albuminuria was defined as sex-specific highest tertile within normal albuminuria (8.1-29.6 mg/g in males and 11.8-28.9 mg/g in females). LVH and LV diastolic dysfunction were identified as recommended by American Society of Echocardiography.

RESULTS

Of the 870 patients, 765 (87.9%) had normal albuminuria, 77 (8.9%) had microalbuminuria, and 28 (3.2%) had macroalbuminuria. Percentage of LVH and LV diastolic dysfunction was increased with ascending UACR. UACR was independently associated with LVH and LV diastolic dysfunction, even in patients with normal albuminuria. Multivariable logistic regression showed that the patients with the highest tertile within normal albuminuria had nearly 80% increase in LVH and nearly 60% increase in LV diastolic dysfunction (adjusted OR for LVH 1.788, 95% CI 1.181-2.708, p = 0.006; adjusted OR for LV diastolic dysfunction 1.567, 95% CI 1.036-2.397, p = 0.034). After further stratification analyses in patients with normal albuminuria, it was shown that this independent association persisted in female patients, those who were younger than 70 years old, and those with duration of hypertension <15 years.

CONCLUSION

Low-grade albuminuria was associated with LVH and LV diastolic dysfunction in hypertensive patients, especially in patients younger than 70 years old, and those with duration of hypertension <15 years.

Serum osteocalcin level as an indicator of low-grade albuminuria in Chinese men free of kidney disease

OBJECTIVE

The presence of low-grade albuminuria (LGA) suggested that the pathophysiology of vascular dysfunction has been initiated. Clear evidence supports a role for osteocalcin in energy metabolism and a great incidence of pathological cardiovascular changes. The observational community-based study aims to examine the association of osteocalcin with LGA, which may provide new insight into potential involvement of osteocalcin in cardiovascular diseases.

METHODS

A total of 1951 adults [58.37 (53.34-63.13) years, 41.3% men] from Shanghai were enrolled. LGA was defined as a urinary albumin-to-creatinine ratio (UACR) < 30 mg/g. Serum osteocalcin was measured using an electrochemiluminescence immunoassay.

RESULTS

Serum osteocalcin level in men decreased with increasing UACR after adjusting for potential covariates (p = 0.045); however, the adjusted association disappeared in women (p = 0.258). Linear regression analysis showed that osteocalcin was a negative variable of UACR in men (standardized β = -0.074, p = 0.030), particularly prominent in non-hyperglycemic, non-hypertensive men, even regardless of estimated glomerular filtration rate (eGFR) (60 ≤ eGFR <90 mL/min/1.73 m², standardized β =-0.422, p = 0.004; ≥ 90 mL/min/1.73 m², standardized β = -0.167, p = 0.037).

CONCLUSION

After controlling for confounders, serum osteocalcin level was independently associated with LGA in men, which suggested that osteocalcin was closely related with atherosclerosis and vascular dysfunction.

The renal tubular damage marker urinary N-acetyl-β-D-glucosaminidase may be more closely associated with early detection of atherosclerosis than the glomerular damage marker albuminuria in patients with type 2 diabetes

Background

To determine the association between urinary N-acetyl-β-d-glucosaminidase (NAG), a marker of renal tubulopathy, and carotid intima-media thickness (IMT) and plaques in patients with type 2 diabetes mellitus (T2D) and to compare the predictive value of NAG versus albuminuria, a marker of renal glomerulopathy.

Methods

A total of 343 participants were enrolled in this retrospective cross-sectional study. We recruited participants with T2D who were tested for blood glucose parameters, urinary NAG, and urinary albumin-to-creatinine ratio (ACR) and had been checked for carotid ultrasonography.

Results

We classified participants into a below-median urinary NAG group (Group I; n = 172) or an above-median group (Group II; n = 171). Mean, maximum, and mean of maximum carotid IMT and the proportion of patients with carotid plaques were significantly higher in Group II compared with Group I. In multiple linear regression analyses, high urinary NAG (Group II) was significantly associated with carotid IMT, independently of urinary ACR and other confounding factors. In terms of carotid plaques, both urinary NAG and ACR were significantly higher in participants with carotid plaques than in those without carotid plaques. After adjustment for confounding factors, both urinary NAG and ACR were significantly associated with the presence of carotid plaques.

Conclusions

Elevated urinary NAG, a marker of renal tubular damage, was related to increased carotid IMT and the presence of carotid plaques in patients with T2D. Urinary NAG may be a more sensitive biomarker than urinary albumin for early detection of atherosclerosis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-017-0497-7) contains supplementary material, which is available to authorized users.

Serum uric acid levels are associated with hypertension and metabolic syndrome but not atherosclerosis in Chinese inpatients with type 2 diabetes

Objective:

Serum uric acid (SUA) is associated with many cardiovascular risk factors such as hypertension (HTN) and metabolic syndrome (MetS). However, the association of SUA with atherosclerosis remains controversial. Our aim was to investigate the relationships of SUA with HTN, MetS and atherosclerosis in Chinese inpatients with type 2 diabetes.

Methods:

This cross-sectional study was performed with a sample of 2388 hospitalized Chinese patients with type 2 diabetes. Both carotid and lower limb atherosclerotic lesions were assessed for intima–media thickness, plaque and stenosis by Doppler ultrasound. Atherosclerotic plaque and stenosis were defined as the presence of either carotid or lower limb plaques and stenoses, respectively.

Results:

There were significant increases in the prevalence of both HTN and MetS across the SUA quartiles (HTN: 43.4, 49.6, 56.1 and 66.3% for the first, second, third and fourth quartiles, respectively, P < 0.001; MetS: 59.9, 68.8, 74.7 and 84.9% for the first, second, third and fourth quartiles, respectively, P < 0.001). A fully adjusted multiple logistic regression analysis revealed that SUA quartile was independently associated with the presence of HTN (P = 0.001) and MetS (P = 0.006). The prevalence of atherosclerotic plaque and stenosis was obviously higher in the patients with either HTN or MetS than in those without HTN or MetS. However, there was no significant association of SUA quartile with the presence of atherosclerotic lesions.

Conclusions:

SUA levels were closely associated with HTN and MetS, but not with atherosclerosis in type 2 diabetes. Our findings strongly suggest that, in select populations such as those with type 2 diabetes, the role of uric acid in atherosclerosis might be attributable to other cardiovascular risk factors, such as HTN and MetS.

High normal albuminuria is associated with arterial stiffness and carotid atherosclerosis in Korean patients with type 2 diabetes

BACKGROUND AND AIMS

Current evidence suggests that high normal albuminuria is significantly associated with increased cardiovascular risk. This study investigated the association between urine albumin-to-creatinine ratio (ACR) within the normal range and subclinical atherosclerosis in Korean patients with type 2 diabetes.

METHODS AND RESULTS

This cross-sectional study involved 521 type 2 diabetic patients with normoalbuminuria. Brachial-ankle pulse wave velocity (baPWV) measurement and ultrasound assessment of carotid atherosclerosis was done. Subclinical atherosclerosis was assessed by the presence of high baPWV (>1682 cm/s), carotid atherosclerosis (intima-media thickness >0.8 mm or the presence of plaques), and carotid stenosis (≥50% of luminal narrowing). Across the tertiles of ACR, there was a trend for an increasing prevalence of high baPWV (16.8%, 20.0%, and 38.2%, P < 0.001), carotid atherosclerosis (46.9%, 55.4%, and 64.7%, P < 0.001), and carotid stenosis (12.7%, 16.0%, and 30.1%, P < 0.001). In multivariate analysis, patients in the highest ACR tertile had an odds ratio of 2.05 (95% confidence interval [CI], 1.13-3.72, P = 0.019) for high baPWV, 1.78 (95% CI, 1.08-2.93, P = 0.024) for carotid atherosclerosis, and 2.72 (95% CI, 1.44-5.11, P = 0.002) for carotid stenosis compared to those in the lowest tertile. The relation of ACR with carotid atherosclerosis and stenosis remained significant even in patients without diabetic retinopathy.

CONCLUSION

High normal albuminuria was significantly associated with atherosclerotic vascular changes, independent of retinopathy and other cardiovascular risk factors. High normal albuminuria may be an early marker for subclinical atherosclerosis in type 2 diabetes.

High-normal urinary albumin-to-creatinine ratio is independently associated with metabolic syndrome in Chinese patients with type 2 diabetes mellitus: A cross-sectional community-based study

Aims/Introduction

Microalbuminuria is positively related to metabolic syndrome (MetS). Our aim was to investigate whether urinary albumin-to-creatinine ratio (UACR) within the normal range is independently associated with MetS in Chinese community-based patients with type 2 diabetes.

Materials and Methods

A total of 514 participants (206 males and 308 females; mean age 66 years) with UACR less than 3.5 mg/mmol were enrolled from two downtown areas of Shanghai. The participants were stratified into quartiles according to UACR levels. The prevalence of MetS was assessed and compared among the four groups by binary logistic regression.

Results

Compared with participants with UACRs in the first quartile, the other quartiles had a higher prevalence of MetS (65.9%, 74.4% and 81.3%, respectively, P = 0.001) after adjustment for sex and age. After adjusting for potential confounders, participants in the second to the fourth quartile group had a 1.36-, 1.84- and 2.73-fold risk of MetS, respectively, relative to those in the lowest quartile. Furthermore, UACR, whether as quartile groups or as a continuous variable, is an independent predictor of MetS after fully adjusting for other variables.

Conclusions

These results suggest that UACR even within the normal range is independently associated with MetS in Chinese community-based patients with type 2 diabetes mellitus.

Normal range albuminuria and metabolic syndrome in South Korea: the 2011-2012 Korean National Health and Nutrition Examination Survey

Background

It is well-known that there is a close relationship between metabolic syndrome (MetS) and microalbuminuria. However, some recent studies have found that even normal range albuminuria was associated with MetS and cardiometabolic risk factors. The purpose of this study is to analyze the relationship between MetS and normal range albuminuria and to calculate the cutoff value for albuminuria that correlates with MetS in the representative fraction of Korean population.

Methods

Data were obtained from the 2011–2012 Korea National Health and Nutrition Examination Survey and included 9,650 subjects aged ≥19 years. We measured metabolic parameters: fasting blood glucose, waist circumference, blood pressure, and lipids, and albumin-to-creatinine ratio (ACR). The optimal ACR cutoff points for MetS were examined by the receiver operating characteristic curve. Multivariate logistic regression was used to obtain the prevalence of MetS and its components according to the ACR levels.

Results

The first cutoff value of ACR were 4.8 mg/g for subjects with ≥3 components of MetS. There was a graded association between ACR and prevalence of MetS and its components. If ACR was <4 mg/g, there was no significant increase in the prevalence of MetS or its components. From the ACR level of 4–5 mg/g, the prevalence of MetS significantly increased after adjusting for age, sex, body mass index, smoking, alcohol intake, exercise, and medications for diabetes mellitus and hypertension (odds ratio; 95% confidence intervals = 1.416; 1.041–1.926).

Conclusions

Albuminuria within the normal range (around 5 mg/g) was associated with prevalence of MetS in the Korean population.

Associations between clinical characteristics and chronic complications in latent autoimmune diabetes in adults and type 2 diabetes

BACKGROUND

This study aimed to assess the associations between clinical characteristics and chronic complications in latent autoimmune diabetes in adults (LADA) and type 2 diabetes.

METHODS

This is a retrospective study. Our diabetes registry included 6975 patients aged 30-75 years old with phenotypic type 2 diabetes who underwent islet autoantibody screening between 2003 and 2012; 384 patients were identified to have LADA. Rates of chronic complications for LADA and type 2 diabetes were compared using a 1 : 2 matched design. Logistic models were fitted to identify the presence of chronic diabetic complications using clinical characteristics including gender, age, duration of diabetes, glycemic control and metabolic syndrome.

RESULTS

When duration of diabetes is <5 years, the prevalence of diabetic nephropathy (nephropathy; 12.2% versus 21.8%, p = 0.018) and diabetic retinopathy (retinopathy; 8.1% versus 15.9%, p = 0.011) were significantly lower in patients with LADA than in patients with type 2 diabetes; the prevalence of nephropathy and retinopathy were comparable between both groups when duration is ≥5 years. There was no significant difference in the prevalence of macrovascular complications between groups. The areas under the receiver operating characteristic curves based on the nephropathy and retinopathy models were larger for LADA than for type 2 diabetes (0.72 versus 0.61, p = 0.013; 0.76 versus 0.68, p = 0.056).

CONCLUSIONS

Patients with LADA had a lower prevalence of microvascular complications than patients with type 2 diabetes when the duration of diabetes was <5 years. Regression equation fitted by clinical characteristics can better predict the risk of microvascular complications in LADA than in type 2 diabetes.

Retinal microvascular abnormalities are associated with early carotid atherosclerotic lesions in hospitalized Chinese patients with type 2 diabetes mellitus

OBJECTIVE

Controversies concerning the association of retinal microvascular abnormalities (RMAs) with atherosclerosis in patients with diabetes exist. The objective of this study was to investigate the association between RMAs and carotid atherosclerotic lesions in Chinese inpatients with type 2 diabetes.

METHODS

This cross-sectional study involved 2870 type 2 diabetic patients including 1602 men aged 15-90 years and 1268 women aged 17-88 years. Both retinal arteriosclerosis (RA) and diabetic retinopathy (DR) were determined by digital fundus photography using a standardized protocol. RMAs are defined as the presence of either RA or DR. Carotid atherosclerotic lesions including carotid intima-media thickness (CIMT), carotid atherosclerotic plaque and stenosis were assessed and compared between patients with and without RMAs based on Doppler ultrasound. The association of RMAs with carotid atherosclerotic lesions was analyzed by linear and binary logistic regression analyses.

RESULTS

The CIMT values in both male and female diabetics with RMAs were significantly greater than in those without RMAs after controlling for age (0.88±0.21 vs. 0.77±0.20 mm for men, p=0.002; and 0.84±0.19 vs. 0.76±0.21 mm for women, p=0.002). The prevalence of carotid plaque was also markedly higher in patients with RMAs than in those without RMAs after adjusting for age (54.3% vs. 23.9% for men, p<0.001; 48.4% vs. 32.0% for women, p=0.046). However, no significant difference was observed in the prevalence of carotid stenosis in either men or women with or without RMAs. After controlling for multiple confounding factors, RMAs were independently associated with increased CIMT in both men (β: 0.067, 95% CI: 0.026-0.269, p=0.018) and women (β: 0.087, 95% CI: 0.058-0.334, p=0.005) with type 2 diabetes, and they were also closely associated with the presence of carotid plaque (OR: 2.17, 95% CI: 1.54-3.05, p<0.001 for men; OR: 1.38, 95% CI: 0.91-2.08, p=0.129 for women) in men with type 2 diabetes.

CONCLUSIONS

RMAs were closely associated with early carotid atherosclerotic lesions in hospitalized Chinese patients with type 2 diabetes. Our results suggested that changes in retinal microvasculature may play a role in the pathogenesis of atherosclerosis and may be used as an indicator of early atherosclerosis in patients with type 2 diabetes.

Prevalence and clinical characteristics of lower limb atherosclerotic lesions in newly diagnosed patients with ketosis-onset diabetes: a cross-sectional study

BACKGROUND

The clinical features of atherosclerotic lesions in ketosis-onset diabetes are largely absent. We aimed to compare the characteristics of lower limb atherosclerotic lesions among type 1, ketosis-onset and non-ketotic type 2 diabetes.

METHODS

A cross-sectional study was performed in newly diagnosed Chinese patients with diabetes, including 53 type 1 diabetics with positive islet-associated autoantibodies, 208 ketosis-onset diabetics without islet-associated autoantibodies, and 215 non-ketotic type 2 diabetics. Sixty-two subjects without diabetes were used as control. Femoral intima-media thickness (FIMT), lower limb atherosclerotic plaque and stenosis were evaluated and compared among the four groups based on ultrasonography. The risk factors associated with lower limb atherosclerotic plaque were evaluated via binary logistic regression in patients with diabetes.

RESULTS

After adjusting for age and sex, the prevalence of lower limb plaque in the patients with ketosis-onset diabetes (47.6%) was significantly higher than in the control subjects (25.8%, p = 0.013), and showed a higher trend compared with the patients with type 1 diabetes (39.6%, p = 0.072), but no difference was observed in comparison to the patients with non-ketotic type 2 diabetes (62.3%, p = 0.859). The mean FIMT in the ketosis-onset diabetics (0.73 ± 0.17 mm) was markedly greater than that in the control subjects (0.69 ± 0.13 mm, p = 0.045) after controlling for age and sex, but no significant differences were found between the ketosis-onset diabetics and the type 1 diabetics (0.71 ± 0.16 mm, p = 0.373), and the non-ketotic type 2 diabetics (0.80 ± 0.22 mm, p = 0.280), respectively. Age and FIMT were independent risk factors for the presence of lower limb plaque in both the ketosis-onset and non-ketotic type 2 diabetic patients, while sex and age in the type 1 diabetic patients.

CONCLUSIONS

The prevalence and risk of lower limb atherosclerotic plaque in the ketosis-onset diabetes were remarkably higher than in the control subjects without diabetes. The features and risk factors of lower limb atherosclerotic lesions in the ketosis-onset diabetes resembled those in the non-ketotic type 2 diabetes, but different from those in the type 1 diabetes. Our findings provide further evidences to support the classification of ketosis-onset diabetes as a subtype of type 2 diabetes rather than idiopathic type 1 diabetes.