Association of estimated glomerular filtration rate and urine albumin-to-creatinine ratio with incidence of cardiovascular diseases and mortality in chinese patients with type 2 diabetes mellitus - a population-based retrospective cohort study

Nonlinear association between proteinuria levels and the risk of cardiovascular disease events and all-cause mortality among chronic kidney disease patients

BACKGROUND

The association between proteinuria levels and cardiovascular disease (CVD) development and all-cause mortality in chronic kidney disease (CKD) patients remains controversial.

METHODS

In this investigation, we conducted a retrospective analysis involving 1138 patients who were registered in the CKD-Research of Outcomes in Treatment and Epidemiology (ROUTE) study. The primary outcome of this study was the composite of cardiovascular events or all-cause death. Cox proportional hazards regression, smooth curve fitting, piecewise linear regression, and subgroup analyses were used.

RESULTS

The mean age of the included individuals was 67.3 ± 13.6 years old. Adjusted hazard ratios (HRs) for UPCR in middle and high groups, compared to the low group, were 1.93 (95% CI: 1.28-2.91) and 4.12 (95% CI: 2.87-5.92), respectively, after multivariable adjustment. Further adjustments maintained significant associations; HRs for middle and high groups were 1.71 (95% CI: 1.12-2.61) and 3.07 (95% CI: 2.08-4.54). A nonlinear UPCR-primary outcome relationship was observed, with an inflection point at 3.93 g/gCr.

CONCLUSION

Among non-dialyzed patients with stage G2-G5 CKD, a nonlinear association between UPCR and the primary outcome was observed. A higher UPCR (when UPCR < 3.93 g/gCr) was an independent predictor of the primary outcome. Importantly, our study predates SGLT2 inhibitor use, showcasing outcomes achievable without these medications. Future research considerations will involve factors like SGLT-2 inhibitor utilization.

Normoalbuminuria-is it normal? The association of urinary albumin within the 'normoalbuminuric' range with adverse cardiovascular and mortality outcomes: A systematic review and meta-analysis

AIM

To assess the association between urinary albumin-to-creatinine ratio (UACR) categories within the normal range with mortality and adverse cardiovascular outcomes.

MATERIALS AND METHODS

PubMed and Embase were systematically searched for real-world evidence studies. Studies were manually evaluated according to predefined eligibility criteria. We included prospective and retrospective cohort studies of the association between UACR categories <30 mg/g and cardiovascular outcomes or mortality. Published information regarding study design, participants, UACR categorization, statistical methods, and results was manually collected. Two UACR categorization approaches were defined: a two-category (UACR <10 mg/g vs. 10-30 mg/g) and a three-category division (UACR <5 mg/g vs. 5-10 and 10-30 mg/g). A random effects meta-analysis was performed on studies eligible for the meta-analysis.

RESULTS

In total, 22 manuscripts were identified for the systematic review, 15 of which were eligible for the meta-analysis. The results suggest an association between elevated UACR within the normal to mildly increased range and higher risks of all-cause mortality, cardiovascular death, and coronary heart disease, particularly in the range of 10-30 mg/g. Compared with UACR <10 mg/g, the hazard ratio [HR (95% confidence interval, CI)] for UACR between 10 and 30 mg/g was 1.41 (1.15, 1.74) for all-cause mortality and 1.56 (1.23, 1.98) for coronary heart disease. Compared with UACR <5 mg/g, the risk of cardiovascular mortality for UACR between 10 and 30 mg/g was more than twofold [HR (95% CI): 2.12 (1.61, 2.80)]. Intermediate UACR (5-10 mg/g) was also associated with a higher risk of all-cause mortality [HR (95% CI): 1.14 (1.05, 1.24)] and cardiovascular mortality [HR (95% CI): 1.50 (1.14, 1.99)].

CONCLUSIONS

We propose considering higher UACR within the normoalbuminuric range as a prognostic factor for cardiovascular morbidity and mortality. Our findings underscore the clinical significance of even mild increases in albuminuria.

Impact of Dapagliflozin Adjunctive Therapy on the Progression of Chronic Kidney Disease in Patients with Type 2 Diabetes and Chronic Kidney Disease Stages 2-5: A systematic review and meta-analysis

This meta-analysis investigated efficacy of dapagliflozin as adjunctive therapy for patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) stages 2-5. A systematic search was conducted of selected databases for randomised controlled trials that reported the mean change in estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR) from baseline. Out of 1,682 identified studies, 9 trials comprising 13,057 patients were included. A pooled estimate of 5 studies indicated that dapagliflozin did not affect eGFR; however, in 2 studies, it significantly reduced chronic eGFR decline compared to placebo (mean difference [MD] ± 2.74; 95% confidence interval [CI]: 1.55, 3.92; P <0.00001). Additionally, a pooled estimate of 4 studies showed that dapagliflozin significantly reduced UACR (MD -23.99%; 95% CI: -34.82--13.15; P <0.0001; I2 = 0%). Therefore, long-term use of dapagliflozin significantly attenuates eGFR decline and reduces albuminuria in patients with T2DM and CKD.

Association of the longitudinal trajectory of urinary albumin/creatinine ratio in diabetic patients with adverse cardiac event risk: a retrospective cohort study

Objective

The baseline urinary albumin/creatinine ratio (uACR) has been proven to be significantly associated with the risk of major adverse cardiac events (MACE). However, data on the association between the longitudinal trajectory patterns of uACR, changes in glycated hemoglobin A1c (HbA1c), and the subsequent risk of MACE in patients with diabetes are sparse.

Methods

This is a retrospective cohort study including 601 patients with type 2 diabetes mellitus (T2DM; uACR < 300 mg/g) admitted to The First Hospital of Shanxi Medical University and The Second Hospital of Shanxi Medical University from January 2015 to December 2018. The uACR index was calculated as urinary albumin (in milligrams)/creatinine (in grams), and latent mixed modeling was used to identify the longitudinal trajectory of uACR during the exposure period (2016-2020). The deadline for follow-up was December 31, 2021. The primary outcome was the MACE [a composite outcome of cardiogenic death, hospitalization related to heart failure (HHF), non-fatal acute myocardial infarction, non-fatal stroke, and acute renal injury/dialysis indications]. The Kaplan-Meier survival analysis curve was used to compare the risk of MACE among four groups, while univariate and multivariate Cox proportional hazards models were employed to calculate the hazard ratio (HR) and 95% confidence interval (CI) for MACE risk among different uACR or HbA1c trajectory groups. The predictive performance of the model, both before and after the inclusion of changes in the uACR and HbA1c, was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC).

Results

Four distinct uACR trajectories were identified, namely, the low-stable group (uACR = 5.2-38.3 mg/g, n = 112), the moderate-stable group (uACR = 40.4-78.6 mg/g, n = 229), the high-stable group (uACR = 86.1-153.7 mg/g, n = 178), and the elevated-increasing group (uACR = 54.8-289.4 mg/g, n = 82). In addition, five distinct HbA1c trajectories were also identified: the low-stable group (HbA1c = 5.5%-6.8%, n = 113), the moderate-stable group (HbA1c = 6.0%-7.9%, n = 169), the moderate-decreasing group (HbA1c = 7.4%-6.1%, n = 67), the high-stable group (HbA1c = 7.7%-8.9%, n = 158), and the elevated-increasing group (HbA1c = 8.4%-10.3%, n = 94). Compared with the low-stable uACR group, patients in the high-stable and elevated-increasing uACR groups were more likely to be older, current smokers, and have a longer DM course, higher levels of 2-h plasma glucose (PG), HbA1c, N-terminal pro-B-type natriuretic peptide (NT-proBNP), uACR, and left ventricular mass index (LVMI), while featuring a higher prevalence of hypertension and a lower proportion of β-receptor blocker treatment (p < 0.05). During a median follow-up of 45 months (range, 24-57 months), 118 cases (19.6%) of MACE were identified, including 10 cases (1.7%) of cardiogenic death, 31 cases (5.2%) of HHF, 35 cases (5.8%) of non-fatal acute myocardial infarction (AMI), 18 cases (3.0%) of non-fatal stroke, and 24 cases (4.0%) of acute renal failure/dialysis. The Kaplan-Meier survival curve showed that, compared with that in the low-stable uACR group, the incidence of MACE in the high-stable (HR = 1.337, 95% CI = 1.083-1.652, p = 0.007) and elevated-increasing (HR = 1.648, 95% CI = 1.139-2.387, p = 0.009) uACR groups significantly increased. Similar results were observed for HHF, non-fatal AMI, and acute renal injury/dialysis indications (p < 0.05). The multivariate Cox proportional hazards models indicated that, after adjusting for potential confounders, the HRs for the risk of MACE were 1.145 (p = 0.132), 1.337 (p = 0.007), and 1.648 (p = 0.009) in the moderate-stable, high-stable, and elevated-increasing uACR groups, respectively. In addition, the HRs for the risk of MACE were 1.203 (p = 0.028), 0.872 (p = 0.024), 1.562 (p = 0.033), and 2.218 (p = 0.002) in the moderate-stable, moderate-decreasing, high-stable, and elevated-increasing groups, respectively. The ROC curve showed that, after adding uACR, HbA1c, or both, the AUCs were 0.773, 0.792, and 0.826, which all signified statistically significant improvements (p = 0.021, 0.035, and 0.019, respectively).

Conclusion

A long-term elevated uACR is associated with a significantly increased risk of MACE in patients with diabetes. This study implies that regular monitoring of uACR could be helpful in identifying diabetic patients with a higher risk of MACE.

Association of Urine Albumin to Creatinine Ratio With Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus

CONTEXT

The urinary albumin to creatinine ratio (UACR) is a widely used indicator of albuminuria and has predictive value for adverse cardiovascular events.

OBJECTIVE

To evaluate the correlation between the UACR and the risk of developing major adverse cardiovascular events (MACEs) and total mortality in patients with type 2 diabetes mellitus (T2DM).

METHODS

This post hoc analysis included 10 171 participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and the ACCORD follow-up study (ACCORDION) with baseline UACR data. The natural logarithm (ln) of each UACR measurement was calculated. Univariate and multivariate Cox proportional hazard regression analyses were conducted to examine the association between the UACR and the risk of MACEs and total mortality. The additional predictive value of UACR was further evaluated. Similar methods were used to analyze the correlation between the UACR and MACEs and total mortality within the normal range.

RESULTS

During a median follow-up period of 8.83 years, 1808 (17.78%) participants experienced MACEs, and there were 1934 (19.01%) total deaths. After adjusting for traditional cardiovascular risk factors, the multivariate analysis revealed a significant association between the UACR and the risk of MACEs and total mortality. The inclusion of UACR in the conventional risk model enhanced the predictive efficacy for MACEs and total mortality.

CONCLUSION

An elevated UACR is associated with a higher risk of MACEs and total mortality in patients with T2DM, even when it falls within the normal range. The UACR improves prediction of MACE and total mortality risk in patients with T2DM.

A cross-sectional study investigating the relationship between urinary albumin creatinine ratio and abdominal aortic calcification in adults

Introduction

The presence of abdominal aortic calcification (AAC) is strongly linked to the development of atherosclerosis and the incidence of morbidity and mortality related to cardiovascular diseases (CVD). Urinary albumin creatinine ratio (UACR) was found related with the increased risk of CVD. The aim of this study is to explore the relationship between the UACR and severe AAC (SAAC).

Methods and Results

This study included a total of 2,379 individuals aged over 40 years, and their information was obtained from the National Health and Nutrition Examination Survey conducted (NHANES) in 2013-2014. The measurement of AAC was conducted through dual-energy x-ray absorptiometry and assessed using the Kauppila scoring system. SAAC was characterized by a Kauppila score of 6 or higher. Multivariate regression models were used to analyze the relationship between UACR level and SAAC, with covariate adjustment. In the completely adapted model, the top third subgroup exhibits increased likelihood of SAAC (odds ratio 1.50; 95%CI: 0.98, 2.29; p = 0.030) in contrast to the bottom third subgroup. The subgroup analyses revealed a more pronounced correlation among the older participants (p-value for interaction = 0.013).

Discussion

In the United States, SAAC was more likely to occur in adults who had a higher probability of UACR. The use of UACR has the potential to be a valuable method for forecasting the likelihood of SAAC.

Poor adherence to clinical practice guidelines: A call to action for increased albuminuria testing in patients with type 2 diabetes

We describe the substantial shortfall in adherence to guideline-recommended albumin-to-creatinine ratio (uACR) testing for people in the United States with type 2 diabetes. Poor compliance with current guidelines leads to delays in diagnosis-and treatment- of chronic kidney disease, which adversely affects clinical outcomes and contributes to incremental economic burden.

Time trajectories of key cardiometabolic parameters and of cardiovascular risk in subjects with diabetes in a real world setting

BACKGROUND AND AIMS

Diabetes is associated with increased cardiovascular risk. Glycated haemoglobin (HbA_1c), lipid parameters and blood pressure are known risk factors for adverse outcome. The aim of the study was to explore the time trajectories of these key parameters and of the associated cardiovascular risk.

METHODS

We linked the diabetes electronic health records to the laboratory information system so as to investigate the trajectories of key metabolic parameters from 3 years prior to the diagnosis of diabetes to 10 years after diagnosis. We calculated the cardiovascular risk at the different time points during this period using the United Kingdom Prospective Study (UKPDS) risk engine.

RESULTS

The study included 21,288 patients. The median age at diagnosis was 56 years and 55.3% were male. There was a sharp decrease in HbA_1c after diagnosis of diabetes, but there was a progressive rise thereafter. All lipid parameters after diagnosis also improved in the year of diagnosis, and these improvements persisted even up to 10 years post-diagnosis. There was no discernible trend in mean systolic or diastolic blood pressures following diagnosis of diabetes. There was a slight decrease in the UKPDS-estimated cardiovascular risk after diagnosis of diabetes followed by a progressive increase. Estimated glomerular filtration rate declined at an average rate of 1.33 ml/min/1.73 m²/year.

CONCLUSIONS

Our data suggest that lipid control should be tightened with increasing duration of diabetes since this is more readily achievable than HbA_1c lowering and since other factors such as age and duration of diabetes are unmodifiable.

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

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

Population-Based Clinical Studies Using Routinely Collected Data in Hong Kong, China: A Systematic Review of Trends and Established Local Practices

Background: Routinely collected health data are increasingly used in clinical research. No study has systematically reviewed the temporal trends in the number of publications and analyzed different aspects of local research practices and their variations in Hong Kong, China, with a specific focus on research ethics governance and approval.

Methods: PubMed was systematically searched from its inception to March 28, 2023, for studies using routinely collected healthcare data from Hong Kong.

Results: A total of 454 studies were included. Between 2000 and 2009, 32 studies were identified. The number of publications increased from 5 to 120 between 2010 and 2022. Of the investigator-led studies using the Hospital Authority (HA)’s cross-cluster data (n = 393), 327 (83.2%) reported receiving ethics approval from a single cluster/university-based REC, whereas 50 studies (12.7%) did not report approval from a REC. For use of the HA Data Collaboration Lab, approval by a single hospital-based or University-based REC is accepted. Repeated submission of identical ethics applications to different RECs is estimated to cost HK$4.2 million yearly.

Conclusions: Most studies reported gaining approval from a single cluster REC before retrieval of cross-cluster HA data. Substantial cost savings would result if repeated review of identical ethics applications were not required.

Associations between different eGFR estimating equations and mortality for CVD patients: A retrospective cohort study based on the NHANES database

To assess the associations of eGFRCKD-EPI (estimated glomerular filtration rate (eGFR) by chronic kidney disease epidemiology collaboration equation), eGFRMDRD (eGFR by modification of diet in renal disease), and serum creatinine (scr) on the death for American people diagnosed with cardiovascular disease (CVD) respectively, and to compare the predicted performance of eGFRCKD-EPI, eGFRMDRD, and scr. A total of 63,078 participants who derived from the National Health and Nutrition Examination Survey (NHANES) database, were obtained in this retrospective cohort study, and collected the baseline characteristics all participants. The outcomes of our study were defined as death, and eGFR estimating equations was defined as eGFRCKD-EPI, eGFRMDRD, and scr. Univariate and multivariate COX analysis were performed to assess the relationship. A subgroup analysis was conducted based on whether patients had anemia. Simultaneously, we also considered the predictive value of eGFRCKD-EPI, eGFRMDRD, and scr in the risk of death. All patients were followed for at most 5-years. After excluded participants who did not meet the inclusion criteria and had missing information, the present study included 2419 participants ultimately, and were divided into alive group (n = 1800) and dead group (n = 619). The mortality rate for CVD patients in this study was approximately 25.59% at the end of follow-up. After adjustment for covariates, the result showed that participants with eGFRCKD-EPI/eGFRMDRD < 30 mL/min/1.73 m2 or 30 to 45 mL/min/1.73 m2 had a higher risk of mortality. Similarly, participants with scr (Q4 ≥ 1.2) were associated with the increased risk of death. Additionally, eGFRCKD-EPI has a higher predictive value in 1-year, 3-years, and 5-years risk of death among patients with CVD than eGFRMDRD and scr. The lower level of eGFR was associated with higher risk of death among American population diagnosed with CVD, especially for non-anemic patients. Importantly, our study also displayed that CKD-EPI-based calculation equation of eGFR (eGFRCKD-EPI) provided for a better predictive value than eGFRMDRD and scr in the risk of death.

Health Needs Assessment: Chronic Kidney Disease Secondary to Type 2 Diabetes Mellitus in a Population without Social Security, Mexico 2016-2032

Health needs assessment is a relevant tracer of planning process of healthcare programs. The objective is to assess the health needs of chronic kidney disease (CKD) secondary to type 2 diabetes mellitus (T2 DM) in a population without social security in Mexico. The study design was a statistical simulation model based on data at the national level of Mexico. A stochastic Markov model was used to simulate the progression from diabetes to CKD. The time horizon was 16 years. The results indicate that in 2022, kidney damage progression and affectation in the diabetic patient cohort will be 34.15% based on the time since T2 DM diagnosis. At the end of the 16-year period, assuming that the model of care remains unchanged, early renal involvement will affect slightly more than twice as many patients (118%) and cases with macroalbuminuria will triple (228%). The need for renal replacement therapy will more than double (169%). Meanwhile, deaths associated with cardiovascular risk will more than triple (284%). We concluded that the clinical manifestations of patients with CKD secondary to T2 DM without social security constitute a double challenge. The first refers to the fact that the greatest health need is early care of CKD, and the second is the urgent need to address cardiovascular risk in order to reduce deaths in the population at risk.

Chronic kidney disease is a key predictive factor for potential myocardial ischaemia and poor prognosis in asymptomatic patients with diabetes mellitus

Some asymptomatic patients with diabetes mellitus (DM) have critical coronary artery disease (CAD), although the guidelines do not recommend aggressive screening for CAD in asymptomatic patients. Chronic kidney disease (CKD) is among the serious co-morbidities of severe systemic atherosclerosis. Thus, CKD may be associated with potential myocardial ischaemia. Therefore, the present study aimed to determine the impact of CKD on the incidence of silent myocardial ischaemia (SMI) and the long-term outcomes in asymptomatic patients with DM. This study investigated 461 consecutive patients with DM. All patients who were asymptomatic and self-sufficient in daily life underwent the ergometer exercise (ERG) test. Coronary angiography was performed if the stress test was positive, or if the patient did not achieve 90% of the target heart rate. The primary end point included major adverse cardiac and cerebrovascular events (MACCE) including death, non-fatal myocardial infarction and stroke. The median follow-up duration after study enrolment was 35 months for the entire cohort of 461 patients. Eighty-one patients were diagnosed with SMI. The estimated glomerular filtration rate was significantly lower in the SMI group (70.5 ± 23.8 vs. 81.8 ± 30.0 mL/min/1.73 m², P < 0.001). SMI occurred more frequently in patients with advanced CKD [27/103, (26.2%) in stages 3–5], whereas only 5/68 (7.3%) patients without CKD, 13/81 (16.0%) patients with stage 1 CKD and 36/209, (17.2%) in stage 2, had SMI. The Kaplan–Meier curves revealed that, patients with SMI had poor clinical outcomes (log-rank: P = 0.016). The incidence of MACCE (log-rank: P = 0.009) was higher in patients with severe CKD > stage 3a in the SMI subgroup. Urinary albumin (mg/gCr) was associated with MACCE in the SMI subgroup [HR 3.37, 95%CI (1.170–9.521), P = 0.025] after adjusting for age, sex, and conventional risk factors. SMI was more prevalent in patients with CKD and the incidence was proportional to the CKD stage in asymptomatic patients with DM. Those Patients with CKD and SMI exhibited poor clinical outcomes. CKD may be a key factor for the identification and management of SMI in asymptomatic patients with DM in routine clinical practice.

Trial Registration: UMIN000038340.

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

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

The influence of hypoglycemia on the specific quality of life in type 2 diabetes mellitus: a comparative cross-sectional study of diabetics with and without hypoglycemia in Xi'an, China

Purpose

This study aims to explore the incidence of hypoglycemia in patients with type 2 diabetes mellitus (T2DM) and the influence of hypoglycemia on the specific quality of life in T2DM patients.

Methods

It was a comparative cross-sectional study consisting of 519 T2DM patients in Xi'an, China and patients were investigated by self-reported hypoglycemia and specific quality of life questionnaires from September 2019 to January 2020. Descriptive analysis, t-test, Chi-square test, hierarchical regression analysis and stepwise multiple regression analysis were applied to assess the influence of hypoglycemia on the specific quality of life.

Results

The incidence of hypoglycemia in T2DM patients was 32.18%. The mean score of specific quality of life in diabetes without hypoglycemia was 57.33 ± 15.36 and was 61.56 ± 17.50 in those with hypoglycemia, which indicated that hypoglycemia had a serious impact on the quality of life of diabetics (t = − 5.172, p = 0.000). In the Univariate analysis of specific quality of life, age, education background, marital status, living status, duration of diabetes, monthly income per capita were independent and significant factors associated with specific quality of life of two groups of T2DM patients (p < 0.05). In the hierarchical regression analysis, the duration of the diabetes more than 11 years and the frequency of hypoglycemia more than 6 times in half a year entered the equation of specific quality of life of 519 diabetics respectively (p < 0.001). In multiple linear regression analysis, age, marital status and income all entered the regression equation of quality of life of the two groups (p < 0.05).

Conclusion

Hypoglycemia will have a serious impact on the quality of life of T2DM patients. In order to improve the living quality in diabetics, effective measurements should be taken to strengthen the management of blood glucose and to avoid hypoglycemia.

Correlation of Kidney Size on Computed Tomography with GFR, Creatinine and HbA1C for an Accurate Diagnosis of Patients with Diabetes and/or Chronic Kidney Disease

Diabetes is considered one of the major causes of chronic kidney disease (CKD), affecting renal blood vessels and nerves. Diagnosis of CKD by traditional biochemical serum and blood analyses is insufficient and insensitive, thus requiring the development of a more robust technique. This novel study aims to propose a new method for the accurate diagnosis of CKD, quantification of kidney damage, and its prognosis by physicians by measuring the kidney volume on computed tomography (CT). In total, 251 patients were enrolled in this retrospective study. They were divided into four groups: control, patients having diabetes, patients having CKD, and patients having both diabetes and CKD. Results showed that kidney volume correlated negatively with both GFR and HbA1C on CT images, in addition to decreasing faster in males than females. Moreover, HbA1C was shown to correlate positively with creatinine and negatively with GFR. Finally, GFR was more robust than creatinine when correlated with age. The association between kidney volume with GFR and HbA1c can be used to accurately anticipate kidney volume in established CKD on CT scan, especially in resource-poor settings. Furthermore, HbA1C can serve as a powerful biomarker for studying renal function in diabetic CKD patients as it correlates with creatinine and GFR.

Microalbuminuria After Kidney Transplantation Predicts Cardiovascular Morbidity

Background: Microalbuminuria is a well-characterized marker of kidney malfunction, both in diabetic and non-diabetic populations, and is used as a prognostic marker for cardiovascular morbidity and mortality. A few studies implied that it has the same value in kidney transplanted patients, but the information relies on spot or dipstick urine protein evaluations, rather than the gold standard of timed urine collection.

Methods: We revisited a cohort of 286 kidney transplanted patients, several years after completing a meticulously timed urine collection and assessed the prevalence of major cardiovascular adverse events (MACE) in relation to albuminuria.

Results: During a median follow up of 8.3 years (IQR 6.4–9.1) 144 outcome events occurred in 101 patients. By Kaplan-Meier analysis microalbuminuria was associated with increased rate of CV outcome or death (p = 0.03), and this was still significant after stratification according to propensity score quartiles (p = 0.048). Time dependent Cox proportional hazard analysis showed independent association between microalbuminuria and CV outcomes 2 years following microalbuminuria detection (HR 1.83, 95% CI 1.07–2.96).

Conclusions: Two years after documenting microalbuminuria in kidney transplanted patients, their CVD risk was increased. There is need for primary prevention strategies in this population and future studies should address the topic.

Prediction models for the risk of cardiovascular diseases in Chinese patients with type 2 diabetes mellitus: a systematic review

OBJECTIVES

Diabetes mellitus (DM) is a serious public health issue worldwide, and DM patients have higher risk of cardiovascular diseases (CVDs), which is the leading cause of DM-related deaths. China has the largest DM population, yet a robust model to predict CVDs in Chinese DM patients is still lacking. This systematic review is carried out to summarize existing models and identify potentially important predictors for CVDs in Chinese DM patients.

STUDY DESIGN

Systematic review.

METHODS

Medline and Embase were searched for data from April 1st, 2011 to May 31st, 2018. A study was eligible if it developed CVD (defined as total CVD or any major cardiovascular component) risk prediction models or explored potential predictors of CVD specifically for Chinese people with type 2 DM. Standardized forms were utilized to extract information, appraise applicability, risk of bias, and availabilities.

RESULTS

Five models and 29 studies focusing on potential predictors were identified. Models for a primary care setting, or to predict total CVD, are rare. A number of common predictors (e.g. age, sex, diabetes duration, smoking status, glycated hemoglobin (HbA1c), blood pressure, lipid profile, and treatment modalities) were observed in existing models, in which urine albumin:creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR) are highly recommended for the Chinese population. Variability of blood pressure (BP) and HbA1c should be included in prediction model development as novel factors. Meanwhile, interactions between age, sex, and risk factors should also be considered.

CONCLUSIONS

A 10-year prediction model for CVD risk in Chinese type 2 DM patients is lacking and urgently needed. There is insufficient evidence to support the inclusion of other novel predictors in CVDs risk prediction functions for routine clinical use.

The prognosis of subjects showing a reduced estimated glomerular filtration rate without albuminuria in Japanese patients with type 2 diabetes: a cohort study for diabetic kidney disease

BACKGROUND

To determine the renal and cardiovascular prognosis and all-cause mortality of Japanese patients with type 2 diabetes showing a reduced estimated glomerular filtration rate (eGFR) without albuminuria.

METHODS

A population of 675 patients with type 2 diabetes was prospectively observed for 4 years to determine the renal and cardiovascular outcomes and mortality. The subjects were divided into the four groups: those with a preserved eGFR and no albuminuria (n = 306), a preserved eGFR and albuminuria (n = 151), a reduced eGFR and no albuminuria (n = 96), and a reduced eGFR and albuminuria (n = 122). The Cox proportional hazard model and Fine and Gray method were used to assess between-group differences in the risk of mortality and cardiovascular events.

RESULTS

In the group with a reduced eGFR, the eGFR value did not significantly change in the subjects without albuminuria (0 ± 8 mL/min/1.73 m²), whereas it decreased continuously in those with albuminuria (-6 ± 12 mL/min/1.73 m²). The incidence of cardiovascular events was significantly (P = 0.03) higher in the subjects with albuminuria (17%) than those without albuminuria (7%) in the group with a reduced eGFR. Cardiovascular events were significantly (P < 0.01) more frequent in the group with a reduced eGFR than in those with a preserved eGFR in both subjects with and without albuminuria.

CONCLUSIONS

The risk of end-stage kidney disease in non-albuminuric subjects with a reduced eGFR is considered to be low. We should focus on cardiovascular prognosis, because these patients are still at high risk of cardiovascular events, even though the prognosis is better in comparison to albuminuric patients.

Albuminuria and Risk of Cardiovascular Events and Mortality in a General Population of Patients with Type 2 Diabetes Without Cardiovascular Disease: A Danish Cohort Study

BACKGROUND

Albuminuria level is associated with cardiovascular events and mortality in patients with diabetes. However, little is known about the association between albuminuria level in diabetes patients without overt cardiovascular disease. We aimed to examine the association between albuminuria level and the risk of ischemic stroke, myocardial infarction, and all-cause mortality in patients with type 2 diabetes without overt cardiovascular disease.

METHODS

We linked Danish nationwide registries to identify patients with type 2 diabetes without cardiovascular disease from May 2005 through June 2015. Patients were followed for the outcomes ischemic stroke, myocardial infarction, and all-cause mortality until December 31, 2015. Albuminuria level was based on 2 consecutive measurements of the urinary albumin excretion rate or albumin-to-creatinine ratio. Associations between albuminuria level and incidence of cardiovascular disease and mortality were evaluated with Cox proportional hazard regression.

RESULTS

The study population consisted of 69,532 patients with type 2 diabetes without cardiovascular disease. When comparing patients with microalbuminuria to patients with normoalbuminuria, in an analysis adjusted for cardiovascular risk factors, we found hazard ratios of 1.28 (95% confidence interval [CI], 1.07-1.52), 1.34 (95% CI, 1.10-1.62), and 1.48 (95% CI, 1.36-1.61) for ischemic stroke, myocardial infarction, and all-cause mortality, respectively. For macroalbuminuria, the hazard ratios were 1.81 (95% CI, 1.46-2.23), 1.99 (95% CI, 1.59-2.48), and 1.83 (95% CI, 1.64-2.04). Similar results were found after adjusting for concomitant medication.

CONCLUSIONS

This study showed that albuminuria level is associated with higher risk of incident ischemic stroke, myocardial infarction, and all-cause mortality in Type 2 diabetes patients without overt cardiovascular disease.

Population, general practitioner and practice characteristics are associated with screening procedures for microvascular complications in Type 2 diabetes care in Norway

AIMS

To assess population, general practitioner (GP) and practice characteristics associated with the performance of microvascular screening procedures and to propose strategies to improve Type 2 diabetes care.

METHODS

A cross-sectional survey in Norway (281 GPs from 77 practices) identified 8246 people with a Type 2 diabetes duration of 1 year or more. We used multilevel regression models with either the recording of at least two of three recommended screening procedures (albuminuria, monofilament, eye examination) or each procedure separately as dependent variable (yes/no), and characteristics related to the person with diabetes, GP or practice as independent variables.

RESULTS

The performance of recommended screening procedures was recorded in the following percentages: albuminuria 31.5%, monofilament 27.5% and eye examination 60.0%. There was substantial heterogeneity between practices, and between GPs within practices for all procedures. Compared with people aged 60-69 years, those aged < 50 years were less likely to have an albuminuria test performed [odds ratio (OR) 0.75, 95% CI 0.61 to 0.93] and eye examination (OR 0.79, 95% CI 0.66 to 0.95). People with macrovascular disease had fewer screening procedures recorded (OR 0.68, 95% CI 0.59 to 0.78). Use of an electronic diabetes form was associated with improved screening  (OR 2.65, 95% CI 1.86 to 3.78). GPs with high workload recorded fewer procedures (OR 0.59, 95% CI 0.39 to 0.90).

CONCLUSIONS

Performance of screening procedures was suboptimal overall, and in people who should be prioritized. Performance varied substantially between GPs and practices. The use of a structured diabetes form should be mandatory.

Assessment of the degree of adherence of medical laboratories to KDIGO 2012 guideline for evaluation and management of CKD in Czechia and Slovakia

Introduction

The aim of the study is to assess the degree of adherence of medical laboratories to Kidney Disease Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) in laboratory practice in Czechia and Slovakia.

Materials and methods

An electronic questionnaire on adherence to KDIGO 2012 guideline was designed by an external quality assessment (EQA) provider SEKK spol. s.r.o. The questionnaire was placed and distributed through website to all medical biochemistry laboratories in Czechia and Slovakia (N = 396).

Results

A total of 212 out of 396 laboratories responded to the questions, though some laboratories only answered some questions, those applicable to their practice. A total of 48 out of 212 laboratories adopted the KDIGO 2012 guideline in full extent. The metrological traceability of creatinine measurement to standard reference material of SRM 967 was declared by 180 out of 210 laboratories (two of the responding laboratories did not measure creatinine). Thirty laboratories are not well educated on traceability of creatinine measurement and seven laboratories do not calculate estimated glomerular filtration rate (eGFR). Both urinary albumin concentration and albumin to creatinine ratio are reported by 144 out of 175 laboratories (37 of the responding laboratories did not measure urinary albumin).

Conclusion

Majority of laboratories in Czechia and Slovakia adopted some parts of the KDIGO 2012 guideline in their practice, but only 23% of the laboratories apply them completely. Thus, further education and action should be conducted to improve its implementation.

Galectin-3 and risk of cardiovascular events and all-cause mortality in type 2 diabetes

AIMS

Recent clinical studies have shown that galectin-3 is a prognostic indicator in patients with coronary heart disease and in patients with heart failure. Experimental data suggest that galectin-3 may play a role in atherogenesis. We have evaluated whether serum galectin-3 level is associated with cardiovascular outcome in type 2 diabetes.

MATERIALS AND METHODS

Galectin-3 was measured in baseline samples in 1495 persons with type 2 diabetes. The primary cardiovascular outcome, incident cardiovascular events, was defined as first non-fatal myocardial infarction, non-fatal stroke, coronary revascularization, or death from cardiovascular cause. The secondary outcome was all-cause mortality.

RESULTS

At baseline, 12% of the subjects had prevalent cardiovascular disease. Serum galectin-3 was increased in the group with incident cardiovascular events compared with those who remained free of events during follow up (9.03 ± 2.98 ng/mL vs 8.15 ± 2.76, P < 0.01). Serum galectin-3 was also significantly increased in those subjects with a fatal outcome. The hazard ratios (HR) for cardiovascular events and all-cause mortality for individuals in the top quartile were 2.50 (95% CI 1.87, 3.36, P < 0.001) and 3.92 (95%CI 2.55, 6.01, P < 0.001), respectively. In a multivariate Cox regression analysis including traditional risk factors, log (eGFR), baseline albuminuria, and cardiovascular disease status, the HR per standard deviation change in galectin-3 was 1.13 (95% CI 1.02, 1.26, P = 0.02) for cardiovascular events and 1.17 (95% CI 1.01, 1.35, P = 0.04) for all-cause mortality.

CONCLUSIONS

Serum galectin-3 is associated with adverse cardiovascular outcomes in persons with type 2 diabetes independent of traditional risk factors.

Phenotyping normal kidney function in elderly patients with type 2 diabetes: a cross-sectional multicentre study

AIMS

Type 2 diabetes (T2D) accelerates the decline in glomerular function; however, some individuals do not develop chronic kidney disease despite advanced age and long-lasting T2D. We aimed to phenotype patients with T2D aged 80 years or older who presented with a fully preserved kidney function.

METHODS

From an Italian population of 281,217 T2D outpatients, we collected data on demographics, anthropometrics, diabetes duration, HbA1c, fasting plasma glucose, lipids, liver enzymes, estimated glomerular filtration rate (eGFR), albumin excretion rate (AER), chronic complications, and medication use. We primarily compared patients with a fully preserved kidney function (eGFR > 90 ml/min/1.73 m² and AER < 30 mg/24 h, or G1A1) with those with mild kidney impairment (eGFR 60-90 ml/min/1.73 m² and AER < 30 mg/24 h, or G2A1).

RESULTS

N = 113,860 had available data for eGFR and AER, 21,648 of whom were aged ≥ 80. G1A1 (n = 278) and G2A1 (n = 6647) patients represented 1.3 and 30.7% of aged T2D patients, respectively, with an average diabetes duration of 16 years. Differences between the G1A1 and G2A1 groups were entered in a multiple logistic regression analysis with and without imputation of missing data. After adjustment and in both imputed and non-imputed datasets, younger age, lower BMI and lower triglycerides were associated with fully preserved versus mildly impaired kidney function. The comparison between G1A1 and G1A2/3 yielded different results.

CONCLUSIONS

In a rare population of patients with a fully preserved kidney function despite old age and long-lasting diabetes, lower BMI and triglycerides suggest that protection from lipotoxicity may preserve kidney function over time.

Analysis on influencing factors of abnormal renal function in elderly patients with type 2 diabetes mellitus

BACKGROUND

To investigate the related influencing factors of abnormal renal function in elderly in patients with type 2 diabetes mellitus (T2DM) and their clinical significance.

METHODS

The clinical data of elderly T2DM patients hospitalized in Beijing Luhe Hospital from January 2013 to June 2016 were retrospectively analyzed. According to their glomerular filtration rate (GFR) levels, these patients were divided into GFR≥90 mL/min/1.73 m2 group (group A), GFR =60-90 mL/min/1.73 m2 group (group B), and GFR <60 mL/min/1.73 m2 group (group C, i.e., abnormal renal function group). Clinical and laboratory indicators were compared among each group.

RESULTS

A total of 614 elderly T2DM patients were collected and divided into group A (N.=186), group B (N.=280) and group C (N.=148, 24.10%). Among them, patients clinically diagnosed with diabetic nephropathy (DN) accounted for 13.68%, and those complicated with high blood pressure (HBP) accounted for 61.40%. In Group C, DN accounted for only 29.73%. In elderly T2DM patients, HBP course, systolic blood pressure (SBP), diastolic blood pressure (DBP), 2h postprandial blood glucose (2hPBG), serum total cholesterol (TC) and blood uric acid (BUA) were independent influencing factors associated with abnormal renal function, among which HBP had a more significant impact on abnormal renal function. With the increase of blood pressure (BP) level, the extension in the course of DM, the increase in urinary albumin/creatinine (Alb/Cr) and the decrease in GFR, the incidence rate of abnormal renal function was increased.

CONCLUSIONS

HBP course, SBP, DBP, 2hPBG, TC and BUA are independent risk factors for abnormal renal function in elderly patients with T2DM. Well-controlled BP and blood glucose are protective factors, and a comprehensive treatment targeting to the above influencing factors has important clinical significance in preventing and delaying the occurrence and development of abnormal renal function.

Association of estimated glomerular filtration rate and proteinuria with all-cause mortality in community-based population in China: A Result from Kailuan Study

This study was based on 95391 participants (18-98 years old) from the Kailuan study, which assessed all-cause mortality in a community-based population in northern China according to estimated glomerular filtration rate (eGFR) by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula and proteinuria estimated from urine dipstick results. Data were analysed based on Cox proportional hazards models with adjustment for relevant confounders, and the results were expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). During eight years of follow-up, a total of 6024 participants died. The two indicators, eGFR < 45 ml/min/1.73 m² and the presence of proteinuria, were independently associated with all-cause mortality. Compared with eGFR ≥45 ml/min/1.73 m² with negative proteinuria, HRs of all-cause mortality were 1.26 (95% CI 1.10-1.44) for eGFR < 45 ml/min/1.73 m² without proteinuria, 1.95 (1.78-2.14) for eGFR ≥45 ml/min/1.73 m² with proteinuria, and 2.63 (2.14-3.23) for eGFR < 45 ml/min/1.73 m² with proteinuria. The all-cause mortality risk of eGFR and/or proteinuria was much higher in females than in males (P for interaction < 0.01). In conclusion, both severely decreased eGFR and proteinuria are independent predictors of all-cause mortality in the general northern Chinese population. A combination of severely decreased eGFR and proteinuria increases the risk of all-cause mortality, which is even over 5-fold higher in females.

Serum cystatin C is associated with subclinical atherosclerosis in patients with type 2 diabetes: A retrospective study

BACKGROUND

The aim of this study was to investigate the association between the serum cystatin C level and cardiovascular disease risk in patients with type 2 diabetes mellitus.

METHODS

We studied 523 patients with type 2 diabetes mellitus and calculated estimated 10-year risk of atherosclerotic cardiovascular disease (%). Subclinical atherosclerosis was defined as brachial-ankle pulse wave velocity ⩾1700 ms, indicating the presence of arterial stiffness.

RESULTS

Cystatin C level was significantly higher in the subclinical atherosclerosis group (brachial-ankle pulse wave velocity ⩾ 1700 ms) than in the non-subclinical atherosclerosis group (brachial-ankle pulse wave velocity < 1700 ms) (7.54 ± 3.15 mg/L vs 10.04 ± 5.12 mg/L, p < 0.001). Subclinical atherosclerosis was mainly determined by age, duration of diabetes and cystatin C level, but not by serum creatinine, 10-year risk of atherosclerotic cardiovascular disease score and estimated glomerular filtration rate in the multiple linear regression analysis. In addition, an increase in cystatin C level was independently associated with the risk of subclinical atherosclerosis after adjusting for age, sex, duration of diabetes, smoking, hypertension, 10-year risk of atherosclerotic cardiovascular disease risk score, serum creatinine level, total cholesterol, high-density lipoprotein cholesterol and haemoglobin A1c (odds ratio = 1.200, 95% confidence interval: 1.04-1.38, p = 0.011).

CONCLUSION

Serum cystatin C level was significantly associated with subclinical atherosclerosis. This result suggests that an increase in cystatin C level could be a valuable surrogate marker for the risk of cardiovascular disease in patients with type 2 diabetes mellitus.