Albuminuria, serum creatinine, and estimated glomerular filtration rate as predictors of cardio-renal outcomes in patients with type 2 diabetes mellitus and kidney disease: a systematic literature review

Biologically Synthesized Gold Nanoparticles Mitigate Aluminum Chloride-Induced Nephrotoxicity via Downregulation of iNOX, LCN2 and IL-1β Genes

Humans are constantly exposed to aluminum (Al), an environmental toxicant, and its accumulation in the glomerular could lead to acute kidney disease. Biologically synthesized gold nanoparticles (AuNPs) have been employed in the management of kidney disorders. This study assessed the modulatory effect of AuNPs mediated by Hibiscus sabdariffa (HS) on aluminum chloride (AlCl3)-induced nephrotoxicity in rats. Experimental rats were randomly distributed into six groups of seven animals each. Aluminum chloride (100 mg/kg bw) was orally given to the rats for 42 days to induce nephrotoxicity. Treatment with silymarin and HS-AuNPs lasted for 14 days. Serum kidney function, tissue arginase level and oxidative stress biomarkers, as well as tissue gene expression of inducible nitric oxide synthase (iNOS), lipocalin 2 (LCN2) and interleukin-1 beta (IL-1β) were evaluated. Exposure of AlCl3 to the rats produced a marked (p < 0.05) increase in the levels of serum urea and creatinine in comparison with the control. Similarly, tissue arginase and malondialdehyde (MDA) levels were also increased while a reduction in the activity of superoxide dismutase (SOD) and the levels of reduced glutathione (GSH) and nitric oxide (NO) were noted in the AlCl3-induced rats. Aluminum chloride also upregulated the mRNA expression of iNOS, LCN2 and IL-1β in the rats. These biochemical alterations were, however, attenuated by the administration of HS-AuNPs but the 5 mg/kg HS-AuNPs exhibited better anti-nephrotoxic activity than the 10 mg/kg dose, and could, thus serve as a potential dose for managing renal diseases.

Biomarker Profiling with Targeted Metabolomic Analysis of Plasma and Urine Samples in Patients with Type 2 Diabetes Mellitus and Early Diabetic Kidney Disease

Background: Over the years, it was noticed that patients with diabetes have reached an alarming number worldwide. Diabetes presents many complications, including diabetic kidney disease (DKD), which can be considered the leading cause of end-stage renal disease. Current biomarkers such as serum creatinine and albuminuria have limitations for early detection of DKD. Methods: In our study, we used UHPLC-QTOF-ESI+-MS techniques to quantify previously analyzed metabolites. Based on one-way ANOVA and Fisher's LSD, untargeted analysis allowed the discrimination of six metabolites between subgroups P1 versus P2 and P3: tryptophan, kynurenic acid, taurine, l-acetylcarnitine, glycine, and tiglylglycine. Results: Our results showed several metabolites that exhibited significant differences among the patient groups and can be considered putative biomarkers in early DKD, including glycine and kynurenic acid in serum (p < 0.001) and tryptophan and tiglylglycine (p < 0.001) in urine. Conclusions: Although we identified metabolites as potential biomarkers in the present study, additional studies are needed to validate these results.

Artificial intelligence for diabetes care: current and future prospects

Artificial intelligence (AI) use in diabetes care is increasingly being explored to personalise care for people with diabetes and adapt treatments for complex presentations. However, the rapid advancement of AI also introduces challenges such as potential biases, ethical considerations, and implementation challenges in ensuring that its deployment is equitable. Ensuring inclusive and ethical developments of AI technology can empower both health-care providers and people with diabetes in managing the condition. In this Review, we explore and summarise the current and future prospects of AI across the diabetes care continuum, from enhancing screening and diagnosis to optimising treatment and predicting and managing complications.

Causal factors of cardiovascular disease in end-stage renal disease with maintenance hemodialysis: a longitudinal and Mendelian randomization study

Background

The risk factors of cardiovascular disease (CVD) in end-stage renal disease (ESRD) with hemodialysis remain not fully understood. In this study, we developed and validated a clinical-longitudinal model for predicting CVD in patients with hemodialysis, and employed Mendelian randomization to evaluate the causal 6study included 468 hemodialysis patients, and biochemical parameters were evaluated every three months. A generalized linear mixed (GLM) predictive model was applied to longitudinal clinical data. Calibration curves and area under the receiver operating characteristic curves (AUCs) were used to evaluate the performance of the model. Kaplan-Meier curves were applied to verify the effect of selected risk factors on the probability of CVD. Genome-wide association study (GWAS) data for CVD (n = 218,792,101,866 cases), end-stage renal disease (ESRD, n = 16,405, 326 cases), diabetes (n = 202,046, 9,889 cases), creatinine (n = 7,810), and uric acid (UA, n = 109,029) were obtained from the large-open GWAS project. The inverse-variance weighted MR was used as the main analysis to estimate the causal associations, and several sensitivity analyses were performed to assess pleiotropy and exclude variants with potential pleiotropic effects.

Results

The AUCs of the GLM model was 0.93 (with accuracy rates of 93.9% and 93.1% for the training set and validation set, sensitivity of 0.95 and 0.94, specificity of 0.87 and 0.86). The final clinical-longitudinal model consisted of 5 risk factors, including age, diabetes, ipth, creatinine, and UA. Furthermore, the predicted CVD response also allowed for significant (p < 0.05) discrimination between the Kaplan-Meier curves of each age, diabetes, ipth, and creatinine subclassification. MR analysis indicated that diabetes had a causal role in risk of CVD (β = 0.088, p < 0.0001) and ESRD (β = 0.26, p = 0.007). In turn, ESRD was found to have a causal role in risk of diabetes (β = 0.027, p = 0.013). Additionally, creatinine exhibited a causal role in the risk of ESRD (β = 4.42, p = 0.01).

Conclusions

The results showed that old age, diabetes, and low level of ipth, creatinine, and UA were important risk factors for CVD in hemodialysis patients, and diabetes played an important bridging role in the link between ESRD and CVD.

Plasma levels and dietary intake of minerals in patients with type 2 diabetes and chronic kidney disease: A case-control study

BACKGROUND AND AIM

Diabetic kidney disease (DKD) is the primary cause of chronic kidney disease (CKD) worldwide. Altered mineral levels leading to adverse outcomes are widely reported in diabetes but limited in DKD, in the Indian scenario, hence this study was taken up to address this issue.

METHODS

A hospital-based case-control study was taken up with 54 healthy controls (C) and 140 subjects with type 2 diabetes wherein 74 subjects with diabetes and CKD formed the DKD group, and 66 subjects with diabetes but no CKD formed the diabetic no-chronic kidney disease (DNCKD) group. High-resolution inductively coupled plasma mass spectrometry was used to evaluate the blood levels of minerals (calcium (Ca), vanadium (V), chromium (Cr), manganese (Mn), iron (Fe), cobalt (Co), copper (Cu), zinc (Zn), and selenium (Se)), and a raw food-based food frequency questionnaire for dietary intakes. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation (mL/min/1.73 m2) and albuminuria. Spearman's rank correlation was used to evaluate the relationship between the categorical variables.

RESULTS

The median values of plasma Ca in the DKD group were significantly lower compared with the DNCKD and C groups (10.5 mg/dL vs. 11.0 mg/dL and 11.7 mg/dL, p<0.001). Furthermore, plasma Ca levels lowered with declining kidney function, as evidenced by the eGFR and albuminuria segregation. Dietary intake of minerals did not correlate with the corresponding plasma levels. However, in the DKD group, eGFR correlated positively with the plasma levels of Ca (r= 0.422, p=0.001), Cr (r= 0.351, p=0.008), Mn (r= 0.338, p=0.011), Fe (r= 0.403, p=0.002), Cu (r= 0.274, p=0.041) and negatively with Se (r= -0.486, p<0.001).

CONCLUSION

Plasma Ca levels are lower in the DKD group with a strong positive association with eGFR, indicating its role in predicting the onset and progression of kidney function decline.

Long-Term Accumulation, Biological Effects and Toxicity of BSA-Coated Gold Nanoparticles in the Mouse Liver, Spleen, and Kidneys

Introduction

Gold nanoparticles are promising candidates as vehicles for drug delivery systems and could be developed into effective anticancer treatments. However, concerns about their safety need to be identified, addressed, and satisfactorily answered. Although gold nanoparticles are considered biocompatible and nontoxic, most of the toxicology evidence originates from in vitro studies, which may not reflect the responses in complex living organisms.

Methods

We used an animal model to study the long-term effects of 20 nm spherical AuNPs coated with bovine serum albumin. Mice received a 1 mg/kg single intravenous dose of nanoparticles, and the biodistribution and accumulation, as well as the organ changes caused by the nanoparticles, were characterized in the liver, spleen, and kidneys during 120 days.

Results

The amount of nanoparticles in the organs remained high at 120 days compared with day 1, showing a 39% reduction in the liver, a 53% increase in the spleen, and a 150% increase in the kidneys. The biological effects of chronic nanoparticle exposure were associated with early inflammatory and fibrotic responses in the organs and were more pronounced in the kidneys, despite a negligible amount of nanoparticles found in renal tissues.

Conclusion

Our data suggest, that although AuNPs belong to the safest nanomaterial platforms nowadays, due to their slow tissue elimination leading to long-term accumulation in the biological systems, they may induce toxic responses in the vital organs, and so understanding of their long-term biological impact is important to consider their potential therapeutic applications.

Determinants of early chronic kidney disease in patients with recently diagnosed type 2 diabetes mellitus: a retrospective study from the Taiwan Diabetes Registry

BACKGROUND

We tried to identify the risk factor associate with early chronic kidney disease (CKD) in recently diagnosed type 2 diabetes mellitus patients by utilizing real-world data from Taiwan Diabetes Registry.

MATERIALS AND METHODS

Patients with type 2 diabetes mellitus recently diagnosed within 1 year. We divided the study participants into control group and early CKD group. Early CKD was defined as either CKD stage G1 with albuminuria, CKD stage G2 with albuminuria, or CKD stage G3a regardless of albuminuria (Urine-albumin to creatinine ratio (UACR) ≥ 3 mg/mmol). Control group was defined as CKD G1 or CKD G2 without albuminuria. Logistic regression analyses were used to compare differences in clinical characteristics between the subgroups. Linear regression models were employed to examine the factors predicting estimated glomerular filtration rate (eGFR) and UACR.

RESULTS

Total 2217 patients with recently diagnosed type 2 diabetes mellitus were included. 1545 patients were assigned to control group and 618 patients were assigned to the early CKD group. Age (odds ratio (OR) 1.215, 95% confidence interval [CI] 1.122-1.316), systolic blood pressure (OR 1.203, 95% CI 1.117-1.296), glycated hemoglobin (OR 1.074, 95% CI 1.023-1.129) and triglyceride (OR 2.18, 95% CI 1.485-3.199) were found to be significant risk factors. Further, presence of bidirectional association between UACR and eGFR was found.

CONCLUSIONS

We reported factors associated with early CKD in recently diagnosed type 2 diabetes mellitus patients. Variables that associated with eGFR and UACR were identified respectively, included a mutual influence between UACR and eGFR.

Influence of the combination of SGLT2 inhibitors and GLP-1 receptor agonists on eGFR decline in type 2 diabetes: post-hoc analysis of RECAP study

Accumulating evidence has demonstrated that both SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP1Ra) have protective effects in patients with diabetic kidney disease. Combination therapy with SGLT2i and GLP1Ra is commonly used in patients with type 2 diabetes (T2D). We previously reported that in combination therapy of SGLT2i and GLP1Ra, the effect on the renal composite outcome did not differ according to the preceding drug. However, it remains unclear how the initiation of combination therapy is associated with the renal function depending on the preceding drug. In this post hoc analysis, we analyzed a total of 643 T2D patients (GLP1Ra-preceding group, n = 331; SGLT2i-preceding group, n = 312) and investigated the differences in annual eGFR decline. Multiple imputation and propensity score matching were performed to compare the annual eGFR decline. The reduction in annual eGFR decline in the SGLT2i-preceding group (pre: -3.5 ± 9.4 mL/min/1.73 m2/year, post: -0.4 ± 6.3 mL/min/1.73 m2/year, p < 0.001), was significantly smaller after the initiation of GLP1Ra, whereas the GLP1Ra-preceding group tended to slow the eGFR decline but not to a statistically significant extent (pre: -2.0 ± 10.9 mL/min/1.73 m2/year, post: -1.8 ± 5.4 mL/min/1.73 m2/year, p = 0.83) after the initiation of SGLT2i. After the addition of GLP1Ra to SGLT2i-treated patients, slower annual eGFR decline was observed. Our data raise the possibility that the renal benefits-especially annual eGFR decline-of combination therapy with SGLT2i and GLP1Ra may be affected by the preceding drug.

Renal, cardiovascular, and safety outcomes of adding sodium-glucose cotransporter-2 inhibitors to insulin therapy in patients with type-2 diabetes: a meta-analysis

AIMS

To investigate the renal, cardiovascular, and safety outcomes when sodium-glucose cotransporter-2 inhibitors (SGLT2is) were added to insulin therapy in patients with type-2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

We searched Embase, PubMed, and Cochrane libraries for reports published up to Feb 2023. Randomized controlled trials (RCTs) comparing SGLT2is and insulin combination therapy (SGLT2is + INS group) with insulin therapy alone (INS group) in T2DM were included.

RESULTS

Fourteen RCTs involving six thousand one hundred twenty subjects with durations of 12-104 weeks were included. Compared with the insulin group, the SGLT2is + INS group showed decreased glycosylated hemoglobin values and insulin dosages (P < 0.00001). Meanwhile, the SGLT2is + INS group had a reduced urinary albumin/creatinine ratio (UACR) by 25.42 mg/g and uric acid concentration (P = 0.030; P = 0.001, respectively) but the estimated glomerular filtration rate (eGFR) and renal-related adverse events were unaffected (P = 0.070; P = 0.880, respectively). Blood pressure and body weight were lower in the SGLT2is + INS group (P < 0.01). However, the risk of genital infection was bigger when SGLT2is were added to insulin therapy (P < 0.00001), but the risks of severe hypoglycemia or urinary tract infection were equal between the two groups (P > 0.05).

CONCLUSION

Adding SGLT2is to insulin therapy in T2DM patients showed better glucose control and decreased albuminuria, uric acid, blood pressure, and body weight without a reduction in the eGFR.

Integrated Care Model by the Village Health Volunteers to Prevent and Slow down Progression of Chronic Kidney Disease in a Rural Community, Thailand

INTRODUCTION

Chronic kidney disease (CKD) is a major health problem in Thailand and health behaviors are central to its risk and progression. Because of the shortage of healthcare personnel, village health volunteers (VHVs) have been collaborating in the primary health care system. However, the contribution of VHVs to CKD reduction has not been evaluated yet. This study aimed to evaluate the efficacy of the VHV-integrated model in preventing and slowing down CKD and its risk factors.

METHODS

The population-based cohort study was conducted in a rural community of Thailand between 2017 and 2019. Baseline clinical and behavioral characteristics including CKD, diabetes, hypertension, and other high-risk factors of the participants were collected. The integrated care model was initiated by the multidisciplinary care team that facilitated, empowered, and trained VHVs targeting risk factors of CKD, health literacy, and health promotion. Then the participants were educated and trained for lifestyle modification and were monitored continuously for 18 months by VHVs. Changes in the CKD risk factors, and kidney functions before and after the application of integrated care model were compared.

RESULTS

A total of 831 subjects participated in the study with an average age of 57.5 years, and 69.5% were female. Among them, 222 participants (26.7%) were diagnosed as having CKD, the vast majority (95%) of which were in the early stages (G1-G3 and A1-A2). CKD risk factors such as high salt intake, smoking, alcohol consumption, self-NSAID (non-steroidal anti-inflammatory drugs) use were significantly decreased after application of the care model. Also, hemoglobin A1c was significantly reduced in diabetic patients, and blood pressure was controlled better than before in the hypertensive patients. Most importantly, a decline of estimated glomerular filtration rate of the CKD group was improved and lower than the non-CKD group.

CONCLUSION

The integrated care model through VHV significantly attenuated the risk factors associated with CKD in the general and high-risk population and effectively slowed down the progression of CKD.

Effect of weight loss on proteinuria in adults with type 2 diabetes: A real-world study

AIMS

To assess the impact of weight loss on proteinuria in patients with type 2 diabetes (T2DM) in real-world settings.

METHODS

A total of 1054 participants were categorized based on weight change from baseline to one-year follow-up: weight gain (≥3%), stable weight, or weight loss (≥3%). Proteinuria outcomes were defined as urinary albumin/creatinine ratio (UACR) progression (≥30 % increase), UACR regression (≥30 % reduction), or UACR stable. Ordered logistic regression analysis evaluated the relationship between weight loss and UACR regression.

RESULTS

Of the 1054 participants, 44.5 % were overweight, and 24.1 % were obese. Patients with obesity were at higher risk of developing proteinuria (OR, 1.783; 95 %CI, 1.195 to 2.659). Weight loss was associated with an 83.3 % increase in UACR regression compared to weight gain (OR, 1.833; 95 % CI, 1.262 to 2.663; P = 0.001). This association remained consistent across most subgroups and stronger in males (P for interaction = 0.023), with a 6 % UACR regression for every 1 kg weight loss (OR, 1.06; 95 % CI, 1.02 to 1.10; P = 0.003).

CONCLUSIONS

Our real-world study reveals that weight reduction is associated with UACR regression in patients with T2DM, regardless of the approach used for weight management, and the association was much stronger in males.

Non-albumin proteinuria marks tubular involvement and is associated with arterial stiffness in subjects affected by severe obesity

INTRODUCTION

Obesity is a well-established risk factor for kidney disease, and tubular damage can play a pivotal role in the development of obesity-related kidney damage. This study aimed to investigate the pathophysiological pathways involved in the development of non-albumin proteinuria (NAP), a marker of tubular involvement, in a cohort of subjects with severe obesity and preserved kidney function.

METHODS

A total of 106 subjects with BMI ≥ 35 kg/m2 in waiting list for bariatric surgery underwent blood chemistry analysis including metabolic and lipid profile, vascular tests for cardiovascular risk stratification and a comprehensive assessment of kidney function, including renal resistive index (RRI) and NAP measurement.

RESULTS

Nineteen patients with ACR ≥ 30 mg/g regardless of NAP values (ALB+), nineteen with NAP≥ 150 mg/g and albuminuria < 30 mg/g (iNAP) and sixty-eight without proteinuria (No-P) were found. Both ALB+ and iNAP groups exhibited a higher prevalence of hypertension and anti-hypertensive treatment compared to No-P, while the prevalence of diabetes was similar between groups. Concerning lipid profile, no differences in total, HDL and LDL cholesterol were found, while ALB+ patients had higher serum triglyceride levels than the other two groups. RRI and carotid-femoral pulse wave velocity (cf-PWV) was significantly higher in ALB+ and iNAP groups compared to No-P. Remarkably, cf-PWV remained still significant after adjustment for age, sex and MBP (p = 0.0004). In overall population, a multiple regression analysis showed that cf-PWV was an independent determinant of NAP in a model including age, sex, glycated hemoglobin, systolic and mean blood pressure (R2 =0.17, p = 0.031).

CONCLUSION

iNAP subjects showed increased arterial stiffness comparable to that observed in ALB+ group, suggesting that they may represent a subgroup at higher cardiovascular risk, often unrecognized in clinical practice.

Evaluation of Renal Function Profile in Human Visceral Leishmaniasis (Kala-Azar) Patients: A Case of Western Tigray, Ethiopia

Background

Leishmaniasis is a vector-borne protozoan infection that has a wide clinical spectrum in the tropics and subtropics. Kidney damage is frequently associated with increased morbidity and mortality in visceral leishmaniasis (VL) patients. However, up to date, there is a very limited report on the effect of visceral leishmaniasis on kidney function profiling in Ethiopia.

Objective

To evaluate the renal function profile in human visceral leishmaniasis (kala-azar) patients.

Materials and Methods

Human blood was taken from VL patients (n = 100) and healthy controls (n = 100) attending Kahsay Abera and Mearg Hospitals, Western Tigray of Ethiopia. Serum was separated according to the conventional protocol and kidney function profiling (creatinine, urea, and uric acid) was analyzed by Mindray 200E automated chemistry analyzer. The estimated glomerular filtration rate (eGFR) was also assessed in this study. The obtained data were processed using SPSS Version 23.0. Descriptive statistics, independent-test, and bivariate correlations were used for data analysis. P values <0.05 were considered statistically significant at a 95% confidence level.

Results

The mean serum creatinine level was found significantly higher, while respective serum urea and eGFR were significantly lower in VL patients compared to healthy controls. Specifically, from 100 VL cases, an increased level of serum creatinine, urea, and uric acid was found in 10%, 9% and 15% VL cases, respectively; meanwhile, a decreased serum urea and eGFR have been reported from 33% to 44% VL cases, respectively.

Conclusion

The finding of this study asserted that visceral leishmaniasis causes derangement in kidney activities characterized by alteration of renal function profile. This may indicate that VL is the determinant factor for developing kidney dysfunction. This study encourages researchers to engage in visceral leishmaniasis and its effect on other organ function profiles in humans and identify potential markers for both prevention and intervention.

The Bidirectional Association of Chronic Kidney Disease, Type 2 Diabetes, Atherosclerotic Cardiovascular Disease, and Heart Failure: The Cardio-Renal-Metabolic Syndrome

Background: The cardiometabolic syndrome focuses on the association between type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease (ASCVD), whereas the cardiorenal syndrome focuses on the association between chronic kidney disease (CKD) and heart failure (HF). Consideration of these two syndromes as a single entity has not been well described. Methods: We used the electronic medical records of Kaiser Permanente Northwest to identify 387,985 members aged 18+ years with a serum creatinine measured from 2005 to 2017. If the estimated glomerular filtration rate was <60 mL/min per 1.73 m², we required a second confirmatory measurement 3-12 months later. Patients were followed through 2019. We calculated the age- and gender-adjusted incidence and progression of CKD per 1000 person-years using generalized estimating equations. We used Cox proportional hazard models to assess the time-dependent effect of each condition on incidence of the other conditions. Results: CKD incidence rates were highest in patients with T2DM, ASCVD, and HF (27.0 per 1000 person-years [95% confidence interval (CI) 24.8-29.4] vs. 5.9 [5.8-6.0] in patients with none of these conditions). Similar results were obtained for CKD progression (309.0, 283.9-336.4 for all three conditions vs. 147.9, 143.3-152.4 for no condition). In time-dependent models, all three conditions were independently associated with CKD incidence, being highest for HF (hazard ratio 2.14, 95% CI 2.07-2.21). All relationships between CKD, T2DM, ASCVD, and HF were significant and bidirectional. Conclusions: The presence of CKD, T2DM, HF, and ASCVD each conveys risk on the others. A cardiometabolic renal syndrome comprising these conditions may be an important disease entity that requires a comprehensive treatment approach.

Impact of Lockdown Measures on Health Outcomes of Adults with Type 2 Diabetes Mellitus in Bangladesh

COVID-19 lockdown measures appreciably affected patients' lifestyles, negatively impacting on their health. This includes patients with Type 2 Diabetes Mellitus (T2DM). Care of these patients was also negatively impacted due to a priority to treat patients with COVID-19, certainly initially, within hospitals and clinics in Bangladesh, combined with a lack of access to clinics and physicians due to lockdown and other measures. This is a concern in Bangladesh with growing rates of T2DM and subsequent complications. Consequently, we sought to critically analyze the situation among patients with T2DM in Bangladesh during the initial stages of the pandemic to address this information gap and provide future direction. Overall, 731 patients were recruited by a simple random sampling method among patients attending hospitals in Bangladesh, with data collected over 3 timescales: before lockdown, during the pandemic, and after lockdown. Data extracted from patients' notes included current prescribed medicines and key parameters, including blood sugar levels, blood pressure, and comorbidities. In addition, the extent of record keeping. The glycemic status of patients deteriorated during lockdown, and comorbidities as well as complications related to T2DM increased during this period. Overall, a significant proportion of key datasets were not recorded in patients' notes by their physician before and during lockdown. This started to change after lockdown measures eased. In conclusion, lockdown measures critically affected the management of patients with T2DM in Bangladesh, building on previous concerns. Extending internet coverage for telemedicine, introduction of structured guidelines, and appreciably increasing data recording during consultations is of the utmost priority to improve the care of T2DM patients in Bangladesh.

Clinical outcomes in patients with type 2 diabetes mellitus-related kidney disease: A Jordanian population cohort study

BACKGROUND

Diabetic kidney disease (DKD) increases the risk of cardiovascular (CV) complications, kidney disease progression, and mortality. We aimed to determine the incidence and risk of these outcomes according to DKD phenotype among the Jordanian population.

METHODS

A total of 1172 type 2 diabetes mellitus patients with estimated glomerular filtration rates (eGFRs) of >30 ml/min/1.73 m² were followed-up from 2019 to 2022. At baseline, patients were classified according to the presence of albuminuria (>30 mg/g creatinine) and reduced eGFR (<60 ml/min/1.73 m²) into four phenotypes: non-DKD (reference category), albuminuric DKD without decreased eGFR, non-albuminuric DKD with decreased eGFR, and albuminuric DKD with decreased eGFR.

RESULTS

Mean follow-up was 2.9 ± 0.4 years. Overall, 147 patients (12.5 %) experienced CV events, while 61 (5.2 %) demonstrated kidney disease progression (eGFR: <30 ml/min/1.73 m²). The mortality rate was 4.0 %. Multivariable-adjusted risk for CV events and mortality was greatest for the albuminuric DKD with decreased eGFR group (hazard ratio [HR]: 1.45, 95 % confidence interval [CI]: 1.02-2.33 and HR: 6.36, 95 % CI: 2.98-13.59, respectively), with the risk increasing when adjusted for prior CV history (HR: 1.47, 95 % CI: 1.06-3.42 and HR: 6.70, 95 % CI: 2.70-16.60, respectively). Risk of a ≥40 % decline in eGFR was greatest for the albuminuric DKD with decreased eGFR group (HR: 3.45, 95 % CI: 1.74-6.85), followed by the albuminuric DKD without decreased eGFR group (HR: 1.6, 95 % CI: 1.06-2.75).

CONCLUSION

Thus, patients with albuminuric DKD and decreased eGFR were at greater risk for poor CV, renal, and mortality outcomes compared to other phenotypes.

Comparative Efficacy of Novel Antidiabetic Drugs on Albuminuria Outcomes in Type 2 Diabetes: A Systematic Review

INTRODUCTION

Albuminuria, or elevated urinary albumin-to-creatine ratio (UACR), is a biomarker for chronic kidney disease that is routinely monitored in patients with type 2 diabetes (T2D). Head-to-head comparisons of novel antidiabetic drugs on albuminuria outcomes remain limited. This systematic review qualitatively compared the efficacy of novel antidiabetic drugs on improving albuminuria outcomes in patients with T2D.

METHODS

We searched the MEDLINE database until December 2022 for Phase 3 or 4 randomized, placebo-controlled trials that evaluated the effects of sodium-glucose co-transporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and dipeptidyl peptidase-4 (DPP-4) inhibitors on changes in UACR and albuminuria categories in patients with T2D.

RESULTS

Among 211 records identified, 27 were included, which reported on 16 trials. SGLT2 inhibitors and GLP-1 RAs decreased UACR by 19-22% and 17-33%, respectively, versus placebo (P < 0.05 for all studies) over median follow-up of ≥ 2 years; DPP-4 inhibitors showed varying effects on UACR. Compared with placebo, SGLT2 inhibitors decreased the risk for albuminuria onset by 16-20% and for albuminuria progression by 27-48% (P < 0.05 for all studies) and promoted albuminuria regression (P < 0.05 for all studies) over median follow-up of ≥ 2 years. Evidence on changes in albuminuria categories with GLP-1 RA or DPP-4 inhibitor treatment were limited with varying outcome definitions across studies and potential drug-specific effects within each class. The effect of novel antidiabetic drugs on UACR or albuminuria outcomes at ≤ 1 year remains poorly studied.

CONCLUSION

Among the novel antidiabetic drugs, SGLT2 inhibitors consistently improved UACR and albuminuria outcomes in patients with T2D, with continuous treatment showing long-term benefit.

Change in albuminuria as a surrogate endpoint for cardiovascular and renal outcomes in patients with diabetes

For the purpose of predicting clinical outcomes in patients with diabetes and chronic kidney disease, change in albuminuria is a good candidate to be a surrogate marker for future cardiovascular events and progression of kidney disease. Spot urine albumin/creatinine ratio is convenient and recognized as a viable alternative to 24-h albumin, with some limitations. Although there is sufficient evidence to validate its use in clinical trials as a surrogate endpoint for renal outcomes, this is not yet the case for cardiovascular outcomes. While change in albuminuria as a primary or secondary endpoint is trial-specific, its use should be encouraged, nonetheless.

Effect of exercise on renal function in diabetic nephropathy-a systematic review and meta-analysis

Diabetic nephropathy causes cardiovascular complications among individuals with diabetes which results in decreased kidney function and overall physical decline. The objective of this systematic review was to determine effects of exercise on various renal function parameters amond individuals with type 2 diabetes and nephropathy. It was registered with PROSPERO (CRD42020198754). Total 6 databases (PubMed/Medline, Scopus, Web of Science, CINAHL, ProQuest, and Cochrane) were searched. Among 1734 records, only four randomized controlled trials were included. The review included a total of 203 participants (103 in the intervention group and 100 in the control/standard group) with type 2 diabetic nephropathy or stage 2,3, or 4 of chronic kidney disease. The meta-analysis showed no effects of exercise on serum creatinine, serum cystatin c and varied eGFR equations. However, exercise decreased urinary albumin to creatinine ratio, urinary protein to creatinine ratio, serum urea nitrogen, creatinine clearance, and urinary protein excretion while increasing urea clearance. Limited evidence on the reno-protective role of exercise demands future research in this direction.

Pathological validation of the Japanese Renal Pathology Society classification and challenges in predicting renal prognosis in patients with diabetic nephropathy

BACKGROUND

Diabetic nephropathy (DN) accounts for approximately half of all cases of chronic kidney disease (CKD) and end-stage kidney disease worldwide. The Renal Pathology Society (RPS) classification has been used to predict the renal prognosis in DN. In 2018, the Japanese Renal Pathology Society (JRPS) proposed a comprehensive classification system that included pathological changes in the kidney. The clinical significance of the JRPS classification system was comparatively evaluated in the present study.

METHODS

A total of 93 cases diagnosed with DN from 2009 to 2019 were enrolled. JRPS scores (J-scores) were calculated by scoring the pathological factors in the JRPS classification system and comparing them with clinical parameters.

RESULTS

Most pathological factors constituting the J-score were significantly correlated with clinical factors. Laminated nodules were inversely correlated with estimated glomerular filtration rate. After adjusting for age, sex, body mass index, hemoglobin A1c, diabetes duration, and hypertension, CKD stage was significantly correlated with JRPS grade, nodular lesions, and exudative lesions in the multivariate logistic regression analysis. However, receiver operating characteristic curve analysis revealed that the J-score (area under the curve [AUC] = 0.639) had lower clinical significance than the traditional RPS classification system (AUC = 0.675).

CONCLUSION

The JRPS classification can more comprehensively reflect renal changes than the RPS classification and is correlated with renal survival. When creating a new pathological classification, arteriolar hyalinosis should not be included, whereas laminated nodules should be included.

Effect of glucagon-like peptide 1 receptor agonists on albuminuria in adult patients with type 2 diabetes mellitus: A systematic review and meta-analysis

AIMS

To determine the effect of glucagon-like peptide 1 receptor agonists (GLP-1RAs) on albuminuria in adult patients with type 2 diabetes mellitus (T2DM).

METHODS

Medline Ovid, Scopus, Web of Science, EMCARE and CINAHL databases from database inception until 27 January 2022. Studies were eligible for inclusion if they were randomized controlled trials that involved treatment with a GLP-1RA in adult patients with T2DM and assessed the effect on albuminuria in each treatment arm. Data extraction was conducted independently by three individual reviewers. The PRISMA guidelines were followed regarding data extraction and quality assessment. Data were pooled using a random effects inverse variance model and all analysis was carried out with RevMan 5.4 software. The Jadad scoring tool was employed to assess the quality of evidence and risk of bias in the randomized controlled trials.

RESULTS

The initial search revealed 2419 articles, of which 19 were included in this study. An additional three articles were identified from hand-searching references of included reviews. Therefore, in total, 22 articles comprising 39 714 patients were included. Meta-analysis suggested that use of GLP1-RAs was associated with a reduction in albuminuria in patients with T2DM (weighted mean difference -16.14%, 95% CI -18.42 to -13.86%; p < .0001) compared with controls.

CONCLUSIONS

This meta-analysis indicates that GLP-1RAs are associated with a significant reduction in albuminuria in adult patients with T2DM when compared with placebo.

Renal Function in Hypertensive Patients Receiving Cilnidipine and L-Type Calcium Channel Blockers: A Meta-Analysis of Randomized Controlled and Retrospective Studies

Nearly 65%-95% of chronic kidney disease (CKD) patients have hypertension. Calcium-channel blockers are the first-line drugs for the treatment of hypertension, including hypertension with diabetes. This study aims to estimate the effect of an L-type calcium channel blocker (CCB), cilnidipine, on the renal function of hypertensive patients. Randomized control trials were selected from PubMed, Embase, Google Scholar, China National Knowledge Infrastructure (CNKI), Science Direct, Elton B. Stephens Company (EBSCO), Springer, Ovid, Cochrane Library, Medline, VIP, and Wanfang databases (from the date of databases' establishment till January 2022). Data were independently evaluated following the Cochrane risk-of-bias tool. The changes in serum creatinine (SCr), urinary protein excretion (UPE), urinary protein/creatinine ratio (UPCR), and estimated glomerular filtration rate (eGFR) before and after treatment, in percentages, were extracted for the meta-analysis. The mean difference (MD) and a CI of 95% were determined using RevMan 5.3 software. A total of 11 studies were analyzed. The standardized mean difference (SMD) between cilnidipine and L-type CCBs was -0.022, suggesting a reduced SCr with cilnidipine. For UPCR, the SMD value is 1.28. Although cilnidipine reduced UPCR in all four studies, the L-type CCBs reported a slight increase in UPCR. For eGFR, the SMD value was found to be 0.693. Cilnidipine had a more favorable effect on eGFR when compared to the L-type CCBs. While cilnidipine had similar effects on SCr to that of L-type CCBs, cilnidipine showed greater improvement in UPCR, UPE, and eGFR values.

Spatial localization of β-unsaturated aldehyde markers in murine diabetic kidney tissue by mass spectrometry imaging

Diabetic nephropathy (DN) is the leading cause of end-stage renal disease. Limitations in current diagnosis and screening methods have sparked a search for more specific and conclusive biomarkers. Hyperglycemic conditions generate a plethora of harmful molecules in circulation and within tissues. Oxidative stress generates reactive α-dicarbonyls and β-unsaturated hydroxyhexenals, which react with proteins to form advanced glycation end products. Mass spectrometry imaging (MSI) enables the detection and spatial localization of molecules in biological tissue sections. Here, for the first time, the localization and semiquantitative analysis of “reactive aldehydes” (RAs) 4-hydroxyhexenal (4-HHE), 4-hydroxynonenal (4-HNE), and 4-oxo-2-nonenal (4-ONE) in the kidney tissues of a diabetic mouse model is presented. Ionization efficiency was enhanced through on-tissue chemical derivatization (OTCD) using Girard’s reagent T (GT), forming positively charged hydrazone derivatives. MSI analysis was performed using matrix-assisted laser desorption ionization (MALDI) coupled with Fourier-transform ion cyclotron resonance mass spectrometry (FT-ICR). RA levels were elevated in diabetic kidney tissues compared to lean controls and localized throughout the kidney sections at a spatial resolution of 100 µm. This was confirmed by liquid extraction surface analysis–MSI (LESA-MSI) and liquid chromatography–mass spectrometry (LC–MS). This method identified β-unsaturated aldehydes as “potential” biomarkers of DN and demonstrated the capability of OTCD-MSI for detection and localization of poorly ionizable molecules by adapting existing chemical derivatization methods. Untargeted exploratory distribution analysis of some precursor lipids was also assessed using MALDI-FT-ICR-MSI.

Efficacy and Safety of Non-Steroidal Mineralocorticoid Receptor Antagonists in Patients With Chronic Kidney Disease and Type 2 Diabetes: A Systematic Review Incorporating an Indirect Comparisons Meta-Analysis

Background: The non-steroidal mineralocorticoid receptor antagonists (MRAs) are promising treatments in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). We conducted a meta-analysis to explore the efficacy and safety of the non-steroidal MRAs (finerenone, apararenone, esaxerenone) and detect the differences among them.

Methods: We searched several databases for eligible randomized controlled trials (RCTs) investigating non-steroidal MRAs versus placebo in patients with CKD and T2D. We performed a conventional meta-analysis separately, and then indirect comparisons for efficacy and safety outcomes were conducted among these included drugs.

Results: Eight RCTs with 14,450 subjects were enrolled. In patients with CKD and T2D, a greater reduction in urinary albumin-to-creatinine ratio (UACR) (WMD −0.40, 95% CI −0.48 to −0.32, p < 0.001), estimated glomerular filtration rate (eGFR) (WMD −2.69, 95% CI −4.47 to −0.91, p = 0.003), systolic blood pressure (SBP) (WMD −4.84, 95% CI −5.96 to −3.72, p < 0.001) and a higher risk of hyperkalemia (RR 2.07, 95% CI 1.86 to 2.30, p < 0.001) were observed in the non-steroidal MRAs versus placebo; there is no significant difference in the incidence of serious adverse events between two groups (RR 1.32, 95% CI 0.98 to 1.79, p = 0.067). Compared with finerenone, esaxerenone showed no significant difference in UACR reduction (WMD 0.24, 95% CI −0.016 to 0.496, p = 0.869); apararenone and esaxerenone showed greater decreases in SBP (WMD 1.37, 95% CI 0.456 to 2.284, p = 0.010; WMD 3.11, 95% CI 0.544 to 5,676, p = 0.021).

Conclusions: Despite the moderate increased risk of hyperkalemia, use of non-steroidal MRAs could reduce proteinuria and SBP in patients with CKD and T2D. In terms of renoprotection, esaxerenone and finerenone may have similar effects. Esaxerenone and apararenone may have better antihypertensive effects than finerenone. The head-to-head RCTs are still needed to compare the differences of the efficacy and safety in these non-steroidal MRAs.

Serum ferritin level in type 2 diabetic patients with renal dysfunction

Background and objective: Nephropathy is the major cause of end-stage renal disease (ESRD) in type 2 diabetes mellitus (T2DM). Delay in identification and management of nephropathy in T2DM may cause development of ESRD. An increased level of serum ferritin plays a role in the pathogenesis of chronic kidney disease (CKD) in T2DM. Hence, the present study intended to assess the level of serum ferritin in renal dysfunction in patients with T2DM. Material and methods: This was a retrospective study with 81 T2DM patients with and without nephropathy. They were categorized into two groups. Group-1 consisted of 46 T2DM cases without nephropathy and remaining 35 with nephropathy.The clinical and biochemical parameters such as blood glucose, urea, creatinine, iron, ferritin, transferrin, total iron binding capacity (TIBC), and haemoglobin were measured by standard methods, and estimated glomerular filtration rate (eGFR) by MDRD formula. Results: Significantly (p<0.05) elevated level of serum ferritin along with urea and creatinine was found in patients with T2DM with nephropathy.A significant positive correlation (r = 0.37) of serum ferritin and negative correlation (r = - 0.852) of eGFR with creatinine were found. It indicated that ferritin could be a good marker to monitor kidney function in T2DM. Conclusion: Apart from eGFR and serum creatinine, raised serum ferritin level was a good indicator of renal dysfunction in T2DM patients and might play an important role in renal dysfunction in early stage diabetic nephropathy. IMC J Med Sci 2022; 16(2): 008. DOI: https://doi.org/10.55010/imcjms.16.018 *Correspondence: Dr. Siva Prasad Palem., M.Sc., Ph.D., Department of Biochemistry, Faculty of Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar-505001, Telangana, India. Affiliated with Kaloji Narayana Rao University of Health Sciences (KNRUHS), Warangal, Telangana, India. E-mail: sp.biocom@yahoo.co.in.

Could outcomes of intracranial aneurysms be better predict using serum creatinine and glomerular filtration rate?

Purpose:

To analyze the role of serum creatinine levels as a biomarker of intracranial aneurysm outcomes.

Methods:

This is a prospective analysis of outcomes of patients with intracranial aneurysm. One hundred forty-seven patients with serum creatinine at admission and 6 months follow up were included. Linear and logistic regressions were used to analyze the data. Modified Rankin scale (mRS) was used to assess outcome.

Results:

Creatinine level was not directly related to aneurysm outcome nor aneurysm rupture (p > 0.05). However, patients with a glomerular filtration rate (GFR) lower than 72.50 mL·min^–1 had an odds ratio (OR) of 3.049 (p = 0.006) for worse outcome. Similarly, aneurysm rupture had an OR of 2.957 (p = 0.014) for worse outcomes. Stepwise selection model selected 4 variables for outcomes prediction: serum creatinine, sex, hypertension and treatment. Hypertensive patients had, on average, an increase in 0.588 in mRS (p = 0.022), while treatment with microsurgery had a decrease in 0.555 (p = 0.038).

Conclusions:

Patients with higher GFR had better outcomes after 6 months. Patients with higher GFR had better outcomes after 6 months. Creatinine presented an indirect role in GFR values and should be included in models for outcome prediction.

An analysis of laboratory parameters of chronic kidney failure in elderly patients

Aim: The chief aim of this study was monitoring of laboratory parameters of chronic kidney failure in elderly patients. Methods: All samples were taken and processed by standard methods and according to the principles of good laboratory practice. Data were collected in an organized and systematic manner in the form of a questionnaire with respect to ethical principles and as such were analyzed by statistical tests and analyses (Student's t-test, Analysis of variance-ANOVA, Pearson's and Spearman's correlation coefficients). The limit of statistical significance was set at p < 0.05. Results: Mean values of creatinine clearance and proteinuria for the total study population were: 41.30 ± 21.43 mL/min, 1.5 ± 2.3 g/L/24 h, respectively. Hematological parameters did not significantly differ from normal values. The highest frequency of comorbidities was observed in subjects aged ≥ 80 years with an average of 2.03 comorbidities per subject. Serum creatinine and urea values as well as creatinine clearance are good indicators of disease progression. Conclusion: The results of the presented research suggest that old age is a predisposing risk factor for the development of chronic kidney disease, and that in combination with comorbidities (hypertension and/or diabetes), it contributes to poor prognosis or disease progression.

Comprehensive Diagnostics of Diabetic Nephropathy by Transcriptome RNA Sequencing

BACKGROUND

Diabetic nephropathy (DN) is a primary driver of end-stage renal disease. Given the heterogeneity of renal lesions and the complex mechanisms of DN, the present-day diagnostic approach remains highly controversial. We aimed to design a diagnostic model by bioinformatics methods for discriminating DN patients from normal subjects.

METHODS

In this study, transcriptome sequencing was performed on 6 clinical samples (3 from DN patients and 3 from healthy volunteers) from the Second Affiliated Hospital of Kunming Medical University. Construction of a competing endogenous RNA (ceRNA) network based on differentially expressed (DE)-mRNAs and -long noncoding RNAs (lncRNAs). Subsequently, the CytoHubba plugin was used to identify hub genes from DE-mRNAs in the ceRNA network and to perform functional enrichment analysis on them. The least absolute shrinkage and selection operator (LASSO) regression analysis was responsible for screening the diagnostic biomarkers from hub genes and assessing their diagnostic power using ROC curves. The pathways involved in hub genes were revealed by single-gene Gene Set Enrichment Analysis (GSEA). Moreover, we verified the expression levels of diagnostic biomarkers by quantitative real-time polymerase chain reaction (qRT-PCR) and Western blot.

RESULTS

A total of 10 hub genes were screened from the ceRNA network, which appeared to be associated with the viral infection, kidney development, and regulation of immune and inflammatory responses. Subsequently, LASSO regression analysis established a diagnostic model consisting of DDX58, SAMD9L, and TLR6 with a robust diagnostic potency (AUC = 1). Similarly, single-gene GSEA showed a strong association of these diagnostic biomarkers with the viral infection. Furthermore, PCR and Western blot demonstrated showed that DDX58, SAMD9L, and TLR6 were upregulated in DN patients at both transcriptome and protein levels compared to healthy controls.

CONCLUSION

We confirmed that differentially expressed hub genes may be novel diagnostic biomarkers in DN.

Machine learning approach to predicting albuminuria in persons with type 2 diabetes: An analysis of the LOOK AHEAD Cohort

Albuminuria and estimated glomerular filtration rate (e-GFR) are early markers of renal disease and cardiovascular outcomes in persons with diabetes. Although body composition has been shown to predict systolic blood pressure, its application in predicting albuminuria is unknown. In this study, we have used machine learning methods to assess the risk of albuminuria in persons with diabetes using body composition and other determinants of metabolic health. This study is a comparative analysis of the different methods to predict albuminuria in persons with diabetes mellitus who are older than 40 years of age, using the LOOK AHEAD study cohort-baseline characteristics. Age, different metrics of body composition, duration of diabetes, hemoglobin A1c, serum creatinine, serum triglycerides, serum cholesterol, serum HDL, serum LDL, maximum exercise capacity, systolic blood pressure, diastolic blood pressure, and the ankle-brachial index are used as predictors of albuminuria. We used Area under the curve (AUC) as a metric to compare the classification results of different algorithms, and we show that AUC for the different models are as follows: Random forest classifier-0.65, gradient boost classifier-0.61, logistic regression-0.66, support vector classifier -0.61, multilayer perceptron -0.67, and stacking classifier-0.62. We used the Random forest model to show that the duration of diabetes, A1C, serum triglycerides, SBP, Maximum exercise Capacity, serum creatinine, subtotal lean mass, DBP, and subtotal fat mass are important features for the classification of albuminuria. In summary, when applied to metabolic imaging (using DXA), machine learning techniques offer unique insights into the risk factors that determine the development of albuminuria in diabetes.

High Blood Uric Acid Is Associated With Reduced Risks of Mild Cognitive Impairment Among Older Adults in China: A 9-Year Prospective Cohort Study

Background: It remains unsolved that whether blood uric acid (UA) is a neuroprotective or neurotoxic agent. This study aimed to evaluate the longitudinal association of blood UA with mild cognitive impairment (MCI) among older adults in China.

Methods: A total of 3,103 older adults (aged 65+ years) free of MCI at baseline were included from the Healthy Aging and Biomarkers Cohort Study (HABCS). Blood UA level was determined by the uricase colorimetry assay and analyzed as both continuous and categorical (by quartile) variables. Global cognition was assessed using the Mini-Mental State Examination four times between 2008 and 2017, with a score below 24 being considered as MCI. Cox proportional hazards models were used to examine the associations.

Results: During a 9-year follow-up, 486 (15.7%) participants developed MCI. After adjustment for all covariates, higher UA had a dose-response association with a lower risk of MCI (all P_{for  trend} < 0.05). Participants in the highest UA quartile group had a reduced risk [hazard ratio (HR), 0.73; 95% (CI): 0.55–0.96] of MCI, compared with those in the lowest quartile group. The associations were still robust even when considering death as a competing risk. Subgroup analyses revealed that these associations were statistically significant in younger older adults (65–79 years) and those without hyperuricemia. Similar significant associations were observed when treating UA as a continuous variable.

Conclusions: High blood UA level is associated with reduced risks of MCI among Chinese older adults, highlighting the potential of managing UA in daily life for maintaining late-life cognition.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Real-World Diagnosis and Treatment of Diabetic Kidney Disease

INTRODUCTION

People with type 2 diabetes mellitus (T2DM) and diabetic kidney disease (DKD) have increased morbidity and mortality risk. Angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB) are recommended to slow kidney function decline in DKD. This representative, real-world data analysis of patients with T2DM was performed to detect onset of DKD and determine methods and timing of DKD diagnosis and time to initiation of ACEi/ARB therapy.

METHODS

Patients diagnosed with T2DM before January 1, 2016 who developed DKD between January 1, 2017 and June 30, 2019 were identified from a longitudinal ambulatory electronic health record (EHR) dataset (Veradigm Inc). Each record was analyzed using the CLinical INTelligence engine (CLINT™, HealthPals, Inc.) to identify delays and gaps in diagnosing DKD. DKD was diagnosed through two reduced estimated glomerular filtration rate (eGFR; < 60 mL/min/1.73 m²) measurements at least 90 days apart, a single elevated urine albumin-to-creatinine ratio (UACR; > 30 mg/g) measurement, or ICD-9/10 diagnosis codes for DKD and/or albuminuria. Time to diagnose (TTD), time to treat (TTT), and diagnosis to treatment time were assessed.

RESULTS

Of 6,499,409 patients with T2DM before January 2016, 245,978 developed DKD between January 1, 2017 and June 30, 2019. In this DKD cohort, ca. 50% were first identified through EHR diagnosis and ca. 50% by UACR or eGFR lab-based diagnosis. In patients who had UACR/eGFR assessed, more than 90% exhibited DKD-level results on the first diagnostic test. Average TTD after eGFR labs was 2 years; average TTT with ACEi/ARB was 6-9 months after DKD lab evidence. The majority of patients who developed DKD received ACEi/ARB therapy 6-7 months after diagnosis.

CONCLUSION

In a contemporary, large national cohort of patients with T2DM, progression to DKD was common but likely underrepresented. The low rate of DKD-screening labs, along with sizable delays in diagnosis of DKD and initiation of ACEi/ARB therapy, indicates that many patients who progress to DKD are not being properly treated.

Fibrosis, the Bad Actor in Cardiorenal Syndromes: Mechanisms Involved

Cardiorenal syndrome is a term that defines the complex bidirectional nature of the interaction between cardiac and renal disease. It is well established that patients with kidney disease have higher incidence of cardiovascular comorbidities and that renal dysfunction is a significant threat to the prognosis of patients with cardiac disease. Fibrosis is a common characteristic of organ injury progression that has been proposed not only as a marker but also as an important driver of the pathophysiology of cardiorenal syndromes. Due to the relevance of fibrosis, its study might give insight into the mechanisms and targets that could potentially be modulated to prevent fibrosis development. The aim of this review was to summarize some of the pathophysiological pathways involved in the fibrotic damage seen in cardiorenal syndromes, such as inflammation, oxidative stress and endoplasmic reticulum stress, which are known to be triggers and mediators of fibrosis.

Risk associated with estimated glomerular filtration rate and albuminuria for PAD among patients with type 2 diabetes

Chronic kidney disease (CKD) is significantly associated with peripheral arterial disease (PAD) in some studies, but data on the association of the risk of PAD across a broad range of kidney function in patients with type 2 diabetes are limited. Between October 17, 2013 and February 7, 2015, all consecutive outpatients with type 2 diabetes underwent ankle-brachial index (ABI) examination. We investigated the association of estimated glomerular filtration rate (eGFR) and albumin-to-creatinine ratio (ACR) with the risk of PAD. A total of 1254 patients were cross-classified into 12 groups based on ACR category (normoalbuminuria, microalbuminuria and macroalbuminuria) and eGFR stage (≥90, 60-89, 30-59 and <30 mL/min/1.73 m²). Logistic regression analysis was used to investigate the association of eGFR and ACR with PAD. Within each ACR category, a lower eGFR stage was associated with PAD. Similarly, within each eGFR group, a higher ACR category was also associated with PAD. The OR for PAD was highest in patients with eGFR <30 mL/min/1.73 m² and macroalbuminuria (OR 14.42, 95% CI 4.60 to 45.31) when compared with the reference group of subjects with eGFR ≥90 mL/min/1.73 m² and normoalbuminuria. Our study found that cross-classification of eGFR with ACR revealed a more comprehensive association with risk of PAD than eGFR or ACR alone.

Probiotics ameliorates glycemic control of patients with diabetic nephropathy: A randomized clinical study

OBJECTIVE

This research aimed to explore the effects of probiotic administration on glycemic control and renal function in patients with diabetic nephropathy (DN).

METHODS

The 101 participants were randomly divided into two treatment groups and 76 patients were included in the final analysis. In 76 patients with diabetic nephropathy of type 2 diabetes, a randomized double-blind and placebo-controlled clinical trial was conducted to evaluate the administration of 3.2 × 109  CFU probiotic supplements per day (Bifidobacterium bifidum, 1.2 × 109  CFU, Lactobacillus acidophilus 4.2 × 109  CFU, Streptococcus thermophilus 4.3 × 109  CFU) for 12 weeks on glycemic control of patients, including fasting blood glucose, 2 h postprandial blood glucose, glycosylated hemoglobin (HbA1c), microalbuminuria/creatinine (mAlb/Cr) and estimated glomerular filtration rate (eGFR) levels. The placebo group daily received empty capsules filled with starch.

RESULTS

After 12 weeks, the administration of probiotics demonstrated a significant reduction in fasting blood glucose (10.68 ± 3.24 mmol/L before vs. 7.81 ± 2.77 mmol/L after, p < 0.05), HbA1c (8.19 ± 1.60% before vs. 7.32 ± 1.20% after, p < 0.05) and mAlb/Cr (101.60 ± 22.17 mg/g before vs. 67.53 ± 20.11 mg/g after, p < 0.05), while only mAlb/Cr level was significantly lower in the probiotic group than in the placebo group after intervention (67.53 ± 20.11 mg/g vs. 87.71 ± 23.01, p < 0.05). Meanwhile, there was no significant reduction of 2 h postprandial blood glucose level (18.95 ± 5.23 mmol/L vs. 17.35 ± 6.28 mmol/L, p = 0.24) and eGFR (84.34 ± 6.97 ml/min vs. 82.8 ± 8.72 ml/min, p = 0.45) in patients before and after probiotic intake. In addition, the placebo group failed to show any significant change of these parameters.

CONCLUSION

This clinical study revealed probiotic administration could ameliorate glycemic control of patients with diabetic nephropathy, potentiating its therapeutic potential in clinical application.

Role of Albuminuria in Detecting Cardio-Renal Risk and Outcome in Diabetic Subjects

The clinical significance of albuminuria in diabetic subjects and the impact of its reduction on the main cardiorenal outcomes by different drug classes are among the most interesting research focuses of recent years. Although nephrologists and cardiologists have been paying attention to the study of proteinuria for years, currently among diabetics, increased urine albumin excretion ascertains the highest cardio-renal risk. In fact, diabetes is a condition by itself associated with a high-risk of both micro/macrovascular complications. Moreover, proteinuria reduction in diabetic subjects by several treatments lowers both renal and cardiovascular disease progression. The 2019 joint ESC-EASD guidelines on diabetes, prediabetes and cardiovascular (CV) disease assign to proteinuria a crucial role in defining CV risk level in the diabetic patient. In fact, proteinuria by itself allows the diabetic patient to be staged at very high CV risk, thus affecting the choice of anti-hyperglycemic drug class. The purpose of this review is to present a clear update on the role of albuminuria as a cardio-renal risk marker, starting from pathophysiological mechanisms in support of this role. Besides this, we will show the prognostic value in observational studies, as well as randomized clinical trials (RCTs) demonstrating the potential improvement of cardio-renal outcomes in diabetic patients by reducing proteinuria.

Kidney Diseases: The Age of Molecular Markers

Kidney diseases are conditions that increase the morbidity and mortality of those afflicted. Diagnosis of these conditions is based on parameters such as the glomerular filtration rate (GFR), measurement of serum and urinary creatinine levels and equations derived from these measurements (Wasung, Chawla, Madero. Clin Chim Acta 438:350-357, 2015). However, serum creatinine as a marker for measuring renal dysfunction has its limitations since it is altered in several other physiological situations, such as in patients with muscle loss, after intense physical exercise or in people on a high protein diet (Riley, Powers, Welch. Res Q Exerc Sport 52(3):339-347, 1981; Juraschek, Appel, Anderson, Miller. Am J Kidney Dis 61(4):547-554, 2013). Besides the fact that serum creatinine is a marker that indicates glomerular damage, it is necessary the discovery of new biomarkers that reflect not only glomerular damage but also tubular impairment. Recent advances in Molecular Biology have led to the generation or identification of new biomarkers for kidney diseases such as: Acute Kidney Failure (AKI), chronic kidney disease (CKD), nephritis or nephrotic syndrome. There are recent markers that have been used to aid in diagnosis and have been shown to be more sensitive and specific than classical markers, such as neutrophil gelatinase associated lipocalin (NGAL) or kidney injury molecule-1 (KIM-1) (Wasung, Chawla, Madero. Clin Chim Acta 438:350-357, 2015; George, Gounden. Adv Clin Chem 88:91-119, 2019; Han, Bailly, Abichandani, Thadhani, Bonventre. Kidney Int 62(1):237-244, 2002; Fontanilla, Han. Expert Opin Med Diagn 5(2):161-173, 2011). However, early diagnostic biomarkers are still necessary to assist the intervention and monitor of the progression of these conditions.

Urinary MMP-9/UCr association with albumin concentration and albumin-creatinine-ratio in Mexican patients with type 2 diabetes mellitus

BACKGROUND

Chronic kidney disease is one of the most common complications of type 2 diabetes mellitus (T2DM), causing an increased risk of cardiovascular morbidity and mortality. Matrix metalloproteinase (MMP) activity has been proposed as useful biomarker for diabetic renal and vascular complications.

METHODS

A cross-sectional study was conducted among T2DM patients who attended a public secondary hospital in Mexico. We performed clinical, biochemical, and microbiological assessments, as well chronic kidney disease diagnosis according to the KDIGO guideline. Urinary MMP-9 was quantified by ELISA and adjusted using urinary creatinine (UCr).

RESULTS

A total of 111 patients were included. Most participants were women (66%). Mean age was 61 ± 10 years and median T2DM duration was estimated at 11 years. Through multivariate analysis, MMP-9/UCr was found to be associated with albumin concentration and albumin to creatinine ratio.

DISCUSSION

Validation of non-invasive biomarkers of chronic kidney disease among T2DM patients is necessary. Here, we demonstrate MMP-9/UCr as a potential biomarker of albumin concentration and albumin to creatinine ratio in Mexican patients with T2DM.

Esaxerenone (CS-3150) in Patients with Type 2 Diabetes and Microalbuminuria (ESAX-DN): Phase 3 Randomized Controlled Clinical Trial

BACKGROUND AND OBJECTIVES

Diabetic kidney disease is an important complication of type 2 diabetes. In a phase 2b study, adding esaxerenone to renin-angiotensin system inhibitors dose dependently reduced the urinary albumin-to-creatinine ratio in patients with type 2 diabetes and microalbuminuria. This 52-week phase 3 study further investigated the effects of esaxerenone on the urinary albumin-to-creatinine ratio in this patient group.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this multicenter, randomized, double-blind study, patients with type 2 diabetes and a urinary albumin-to-creatinine ratio of 45 to <300 mg/g creatinine treated with renin-angiotensin system inhibitors were randomized to esaxerenone or placebo for 52 weeks (n=455). Esaxerenone was initiated at 1.25 mg/d and titrated to 2.5 mg/d on the basis of serum potassium monitoring. The primary endpoint was the proportion of patients achieving urinary albumin-to-creatinine ratio remission (<30 mg/g creatinine and ≥30% reduction from baseline on two consecutive occasions).

RESULTS

Overall, 49 (22%) and nine (4%) patients in the esaxerenone and placebo groups, respectively, achieved urinary albumin-to-creatinine ratio remission (absolute difference 18%; 95% confidence interval, 12% to 25%; P<0.001). The percent change in urinary albumin-to-creatinine ratio from baseline to end of treatment was significantly higher with esaxerenone versus placebo (-58% versus 8%; geometric least-squares mean ratio to placebo 0.38, 95% confidence interval, 0.33 to 0.44). There was a significant improvement with esaxerenone versus placebo in time to first remission (hazard ratio, 5.13; 95% confidence interval, 3.27 to 8.04) and time to first transition to urinary albumin-to-creatinine ratio ≥300 mg/g creatinine (hazard ratio, 0.23; 95% confidence interval, 0.11 to 0.48). More patients had a serum potassium level ≥6.0 or ≥5.5 mEq/L on two consecutive measurements in the esaxerenone group (20 [9%]) versus placebo (5 [2%]); these events were asymptomatic and resolved after dosage reduction or treatment discontinuation.

CONCLUSIONS

Adding esaxerenone to existing renin-angiotensin system inhibitor therapy in patients with type 2 diabetes and microalbuminuria increased the likelihood of albuminuria returning to normal levels, and reduced progression of albuminuria to higher levels.

Differential metabolomic signatures of declining renal function in Types 1 and 2 diabetes

BACKGROUND

Chronic kidney disease (CKD) shows different clinical features in Types1 (T1D) and 2 diabetes (T2D). Metabolomics have recently provided useful contribution to the identification of biomarkers of CKD progression in either form of the disease. However, no studies have so far compared plasma metabolomics between T1D and T2D in order to identify differential signatures of progression of estimated glomerular filtration rate (eGFR) decline.

METHODS

We used two large cohorts of T1D (from Finland) and T2D (from Italy) patients followed up to 7 and 3 years, respectively. In both groups, progression was defined as the top quartile of yearly decline in eGFR. Pooled data from the two groups were analysed by univariate and bivariate random forest (RF), and confirmed by bivariate partial least squares (PLS) analysis, the response variables being type of diabetes and eGFR progression.

RESULTS

In progressors, yearly eGFR loss was significantly larger in T2D [-5.3 (3.0), median (interquartile range)mL/min/1.73 m2/year] than T1D [-3.7 (3.1) mL/min/1.73 m2/year ; P = 0.018]. Out of several hundreds, bivariate RF extracted 22 metabolites associated with diabetes type (all higher in T1D than T2D except for 5-methylthioadenosine, pyruvate and β-hydroxypyruvate) and 13 molecules associated with eGFR progression (all higher in progressors than non-progressors except for sphyngomyelin). Three of the selected metabolites (histidylphenylalanine, leucylphenylalanine, tryptophylasparagine) showed a significant interaction between disease type and progression. Only eight metabolites were common to both bivariate RF and PLS.

CONCLUSIONS

Identification of metabolomic signatures of CKD progression is partially dependent on the statistical model. Dual analysis identified molecules specifically associated with progressive renal impairment in both T1D and T2D.

Clinicopathological features of fast eGFR decliners among patients with diabetic nephropathy

INTRODUCTION

The speed of declining kidney function differs among patients with diabetic nephropathy. This study was undertaken to clarify clinical and pathological features that affect the speed of declining kidney function in patients with diabetic nephropathy.

RESEARCH DESIGN AND METHODS

This study was design as multicenter retrospective study. The subjects (377 patients with diabetic nephropathy diagnosed by kidney biopsy at 13 centers in Japan) were classified into three groups based on the estimated glomerular filtration rate (eGFR) declining speed. The eGFR increasing group, the control group, and the eGFR declining group were divided at 0 and 5 mL/min/1.73 m²/year, respectively. Characteristics of clinicopathological findings of declining kidney function were evaluated.

RESULTS

The mean observation period of this study was 6.9 years. The control group, the eGFR increasing group, and the eGFR declining group included 81, 66, and 230 patients, respectively. The incidences of composite kidney events represented by 100 persons/year were 25.8 in the eGFR declining group and 2.0 in the eGFR increasing group. After adjustment for age, sex, systolic blood pressure, hemoglobin, and urinary albumin levels, three clinicopathological findings (urinary albumin levels, presence of nodular lesion, and mesangiolysis) were risk factors for inclusion in the eGFR declining group (the ORs were 1.49, 2.18, and 2.08, respectively). In contrast, the presence of subendothelial space widening and polar vasculosis were characteristic findings for inclusion in the eGFR increasing group (the ORs were 0.53 and 0.41, respectively).

CONCLUSIONS

As well as urinary albumin elevation, nodular lesion and mesangiolysis were characteristic pathological features of patients with fast declining kidney function.

Biomarkers of vascular disease in diabetes: the adipose-immune system cross talk

Experimental and clinical studies aimed at investigating the mechanism(s) underlying vascular complications of diabetes indicate that a great number of molecules are involved in the pathogenesis of these complications. Most of these molecules are inflammatory mediators or markers generated by immune or adipose tissue. Some of them, i.e. resistin and sortilin, have been shown to be involved in the cross talk between adipocytes and inflammatory cells. This interaction is an attractive area of research, particularly in type 2 diabetes and obesity. Other proteins, such as adiponectin and visfatin, appear to be more promising as possible vascular markers. In addition, some molecules involved in calcium/phosphorus metabolism, such as klotho and FGF23, have an involvement in the pathogenesis of diabetic vasculopathy, which appears to be dependent on the degree of vascular impairment. Inflammatory markers are a promising tool for treatment decisions while measuring plasma levels of adipokines, sortilin, Klotho and FGF23 in adequately sized longitudinal studies is expected to allow a more precise characterization of diabetic vascular disease and the optimal use of personalized treatment strategies.

Correlation between kidney and peripheral nerve functions in Type 2 diabetes

BACKGROUND

Although greater impairments in nerve functions parameters are most likely to occur with a lower kidney function, there is a paucity of information on the relationship between the kidney and peripheral nerve functions parameters in Type 2 diabetes.

AIM

To address the impact of peripheral nerve functions in Type 2 diabetes patients in different stages of chronic kidney diseases (CKD).

DESIGN

This prospective study enrolled 238 patients with Type 2 diabetes at a tertiary medical center.

METHOD

We designed composite amplitude scores of nerve conductions (CAS) as a measure of severity of peripheral neuropathy (PN), and used estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR) parameters to stage CKD in Type 2 diabetes patients. The intrapersonal mean, standard deviation and coefficient of variation of eGFR for 238 patients were obtained in the 3 years prior to the study.

RESULTS

The patients who had lower eGFR and higher UACR were older, with longer diabetes duration, a greater percentage of retinopathy and PN and higher CAS. Multiple linear regression analysis revealed that diabetes duration and eGFR were independently associated with CAS, and a cut-off value of eGFR in the presence of PN was 65.3 ml/min/1.73 m2.

CONCLUSION

We observed a close relationship between the severity of kidney and peripheral nerve function in patients with diabetes. If a patient's eGFR value is below 65.3 ml/min/1.73 m2 or the UACR value is above 98.6 mg/dl, caution is needed with the presence of PN even in diabetic patients who are asymptomatic.

Urine Markers of Kidney Tubule Cell Injury and Kidney Function Decline in SPRINT Trial Participants with CKD

BACKGROUND AND OBJECTIVES

eGFR and albuminuria primarily reflect glomerular function and injury, whereas tubule cell atrophy and interstitial fibrosis on kidney biopsy are important risk markers for CKD progression. Kidney tubule injury markers have primarily been studied in hospitalized AKI. Here, we examined the association between urinary kidney tubule injury markers at baseline with subsequent loss of kidney function in persons with nondiabetic CKD who participated in the Systolic Blood Pressure Intervention Trial (SPRINT).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Among 2428 SPRINT participants with CKD (eGFR<60 ml/min per 1.73 m²) at baseline, we measured urine markers of tubule injury (IL-18, kidney injury molecule-1 [KIM-1], neutrophil gelatinase-associated lipocalin [NGAL]), inflammation (monocyte chemoattractant protein-1 [MCP-1]), and repair (human cartilage glycoprotein-40 [YKL-40]). Cox proportional hazards models evaluated associations of these markers with the kidney composite outcome of 50% eGFR decline or ESKD requiring dialysis or kidney transplantation, and linear mixed models evaluated annualized change in eGFR.

RESULTS

Mean participant age was 73±9 (SD) years, 60% were men, 66% were white, and mean baseline eGFR was 46±11 ml/min per 1.73 m². There were 87 kidney composite outcome events during a median follow-up of 3.8 years. Relative to the respective lowest quartiles, the highest quartiles of urinary KIM-1 (hazard ratio, 2.84; 95% confidence interval [95% CI], 1.31 to 6.17), MCP-1 (hazard ratio, 2.43; 95% CI, 1.13 to 5.23), and YKL-40 (hazard ratio, 1.95; 95% CI, 1.08 to 3.51) were associated with higher risk of the kidney composite outcome in fully adjusted models including baseline eGFR and urine albumin. In linear analysis, urinary IL-18 was the only marker associated with eGFR decline (-0.91 ml/min per 1.73 m² per year for highest versus lowest quartile; 95% CI, -1.44 to -0.38), a finding that was stronger in the standard arm of SPRINT.

CONCLUSIONS

Urine markers of tubule cell injury provide information about risk of subsequent loss of kidney function, beyond the eGFR and urine albumin.

Serum uric acid as a risk factor of all-cause mortality and cardiovascular events among type 2 diabetes population: Meta-analysis of correlational evidence

AIMS

To explore the association between serum uric acid (SUA) level and the risk of cardiovascular complications and all-cause mortality rates among individuals with type 2 diabetes.

METHODS

Web of Science and PubMed database were searched for studies reported associations between SUA level and cardiovascular complications and all-cause mortality among individuals with type 2 diabetes. Hazard ratios (HRs) were independently extracted by two investigators and synthesized through meta-analysis across selected studies.

RESULTS

6 (n = 11,750 patients), 4 (n = 3044 patients) and 2 studies (n = 7792 patients) were identified reporting associations between SUA level and all-cause mortality, coronary heart disease (CHD) and stroke respectively. HR for all-cause mortality, CHD, and stroke per 59 μmol/l increase was 1.06 (95% CI: 1.03, 1.09), 1.09 (95% CI: 0.94, 1.26) and 1.19 (95% CI: 1.08, 1.31), respectively.

CONCLUSIONS

Overall, the SUA level was associated with a higher risk of all-cause mortality and stroke. We found no significant association between SUA level and CHD among type 2 diabetes population.

An untargeted metabolomics approach reveals further insights of Lycium barbarum polysaccharides in high fat diet and streptozotocin-induced diabetic rats

Lycium barbarum polysaccharide (LBP), as one bioactive macromolecular abstracted from goji berry, has shown an abundance of potential function. The present study aimed to evaluate the metabolic effects of LBP on the urine and liver metabolomics on a high-fat diet and streptozotocin-induced diabetic rat model. After 8 weeks of high-fat diet and streptozotocin induction of diabetes, 24 diabetic rats were randomly allocated to the diabetic control (DC) group, LBP low, moderate, and high dosage (LBP-L, LBP-M, LBP-H) groups and 6 non-diabetic rats were established as the non-diabetic control (NDC) group for 30 days' intervention. Metabolomics was performed on liver and urine. LBP positively regulated fasting blood glucose, hemoglobin-A1c, homeostasis model assessment for insulin resistance, liver glycogen and SOD levels significantly, as compared to the DC group. Liver metabolomics showed higher levels of myo-inositol and lower levels of L-malic acid, fumaric acid, D-arabitol, L-allothreonine 1, xylitol, O-phosphorylethanolamine, ribitol, 5-methoxytryptamine 2 and digitoxose 2 in the LBP-H group vs. the DC group, which indicates that LBP may regulate the citrate cycle, alanine, aspartate and glutamate metabolism, glyoxylate and dicarboxylate metabolism. Urine metabolomics showed increased levels of creatinine, D-galacturonic acid 2, 2,3-dihydroxybutyric acid and citric acid, and decreased levels of methylmalonic acid, benzoic acid and xylitol between the LBP-H and DC groups. The present study exhibited the effects of LBP on the urine and liver metabolomics in a high-fat diet and streptozotocin-induced rat model, which not only provides a better understanding of the anti-diabetic effects of LBP but also supplies a useful database for further specific mechanism study.