Assessment of glycemia in chronic kidney disease

Predictive ability of visit-to-visit glucose variability on diabetes complications

BACKGROUND

Identification of prognostic factors for diabetes complications are crucial. Glucose variability (GV) and its association with diabetes have been studied extensively but the inclusion of measures of glucose variability (GVs) in prognostic models is largely lacking. This study aims to assess which GVs (i.e., coefficient of variation (CV), standard deviation (SD), and time-varying) are better in predicting diabetic complications, including cardiovascular disease (CVD), diabetic retinopathy (DR), and chronic kidney disease (CKD). The model performance between traditional statistical models (adjusting for covariates) and machine learning (ML) models were compared.

METHODS

A retrospective cohort of type 2 diabetes (T2D) patients between 2010 and 2019 in Ramathibodi Hospital was created. Complete case analyses were used. Three GVs using HbA1c and fasting plasma glucose (FPG) were considered including CV, SD, and time-varying. Cox proportional hazard regression, ML random survival forest (RSF) and left-truncated, right-censored (LTRC) survival forest were compared in two different data formats (baseline and longitudinal datasets). Adjusted hazard ratios with 95% confidence intervals were used to report the association between three GVs and diabetes complications. Model performance was evaluated using C-statistics along with feature importance in ML models.

RESULTS

A total of 40,662 T2D patients, mostly female (61.7%), with mean age of 57.2 years were included. After adjusting for covariates, HbA1c-CV, HbA1c-SD, FPG-CV and FPG-SD were all associated with CVD, DR and CKD, whereas time-varying HbA1c and FPG were associated with DR and CKD only. The CPH and RSF for DR (C-indices: 0.748-0.758 and 0.774-0.787) and CKD models (C-indices: 0.734-0.750 and 0.724-0.740) had modestly better performance than CVD models (C-indices: 0.703-0.730 and 0.698-0.727). Based on RSF feature importance, FPG GV measures ranked higher than HbA1c GV, and both GVs were the most important for DR prediction. Both traditional and ML models had similar performance.

CONCLUSIONS

We found that GVs based on HbA1c and FPG had comparable performance. Thus, FPG GV may be used as a potential monitoring parameter when HbA1c is unavailable or less accessible.

Cross-Sectional Associations between Clinical Biochemistry and Nutritional Biomarkers and Sarcopenic Indices of Skeletal Muscle in the Baltimore Longitudinal Study of Aging

BACKGROUND

Investigating relationships between nutritional and clinical biochemistry biomarkers and skeletal muscle mass, strength and function (sarcopenic indices) may 1) highlight micronutrients of interest for potential preventive or treatment strategies for sarcopenia, or 2) highlight biomarkers that may be useful for identifying individuals at risk of sarcopenia.

OBJECTIVES

Investigate associations between nutritional biomarkers (vitamin D, vitamin B12, folate, magnesium, potassium, calcium, and iron), clinical biomarkers (hemoglobin, ferritin, albumin, creatinine, and hemoglobin A1c: HbA1c), and sarcopenic indices (appendicular lean mass: ALM); height-adjusted ALM: ALMht; fat-free mass as a percentage of total body weight; extended short physical performance battery score: extSPPB; height-adjusted hand grip strength: HGSht; height-adjusted knee extension concentric strength, and; height-adjusted knee extension isometric strength) in males and females.

METHODS

Using multivariable linear regression analysis, we investigated cross-sectional associations between biomarkers and sarcopenic indices in data collected from 1761 participants (age 22-103 y) from the Baltimore Longitudinal Study of Aging.

RESULTS

Hemoglobin was positively associated with ALM (β = 0.20, P = 0.021), HGSht (β = 0.25, P = 0.001), and extSPPB (β = 0.13, P = 0.024) in males, and with extSPPB in females (β = 0.15, P = 0.019). In males, serum iron was positively associated with ALMht (β = 0.0021, P = 0.038) and extSPPB (β = 0.0043, P = 0.045). In females, ferritin was positively associated with knee-extension strength measurements. Serum creatinine was positively associated with lean mass measures in males and females and with muscle strength and function measures in males with normal renal function (estimated glomerular filtration rate ≥60 mL/min/1.73 m2). In males, high HbA1c was associated with lower ALMht (β = -0.21, P = 0.023), extSPPB (β = -0.40, P = 0.027), and HGSht (β = -0.56, P = 0.031). In males and females, magnesium was positively associated with extSPPB, and potassium was positively associated with measures of knee-extension strength.

CONCLUSIONS

The associations found between measures of iron status and creatinine and sarcopenic indices, in males in particular, indicate potential importance for muscle health. Future longitudinal and intervention studies are warranted to confirm these findings.

Prevalence and determinants of poor glycemic control among diabetic chronic kidney disease patients on maintenance hemodialysis in Tanzania

BACKGROUND

Poor glycemic control in diabetic chronic kidney disease (CKD) patients on maintenance hemodialysis is of great challenge, resulting in increased risk of morbidity and mortality. This study aimed to determine the prevalence and determinants of poor glycemic control among diabetic CKD patients on maintenance hemodialysis.

METHODOLOGY

A cross-sectional study was conducted in 12 dialysis centers located in four regions of Tanzania from March to June 2023. The study population was diabetic CKD patients above 18 years on maintenance hemodialysis for three months or more. A consecutive sampling technique was used for patient recruitment, and a semi-structured questionnaire was used to collect data. The primary outcome was poor glycemic control were considered when glycated hemoglobin (HbA1c) levels were <  6% or > 8%. Statistical Package for Social Sciences (SPSS) version 23 was used for data analysis. Univariate and multivariable regression models were used to evaluate the determinants of poor glycemic control. A p-value < 0.05 was considered statistically significant.

RESULTS

Out of 233 enrolled patients, the overall prevalence of poor glycemic control was 55.4%, whereby 27.0% had HbA1c < 6% and 28.33% had HbA1c > 8%. A high risk of HbA1c > 8% was observed among patients who were on antidiabetic medication (2.16 (95% CI: 1.06-4.41) p =  0.035) and those attending dialysis sessions less than 3 times a week (1.59 (95% CI: 1.02-2.48) p =  0.040). The lower risk of HbA1c < 6% was observed in patients dialyzed using glucose-containing dialysates than those dialyzed with glucose-free dialysate (0.57 (95% CI 0.36-0.87) p =  0.020).

CONCLUSION

The high prevalence of poor glycemic control among diabetic CKD patients, as revealed by this study, has significant implications. Patients on antidiabetic medication and those with less than three dialysis sessions per week are at a high risk of HbA1c > 8%. Conversely, patients dialyzed using glucose-free dialysates are at a high risk of HbA1c < 6%. Glycemic control in diabetic chronic kidney disease (CKD) patients is a great challenge due to altered glucose homeostasis, gluconeogenesis, tubular glucose reabsorption and inaccuracy of glycemic regulation metrics [1]. Furthermore, changed renal pharmacokinetics of antihyperglycemic agents (AHA), uremic milieu, and dialysis therapy also contribute to this challenge [2]. Based on the severe risk of hyperglycemia and hypoglycemia in patients with diabetic end-stage renal disease (ESRD), glycemic control is of paramount importance.

Investigating the cause of cardiovascular dysfunction in chronic kidney disease: capillary rarefaction and inflammation may contribute to detrimental cardiovascular outcomes

Myocardial ischemia-reperfusion (IR) injury is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD). The most frequently used and representative experimental model is the rat dietary adenine-induced CKD, which leads to CKD-associated CVD. However, the continued intake of adenine is a potential confounding factor. This study investigated cardiovascular dysfunction following brief adenine exposure, CKD development and return to a normal diet. Male Wistar rats received a 0.3% adenine diet for 10 weeks and normal chow for an additional 8 weeks. Kidney function was assessed by urinalysis and histology. Heart function was assessed by echocardiography. Sensitivity to myocardial IR injury was assessed using the isolated perfused rat heart (Langendorff) model. The inflammation profile of rats with CKD was assessed via cytokine ELISA, tissue histology and RNA sequencing. Induction of CKD was confirmed by a significant increase in plasma creatinine and albuminuria. Histology revealed extensive glomerular and tubular damage. Diastolic dysfunction, measured by the reduction of the E/A ratio, was apparent in rats with CKD even following a normal diet. Hearts from rats with CKD had significantly larger infarcts after IR injury. The CKD rats also had statistically higher levels of markers of inflammation including myeloperoxidase, KIM-1 and interleukin-33. RNA sequencing revealed several changes including an increase in inflammatory signaling pathways. In addition, we noted that CKD induced significant cardiac capillary rarefaction. We have established a modified model of adenine-induced CKD, which leads to cardiovascular dysfunction in the absence of adenine. Our observations of capillary rarefaction and inflammation suggest that these may contribute to detrimental cardiovascular outcomes.

Tanshinone I improves renal fibrosis by promoting gluconeogenesis through upregulation of peroxisome proliferator-activated receptor-γ coactivator 1α

BACKGROUND

Renal fibrosis, a hallmark of chronic kidney disease, is closely associated with dysregulated gluconeogenesis. Tanshinone I (Tan I), a bioactive compound derived from the traditional Chinese medicine Danshen, exhibits antifibrotic and anti-inflammatory properties. However, its effects on gluconeogenesis and the mechanisms through which it alleviates renal fibrosis remain unclear. This study aimed to investigate whether Tan I promotes gluconeogenesis and mitigates renal fibrosis.

METHODS

Both in vivo and in vitro experiments were conducted. A unilateral ureteral obstruction (UUO) mouse model was used. Masson's trichrome, HE, and immunofluorescence staining, along with Western blotting, were employed. Lactate concentrations and a pyruvate tolerance test were conducted to assess glucose metabolism. In vitro, HK2 cells and primary renal tubular cells were treated with transforming growth factor-β (TGFβ) to induce fibrosis, and the effects of Tan I on glucose and lactate levels were examined.

RESULTS

In the UUO model, Tan I reduced fibrosis, decreased lactate accumulation, and modulated fibrosis markers while upregulating gluconeogenesis markers. Tanshinone I restored impaired renal gluconeogenesis, as evidenced by increased pyruvate levels. In vitro, Tan I inhibited fibrosis, reduced lactate levels, and increased glucose levels in cell supernatants. It also restored gluconeogenesis protein expression and decreased fibrotic protein levels. Peroxisome proliferator-activated receptor-γ coactivator (PGC1α) expression was downregulated in UUO and TGFβ-stimulated models, and Tan I reversed this downregulation. Inhibition of PGC1α in TGFβ-stimulated cells counteracted the antifibrotic and gluconeogenesis-promoting effects of Tan I.

CONCLUSIONS

Tanshinone I ameliorated renal fibrosis by enhancing gluconeogenesis through upregulation of PGC1α.

Metabolomic Fingerprints of Medical Therapy Versus Bariatric Surgery in Patients With Obesity and Type 2 Diabetes: The STAMPEDE Trial

OBJECTIVE

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are effective procedures to treat and manage type 2 diabetes (T2D). However, the underlying metabolic adaptations that mediate improvements in glucose homeostasis remain largely elusive. The purpose of this study was to identify metabolic signatures associated with biochemical resolution of T2D after medical therapy (MT) or bariatric surgery.

RESEARCH DESIGN AND METHODS

Plasma samples from 90 patients (age 49.9 ± 7.6 years; 57.7% female) randomly assigned to MT (n = 30), RYGB (n = 30), or SG (n = 30) were retrospectively subjected to untargeted metabolomic analysis using ultra performance liquid chromatography with tandem mass spectrometry at baseline and 24 months of treatment. Phenotypic importance was determined by supervised machine learning. Associations between change in glucose homeostasis and circulating metabolites were assessed using a linear mixed effects model.

RESULTS

The circulating metabolome was dramatically remodeled after SG and RYGB, with largely overlapping signatures after MT. Compared with MT, SG and RYGB profoundly enhanced the concentration of metabolites associated with lipid and amino acid signaling, while limiting xenobiotic metabolites, a function of decreased medication use. Random forest analysis revealed 2-hydroxydecanoate as having selective importance to RYGB and as the most distinguishing feature between MT, SG, and RYGB. To this end, change in 2-hydroxydecanoate correlated with reductions in fasting glucose after RYGB but not SG or MT.

CONCLUSIONS

We identified a novel metabolomic fingerprint characterizing the longer-term adaptations to MT, RYGB, and SG. Notably, the metabolomic profiles of RYGB and SG procedures were distinct, indicating equivalent weight loss may be achieved by divergent effects on metabolism.

Asia-Pacific Perspectives on the Role of Continuous Glucose Monitoring in Optimizing Diabetes Management

Diabetes is prevalent, and it imposes a substantial public health burden globally and in the Asia-Pacific (APAC) region. The cornerstone for optimizing diabetes management and treatment outcomes is glucose monitoring, the techniques of which have evolved from self-monitoring of blood glucose (SMBG) to glycated hemoglobin (HbA1c), and to continuous glucose monitoring (CGM). Contextual differences with Western populations and limited regionally generated clinical evidence warrant regional standards of diabetes care, including glucose monitoring in APAC. Hence, the APAC Diabetes Care Advisory Board convened to gather insights into clinician-reported CGM utilization for optimized glucose monitoring and diabetes management in the region. We discuss the findings from a pre-meeting survey and an expert panel meeting regarding glucose monitoring patterns and influencing factors, patient profiles for CGM initiation and continuation, CGM benefits, and CGM optimization challenges and potential solutions in APAC. While CGM is becoming the new standard of care and a useful adjunct to HbA1c and SMBG globally, glucose monitoring type, timing, and frequency should be individualized according to local and patient-specific contexts. The results of this APAC survey guide methods for the formulation of future APAC-specific consensus guidelines for the application of CGM in people living with diabetes.

Megestrol acetate as an overlooked cause of hyperglycemia in end-stage renal disease: A case of polypharmacy

BACKGROUND

This case report highlights an overlooked cause of hyperglycemia and risk of polypharmacy in a patient with end-stage renal disease (ESRD).

CASE SUMMARY

A 75-year-old non-English speaking male with type 2 diabetes mellitus, hypertension, coronary artery disease status post percutaneous coronary intervention, and ESRD secondary to immunoglobulin G kappa nephropathy on nightly peritoneal dialysis reported a loss of appetite, decrease in weight, and an increase in symptoms of depression. As a result of these symptoms, his nephrologist initiated megestrol acetate (MA), an agent commonly used in ESRD to help stimulate appetite and improve weight. After starting MA, his blood glucose (BG) significantly worsened, due to its glucocorticoid properties. Basal insulin was started to manage his hyperglycemia, but there was minimal improvement in BG. As the patient was referred to the endocrinology clinical pharmacist for diabetes management, it was identified that his weight loss began after starting dulaglutide, which led to a weight loss of 11 kg (12.9%). The Naranjo algorithm was used, and he had a score of 6, which is a probable reaction. The patient's endocrinology and nephrology teams agreed to discontinue MA and dulaglutide as they resulted in opposing effects on appetite and BG, as well as insulin glargine. The patient's BG was tightly controlled off MA and his appetite, weight, and mood improved off dulaglutide.

PRACTICE IMPLICATIONS

This case report reflects the potential effects of polypharmacy in ESRD, resulting in poor patient outcomes and drug interactions. It is imperative that a comprehensive medication reconciliation is completed on all patients, especially for patients on dialysis. It is also important for healthcare professionals to be cognizant of medications that may exhibit glucocorticoid properties, which can cause hyperglycemia. Including a clinical pharmacist in the care team can assist with medication reconciliation, screening for drug interactions and polypharmacy, and optimizing chronic disease management.

Predictive value of stress hyperglycemia ratio on one-year mortality in chronic kidney disease patients admitted to intensive care unit

BACKGROUND

Stress Hyperglycemia Ratio (SHR) reflects the acute blood glucose variation in critically ill conditions. However, its prognostic value in chronic kidney disease (CKD) remains understudied. This study aimed to investigate the association between SHR and one-year mortality in CKD patients hospitalized in the Intensive Care Unit (ICU).

METHODS

Patients with diagnosis of CKD in the Medical Information Mart for Intensive Care IV (MIMIC-IV) database were enrolled. Incidence of all-cause mortality within one-year follow-up was used as the primary endpoint.

RESULTS

1825 CKD patients were included in the study. A "U-shaped" relationship between SHR and one-year mortality as identified using multivariate restricted cubic spline (RCS) analysis. Then study population were categorized into three groups: Group 1 (SHR < 0.70), Group 2 (0.70 ≤ SHR ≤ 0.95) and Group 3 (SHR > 0.95). Group 2 showed significantly better one-year outcomes compared to the other two groups (p = 0.0031). This survival benefit persisted across subgroup analyses stratified by age, sex, CKD stage, anemia and various clinical conditions.

CONCLUSION

SHR proved to be a meaningful biomarker for predicting one-year mortality in ICU-admitted CKD patients, with a "U-shaped" correlation. The identification of the optimal SHR range (0.70-0.95) provided clinicians with a valuable tool for detecting high-risk populations.

Suppression of the postprandial hyperglycemia in patients with type 2 diabetes by a raw medicinal herb powder is weakened when consumed in ordinary hard gelatin capsules: A randomized crossover clinical trial

INTRODUCTION

Contradictory claims about the efficacy of several medicinal plants to promote glycemic control in patients with type 2 diabetes mellitus (T2DM) have been explained by divergences in the administration form and by extrapolation of data obtained from healthy individuals. It is not known whether the antidiabetic effects of traditional herbal medicines are influenced by gelatin capsules. This randomized crossover trial aimed to evaluate the acute effect of a single dose of raw cinnamon consumed orally either dissolved in water as a beverage or as ordinary hard gelatin capsules on postprandial hyperglycemia (>140 mg/dL; >7.8 mmol/L) in T2DM patients elicited by a nutritionally-balanced meal providing 50 g of complex carbohydrates.

METHODS

Fasting T2DM patients (n = 19) randomly ingested a standardized meal in five experimental sessions, one alone (Control) and the other after prior intake of 3 or 6 g of crude cinnamon in the form of hard gelatin capsules or powder dissolved in water. Blood glucose was measured at fasting and at 0.25, 0.5, 0.75, 1, 1.5 and 2 hours postprandially. After each breakfast, its palatability scores for visual appeal, smell and pleasantness of taste were assessed, as well as the taste intensity sweetness, saltiness, bitterness, sourness and creaminess.

RESULTS

The intake of raw cinnamon dissolved in water, independently of the dose, decreased the meal-induced large glucose spike (peak-rise of +87 mg/dL and Δ1-hour glycemia of +79 mg/dL) and the hyperglycemic blood glucose peak. When cinnamon was taken as capsules, these anti-hyperglycemic effects were lost or significantly diminished. Raw cinnamon intake did not change time-to-peak or the 2-h post-meal glycaemia, but flattened the glycemic curve (lower iAUC) without changing the shape that is typical of T2DM patients.

CONCLUSIONS

This cinnamon's antihyperglycemic action confirms its acarbose-like property to inhibit the activities of the carbohydrate-digesting enzymes α-amylases/α-glucosidases, which is in accordance with its exceptionally high content of raw insoluble fiber. The efficacy of using raw cinnamon as a diabetes treatment strategy seems to require its intake at a specific time before/concomitantly the main hyperglycemic daily meals. Trial registration: Registro Brasileiro de Ensaios Clínicos (ReBEC), number RBR-98tx28b.

Glycated Albumin and Adverse Clinical Outcomes in Patients With CKD: A Prospective Cohort Study

RATIONALE & OBJECTIVE

Hemoglobin A1c (HbA1c) is widely used to estimate glycemia, yet it is less reliable in patients with chronic kidney disease (CKD). There is growing interest in the complementary use of glycated albumin (GA) to improve glycemic monitoring and risk stratification. However, whether GA associates with clinical outcomes in a non-dialysis-dependent CKD population remains unknown.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

3,110 participants with CKD from the Chronic Renal Insufficiency Cohort study.

EXPOSURE

Baseline GA levels.

OUTCOME

Incident end-stage kidney disease (ESKD), cardiovascular disease (CVD) events, and all-cause mortality.

ANALYTICAL APPROACH

Cox proportional hazards regression.

RESULTS

Participant characteristics included mean age 59.0±10.8 SD years; 1,357 (43.6%) female; and 1,550 (49.8%) with diabetes. The median GA was 18.7% (IQR, 15.8%-23.3%). During an average 7.9-year follow-up, there were 980 ESKD events, 968 CVD events, and 1,084 deaths. Higher GA levels were associated with greater risks of all outcomes, regardless of diabetes status: hazard ratios for ESKD, CVD, and death among participants with the highest quartile compared with quartile 2 (reference) were 1.42 (95% CI, 1.19-1.69), 1.67 (95% CI, 1.39-2.01), and 1.63 (95% CI, 1.37-1.94), respectively. The associations with CVD and death appeared J-shaped, with increased risk also seen at the lowest GA levels. Among patients with coexisting CKD and diabetes, the associations of GA with outcomes remained significant even after adjusting for HbA1c. For each outcome, we observed a significant increase in the fraction of new prognostic information when both GA and HbA1c were added to models.

LIMITATIONS

Lack of longitudinal GA measurements; and HbA1c measurements were largely unavailable in participants without diabetes.

CONCLUSIONS

Among patients with CKD, GA levels were independently associated with risks of ESKD, CVD, and mortality, regardless of diabetes status. GA added prognostic value to HbA1c among patients with coexisting CKD and diabetes.

PLAIN-LANGUAGE SUMMARY

Hemoglobin A1c (HbA1c) is widely used to estimate glycemia, yet it is less reliable in patients with chronic kidney disease (CKD). There is growing interest in the complementary use of glycated albumin (GA) to improve glycemic monitoring and risk stratification. However, whether GA associates with clinical outcomes in a non-dialysis-dependent CKD population remains unknown. In this cohort study of 3,110 individuals with non-dialysis-dependent CKD, GA levels were independently associated with risks of end-stage kidney disease, cardiovascular disease (CVD), and mortality. The associations with CVD and mortality appeared to be J-shaped. Among patients with coexisting CKD and diabetes, GA added prognostic value to HbA1c. Thus, GA may be a valuable complementary test to HbA1c in patients with CKD.

Is the enteric nervous system a lost piece of the gut-kidney axis puzzle linked to chronic kidney disease?

The enteric nervous system (ENS) regulates numerous functional and immunological attributes of the gastrointestinal tract. Alterations in ENS cell function have been linked to intestinal outcomes in various metabolic, intestinal, and neurological disorders. Chronic kidney disease (CKD) is associated with a challenging intestinal environment due to gut dysbiosis, which further affects patient quality of life. Although the gut-related repercussions of CKD have been thoroughly investigated, the involvement of the ENS in this puzzle remains unclear. ENS cell dysfunction, such as glial reactivity and alterations in cholinergic signaling in the small intestine and colon, in CKD are associated with a wide range of intestinal pathways and responses in affected patients. This review discusses how the ENS is affected in CKD and how it is involved in gut-related outcomes, including intestinal permeability, inflammation, oxidative stress, and dysmotility.

Lifestyle Modifications and Nutritional and Therapeutic Interventions in Delaying the Progression of Chronic Kidney Disease: A Review

Chronic kidney disease (CKD) is a debilitating progressive illness that affects more than 10% of the world's population. In this literature review, we discussed the roles of nutritional interventions, lifestyle modifications, hypertension (HTN) and diabetes mellitus (DM) control, and medications in delaying the progression of CKD. Walking, weight loss, low-protein diet (LPD), adherence to the alternate Mediterranean (aMed) diet, and Alternative Healthy Eating Index (AHEI)-2010 slow the progression of CKD. However, smoking and binge alcohol drinking increase the risk of CKD progression. In addition, hyperglycemia, altered lipid metabolism, low-grade inflammation, over-activation of the renin-angiotensin-aldosterone system (RAAS), and overhydration (OH) increase diabetic CKD progression. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend blood pressure (BP) control of <140/90 mmHg in patients without albuminuria and <130/80 mmHg in patients with albuminuria to prevent CKD progression. Medical therapies aim to target epigenetic alterations, fibrosis, and inflammation. Currently, RAAS blockade, sodium-glucose cotransporter-2 (SGLT2) inhibitors, pentoxifylline, and finerenone are approved for managing CKD. In addition, according to the completed Study of Diabetic Nephropathy with Atrasentan (SONAR), atrasentan, an endothelin receptor antagonist (ERA), decreased the risk of renal events in diabetic CKD patients. However, ongoing trials are studying the role of other agents in slowing the progression of CKD.

Diabetic kidney disease in type 2 diabetes: a consensus statement from the Swiss Societies of Diabetes and Nephrology

Diabetic kidney disease is highly prevalent in patients with type 2 diabetes and is a major cause of end-stage renal disease in Switzerland. Patients with diabetic kidney disease are among the most complex patients in diabetes care. They require a multifactorial and multidisciplinary approach with the goal to slow the decline in glomerular filtration rate (GFR) and cardiovascular morbidity. With this consensus we propose an evidence-based guidance to health care providers involved in the care of type 2 diabetic patients with diabetic kidney disease.First, there is a need to increase physician awareness and improve screening for diabetic kidney disease as early intervention may improve clinical outcomes and the financial burden. Evaluation of estimated GFR (eGFR) and spot urine albumin/creatinine ratio is recommended at least annually. Once it is diagnosed, glucose control and optimisation of blood pressure control with renin-angiotensin system blockers have been recommended as mainstay management of diabetic kidney disease for more than 20 years. Recent, high quality randomised controlled trials have shown that sodium-glucose cotransporter-2 (SGLT2) inhibition slows eGFR decline and cardiovascular events beyond glucose control. Likewise, mineralocorticoid receptor antagonism with finerenone has cardiorenal protective effects in diabetic kidney disease. Glucagon-like peptide-1 (GLP1) receptor agonists improve weight loss if needed, and decrease albuminuria and cardiovascular morbidity. Lipid control is also important to decrease cardiovascular events. All these therapies are included in the treatment algorithms proposed in this consensus. With advancing kidney failure, other challenges may rise, such as hyperkalaemia, anaemia and metabolic acidosis, as well as chronic kidney disease-mineral and bone disorder. These different topics and treatment strategies are discussed in this consensus. Finally, an update on diabetes management in renal replacement therapy such as haemodialysis, peritoneal dialysis and renal transplantation is provided. With the recent developments of efficient therapies for diabetic kidney disease, it has become evident that a consensus document is necessary. We are optimistic that it will significantly contribute to a high-quality care for patients with diabetic kidney disease in Switzerland in the future.

Development and validation of a cardiovascular diseases risk prediction model for Chinese males (CVDMCM)

Background

Death due to cardiovascular diseases (CVD) increased significantly in China. One possible way to reduce CVD is to identify people at risk and provide targeted intervention. We aim to develop and validate a CVD risk prediction model for Chinese males (CVDMCM) to help clinicians identify those males at risk of CVD and provide targeted intervention.

Methods

We conducted a retrospective cohort study of 2,331 Chinese males without CVD at baseline to develop and internally validate the CVDMCM. These participants had a baseline physical examination record (2008–2016) and at least one revisit record by September 2019. With the full cohort, we conducted three models: A model with Framingham CVD risk model predictors; a model with predictors selected by univariate cox proportional hazard model adjusted for age; and a model with predictors selected by LASSO algorithm. Among them, the optimal model, CVDMCM, was obtained based on the Akaike information criterion, the Brier's score, and Harrell's C statistic. Then, CVDMCM, the Framingham CVD risk model, and the Wu's simplified model were all validated and compared. All the validation was carried out by bootstrap resampling strategy (TRIPOD statement type 1b) with the full cohort with 1,000 repetitions.

Results

CVDMCM's Harrell's C statistic was 0.769 (95% CI: 0.738–0.799), and D statistic was 4.738 (95% CI: 3.270–6.864). The results of Harrell's C statistic, D statistic and calibration plot demonstrated that CVDMCM outperformed the Framingham CVD model and Wu's simplified model for 4-year CVD risk prediction.

Conclusions

We developed and internally validated CVDMCM, which predicted 4-year CVD risk for Chinese males with a better performance than Framingham CVD model and Wu's simplified model. In addition, we developed a web calculator–calCVDrisk for physicians to conveniently generate CVD risk scores and identify those males with a higher risk of CVD.

From screening to treatment: the new landscape of diabetic kidney disease

Globally, diabetes mellitus is the leading cause of chronic kidney disease (CKD), and it is predicted to increase in the following years. Despite its high prevalence, CKD remains under diagnosed. In this BMC Medicine collection of articles on diabetic kidney disease (DKD), we place in context the importance of screening and early detection of DKD and the most accurate tools to monitor for optimal glycemic control in this his risk population. Further, we address this population's risk for severe complications such as stroke and all-cause mortality. We close this editorial by summarizing recent advances in management of this vulnerable population of patients with DKD, including guideline-directed medical therapy, novel treatments, and predictors of treatment failure.