Systolic inter-arm blood pressure difference and estimated glomerular filtration rate in type 2 diabetic patients in Palestine: a cross-sectional study

OBJECTIVES

This study aimed to investigate the association between systolic inter-arm blood pressure difference (IABPD) and the estimated glomerular filtration rate (eGFR), as well as chronic kidney disease (CKD), in patients with type 2 diabetes mellitus (T2DM).

PATIENTS AND METHODS

This cross-sectional study included 189 Palestinians diagnosed with T2DM. Data were collected through personal interviews, medical records and three separate blood pressure measurements from both arms. Patients were stratified in two ways: based on systolic IABPD ≥15 mmHg and the presence of CKD, indicated by an eGFR of <60 mL/min/1.73 m2 over a three months period. We used simple and multiple linear regression analyses to clarify the association between systolic IABPD (mmHg) and eGFR and to identify independent predictors for eGFR.

RESULTS

The mean age was 61.3 years, with a female percentage of 57.7%. The prevalence of systolic IABPD ≥15 mmHg and CKD was 27.5% and 30.2%, respectively. Among patients with eGFR <60 mL/min/1.73 m2, the median systolic IABPD was 12.5 mmHg (interquartile range (IQR), 13.5 mmHg), whereas in patients with eGFR ≥60 mL/min/1.73 m2, it was 7.5 mmHg (IQR, 9.8 mmHg) with a significant difference (p = .021). The results of the multiple linear regression model did not reveal an independent association between systolic IABPD and eGFR, with an unstandardized coefficient (B) of -0.257 (95% confidence interval (CI), -0.623 to 0.109; p = .167). However, older age (B, -0.886; 95% CI, -1.281 to -0.49; p < .001), hypertension (B, -12.715; 95% CI, -22.553 to -2.878; p = .012) and a longer duration of DM (B, -0.642; 95% CI, -1.10 to -0.174; p = .007) were significantly and negatively associated with eGFR.

CONCLUSIONS

Systolic IABPD did not exhibit an independent association with eGFR in T2DM patients. However, older age, a previous history of hypertension, and a longer duration of DM were all significantly associated with lower eGFR.

Risk factors associated with the development of diabetic kidney disease in Sudanese patients with type 2 diabetes mellitus: A case-control study

BACKGROUND AND AIMS

Limited data are available regarding the risk factors associated with the development of diabetic kidney disease (DKD) among Sudanese adults with type 2 diabetes mellitus (T2DM).

METHODS

A case-control study was conducted at Dr. Salma Center for Kidney Diseases between April and September 2019. Patients with T2DM and DKD were compared to age and sex-matched T2DM patients with no kidney disease (NKD). Socio-demographic features, clinical findings, and laboratory investigations of the study subjects and controls were analyzed using SPSS.

RESULTS

A total of 372 patients with DKD were compared to 364 T2DM patients with NKD. The mean age of the DKD patients was 58 ± 13.4 years, their median eGFR was 37.3 ± 4.9 ml/min/1.73 m²; they had their T2DM at a significantly younger age compared to controls (P = 0.014). Logistic regression analysis revealed that a family history of diabetes mellitus, a family history of chronic kidney disease, the presence of hypertension, obesity, hypercholesterolemia, hyperuricemia, smoking, recurrent urinary tract infection, and the regular use of non-steroidal anti-inflammatory drugs were significantly associated with the development of DKD (P values < 0.05).

CONCLUSION

A series of modifiable risk factors were found to be significant determinants for developing DKD. Primary care physicians are expected to pay considerable attention to their control.

Lipid Profile Modulates Cardiometabolic Risk Biomarkers Including Hypertension in People with Type-2 Diabetes: A Focus on Unbalanced Ratio of Plasma Polyunsaturated/Saturated Fatty Acids

Type 2 diabetes mellitus (T2DM) is associated with lipid metabolism disorder, particularly elevated plasma levels of non-esterified free fatty acids (NEFFA) and an increased cardiovascular disease risk, such as essential hypertension (H). The plasma unbalance of saturated fatty acid (SFA)/polyunsaturated fatty acid (PUFA) ratio is a likely contributor, but the mechanisms involved are not clearly elucidated. The aim of this study is to explore the association between plasma SFA/PUFA ratio and the clusters of cardiometabolic syndrome (CMS), including the atherogenic biomarkers, inflammatory status, feeding patterns, and physical activity in people with T2DM with or without essential hypertension. The study was conducted on 784 adult male and female participants, aged between 30 and 50 years, and divided into 3 groups: 100 T2DM without hypertension (D); 368 T2DM with hypertension (DM); and 316 hypertensive participants without T2DM (H). All Participants were phenotyped regarding CMS clusters according to the NCEP/ATPIII criteria. Insulin resistance was assessed by Homeostasis model assessment (HOMA model). Metabolic, atherogenic, and inflammatory parameters were analyzed by biochemical methods; NEFFA by microfluorimetry; SFA, PUFA-n6 and PUFA-n3 by gas phase chromatography. Dietary lipids and physical activity were analyzed through the use of validated questionnaires. The clusters of CMS were found in all groups. Dyslipidemia was correlated with accretion NEFFA levels in all groups, but more accentuated in the DH group (r = +0.77; p < 0.001). Similarly, plasma PUFA/SFA ratio and PUFA-3 level was lower, concomitantly with a higher plasma ApoB100/ApoA1 (p < 0.001), lipoprotein (a), homocysteine (p < 0.001), and pro-inflammatory cytokines (TNFα, IL-6, IL1-β) in the DH group. Likewise, the depletion of PUFA-n3/PUFA-n6 ratio is associated with the decrease of omega 3-DHA (docosahexaenoic acid) and omega 3-EPA (eicosapentaenoic acid) (p < 0.001). It appears that the PUFAs-n3 ratio modulates cardiometabolic risk, inflammatory state and atherogenic biomarkers. The plasma unbalanced ratio of SFA/PUFA reflects dietary fatty acids intake. The contribution of dietary lipids is undisputed. Nutritional recommendations are required to determine the fatty acids ratio (saturated and unsaturated) provided in the diet.

Incidence of diabetic nephropathy in patients with type 2 diabetes mellitus at a tertiary healthcare setting in Ethiopia

BACKGROUND AND AIMS

Diabetic nephropathy (DN) is a leading cause of morbidity and mortality in diabetic patients representing a huge health and economic burden. Despite the increasing number of patients with Diabetes Mellitus in Ethiopia, the incidence of diabetic nephropathy in patients with DM has not been well established. Therefore, this study aimed to estimate the incidence and predictors of DN in patients with T2DM at tertiary healthcare setting, Ethiopia.

METHODS

An institution based retrospective follow study was conducted from March 1 to April 28, 2019. Kaplan-meier survival curve together with log rank test were used. Cox proportional hazard model was used at 5% level of significance to determine the net effect of each explanatory variable on diabetic nephropathy. An assumption was check by schoenfeld residual test.

RESULTS

The incidence rate of diabetic nephropathy was 3.6% per 100 person-years (95% CI = 2.49-11.47). The median time to develop nephropathy was 100(95% CI, 96.7-107) months. Predictors of diabetic nephropathy were males (AHR: 2.7, 95%CI: 1.39, 5.23), long duration of diabetes (AHR: 1.03, 95%CI: 1.01, 1.06), HbA1c> 7% (AHR: 1.74, 95% CI: 1.67, 3.12), high density lipoprotein (AHR: 0.37, 95% CI: 0.16, 0.83), and mixed anti-diabetic therapy (AHR: 0.07, 95% CI: 0.01, 0.59).

CONCLUSION

The incidence of diabetic nephropathy among T2DM patients was relatively high. Males, longer duration of diabetes, HbA1c, and fasting blood glucose were increase the risk of diabetic nephropathy.

Prevalence of Diabetic Nephropathy and associated risk factors among type 2 diabetes mellitus patients in Ramallah, Palestine

AIMS

Albuminuria is an established marker for endothelial dysfunction and cardiovascular risk in diabetes and prediabetes. So we aimed to explore the prevalence of albuminuria (microalbuminuria and macroalbuminuria) in patients with type2 diabetes mellitus (DM) in the Palestinian community and to determine the association between albuminuria and other health care and biochemical indicators.

MATERIALS AND METHODS

A cross-sectional study was carried out at private health care center. A total of 550 diabetic patients aged 35 years and above with type 2 diabetes mellitus who attended the clinic from May 2017 through February 2018 were included. Socio-demographic, clinical, and laboratory data were obtained from the medical records of patients. Statistical analysis was carried out using the Statistical Package for the Social Sciences (SPSS, version 23).

RESULTS

Out of the 550 patients recruited, the mean age and duration of diabetes were 57.8 years and 9.5 years, respectively. Approximately 62% were being managed by oral hypoglycemic agents alone, 4.3% by insulin alone, 31.7% were on a combination of oral hypoglycemic agents and insulin and slightly less than 2% were on dietary measures alone. The mean value for HbA1c was 7.71%. The overall prevalence of albuminuria among participants was found to be 34.6%; microalbuminuria (29.3%) and macroalbuminuria (5.3%).

CONCLUSION

Albuminuria is highly prevalent among Palestinian population with type 2 diabetes. This calls for early and universal screening of urinary albumin. There is also an urgent need for measures that target tight glycemic and optimal blood pressure control and the use of renin-angiotensin system blockade.

Red cell distribution width as a significant indicator of medication and prognosis in type 2 diabetic patients

Whether red cell distribution width (RDW) can be a potential indicator for diabetic nephropathy (DN) is unknown. A total of 809 type 2 diabetes mellitus (T2D) patients were divided into 4 groups according to the quartiles (Q) of the RDW (%): Q1 ≤ 12.4 (n = 229), 12.4 < Q2 ≤ 12.9 (n = 202), 12.9 < Q3 < 13.5 (n = 168), Q4 ≥ 13.5 (n = 210). Results showed that the levels in Q4 group was higher in age, disease duration, systolic blood pressure, blood urea nitrogen, creatinine, uric acid and proteinuria but lower in hemoglobin, serum albumin and glycosylated hemoglobin compared to Q1 group. Furthermore, the incidences of DN, diabetic peripheral neuropathy, hypertension and coronary heart disease in the Q3 or Q4 group were higher compared to Q1 group. Medications including calcium channel blockers and antiplatelet therapy also showed higher frequencies in Q3 or Q4 group compared to Q1. Logistic regression indicated that the antiplatelet therapy (OR = 2.065), hypertension (OR = 2.819), creatinine (OR = 4.473) and proteinuria (OR = 2.085) were positively associated with level of Q4 group, but higher hemoglobin (OR = 0.021) and serum Ca²⁺ (OR = 0.178) were negatively associated with Q4. This data suggest that high level of RDW in T2D patients indicates a higher risk and a poor prognosis for DN.

Intensive statin therapy, used alone or in combination with ezetimibe, improves homocysteine level and lipid peroxidation to a similar degree in patients with coronary artery diseases

BACKGROUND

Increase in the concentration of homocysteine is one of the risks of cardiovascular diseases. Coronary artery disease accompanied the increase of LDL cholesterol level and hipolipemic drugs are used in such treatments. Also these drugs have pleiotropic effects, which are not greatly known. The aim of that study is to compare the effect of three different hipolipemic therapies (rosuvastatin 15mg/d; atorvastatin 40mg/d; atorvastatin+ezetymibe 10mg/d+10mg/d) depending upon the concentration of homocysteine and lipid peroxidation in plasma of CAD patients with non-target LDL-cholesterol level.

METHODS AND RESULTS

The study involved 30 healthy subjects as well as 30 patients with angiographically confirmed coronary artery disease who despite at least 6 months hypolipidemic treatment did not achieve LDL-C <70mg/dl. The following parameters studied included homocysteine level, lipid peroxidation in plasma and lipidogram parameters. Our study showed increase of homocysteine level, lipid peroxidation in plasma, LDL-C concentration and total cholesterol level. After six months therapy, the following changes were observed in comparison to the values before therapy: decrease of homocysteine level in plasma - R15 20%, A40 26% and A+E 28%; decrease of lipid peroxidation in plasma - R15 31%, A40 27% and A+E 32%; decrease of LDL-C cholesterol level - R15 18%; A40 17% and A+E 33% and decrease of total cholesterol level - R15 9%, A40 15% and A+E 17%.

CONCLUSION

Our results suggest that intensive lipid-lowering therapy has a beneficial effect on certain parameters of the blood of CAD patients.

Prevalence and risk factors of microalbuminuria in type 2 diabetes mellitus outpatients at University Sains Malaysia Hospital

BACKGROUND AND OBJECTIVE

Microalbuminuria is early stage of diabetic nephropathy as well as a marker of cardiovascular disease. The objective of this study is to determine the prevalence of microalbuminuria and associated risk factors among type 2 diabetic outpatients, attending a diabetic clinic in University Sains Malaysia Hospital (HUSM).

PATIENTS AND METHODS

Prospective study design was used in the data collection process. The study sample consists of 1066 type 2 diabetes mellitus outpatients who fit the inclusion criteria. All the patients were recruited from the diabetic outpatient clinics from HUSM. The study period was from January till December 2008. Microalbuminuria was diagnosed if the urinary albumin excretion more than 30 mg/g of creatinine.

RESULTS

A total of 1661 patients were included in this study. Microalbuminuria was diagnosed in 273 (25.4%) patients. Multivariate logistic regression analysis indicated that microalbuminuria was positively associated with duration of hypertension (P=0.044), HbA1c (P=0.004), systolic blood pressure (<0.001), creatinine clearance (P=0.007) and the presence of neuropathy (P=0.004).

CONCLUSION

High prevalence of microalbuminuria was in type 2 diabetic outpatients. Predictive factors for microalbuminuria were duration of hypertension, HbA1c, systolic blood pressure, creatinine clearance and the presence of neuropathy. The study suggests the need to screen for microalbuminuria early and the active management of modifiable risk factors in particular, hyperglycemia, hypertension and creatinine clearance, to reduce the burden of end-stage renal disease in the future.

Cell oxidant stress delivery and cell dysfunction onset in type 2 diabetes

Most known pathways of diabetic complications involve oxidative stress. The mitochondria electron transport chain is a significant source of reactive oxygen species (ROS) in insulin secretory cells, insulin peripheral sensitive cells and endothelial cells. Elevated intracellular glucose level induces tricarboxylic acid cycle electron donor overproduction and mitochondrial proton gradient increase leading to an increase in electron transporter lifetime. Subsequently, the electrons leaked combine with respiratory oxygen (O(2)) resulting in superoxide anion ((•)O(2)(-)) production. Advanced glycation end products derive ROS via interaction with their receptors. Elevated diacylglycerol and ROS activate the protein kinase C pathway which, in turn, activates NADPH oxidases. A vicious circle of pathway derived ROS installs. Pathologic pathways induced ROS are activated and persistent though glycemia returns to normal due to hyperglycemia memory. Endothelial nitric oxide synthase may produce both superoxide anion ((•)O(2)(-)) and nitric oxide (NO) leading to peroxynitrite ((•)ONOO(-)) generation. Homocysteine is also implicated in oxidative stress pathogenesis. In this paper we have highlighted the pathologic mechanisms of ROS on atherosclerosis, renal dysfunction, retina dysfunction and nerve dysfunction in type 2 diabetes. Cell oxidant stress delivery have pivotal role in cell dysfunction onset and progression of angiopathies but an early introduction of good glycemic control may protect cells more efficiently than antioxidants.

Glucoraphanin does not reduce plasma homocysteine in rats with sufficient Se supply via the induction of liver ARE-regulated glutathione biosynthesis enzymes

Data from human and animal trials have revealed contradictory results regarding the influence of selenium (Se) status on homocysteine (HCys) metabolism. It was hypothesised that sufficient Se reduces the flux of HCys through the transsulphuration pathway by decreasing the expression of glutathione (GSH) synthesising enzymes. Glucoraphanin (GRA) is a potent inducer of genes regulated via an antioxidant response element (ARE), including those of GSH biosynthesis. We tested the hypothesis that GRA supplementation to rat diets lowers plasma HCys levels by increasing GSH synthesis. Therefore 96 weaned albino rats were assigned to 8 groups of 12 and fed diets containing four different Se levels (15, 50, 150 and 450 μg kg(diet)(-1)), either without GRA (groups: C15, C50, C150 and C450) or in combination with 700 μmol GRA kg(diet)(-1) (groups G15, G50, G150 and G450). Rats fed the low Se diets C15 and G15 showed an impressive decrease of plasma HCys. Se supplementation increased plasma HCys and lowered GSH significantly by reducing the expression of GSH biosynthesis enzymes. As new molecular targets explaining these results, we found a significant down-regulation of the hepatic GSH exporter MRP4 and an up-regulation of the HCys exporter Slco1a4. In contrast to our hypothesis, GRA feeding did not reduce plasma HCys levels in Se supplemented rats (G50, G150 and 450) through inducing GSH biosynthesis enzymes and MRP4, but reduced their mRNA in some cases to a higher extent than Se alone. We conclude: 1. That the long-term supplementation of moderate GRA doses reduces ARE-driven gene expression in the liver by increasing the intestinal barrier against oxidative stress. 2. That the up-regulation of ARE-regulated genes in the liver largely depends on GRA cleavage to free sulforaphane and glucose by plant-derived myrosinase or bacterial β-glucosidases. As a consequence, higher dietary GRA concentrations should be used in future experiments to test if GRA or sulforaphane can be established as HCys lowering compounds.

Study of molecular targets influencing homocysteine and cholesterol metabolism in growing rats by manipulation of dietary selenium and methionine concentrations

Inconsistent results exist from human and animal studies for Se and methionine (Met) regarding their influence on homocysteine (HCys) and cholesterol (Chol) metabolism. To elucidate these contradictions, sixty-four weanling albino rats were divided into eight groups of 8, and were fed diets containing four different Se levels (15, 50, 150 and 450 microg/kg) either in combination with the recommended Met level of 3 g/kg (C15, C50, C150 and C450) or with an increased Met concentration of 15 g/kg (M15, M50, M150 and M450) for 8 weeks. Plasma HCys was twofold higher in the Se-supplemented C groups than in group C15. Met addition also doubled plasma HCys compared with the respective C groups. In contrast, the expression of the key enzymes of glutathione biosynthesis in the liver was significantly lowered by Se and in particular by Met. Liver Chol concentration was significantly higher in all the Se-supplemented C and M groups than in groups C15 and M15. Plasma Chol was, however, lowered. The uninfluenced expression of sterol-regulatory element-binding protein 2 and of hydroxymethyl-glutaryl-CoA reductase, the increased LDL receptor expression and the reduced expression of the hepatobiliary Chol exporter ATP-binding-cassette-transporter 8 (ABCG8) by Se and/or Met explain these findings. We conclude that the elevation of plasma HCys in rats by Se and Met results from a higher export into plasma. The fact that Se in particular combined with Met increases liver Chol but reduces plasma Chol should be addressed in future investigations focussing on the regulation of ABCG8, which is also selectively involved in the reverse transport of phytosterols in the small intestine.

Potential impact of omega-3 treatment on cardiovascular disease in type 2 diabetes

PURPOSE OF REVIEW

Hypothesis-generating systematic review of the impact of marine-derived omega-3 polyunsaturated fatty acids (PUFAs) on lipid, glycemic and hematological risk factors in type 2 diabetes using pooled data from randomized controlled trials searched up to 20 September 2008.

RECENT FINDINGS

Seven new trials in 2007 and 2008 were identified from 206 abstracts to give a total of 24 trials between 1966 and 2008 involving 1533 participants that could be pooled. The mean omega-3 PUFAs dose and duration of treatment in the new trials was 2.4 g/day and 24 weeks, respectively. Compared with placebo, omega-3 PUFAs supplementation decreased triglycerides by 7% (mean -0.17 mmol/l, 24 trials, 1530 participants), fibrinogen by 10% (mean -0.96 micromol/l, three trials, 159 participants), ADP platelet aggregation to ADP by 22% (mean -10.30%, two trials, 64 participants) and to collagen by 21% (mean -10.55%, two trials, 64 participants), with an LDL-cholesterol increase of 3% (mean 0.08 mmol/l, 21 trials, 1104 participants). None of the following risk factors appeared to be beneficially influenced: HDL-cholesterol, LDL particle size, glycemia, insulinemia, inflammatory biomarkers, blood pressure. However for some of these risk factors (such as inflammatory biomarkers) the number of trial patients was small Higher doses of omega-3 PUFAs (>or=2 g/day) may have greater triglyceride lowering effects.

SUMMARY

This systematic review and meta-analysis confirms the triglyceride lowering effects of omega-3 PUFAs, demonstrates potential dose-response effects and shows improvements in thrombogenesis. Omega-3 PUFAs raise LDL levels without concomitant changes in lipid particle size. Changes seen in conventional risk factors are insufficient to explain the cardiovascular disease risk reductions suggested to occur with omega-3 PUFAs.