Type 2 Diabetes Mellitus and Kidney Cancer Risk: A Retrospective Cohort Analysis of the National Health Insurance

Effect of smoking, hypertension and lifestyle factors on kidney cancer - perspectives for prevention and screening programmes

Renal cell carcinoma (RCC) incidence has doubled over the past few decades. However, death rates have remained stable as the number of incidental renal mass diagnoses peaked. RCC has been recognized as a European health care issue, but to date, no screening programmes have been introduced. Well-known modifiable risk factors for RCC are smoking, obesity and hypertension. A direct association between cigarette consumption and increased RCC incidence and RCC-related death has been reported, but the underlying mechanistic pathways for this association are still unclear. Obesity is associated with an increased risk of RCC, but interestingly, improved survival outcomes have been reported in obese patients, a phenomenon known as the obesity paradox. Data on the association between other modifiable risk factors such as diet, dyslipidaemia and physical activity with RCC incidence are conflicting, and potential mechanisms underlying these associations remain to be elucidated.

Global, regional, and national time trends in cancer mortality attributable to high fasting plasma glucose: an age-period cohort analysis

BACKGROUND

High fasting plasma glucose (HFPG) is the fastest-growing risk factor for cancer deaths worldwide. We reported the cancer mortality attributable to HFPG at global, regional, and national levels over the past three decades and associations with age, period, and birth cohort.

METHODS

Data for this study were retrieved from the Global Burden of Disease Study 2019, and we used age-period-cohort modelling to estimate age, cohort and period effects, as well as net drift (overall annual percentage change) and local drift (annual percentage change in each age group).

RESULTS

Over the past 30 years, the global age-standardized mortality rate (ASMR) attributable to HFPG has increased by 27.8%. The ASMR in 2019 was highest in the male population in high sociodemographic index (SDI) areas (8.70; 95% CI, 2.23-18.04). The net drift for mortality was highest in the female population in low SDI areas (2.33; 95% CI, 2.12-2.55). Unfavourable period and cohort effects were found across all SDI quintiles. Cancer subtypes such as "trachea, bronchus, and lung cancers", "colon and rectal cancers", "breast cancer" and "pancreatic cancer" exhibited similar trends.

CONCLUSIONS

The cancer mortality attributable to HFPG has surged during the past three decades. Unfavourable age-period-cohort effects on mortality were observed across all SDI quintiles, and the cancer mortality attributable to HFPG is expected to continue to increase rapidly in the future, particularly in lower SDI locations. This is a grim global public health issue that requires immediate attention.

Association of Metabolic Syndrome Components and Nutritional Status with Kidney Cancer in Young Adult Population: A Nationwide Population-Based Cohort Study in Korea

The aim of this study was to determine the association of metabolic syndrome (MetS) with kidney cancer and the impact of age and gender on such an association. Using the Korean National Health Insurance Service database, 9,932,670 subjects who had check-ups in 2009 were followed up until the diagnosis of kidney cancer or death or until 2019. Kidney cancer was significantly associated with MetS (HR 1.56). This association was higher in the younger age group (HR: 1.82, 1.5, and 1.37 in 20-39 years, 40-64 years, and ≥65 years, respectively). In terms of the association of kidney cancer with obesity and central obesity, young-aged males showed higher HR for kidney cancer than old-aged ones (HR of obesity: 1.96, 1.52, and 1.25; HR of central obesity: 1.94, 1.53, and 1.3 in 20-39 years, 40-64 years, ≥65 years, respectively), while young-aged females showed lower HR. Kidney cancer was associated with obesity and MetS. The association was higher in younger populations than in older ones. Regarding gender, MetS, obesity, and central obesity showed higher associations with kidney cancer in younger aged male population, while there was no significant difference in such associations according to age in the female population.

Endoplasmic Reticulum Stress in Renal Cell Carcinoma

The endoplasmic reticulum is an organelle exerting crucial functions in protein production, metabolism homeostasis and cell signaling. Endoplasmic reticulum stress occurs when cells are damaged and the capacity of this organelle to perform its normal functions is reduced. Subsequently, specific signaling cascades, together forming the so-called unfolded protein response, are activated and deeply impact cell fate. In normal renal cells, these molecular pathways strive to either resolve cell injury or activate cell death, depending on the extent of cell damage. Therefore, the activation of the endoplasmic reticulum stress pathway was suggested as an interesting therapeutic strategy for pathologies such as cancer. However, renal cancer cells are known to hijack these stress mechanisms and exploit them to their advantage in order to promote their survival through rewiring of their metabolism, activation of oxidative stress responses, autophagy, inhibition of apoptosis and senescence. Recent data strongly suggest that a certain threshold of endoplasmic reticulum stress activation needs to be attained in cancer cells in order to shift endoplasmic reticulum stress responses from a pro-survival to a pro-apoptotic outcome. Several endoplasmic reticulum stress pharmacological modulators of interest for therapeutic purposes are already available, but only a handful were tested in the case of renal carcinoma, and their effects in an in vivo setting remain poorly known. This review discusses the relevance of endoplasmic reticulum stress activation or suppression in renal cancer cell progression and the therapeutic potential of targeting this cellular process for this cancer.

Post-transplant diabetes mellitus and renal cell cancer after renal transplantation

Background

Diabetes is a risk factor for cancer in the general population. However, few data are available on the association between post-transplant diabetes mellitus (PTDM) and cancer after transplantation.

Methods

We analyzed this issue in a Spanish cohort of patients without diabetes before transplantation. PTDM was diagnosed with consensus criteria at 12 months after transplantation and 12 months before the diagnosis of cancer. The association between PTDM and cancer (overall and specific types) was evaluated with regression analysis.

Results

During a follow-up of 12 years (interquartile range 8–14), 85 cases of 603 developed cancer (829/100 000/year) and 164 (27%) PTDM. The most frequent cancers were renal cell cancer (RCC) n = 15, 146/cases/100 000/year), lung (n = 12, 117/cases/100 000/year), colon (n = 9, 88/cases/100 000/year) and prostate (n = 9, 88/cases/100 000/year). In logistic regression, PTDM was not associated with cancer. Eight of the 164 patients with PTDM (4.9%) vs 7 of the 439 without PTDM developed RCC (1.6%) (P = .027). In multivariate analysis, PTDM was independently associated with RCC [odds ratio (OR) 2.92, confidence interval (CI) 1.03–8.27], adjusting for smoking (OR 4.020, 95% CI 1.34–12.02) and other covariates. PTDM was not associated with other types of cancer.

Conclusions

Patients with PTDM must be considered a population at risk for RCC and accordingly, the subject of active surveillance.

Association Between Diabetes and the Risk of Kidney Cancer: Systematic Review and Meta-Analysis

Diabetes is a risk factor for several types of cancer, but the specific relationship between diabetes and kidney cancer is not well understood. We conducted a search strategy in scientific databases for case-control and cohort studies on this topic. We analyzed 17 studies and found that diabetes was significantly associated with the risk of developing kidney cancer and that this risk was slightly stronger for women and for people living in Asia. These findings were not influenced by obesity, cigarette smoking, or hypertension. We conclude that diabetes is an independent risk factor for the development of kidney cancer.

Novel pharmacological effects of lecithinized superoxide dismutase on ischemia/reperfusion injury in the kidneys of mice

Renal ischemia/reperfusion (I/R) injury is a major clinical problem because it can cause acute kidney injury (AKI) or lead to the transition from AKI to chronic kidney disease (CKD). Oxidative stress, which involves the production of reactive oxygen species (ROS), plays an important role in the development and exacerbation of I/R-induced kidney injury. However, we have previously reported that lecithinized superoxide dismutase (PC-SOD), a SOD derivative with high tissue affinity and high stability in plasma, has beneficial effects in various disease models because of its inhibitory effect on ROS production. Therefore, we aimed to determine the effects of intravenous PC-SOD administration in a mouse model of renal injury induced by I/R. PC-SOD markedly ameliorated the I/R-induced increases in markers of renal damage (urea nitrogen, creatinine, neutrophil gelatinase-associated lipocalin, and interleukin-6) and tubular necrosis 48 h after the intervention. We also found that PC-SOD significantly ameliorated the I/R-induced increase in ROS production, using an ex vivo imaging system. Furthermore, PC-SOD inhibited the increases in expression of markers of fibrosis (α-smooth muscle actin and collagen 1A1) 96 h after, and renal fibrosis 25 days after I/R was induced. Finally, we found that PC-SOD ameliorated the I/R-induced AKI in mice with high-fat diet-induced prediabetes. These results suggest that PC-SOD inhibits AKI and the transition from AKI to CKD through the inhibition of ROS production. Therefore, we believe that PC-SOD may represent an effective therapeutic agent for I/R-induced renal injury.

The association between diabetes and cancer in Mexico: Analysis using death certificate databases, 2009-2017

Context

Previous studies have shown that diabetes mellitus (DM) is a risk factor of some type-specific cancers. However, no data are available on the association between cancer and DM in Latin America.

Aims

The aim of this study is to determine which type-specific cancers are associated with DM using multiple cause of death data.

Settings and Design

Whole country of Mexico, cross-sectional design.

Materials and Methods

Analysis of all cancer deaths (2009-2017) using death certificate databases of Mexican adults aged ≥20 years.

Statistical Analysis Used

Multivariable logistic regression.

Results

There were 710,292 total cancer deaths. DM increased the risk of pancreatic (adjusted odds ratio [aOR] = 1.7), liver (aOR = 1.6), kidney (aOR = 1.4), gallbladder (aOR = 1.2) and endometrial (aOR = 1.1) cancers, all P < 0.05. Type 2 or unknown-type DM were associated with the same cancer types with little variation of estimates. Higher estimates were found in males than females (except for kidney cancer). Type 1 DM was associated with pancreatic cancer only (aOR = 1.9).

Conclusions

DM in Mexico is associated with gastrointestinal (pancreatic, liver, gallbladder), kidney and endometrial cancers. Dissemination of knowledge to both health-care workers and diabetics regarding potential cancer risks including adequate diet, regular exercise, weight reduction if obese/overweight, cessation of smoking, and good glucose control and medication compliance should be reinforced. Specific cancer preventative measures should be implemented for patients with DM.

Examining the Relationship between Depression, Anxiety and Stress in Kidney Cancer Patients

Cancer of the kidney is one of the 10 most common cancers found globally. Overall, it is the fourth most common cancer in men and the eighth most common cancer in women. Many kidney cancer patients experience psychologic problems and reactions. The present study examined relationship between anxiety, depression, and perceived stress symptoms in kidney cancer patients. Cross-sectional data were obtained from the patients diagnosed with kidney cancer. All participants completed sociodemographic form, Hospital Anxiety and Depression form, and Perceived Stress Scale. Statistical analysis was exercised using the Student's t-test, Chi-squared test (χ²), Fischer's exact test, ANOVA, Mann-Whitney U test, and Kruskal-Wallis one-way variance analysis. A total of 250 patients participated in the study. The mean age was 57.4 years (SD 6.4, range = 25-76 years). The majority of patients were males (73%) and married (218). Anxiety symptoms were determined in 91.2% patients, depression symptoms in 87.2% patients, and perceived stress symptoms in 93.6% patients. The mean scores of Hospital Depression and Anxiety Scale (HADS)-Anxiety, HADS-Depression, and HADS-Perceived Stress were significantly different between age (P < 0.05), gender (P < 0.05), and income groups (P < 0.001). Kidney cancer patients showed poorer psychologic health. The overall levels of anxiety, depression, and perceived stress symptoms were higher among the studied kidney cancer patients. Findings of the current study could improve both psychologic well-being of patients and health-related quality of life.

Causes of in-hospital death in patients with type 2 diabetes with microvascular and macrovascular complications in Taiwan

AIMS

Diabetes mellitus is a major cause of death worldwide, including Taiwan. The mortality data of the subsets of patients who suffered from microvascular or macrovascular complications is limited. The aim of this study was to investigate the causes of in-hospital death of patients with type 2 diabetes, especially the patients with microvascular, macrovascular and both micro-macrovascular complications.

METHODS

A total of 12 159 patients with type 2 diabetes were identified from the Taiwan National Health Insurance Research Database (NHIRD) to analyse the causes of death. Type 2 diabetic subjects with microvascular, macrovascular and both micro-macrovascular complications were further classified and compared to patients without microvascular and macrovascular complications in the logistic regression analysis of the risk of death.

RESULTS

Pneumonia increased risk of in-hospital death in patients with microvascular, macrovascular and both micro-macrovascular complications, with adjusted odds ratios (AORs) of 2.13 (95% confidence interval [CI] 1.09-4.18), 3.26 (1.71-6.24) and 3.96 (2.17-7.22), respectively. Septicaemia increased risk of in-hospital death in patients with macrovascular (AOR 2.57 [1.31-5.04]) and both micro-macrovascular complications (AOR 4.69 [2.58-8.50]).

CONCLUSION

Pneumonia increased risk of in-hospital death among the type 2 diabetic patients with microvascular, macrovascular and both micro-macrovascular complications. Therefore, efforts aim at preventing pneumonia or decreasing its severity may increase survival.

Bioinformatic gene analysis for potential biomarkers and therapeutic targets of diabetic nephropathy associated renal cell carcinoma

Background

Numerous epidemiological studies have confirmed that diabetes can promote the development of malignant tumors. However, the relationship between renal cell carcinoma (RCC) and diabetic nephropathy (DN) is still controversial. This study aimed to investigate the genes that are co-expressed in DN and RCC in order to gain a better understanding of the relationship between these diseases, and to identify potential biomarkers and targets for the treatment of DN-related RCC.

Methods

We evaluated the differentially expressed genes (DEGs) that are co-expressed in DN and RCC using a wide range of target prediction and analysis methods. Twenty-four genes were identified by intersecting the differential genes of 3 DN datasets and 2 RCC datasets. We predicted the micro-ribonucleic acids (miRNAs) of these genes that may be controlled using the miRNA Data Integration Portal (mirDIP) database, and rated them according to each data forecast based on the Comparative Toxicogenomics Database (CTD) and the StarBase database.

Results

Four genes were associated with DN and RCC patients: the predicted miRNAs hsa-miR-200b-3p and hsa-miR-429 of fibronectin 1 (FN1); the predicted miRNA hsa-miR-29c-3p of collagen type 1 alpha 2 (COL1A2); the predicted miRNA hsa-miR-29c-3p of collagen type 3 alpha 1 (COL3A1); and the predicted miRNA hsa-miR-29a-3p and hsa-miR-200c-3p of glucose-6-phosphatase catalytic subunit (G6PC). These genes may serve as potential biomarkers or specific targets in the treatment of DN-related RCC.

Conclusions

A significant correlation was identified between DN and RCC. The FN1, COL1A2, COL3A1, and G6PC genes could be novel biomarkers of DN-related RCC.

Examining the Impact of First Nations Status on the Relationship Between Diabetes and Cancer

Purpose: This population-based study examined the relationship between diabetes and cancer and determined if this relationship was influenced by First Nations (FN) status.

Methods: In a matched case–cohort study, individuals 30–74 years of age diagnosed with diabetes during 1984–2008 in the province of Manitoba, Canada, with no cancer diagnosis before their diabetes diagnosis were matched to one diabetes-free control by age, sex, FN status, and residence. Flexible competing risk and Royston–Parmar regression models were used to compare cancer rates.

Results: Overall, 72,715 individuals diagnosed with diabetes were matched to controls. In all age groups, diabetes was related to an increased risk of cancer. The relationship between diabetes and any type of cancer was not influenced by FN status (i.e., there was no interaction between the diagnosis of diabetes and people's FN status for any age group). The only significant interaction between diabetes and FN status was for kidney cancer for individuals 60–74 years of age; diabetes increased the risk of kidney cancer for all other Manitobans (AOMs) but not for FN.

Conclusions: Diabetes increased the risk of cancer. The association was not modified by FN status except for kidney cancer where diabetes increased the risk for AOMs but not for FN.

Effects of hyperglycemia on the progression of tumor diseases

Malignant tumors are often multifactorial. Epidemiological studies have shown that hyperglycemia raises the prevalence and mortality of certain malignancies, like breast, liver, bladder, pancreatic, colorectal, endometrial cancers. Hyperglycemia can promote the proliferation, invasion and migration, induce the apoptotic resistance and enhance the chemoresistance of tumor cells. This review focuses on the new findings in the relationship between hyperglycemia and tumor development.

Incidence and relative risk for developing cancers in women with gestational diabetes mellitus: a nationwide cohort study in Taiwan

OBJECTIVES

To evaluate the risk of developing cancers, particularly site-specific cancers, in women with gestational diabetes mellitus (GDM) in Taiwan.

SETTING

The National Health Insurance Research Database (NHIRD) of Taiwan.

PARTICIPANTS

This study was conducted using the nationwide data from 2000 to 2013. In total, 1 466 596 pregnant women with admission for delivery were identified. Subjects with GDM consisted of 47 373 women, while the non-exposed group consisted of 943 199 women without GDM. The participants were followed from the delivery date to the diagnosis of cancer, death, the last medical claim or the end of follow-up (31 December 2013), whichever came first.

PRIMARY OUTCOME MEASURES

Patients with a new diagnosis of cancer (International Classification of Diseases, ninth edition, with clinical modification (ICD-9-CM codes 140-208)) recorded in NHIRD were identified. The risk of 11 major cancer types was assessed, including cancers of head and neck, digestive organs, lung and bronchus, bone and connective tissue, skin, breast, genital organs, urinary system, brain, thyroid gland and haematological system.

RESULTS

The rates of developing cancers were significantly higher in women with GDM compared with the non-GDM group (2.24% vs 1.96%; p<0.001). After adjusting for maternal age at delivery and comorbidities, women with GDM had increased risk of cancers, including cancers of nasopharynx (adjusted HR, 1.739; 95 % CI, 1.400 to 2.161; p<0.0001), kidney (AHR, 2.169; 95 % CI, 1.428 to 3.293; p=0.0003), lung and bronchus (AHR, 1.372; 95 % CI, 1.044 to 1.803; p=0.0231), breast (AHR, 1.234; 95% CI, 1.093 to 1.393; p=0.007) and thyroid gland (AHR, 1.389; 95 % CI, 1.121 to 1.721; p=0.0026).

CONCLUSION

Women with GDM have a higher risk of developing cancers. Cancer screening is warranted in women with GDM. Future research should be aimed at establishing whether this association is causal.

Kidney cancer in Saudi Arabia. A 25-year analysis of epidemiology and risk factors in a tertiary center

OBJECTIVES

To evaluate available epidemiological data and risk factors for kidney cancer in a tertiary care center in Riyadh, Saudi Arabia, over a period of 25 years.

METHODS

This retrospective study conducted in a tertiary care center included all adult patients with primary kidney cancer who presented and were managed between 1990 and 2015. Based on this information, we forecast the incidence of the disease in our center over the next 5 years (2016 to 2020).

RESULTS

In total, 371 patients were included in the study. The mean age of the patients was 56.3 years and the majority were male (61%). Among the patients, 55.8% were diagnosed incidentally. At the time of diagnosis, 53.2% were hypertensive, 46.2% were diabetic, 39.1% had dyslipidemia, and 25% were smokers. In addition, most patients were obese (42.3%) or overweight (30%). The most frequent histopathological variants were clear cell and chromophobe. Most patients presented with Stage 1. Minimally invasive surgery (laparoscopic, robotic) was performed in 55% of cases. Based on these data, we predicted that 172 new cases will present at our tertiary care center in 5 years from 2016 to 2020.

CONCLUSION

The incidence in kidney cancer is increasing and is associated with an alarming increase in the prevalence of associated risk factors.

Increased risk of incident nasopharyngeal carcinoma with exposure to air pollution

Background

Nasopharyngeal carcinoma (NPC) is a race-specific malignancy. The nasal cavity is the main entry point for air pollutants or poisonous gases into the human body. However, the risk of NPC in populations exposed to air pollution remains unknown.

Methods

We combined data from the Taiwan Air Quality Monitoring Database (TAQMD) and the Longitudinal Health Insurance Database (LHID) to assess the risk of NPC in a population exposed to air pollution.

Results

Multivariate analysis revealed positive trends for the association between the risk of NPC and exposure to air pollution. After adjusting for potential covariates, the risk of developing NPC increased with the increase in nitrogen dioxide (NO₂) and fine particulate matter (PM_2.5) exposure concentrations from 1.39 to 2.28 and 2.01 to 1.97, respectively, compared to the risks at the lowest concentration levels.

Conclusions

We identified a significant risk of NPC in a population exposed to air pollution. However, this study had several limitations. Moreover, additional experimental and clinical studies on the associations between environmental factors and NPC risk are warranted.

Metformin use and cervical cancer risk in female patients with type 2 diabetes

This study evaluated whether metformin may affect the risk of cervical cancer. The reimbursement databases of the Taiwan's National Health Insurance were used. Female patients with type 2 diabetes at an onset age of 25-74 years during 1999-2005 and newly treated with metformin (n=132971, "ever users of metformin") or other antidiabetic drugs (n=6940, "never users of metformin") were followed for at least 6 months until December 31, 2011. The treatment effect of metformin (for ever versus never users, and for tertiles of cumulative duration of therapy) was estimated by Cox regression incorporated with the inverse probability of treatment weighting using propensity score. Analyses were also conducted in a 1:1 matched pair cohort based on 8 digits of propensity score. Results showed that the respective numbers of incident cervical cancer in ever users and never users were 438 (0.33%) and 38 (0.55%), with respective incidences of 68.29 and 121.38 per 100,000 person-years. The overall hazard ratio suggested a significantly lower risk in metformin users (0.558, 95% confidence intervals: 0.401-0.778). In tertile analyses, the hazard ratios (95% confidence intervals) for the first (<23.0 months), second (23.0-47.9 months) and third (>47.9 months) tertile of cumulative duration were 1.272 (0.904-1.790), 0.523 (0.366-0.747) and 0.109 (0.070-0.172), respectively. Findings were supported by the analyses in the matched cohort. In conclusion, metformin may significantly reduce the risk of cervical cancer, especially when the cumulative duration is more than 2 years.

A posteriori dietary patterns and risk of pancreatic and renal cancers

Purpose

Dietary patterns have been used to explore the association between dietary factors and risk of pancreatic cancer (PC) and renal cancer (RC); however, the association remains unclear. The purpose of this paper is to comprehensively review these associations.

Design/methodology/approach

Pertinent studies published prior to March 2016 were systematically searched and retrieved through PubMed and Scopus databases. Adjusted risk estimates were derived by comparing the highest with the lowest categories of dietary pattern scores and were combined by using the fixed-effects model when no substantial heterogeneity was observed; otherwise, the random-effects model was used.

Findings

A total of nine studies, five for PC (including 2,059 cases and 41,774 participants/controls) and four for RC (with 1,327 cases and 53,007 participants/controls), were included in this meta-analysis. A decreased risk of PC was shown for the highest compared with the lowest categories of the healthy dietary pattern (OR = 0.72, 95 per cent CI = 0.51-0.94, random effects (p-value for heterogeneity = 0.004)), whereas no significant association with Western dietary was observed (OR = 1.16, 95 per cent CI = 0.87-1.44, fixed effects). In the overall analysis, a significant association was found between the healthy dietary pattern and reduced risk of RC (OR = 0.59, 95 per cent CI = 0.48-0.71, fixed effects (p-value for heterogeneity = 0.459)), whereas the Western pattern was positively associated with risk of RC (OR = 1.42, 95 per cent CI = 1.14-1.69, fixed effects). For both cancers, the reduced risk associated with the healthy pattern was restricted to case-control, but not cohort, studies. Furthermore, drinking pattern was significantly related to reduced risk of RC (OR = 0.68, 95 per cent CI = 0.42-0.94).

Originality/value

To the authors’ knowledge, the present study is the first English document to summarize systematically the findings from observational studies in response to this question whether a posteriori dietary patterns are associated with susceptibility to the risk of renal and ovarian cancers.

Enemies or weapons in hands: investigational anti-diabetic drug glibenclamide and cancer risk

Epidemiological evidence suggests that diabetes is associated with elevated cancer risk through the actions of hyperglycemia, hyperinsulinemia and chronic inflammation. Metformin, a first-line medication for type 2 diabetes mellitus, arouses growing concerns on its anti-cancer effect. However, data regarding the effect of glibenclamide on tumor growth and cancer risk are less consistent, which may be a potential anti-cancer drug. Areas covered: In this review, we clarified probable underlying mechanisms in preclinical studies and reviewed epidemiological evidence on glibenclamide's cancer risk in clinical studies. Glibenclamide inhibited carcinogenesis through ATP-binding cassette protein super-family and ATP-sensitive potassium channels, while majority of clinical researches reported an increased or non-significant elevated cancer risk of glibenclamide users compared with metformin users. Other sulfonylureas and diarylsulfonylureas were also briefly introduced. Expert opinion: The inconsistency between the results of studies was probably ascribed to undiscovered mechanisms, confounding factors, inconsistent comparators and publication bias. Existing clinical trials were prone to be afflicted by time-related bias including immortal time bias, time-window bias, and time-lag bias. Glibenclimiade could be a promising and well-tolerated anti-neoplastic drug targeting ATP-binding cassette protein super-family and KATP channels, but its efficacy still needs to be proven in well-designed long-term randomized controlled clinical trials.

Risks of Metformin in Type 2 Diabetes and Chronic Kidney Disease: Lessons Learned from Taiwanese Data

Like other biguanide agents, metformin is an anti-hyperglycemic agent with lower tendency towards hypoglycemia compared to other anti-diabetic drugs. Given its favorable effects on serum lipids, obese body habitus, cardiovascular disease, and mortality, metformin is recommended as the first-line pharmacologic agent for type 2 diabetes in the absence of contraindications. However, as metformin accumulation may lead to type B non-hypoxemic lactic acidosis, especially in the setting of kidney injury, chronic kidney disease, and overdose, regulatory agencies such as the United States Food and Drug Administration (FDA) have maintained certain restrictions regarding its use in kidney dysfunction. Case series have demonstrated a high fatality rate with metformin-associated lactic acidosis (MALA), and the real-life incidence of MALA may be underestimated by observational studies and clinical trials that have excluded patients with moderate-to-advanced kidney dysfunction. A recent study of advanced diabetic kidney disease patients in Taiwan in Lancet Endocrinology and Diabetes has provided unique insight into the potential consequences of unrestricted metformin use, including a 35% higher adjusted mortality risk that was dose-dependent. This timely study, as well as historical data documenting the toxicities of other biguanides, phenformin and buformin, suggest that the recent relaxation of FDA recommendations to expand metformin use in patients with kidney dysfunction (i.e., those with estimated glomerular filtration rates ≥30 instead of our recommended ≥45 ml/min/1.73 m2) may be too liberal. In this article, we will review the history of metformin use; its pharmacology, mechanism of action, and potential toxicities; and policy-level changes in its use over time.

Diabetes Mellitus Type 2: A Driving Force for Urological Complications

Type 2 diabetes mellitus (T2DM) is a growing epidemic associated with many adverse complications. Urological complications of diabetes mellitus in men are gaining recognition. Previously unknown associations between T2DM and risk for prostate cancer, bladder cancer, renal cell carcinomas, urinary tract infections, nephrolithiasis, penile lesions, androgen deficiency, and erectile dysfunction have been discovered. Significantly, metformin could play a role in the management of urological malignancies, and therapies used for management of these cancers could in return lead to increased risk for diabetes. In this review, we aim to bridge the gap between T2DM and urological complications by discussing the latest findings in these fields, with the ultimate goal being improved patient care on both fronts.