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Jansson Sigfrids F, Lithovius R, Groop PH, Thorn LM. Lessons learned from the FinnDiane Study: Epidemiology and metabolic risk factors for diabetic kidney disease in type 1 diabetes. Diabet Med 2024:e15431. [PMID: 39235140 DOI: 10.1111/dme.15431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 08/16/2024] [Accepted: 08/22/2024] [Indexed: 09/06/2024]
Abstract
AIMS Across its operational span of more than 25 years, the observational, nationwide, multicentre Finnish Diabetic Nephropathy (FinnDiane) Study has aimed to unravel mechanisms underlying diabetic kidney disease, with a special focus on its metabolic risk factors. We sought to compile key findings relating to this topic and to offer a current perspective on the natural course of diabetic kidney disease among individuals with type 1 diabetes. METHODS In this narrative review, articles relevant to the subject published by the FinnDiane Study were identified and summarized together with work published by others, when relevant. RESULTS The FinnDiane Study has underscored the significance of dysglycaemia and insulin resistance, increased visceral fat mass, hypertension and dyslipidaemia-particularly high triglycerides and remnant cholesterol-as risk factors for diabetic kidney disease. Factors like abdominal obesity seem to influence the early stages of the disease, while the presence of the metabolic syndrome becomes implicated at later stages. Epidemiological reports have revealed that after an initial decline, the cumulative incidence of albuminuria plateaued post-1980s, with the progression rate to kidney failure remaining high. Fortunately, 23% of the FinnDiane cohort regressed to less advanced stages of albuminuria, improving their overall prognosis. CONCLUSION A substantial burden of albuminuria associated with type 1 diabetes persists, and therefore, novel kidney-protecting therapies are highly awaited. In addition, given that metabolic factors influence the progression of diabetic kidney disease both in its early and advanced stages, emphasis should be placed on ensuring that their treatment targets are met.
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Affiliation(s)
- Fanny Jansson Sigfrids
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Raija Lithovius
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Per-Henrik Groop
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Lena M Thorn
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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2
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Limonte CP, Gao X, Bebu I, Seegmiller JC, Karger AB, Lorenzi GM, Molitch M, Karanchi H, Perkins BA, de Boer IH. Associations of Kidney Tubular Biomarkers With Incident Macroalbuminuria and Sustained Low eGFR in DCCT/EDIC. Diabetes Care 2024; 47:1539-1547. [PMID: 38484321 PMCID: PMC11362110 DOI: 10.2337/dc23-2196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/30/2024] [Indexed: 08/29/2024]
Abstract
OBJECTIVE Tubulointerstitial injury contributes to diabetic kidney disease (DKD) progression. We tested tubular biomarker associations with DKD development in type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS We performed a case-cohort study examining associations of tubular biomarkers, measured across seven time points spanning ∼30 years, with incident macroalbuminuria ("severely elevated albuminuria," urinary albumin excretion rate [AER] ≥300 mg/day) and sustained low estimated glomerular filtration rate (eGFR) (persistent eGFR <60 mL/min/1.73 m2) in the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) study. Biomarkers included KIM-1 and sTNFR1 in serum/plasma, MCP-1 and EGF in urine, and a composite tubular secretion score reflecting secreted solute clearance. We assessed biomarkers using single values, as mean values from consecutive time points, and as change over consecutive time points, each as time-updated exposures. RESULTS At baseline, mean diabetes duration was 5.9 years, with mean HbA1c 8.9%, eGFR 125 mL/min/1.73 m2, and AER 16 mg/day. There were 4.8 and 3.5 cases per 1,000 person-years of macroalbuminuria and low eGFR, respectively. Assessed according to single biomarker values, KIM-1 was associated with risk of subsequent macroalbuminuria and low eGFR (hazard ratio [HR] per 20% higher biomarker 1.11 [95% CI 1.06, 1.16] and 1.12 [1.04, 1.21], respectively) and sTNFR1 was associated with subsequent macroalbuminuria (1.14 [1.03, 1.25]). Mean KIM-1 and EGF-to-MCP-1 ratio were associated with subsequent low eGFR. In slope analyses, increases in KIM-1 and sTNFR1 were associated with subsequent macroalbuminuria (per 20% biomarker increase, HR 1.81 [1.40, 2.34] and 1.95 [1.18, 3.21]) and low eGFR (2.26 [1.65, 3.09] and 2.94 [1.39, 6.23]). CONCLUSIONS Serial KIM-1 and sTNFR1 are associated with incident macroalbuminuria and sustained low eGFR in T1D.
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Affiliation(s)
- Christine P. Limonte
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
- Kidney Research Institute, University of Washington, Seattle, WA
| | - Xiaoyu Gao
- Biostatistics Center, The George Washington University, Rockville, MD
| | - Ionut Bebu
- Biostatistics Center, The George Washington University, Rockville, MD
| | - Jesse C. Seegmiller
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Amy B. Karger
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Gayle M. Lorenzi
- Department of Medicine, University of California, San Diego, La Jolla, CA
| | | | - Harsha Karanchi
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Bruce A. Perkins
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ian H. de Boer
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
- Kidney Research Institute, University of Washington, Seattle, WA
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Zhang J, Zhong Q, Lin Y, Zhang Y, Teng Y, Chen J, Ou C, Feng W. Longitudinal albuminuria patterns predict coronary artery calcification progression: Findings from the Coronary Artery Risk Development in Young Adults study. Atherosclerosis 2024; 395:117574. [PMID: 38797614 DOI: 10.1016/j.atherosclerosis.2024.117574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 04/06/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND AND AIMS Albuminuria is an established risk factor for adverse cardiovascular outcomes. However, few studies have characterized longitudinal albuminuria patterns based on long-term measurement of urine albumin-to-creatinine ratio (UACR) levels. We aimed to evaluate the association between longitudinal albuminuria patterns in midlife adults and subsequent CAC progression. METHODS We included 1919 participants with CAC assessment by computed tomography from CARDIA (Coronary Artery Risk Development in Young Adults) study. CAC progression was determined for each individual as the difference of logarithmic CAC scores at follow-up and baseline. Albuminuria patterns across a 10-year span were estimated by longitudinal UACR levels. Multivariable general linear models were used to evaluate the association of long-term albuminuria patterns with CAC progression. RESULTS Of the 1919 included participants, 583 (30.4 %) participants experienced CAC progression, and the mean (SD) age was 50.4 (3.5) years at year 25. A total of four dynamic albuminuria patterns were identified. After multivariable adjustment, there were significant differences in CAC progression by albuminuria patterns as demonstrated as percent change in CAC with 36.0 % (SE, 1.5) progression for mid- and late-life normoalbuminuria group, 46.0 % (SE, 7.6) for midlife normoalbuminuria and late-life high albuminuria group, 52.4 % (SE, 7.1) for midlife high albuminuria and late-life normoalbuminuria group, and 54.5 % (SE, 8.7) for mid- and late-life high albuminuria group (p = 0.019). Similar findings were also observed in CAC volume score changes. CONCLUSIONS Longitudinal albuminuria patterns across a 10-year span were associated with worse CAC progression independent of baseline CAC level and albuminuria changes, suggesting that it may provide early identification of high-risk individuals with dynamic rises in albuminuria who may benefit from aggressive risk factor modification.
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Affiliation(s)
- Jianwu Zhang
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qingping Zhong
- The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Southern Medical University, Dongguan, China
| | - Yuhui Lin
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yangmei Zhang
- The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Southern Medical University, Dongguan, China
| | - Yintong Teng
- The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Southern Medical University, Dongguan, China
| | - Jiajing Chen
- The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Southern Medical University, Dongguan, China
| | - Caiwen Ou
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Nanfang Hospital, Southern Medical University, Guangzhou, China; The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Southern Medical University, Dongguan, China
| | - Weijing Feng
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Palomo-Piñón S, Aguilar-Alonso JA, Chávez-Iñiguez JS, Hernández-Arellanes FE, Mariano-Murga JA, Flores-Rodríguez JC, Pérez-López MJ, Pazos-Pérez F, Treviño-Becerra A, Guillen-Graf AE, Ramos-Gordillo JM, Trinidad-Ramos P, Antonio-Villa NE. Strategies to address diabetic kidney disease burden in Mexico: a narrative review by the Mexican College of Nephrologists. Front Med (Lausanne) 2024; 11:1376115. [PMID: 38962740 PMCID: PMC11219582 DOI: 10.3389/fmed.2024.1376115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/07/2024] [Indexed: 07/05/2024] Open
Abstract
Chronic kidney disease (CKD) is a growing global public health challenge worldwide. In Mexico, CKD prevalence is alarmingly high and remains a leading cause of morbidity and mortality. Diabetic kidney disease (DKD), a severe complication of diabetes, is a leading determinant of CKD. The escalating diabetes prevalence and the complex regional landscape in Mexico underscore the pressing need for tailored strategies to reduce the burden of CKD. This narrative review, endorsed by the Mexican College of Nephrologists, aims to provide a brief overview and specific strategies for healthcare providers regarding preventing, screening, and treating CKD in patients living with diabetes in all care settings. The key topics covered in this review include the main cardiometabolic contributors of DKD (overweight/obesity, hyperglycemia, arterial hypertension, and dyslipidemia), the identification of kidney-related damage markers, and the benefit of novel pharmacological approaches based on Sodium-Glucose Co-Transporter-2 Inhibitors (SGLT2i) and Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RA). We also address the potential use of novel therapies based on Mineralocorticoid Receptor Antagonists (MRAs) and their future implications. Emphasizing the importance of multidisciplinary treatment, this narrative review aims to promote strategies that may be useful to alleviate the burden of DKD and its associated complications. It underscores the critical role of healthcare providers and advocates for collaborative efforts to enhance the quality of life for millions of patients affected by DKD.
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Affiliation(s)
- Silvia Palomo-Piñón
- Vicepresidente del Colegio de Nefrólogos de México AC, Mexico City, Mexico
- Directora General del Registro Nacional de Hipertensión Arterial México (RIHTA) Grupo de Expertos en Hipertensión Arterial México (GREHTA), Mexico City, Mexico
| | | | | | - Felipe Ericel Hernández-Arellanes
- Departamento de Nefrología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | | | - María Juana Pérez-López
- Departamento de Nefrología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Fabiola Pazos-Pérez
- Nefrología, UMAE Hospital de Especialidades Dr. Bernardo Sepúlveda Gutiérrez, Centro Medico Siglo XXI, Mexico City, Mexico
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Pesantez M, Ebekozien O, Vendrame F. Type 1 Diabetes and Cardiovascular Health. Endocrinol Metab Clin North Am 2024; 53:151-163. [PMID: 38272593 DOI: 10.1016/j.ecl.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Type 1 diabetes (T1D) is associated with an increased risk of cardiovascular disease (CVD). CVD occurs much earlier in people with T1D than in the general population, and several risk factors have been identified some of which are modifiable. Risk prediction models and imaging tests to detect early signs of CVD have not been extensively validated. Strategies to promote cardiovascular health (CVH) in T1D include identifying risk factors, early treatment to achieve CVH targets, and improving the education of health care providers and people with T1D.
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Affiliation(s)
- Maria Pesantez
- Jackson Memorial Hospital, 1450 Northwest 10 Avenue, Miami, FL 33136, USA
| | - Osagie Ebekozien
- T1D Exchange, 101 Federal Street Suite 440, Boston, MA 02110, USA
| | - Francesco Vendrame
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, 1450 Northwest 10 Avenue, Room 1086, Miami, FL 33136, USA.
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S219-S230. [PMID: 38078574 PMCID: PMC10725805 DOI: 10.2337/dc24-s011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Jansson Sigfrids F, Groop PH. Progression and regression of kidney disease in type 1 diabetes. FRONTIERS IN NEPHROLOGY 2023; 3:1282818. [PMID: 38192517 PMCID: PMC10773897 DOI: 10.3389/fneph.2023.1282818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024]
Abstract
Diabetic kidney disease is distinguished by the presence of albuminuria, hypertension, declining kidney function, and a markedly elevated cardiovascular disease risk. This constellation of clinical features drives the premature mortality associated with type 1 diabetes. The first epidemiological investigations concerning type 1 diabetes-related albuminuria date back to the 1980s. The early studies found that proteinuria - largely equivalent to severe albuminuria - developed in 35 to 45% of individuals with type 1 diabetes, with the diabetes duration-specific incidence rate pattern portraying one or two peaks. Furthermore, moderate albuminuria, the first detectable sign of diabetic kidney disease, was found to nearly inexorably progress to overt kidney disease within a short span of time. Since the early reports, studies presenting more updated incidence rates have appeared, although significant limitations such as study populations that lack broad generalizability, study designs vulnerable to substantive selection bias, and constrained follow-up times have been encountered by many. Nevertheless, the most recent reports estimate that in modern times, moderate - instead of severe - albuminuria develops in one-third of individuals with type 1 diabetes; yet, a considerable part (up to 40% during the first ten years after the initial albuminuria diagnosis) progresses to more advanced stages of the disease over time. An alternative pathway to albuminuria progression is its regression, which affects up to 60% of the individuals, but notably, the relapse rate to a more advanced disease stage is high. Whether albuminuria regression translates into a decline in cardiovascular disease and premature mortality risk is an area of debate, warranting more detailed research in the future. Another unclear but alarming feature is that although the incidence of severe albuminuria has fallen since the 1930s, the decline seems to have reached a plateau after the 1980s. This stagnation may be due to the lack of kidney-protective medicines since the early 1980s, as the recent breakthroughs in type 2 diabetes have not been applicable to type 1 diabetes. Therefore, novel treatment strategies are at high priority within this patient population.
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Affiliation(s)
- Fanny Jansson Sigfrids
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
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8
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方 晨, 孙 丽, 刘 研, 肖 力, 孙 林. [Non-Classical Clinical Types and Pathological Changes of Diabetic Kidney Disease: A Review]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2023; 54:1074-1079. [PMID: 38162079 PMCID: PMC10752793 DOI: 10.12182/20231160102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Indexed: 01/03/2024]
Abstract
Diabetic kidney disease (DKD) is a common complication of diabetes mellitus and approximately 1/3 of diabetic patients may progress to DKD. A typical early clinical manifestation of DKD is microalbuminuria and patients may present with macroproteinuria accompanied by a decrease in renal function condition as the disease progresses. It is generally believed that the likelihood of a reversal of the disease is reduced after the development of macroproteinuria in patients with DKD, and that eventually some patients' condition may develop into end-stage renal disease (ESRD). Moreover, the thickening of the glomerular basement membrane, mesangial matrix expansion, Kimmelstiel-Wilson (K-W) nodules, and glomerulosclerosis in end-stage diabetes mellitus are typical pathologic changes of DKD. However, some DKD patients, especially those with type 2 diabetes mellitus (T2DM) combined with DKD, may have diverse clinical manifestations, showing variations in disease progression and regression, and manifesting as non-classical types of DKD, such as normoalbuminuric DKD, proteinuria-reduced DKD, and DKD with rapid decline in renal function. In addition, the formation of crescents, a special pathological change, is observed in renal biopsy. However, this issue is currently under-recognized by clinicians and therefore deserves more attention. In order to improve clinicians' understanding of the presentations and pathological changes of non-classical DKD and the level of DKD prevention and treatment in China, we present a preliminary introduction to the clinical phenotypes and pathological changes of non-classical types of DKD in this paper by summarizing the findings of our prior studies as well as domestic and international literature.
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Affiliation(s)
- 晨茜 方
- 中南大学湘雅二医院 肾内科 (长沙 410011)Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - 丽雅 孙
- 中南大学湘雅二医院 肾内科 (长沙 410011)Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - 研 刘
- 中南大学湘雅二医院 肾内科 (长沙 410011)Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - 力 肖
- 中南大学湘雅二医院 肾内科 (长沙 410011)Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - 林 孙
- 中南大学湘雅二医院 肾内科 (长沙 410011)Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
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9
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Heerspink HJL, Birkenfeld AL, Cherney DZI, Colhoun HM, Ji L, Mathieu C, Groop PH, Pratley RE, Rosas SE, Rossing P, Skyler JS, Tuttle KR, Lawatscheck R, Scott C, Edfors R, Scheerer MF, Kolkhof P, McGill JB. Rationale and design of a randomised phase III registration trial investigating finerenone in participants with type 1 diabetes and chronic kidney disease: The FINE-ONE trial. Diabetes Res Clin Pract 2023; 204:110908. [PMID: 37805000 DOI: 10.1016/j.diabres.2023.110908] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 10/09/2023]
Abstract
AIMS Despite guideline-recommended treatments, including renin angiotensin system inhibition, up to 40 % of individuals with type 1 diabetes develop chronic kidney disease (CKD) putting them at risk of kidney failure. Finerenone is approved to reduce the risk of kidney failure in individuals with type 2 diabetes. We postulate that finerenone will demonstrate benefits on kidney outcomes in people with type 1 diabetes. METHODS FINE-ONE (NCT05901831) is a randomised, placebo-controlled, double-blind phase III trial of 7.5 months' duration in ∼220 adults with type 1 diabetes, urine albumin/creatinine ratio (UACR) of ≥ 200-< 5000 mg/g (≥ 22.6-< 565 mg/mmol) and eGFR of ≥ 25-< 90 ml/min/1.73 m2. RESULTS The primary endpoint is relative change in UACR from baseline over 6 months. UACR is used as a bridging biomarker (BB), since the treatment effect of finerenone on UACR was associated with its efficacy on kidney outcomes in the type 2 diabetes trials. Based on regulatory authority feedback, UACR can be used as a BB for kidney outcomes to support registration of finerenone in type 1 diabetes, provided necessary criteria are met. Secondary outcomes include incidences of treatment-emergent adverse events, treatment-emergent serious adverse events and hyperkalaemia. CONCLUSIONS FINE-ONE will evaluate the efficacy and safety of finerenone in type 1 diabetes and CKD. Finerenone could become the first registered treatment for CKD associated with type 1 diabetes in almost 30 years. TRIAL REGISTRATION ClinicalTrials.gov NCT05901831.
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Affiliation(s)
- Hiddo J L Heerspink
- Clinical Pharmacy and Pharmacology, University of Groningen University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, Netherlands.
| | - Andreas L Birkenfeld
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Otfried Müller Street 47, 72076 Tübingen, Germany; German Centre for Diabetes Research (DZD), Neuherberg, Germany; Department of Internal Medicine, Division of Endocrinology, Diabetology and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - David Z I Cherney
- Division of Nephrology, University Health Network, Toronto General Hospital, University of Toronto, 585 University Ave, 8N-845, Toronto, Ontario M5G 2N2, Canada
| | - Helen M Colhoun
- Institute of Genetics and Cancer, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH4 2XU, UK
| | - Linong Ji
- Departments of Endocrinology and Metabolism, Peking University People's Hospital, Peking University Diabetes Centre, No 11, Xizhimen South Street, Beijing 100044, China
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium
| | - Per-Henrik Groop
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki (C318b), Haartmaninkatu 8, FIN-00290 Helsinki, Finland
| | - Richard E Pratley
- AdventHealth Translational Research Institute, Orlando, FL 32804, USA
| | - Sylvia E Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Harvard Medical School, One Joslin Place, Boston, MA 02215, USA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730 Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen N, Denmark
| | - Jay S Skyler
- Department of Medicine, University of Miami, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Katherine R Tuttle
- Providence Inland Northwest Health, University of Washington School of Medicine, 105 W. 8th Avenue, Suite 250 E, Spokane, WA 99204, USA
| | - Robert Lawatscheck
- Cardiology and Nephrology Clinical Research, Bayer AG, Research & Development, Pharmaceuticals, Clinical Development, Building S101, 13342 Berlin, Germany
| | - Charlie Scott
- Data Science and Analytics, Bayer PLC, Research & Development, Pharmaceuticals, 400 South Oak Way, Reading RG2 6AD, UK
| | - Robert Edfors
- Cardiovascular Studies & Pipeline, Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Building S102, 13342 Berlin, Germany
| | - Markus F Scheerer
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, TA CardioRenal & Heart Disease, Bayer AG, Building S102, 04/160, 13353 Berlin, Germany
| | - Peter Kolkhof
- Research and Development, Pharmaceuticals, Cardiovascular Precision Medicines, Bayer AG, 42113 Wuppertal, Germany
| | - Janet B McGill
- Division of Endocrinology, Metabolism & Lipid Research, Washington University in St. Louis, School of Medicine, 660 S. Euclid, Campus Box 8127, St. Louis, MO 63110, USA
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Wretlind A, Curovic VR, Suvitaival T, Theilade S, Tofte N, Winther SA, Vilsbøll T, Vestergaard H, Rossing P, Legido-Quigley C. Ceramides as Risk Markers for Future Cardiovascular Events and All-Cause Mortality in Long-standing Type 1 Diabetes. Diabetes 2023; 72:1493-1501. [PMID: 37478203 PMCID: PMC10545556 DOI: 10.2337/db23-0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
Ceramides are lipid molecules involved in inflammation-related signaling. Recent studies have shown that higher amounts of specific circulating ceramides and their ratios are associated with future development of cardiovascular (CV) disease (CVD). We examined the associations between serum ceramide levels with CVD, kidney failure, and all-cause mortality in individuals with long-standing type 1 diabetes (T1D). We included 662 participants with T1D and 6-year follow-up, with a mean age of 55 years and mean diabetes duration of 33 years. Baseline serum samples were analyzed using liquid chromatography-mass spectrometry. Six predefined ceramide levels were measured, and predefined ratios were calculated. Adjusted Cox regression analyses on ceramide levels in relation to future CV events (CVE), kidney failure, and all-cause mortality were performed, with and without adjustment for age, sex, BMI, LDL, triglycerides, systolic blood pressure, HbA1c, history of CVD, smoking status, statin use, estimated glomerular filtration rate (eGFR), and urinary albumin excretion rate (UAER). The ceramide ratio cer(d18:1/18:0)/cer(d18:1/24:0) was significantly associated with risk of CVE (hazard ratio [HR] = 1.33, P = 0.01) and all-cause mortality (HR = 1.48, P = 0.01) before and after adjustments. All five investigated ceramide ratios were associated with kidney failure, before adjusting for the kidney markers eGFR and UAER. In this study, we demonstrate specific ceramides and ratios associated with 6-year cardiovascular risk and all-cause mortality in a T1D cohort. This highlights the strength of ceramide association with vascular complications and presents a new potential tool for early risk assessment if validated in other cohorts. ARTICLE HIGHLIGHTS Improved tools for assessing risk for diabetes complication before onset will help in complication prevention. We investigated a set of six predefined ceramides and their ratios versus 6-year outcomes of cardiovascular events, kidney failure, and all-cause mortality in people with long-standing type 1 diabetes, using Cox regression with and without adjustment for potential confounders. We found that several ceramides and ceramide ratios associated with cardiovascular events and all-cause mortality. The ratio of cer(d18:1/18:0)/cer(d18:1/24:0) was an especially robust marker. These finding show that ceramides can be biomarkers of cardiovascular disease and all-cause mortality in individuals with long-standing type 1 diabetes.
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Affiliation(s)
- Asger Wretlind
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | | | | | - Simone Theilade
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Herlev-Gentofte Hospital, Herlev, Denmark
| | | | | | | | - Henrik Vestergaard
- University of Copenhagen, Copenhagen, Denmark
- Bornholms Hospital, Rønne, Denmark
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- University of Copenhagen, Copenhagen, Denmark
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11
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Park SK, Jung JY, Kim MH, Oh CM, Ha E, Yang EH, Lee HC, Shin S, Hwang WY, Lee S, Shin SY, Ryoo JH. Changes in proteinuria and the associated risks of ischemic heart disease, acute myocardial infarction, and angina pectoris in Korean population. Epidemiol Health 2023; 45:e2023088. [PMID: 37817566 PMCID: PMC10867523 DOI: 10.4178/epih.e2023088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/13/2023] [Accepted: 03/14/2023] [Indexed: 10/12/2023] Open
Abstract
OBJECTIVES Proteinuria is widely used to predict cardiovascular risk. However, there is insufficient evidence to predict how changes in proteinuria may affect the incidence of cardiovascular disease. METHODS The study included 265,236 Korean adults who underwent health checkups in 2003-2004 and 2007-2008. They were categorized into 4 groups based on changes in proteinuria (negative: negative → negative; resolved: proteinuria ≥1+ → negative; incident: negative → proteinuria ≥1+; persistent: proteinuria ≥1+ → proteinuria ≥1+). We conducted 6 years of follow-up to identify the risks of developing ischemic heart disease (IHD), acute myocardial infarction (AMI), and angina pectoris according to changes in proteinuria. A multivariate Cox proportional-hazards model was used to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for incident IHD, AMI, and angina pectoris. RESULTS The IHD risk (expressed as HR [95% CI]) was the highest for persistent proteinuria, followed in descending order by incident and resolved proteinuria, compared with negative proteinuria (negative: reference, resolved: 1.211 [95% CI, 1.104 to 1.329], incident: 1.288 [95% CI, 1.184 to 1.400], and persistent: 1.578 [95% CI, 1.324 to 1.881]). The same pattern was associated with AMI (negative: reference, resolved: 1.401 [95% CI, 1.048 to 1.872], incident: 1.606 [95% CI, 1.268 to 2.035], and persistent: 2.069 [95% CI, 1.281 to 3.342]) and angina pectoris (negative: reference, resolved: 1.184 [95% CI, 1.065 to 1.316], incident: 1.275 [95% CI, 1.160 to 1.401], and persistent: 1.554 [95% CI, 1.272 to 1.899]). CONCLUSIONS Experiencing proteinuria increased the risks of IHD, AMI, and angina pectoris even after proteinuria resolved.
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Affiliation(s)
- Sung Keun Park
- Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju Young Jung
- Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min-Ho Kim
- Department of Preventive Medicine, Graduate School, Kyung Hee University, Seoul, Korea
- Informatization Department, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Chang-Mo Oh
- Department of Preventive Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Eunhee Ha
- Department of Occupational and Environment Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Eun Hye Yang
- Department of Occupational and Environmental Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Hyo Choon Lee
- Department of Occupational and Environmental Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Soonsu Shin
- Department of Preventive Medicine, Graduate School, Kyung Hee University, Seoul, Korea
| | - Woo Yeon Hwang
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital, Seoul, Korea
| | - Sangho Lee
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | - So Youn Shin
- Department of Radiology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae-Hong Ryoo
- Department of Occupational and Environmental Medicine, Kyung Hee University School of Medicine, Seoul, Korea
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12
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Khatri M, Ryan CM, Gao X, de Boer IH, Braffett BH, Molitch M, Karger AB, Lorenzi GM, Lee P, Trapani VR, Lachin JM, Jacobson AM. CKD Associates with Cognitive Decline in Middle-Aged and Older Adults with Long-Standing Type 1 Diabetes. KIDNEY360 2023; 4:1058-1071. [PMID: 37291722 PMCID: PMC10476689 DOI: 10.34067/kid.0000000000000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 06/10/2023]
Abstract
Key Points We found that development of both albuminuria and reduced eGFR was associated with clinically significant cognitive decline, particularly in the psychomotor and mental efficiency domain. There was also a significant interaction between worsened albuminuria and eGFR, the combination of which augmented cognitive deficits. A more comprehensive longitudinal phenotype of albuminuria showed that regressed albuminuria did not associate with worsened cognitive decline, as opposed to persistent albuminuria. Background Individuals with CKD or type 1 diabetes (T1D) are at risk for cognitive decline, but it is unclear whether these associations are with albuminuria, eGFR, or both. Methods We examined the longitudinal relationships between CKD and change in cognition in 1051 participants with T1D in the Diabetes Control and Complications Trial and its follow-up, the Epidemiology of Diabetes Interventions and Complications study. Albumin excretion rate and eGFR were measured every 1–2 years. Three cognitive domains were assessed repeatedly over a 32-year period: immediate memory, delayed memory, and psychomotor and mental efficiency. Associations between cognitive function and CKD were assessed: (1 ) longitudinally and (2 ) in models using eGFR and albuminuria measurements over the first 15–20 years with subsequent change in cognitive function over the ensuing 14 years (when decline in cognition was greatest). Results In fully adjusted longitudinal analyses, the magnitude of decline in the psychomotor and mental efficiency domain score was associated with eGFR <60 ml/min per 1.73 m2 (β −0.449; 95% confidence interval [CI], −0.640 to −0.259) and sustained albumin excretion rate 30 to <300 mg/24 hours (β −0.148; 95% CI, −0.270 to −0.026). This was equivalent to a decrease associated with approximately 11 and 4 years of aging, respectively. In analyses focused on changes in cognition between study years 18 and 32, eGFR <60 ml/min per 1.73 m2 was associated with reduced psychomotor and mental efficiency (β −0.915; 95% CI, −1.613 to −0.217). Conclusions In T1D, development of CKD was associated with a subsequent reduction on cognitive tasks requiring psychomotor and mental efficiency. These data highlight the need for increased recognition of risk factors for neurologic sequelae in patients with T1D, as well as preventive and treatment strategies to ameliorate cognitive decline.
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Affiliation(s)
- Minesh Khatri
- NYU Long Island School of Medicine, Mineola, New York
| | | | - Xiaoyu Gao
- Biostatistics Center, The George Washington University, Rockville, Maryland
| | - Ian H. de Boer
- Division of Nephrology, University of Washington, Seattle, Washington
| | | | - Mark Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amy B. Karger
- University of Minnesota Twin Cities, Twin Cities, Minnesota
| | | | - Pearl Lee
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - John M. Lachin
- Biostatistics Center, The George Washington University, Rockville, Maryland
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13
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Heerspink HJ, Cherney DZ, Groop PH, Matthieu C, Rossing P, Tuttle KR, McGill JB. People with type 1 diabetes and chronic kidney disease urgently need new therapies: a call for action. Lancet Diabetes Endocrinol 2023:S2213-8587(23)00168-7. [PMID: 37364589 DOI: 10.1016/s2213-8587(23)00168-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023]
Affiliation(s)
- Hiddo Jl Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, 9700 RB Groningen, Netherlands; The George Institute for Global Health, Sydney, NSW, Australia.
| | | | - Per-Henrik Groop
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland; Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | | | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA, USA; Kidney Research Institute and Institute of Translational Health Sciences, University of Washington, Seattle, WA, USA
| | - Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO, USA
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14
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Lan NSR, Bell DA, Watts GF, Fegan PG. Lipid-lowering therapies and cardiovascular risk-stratification strategies in adults with type 1 diabetes. Curr Opin Endocrinol Diabetes Obes 2023; 30:103-112. [PMID: 36472130 DOI: 10.1097/med.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of mortality in adults with type 1 diabetes (T1D). Although dyslipidaemia is a modifiable and prevalent risk factor in individuals with T1D, determining when to initiate lipid-lowering therapy for primary prevention of ASCVD can be challenging. In this article, recommendations for lipid-lowering therapy from updated clinical guidelines over the last 5 years, additional risk-stratification methods, hypertriglyceridaemia management and potential barriers to optimal care in adults with T1D are discussed. RECENT FINDINGS Low-density lipoprotein cholesterol (LDL-C) is the primary target for lipid-lowering. However, international guidelines recommend differing approaches to ASCVD risk-stratification, lipid-lowering, and LDL-C goals in individuals with diabetes, predominantly reflecting evidence from studies in type 2 diabetes. Despite guideline recommendations, several studies have demonstrated that statins are underused, and LDL-C goals are not attained by many individuals with T1D. Additional risk-stratification methods including T1D-specific ASCVD risk calculators, coronary artery calcium scoring, and lipoprotein(a) may provide additional information to define when to initiate lipid-lowering therapy. SUMMARY Clinical trial evidence for lipid-lowering therapies in T1D is lacking, and further studies are needed to inform best practice. Optimization and harmonization of ASCVD risk-stratification and lipid management in individuals with T1D is required.
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Affiliation(s)
- Nick S R Lan
- Medical School, University of Western Australia
- Department of Cardiology, Royal Perth Hospital
| | - Damon A Bell
- Medical School, University of Western Australia
- Department of Clinical Biochemistry and Cardiovascular Genetics, PathWest Laboratory Medicine WA, Royal Perth and Fiona Stanley Hospitals
- Department of Biochemistry, Clinipath Pathology, Sonic Healthcare
- Departments of Internal Medicine and Cardiology, Royal Perth Hospital
| | - Gerald F Watts
- Medical School, University of Western Australia
- Departments of Internal Medicine and Cardiology, Royal Perth Hospital
| | - P Gerry Fegan
- Medical School, Curtin University
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Australia
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15
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Bebu I, Braffett BH, de Boer IH, Aiello LP, Bantle JP, Lorenzi GM, Herman WH, Gubitosi-Klug RA, Perkins BA, Lachin JM, Molitch ME. Relationships Between the Cumulative Incidences of Long-term Complications in Type 1 Diabetes: The DCCT/EDIC Study. Diabetes Care 2023; 46:361-368. [PMID: 36520643 PMCID: PMC9887612 DOI: 10.2337/dc22-1744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To describe the relationships between the cumulative incidences of long-term complications in individuals with type 1 diabetes (T1D) and assess whether observed associations are independent of age, duration of diabetes, and glycemic levels. METHODS Proliferative diabetic retinopathy (PDR), clinically significant macular edema (CSME), reduced estimated glomerular filtration rate (eGFR), amputations, cardiovascular disease (CVD), and mortality were assessed in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study over ∼30 years. RESEARCH DESIGN AND RESULTS The cumulative incidence of complications ranged from 3% (amputations) to 37% (CSME). There were large differences in the cumulative incidence of PDR between participants with versus without prior CSME (66% vs. 15%), reduced eGFR (59% vs. 29%), and amputation (68% vs. 32%); reduced eGFR with or without prior PDR (25% vs. 9%), amputation (48% vs. 13%), and CVD (30% vs. 11%); CVD with or without prior reduced eGFR (37% vs. 14%) and amputation (50% vs. 16%); and mortality with or without prior reduced eGFR (22% vs. 9%), amputation (35% vs. 8%), and CVD (25% vs. 8%). Adjusted for age, duration of T1D, and mean updated HbA1c, the complications and associations with higher risk included PDR with CSME (hazard ratio [HR] 1.88; 95% CI 1.42, 2.50), reduced eGFR (HR 1.41; 95% CI 1.01, 1.97), and CVD (HR 1.43; 95% CI 1.06, 1.92); CSME with higher risk of PDR (HR 3.94; 95% CI 3.18 4.89), reduced eGFR (HR 1.49; 95% CI 1.10, 2.01), and CVD (HR 1.35; 95% CI 1.03, 1.78); reduced eGFR with higher risk of CVD (HR 2.09; 95% CI 1.44, 3.03), and death (HR 3.40; 95% CI 2.35, 4.92); amputation(s) with death (HR 2.97; 95% CI 1.70, 2.90); and CVD with reduced eGFR (HR 1.59; 95% CI 1.08, 2.34) and death (HR 1.95; 95% CI 1.32, 2.90). CONCLUSIONS Long-term micro- and macrovascular complications and mortality are highly correlated. Age, diabetes duration, and glycemic levels do not completely explain these associations.
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Affiliation(s)
- Ionut Bebu
- Biostatistics Center, The George Washington University, Rockville, MD
| | | | - Ian H. de Boer
- Division of Nephrology, University of Washington, Seattle, WA
| | - Lloyd P. Aiello
- Department of Ophthalmology, Joslin Diabetes Center, Boston, MA
| | - John P. Bantle
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Gayle M. Lorenzi
- Department of Medicine, University of California San Diego, La Jolla, CA
| | | | | | - Bruce A. Perkins
- Division of Endocrinology and Metabolism, University of Toronto, Toronto, Canada
| | - John M. Lachin
- Biostatistics Center, The George Washington University, Rockville, MD
| | - Mark E. Molitch
- Division of Endocrinology, Metabolism, and Molecular Medicine, Department of Medicine, Northwestern University, Chicago, IL
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16
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Khan MS, Shahid I, Anker SD, Fonarow GC, Fudim M, Hall ME, Hernandez A, Morris AA, Shafi T, Weir MR, Zannad F, Bakris GL, Butler J. Albuminuria and Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 81:270-282. [PMID: 36653095 DOI: 10.1016/j.jacc.2022.10.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/03/2022] [Indexed: 01/18/2023]
Abstract
Although chronic kidney disease is characterized by low glomerular filtration rate (GFR) or albuminuria, estimated GFR (eGFR) is more widely utilized as a marker of risk profile in cardiovascular diseases, including heart failure (HF). The presence and magnitude of albuminuria confers a strong prognostic association in forecasting risk of incident HF as well as its progression, irrespective of eGFR. Despite the high prevalence of albuminuria in HF, whether it adds incremental prognostic information in clinical practice and serves as an independent risk marker, and whether there are any therapeutic implications of assessing albuminuria in patients with HF is less well-established. In this narrative review, we assess the potential role of albuminuria in risk profiling for development and progression of HF, strengths and limitations of utilizing albuminuria as a risk marker, its ability to serve in HF risk prediction models, and the implications of adopting albuminuria as an effective parameter in cardiovascular trials and practice.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA. https://twitter.com/ShahzebkhanMD
| | - Izza Shahid
- Division of Preventive Cardiology, Department of Cardiology, Houston Methodist Academic Institute, Houston, Texas, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Charité-Universitätsmedizin Berlin; Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research, Berlin, Germany
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles, California, USA
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Michael E Hall
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Adrian Hernandez
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Alanna A Morris
- Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Tariq Shafi
- Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Matthew R Weir
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Faiez Zannad
- Université de Lorraine, CIC Inserm, CHRU, Nancy, France
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA.
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17
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S191-S202. [PMID: 36507634 PMCID: PMC9810467 DOI: 10.2337/dc23-s011] [Citation(s) in RCA: 109] [Impact Index Per Article: 109.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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18
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Bjornstad P, Dart A, Donaghue KC, Dost A, Feldman EL, Tan GS, Wadwa RP, Zabeen B, Marcovecchio ML. ISPAD Clinical Practice Consensus Guidelines 2022: Microvascular and macrovascular complications in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1432-1450. [PMID: 36537531 DOI: 10.1111/pedi.13444] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Petter Bjornstad
- Section of Endocrinology, Department of Pediatrics, Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Allison Dart
- Department of Pediatrics, Divison of Nephrology, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Kim C Donaghue
- Department of Pediatrics, Division of Endocrinology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Axel Dost
- Department of Pediatrics, Division of Endocrinology, Jena University Hospital, Jena, Germany
| | - Eva L Feldman
- Department of Medicine, Division of Neurology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Gavin S Tan
- Singapore Eye Research Institute, Singapore National Eye Center, Singapore.,Department of Ophthalmology and Visual Sciences, Duke-NUS Medical School, National University of Singapore, Singapore
| | - R Paul Wadwa
- Section of Endocrinology, Department of Pediatrics, Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Bedowra Zabeen
- Department of Paediatrics and Changing Diabetes in Children Program, Bangladesh Institute of Research and Rehabilitation in Diabetes Endocrine and Metabolic Disorders, Dhaka, Bangladesh
| | - M Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge, and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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19
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Rossing P, Caramori ML, Chan JC, Heerspink HJ, Hurst C, Khunti K, Liew A, Michos ED, Navaneethan SD, Olowu WA, Sadusky T, Tandon N, Tuttle KR, Wanner C, Wilkens KG, Zoungas S, de Boer IH. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int 2022; 102:S1-S127. [PMID: 36272764 DOI: 10.1016/j.kint.2022.06.008] [Citation(s) in RCA: 313] [Impact Index Per Article: 156.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 02/07/2023]
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20
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Seyed Ahmadi S, Pivodic A, Svensson AM, Wedel H, Rathsman B, Nyström T, Ludvigsson J, Lind M. Risk factors for nephropathy in persons with type 1 diabetes: a population-based study. Acta Diabetol 2022; 59:761-772. [PMID: 35201418 PMCID: PMC9085666 DOI: 10.1007/s00592-022-01863-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/19/2021] [Indexed: 12/22/2022]
Abstract
AIMS Albuminuria is strongly associated with risk of renal dysfunction, cardiovascular disease and mortality. However, clinical guidelines diverge, and evidence is sparse on what risk factor levels regarding blood pressure, blood lipids and BMI are needed to prevent albuminuria in adolescents and young adults with type 1 diabetes. METHODS A total of 9347 children and adults with type 1 diabetes [mean age 15.3 years and mean diabetes duration 1.4 years at start of follow-up] from The Swedish National Diabetes Registry were followed from first registration until end of 2017. Levels for risk factors for a risk increase in nephropathy were evaluated, and the gradient of risk per 1 SD (standard deviation) was estimated to compare the impact of each risk factor. RESULTS During the follow-up period, 8610 (92.1%) remained normoalbuminuric, 737 (7.9%) individuals developed micro- or macroalbuminuria at any time period of whom 132 (17.9% of 737) individuals developed macroalbuminuria. Blood pressure ≥ 140/80 mmHg was associated with increased risk of albuminuria (p ≤ 0.0001), as were triglycerides ≥ 1.0 mmol/L (p = 0.039), total cholesterol ≥ 5.0 mmol/L (p = 0.0003), HDL < 1.0 mmol/L (p = 0.013), LDL 3.5- < 4.0 mmol/L (p = 0.020), and BMI ≥ 30 kg/m2 (p = 0.033). HbA1c was the strongest risk factor for any albuminuria estimated by the measure gradient of risk per 1 SD, followed by diastolic blood pressure, triglycerides, systolic blood pressure, cholesterol and LDL. In patients with HbA1c > 65 mmol/mol (> 8.1%), blood pressure > 140/70 mmHg was associated with increased risk of albuminuria. CONCLUSIONS Preventing renal complications in adolescents and young adults with type 1 diabetes need avoidance at relatively high levels of blood pressure, blood lipids and BMI, whereas very tight control is not associated with further risk reduction. For patients with long-term poor glycaemic control, stricter blood pressure control is advocated.
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Affiliation(s)
- Shilan Seyed Ahmadi
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
- Department of Medicine, Uddevalla Hospital, 45180, Uddevalla, Sweden.
| | - Aldina Pivodic
- Statistiska Konsultgruppen, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Hans Wedel
- Department of Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Rathsman
- Department of Clinical Science and Education, Sachs' Children and Youth Hospital, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Nyström
- Department of Clinical Science and Education, Internal Medicine, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Johnny Ludvigsson
- Department of Biomedical and Clinical Sciences, Crown Princess Victoria Children's Hospital, and Division of Paediatrics, Linköping University, Linköping, Sweden
| | - Marcus Lind
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
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21
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Continuous Glucose Monitoring metrics in the Assessment of Glycemia in Moderate-to-Advanced Chronic Kidney Disease (CKD) in Diabetes. Kidney Int Rep 2022; 7:1354-1363. [PMID: 35685309 PMCID: PMC9171696 DOI: 10.1016/j.ekir.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/20/2022] [Accepted: 03/28/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Glycated hemoglobin A1c (HbA1c) has reduced reliability in advanced chronic kidney disease (CKD) owing to factors influencing red cell turnover. Recent guidelines support the use of continuous glucose monitoring (CGM) in glycemic assessment in these patients. We evaluated relationships between HbA1c and CGM metrics of average glycemia and glucose variability (GV) in moderate-to-advanced CKD. Methods There were a total of 90 patients with diabetes in CKD stages G3b (n = 33), G4 (n = 43), and G5 (nondialysis) (n = 14) (age [mean ± SD] 65.4 ± 9.0 years, estimated glomerular filtration rate [eGFR] 26.1 ± 9.6 ml/min per 1.73 m2, and HbA1c 7.4 ± 0.8%). CGM metrics were estimated from blinded CGM (Medtronic Ipro2 with Enlite sensor) and compared with HbA1c in the same week. Results Correlations between glucose management indicator (GMI) and HbA1c attenuated with advancing CKD (G3b [r = 0.68, P < 0.0001], G4 [r = 0.52, P < 0.001], G5 [r = 0.22, P = 0.44], P = 0.01 for CKD stage). In G3b and G4, HbA1c correlated significantly with time-in-range (TIR) (3.9–10.0 mmol/l) (r = −0.55 and r = −0.54, respectively) and % time > 13.9 mmol/l (r = 0.53 and r = 0.44, respectively), but not in G5. HbA1c showed no correlation with % time <3.0 mmol/l (r = −0.045, P = 0.67) or % coefficient of variation (CV) (r = −0.05, P = 0.64) in any CKD stage. Only eGFR was a significant determinant of bias for the difference between GMI and HbA1c (difference −0.28%, 95% CI [−0.52 to −0.03] per 15 ml/min per 1.73 m2 decrement, P = 0.03). Conclusion CGM-derived indices might serve as an adjunct to HbA1c monitoring to guide glycemic management, especially in those with eGFR <30 ml/min per 1.73 m2. Time in hypoglycemia and glycemic variability are relevant glycemic targets for optimization not reflected by HbA1c.
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Perkins BA, Bebu I, Gao X, Karger AB, Hirsch IB, Karanchi H, Molitch ME, Zinman B, Lachin JM, de Boer IH. Early Trajectory of Estimated Glomerular Filtration Rate and Long-term Advanced Kidney and Cardiovascular Complications in Type 1 Diabetes. Diabetes Care 2022; 45:585-593. [PMID: 35015817 PMCID: PMC8918200 DOI: 10.2337/dc21-1883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/21/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Rapid loss of estimated glomerular filtration rate (eGFR) within its normal range has been proposed as a strong predictor of future kidney disease. We investigated this association of eGFR slope early in the course of type 1 diabetes with long-term incidence of kidney and cardiovascular complications. RESEARCH DESIGN AND METHODS The annual percentage change in eGFR (slope) was calculated during the Diabetes Control and Complications Trial (DCCT) for each of 1,441 participants over a mean of 6.5 years and dichotomized by the presence or absence of early rapid eGFR loss (slope ≤-3% per year) as the exposure of interest. Outcomes were incident reduced eGFR (eGFR <60 mL/min/1.73 m2), composite cardiovascular events, or major adverse cardiovascular events (MACE) during the subsequent 24 years post-DCCT closeout follow-up. RESULTS At DCCT closeout (the baseline for this analysis), diabetes duration was 12 ± 4.8 years, most participants (85.9%) had normoalbuminuria, mean eGFR was 117.0 ± 13.4 mL/min/1.73 m2, and 149 (10.4%) had experienced early rapid eGFR loss over the preceding trial phase. Over the 24-year subsequent follow-up, there were 187 reduced eGFR (6.3 per 1,000 person-years) and 113 MACE (3.6 per 1,000 person-years) events. Early rapid eGFR loss was associated with risk of reduced eGFR (hazard ratio [HR] 1.81, 95% CI 1.18-2.79, P = 0.0064), but not after adjustment for baseline eGFR level (HR 0.94, 95% CI 0.53-1.66, P = 0.84). There was no association with composite cardiovascular events or MACE. CONCLUSIONS In people with type 1 diabetes primarily with normal eGFR and normoalbuminuria, the preceding slope of eGFR confers no additional association with kidney or cardiovascular outcomes beyond knowledge of an individual's current level.
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Affiliation(s)
- Bruce A. Perkins
- Department of Endocrinology and Metabolism, University of Toronto, Toronto, Ontario, Canada
| | - Ionut Bebu
- The Biostatistics Center, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Xiaoyu Gao
- The George Washington University, Washington, DC
| | - Amy B. Karger
- University of Minnesota Twin Cities, Twin Cities, MN
| | - Irl B. Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA
| | - Harsha Karanchi
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Mark E. Molitch
- Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bernard Zinman
- Departments of Endocrinology and Metabolism, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - John M. Lachin
- The Biostatistics Center, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Ian H. de Boer
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA
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23
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Negative association of time in range and urinary albumin excretion rate in patients with type 2 diabetes mellitus: a retrospective study of inpatients. Chin Med J (Engl) 2022; 135:1052-1056. [PMID: 35089882 PMCID: PMC9276240 DOI: 10.1097/cm9.0000000000001914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Time in range (TIR) refers to the time an individual spends within their target glucose range, which now has been popularized as an important metric to classify glycemic management and also recognized as an important outcome of current diabetes therapies. This study aimed to investigate the association between TIR and the severity of the urinary albumin excretion rate (UAER) in patients with type 2 diabetes mellitus (T2DM). Methods: We retrospectively analyzed the data of 1014 inpatients with T2DM at the Department of Endocrinology and Metabolism of Peking University International Hospital, China. TIR was defined as the percentage of blood glucose within the target range of 3.90–10.00 mmol/L. Urine samples for assessment of UAER were collected for 3 consecutive days from the start of hospitalization. Results: The TIR values for patients with normal urine levels of albumin, microalbuminuria, and macroalbuminuria were 70% ± 20%, 50% ± 20%, and 30% ± 20%, respectively (all P < 0.001). The patients were stratified according to quartiles of TIR as follows: quartile (Q) 1, <55%; Q2, 55%–72%; Q3, 73%–83%; and Q4, >83%. The incidences of microalbuminuria in Q1, Q2, Q3, and Q4 were 41.1%, 21.6%, 7.1%, and 5.5% (all P < 0.001), respectively. The respective incidences of macroalbuminuria were 24.2%, 1.1%, 1.4%, and 0% (all P < 0.001). In multinomial logistic regression analyses, TIR was significantly correlated with microalbuminuria (odds ratio [OR] 0.58, 95% confidence interval [CI]: 0.52–0.65, P < 0.001) and macroalbuminuria (OR 0.26, 95% CI: 0.18–0.38, P < 0.001) after adjusting for age, sex, body mass index, diabetes duration, systolic blood pressure, and levels of triglycerides, glycosylated hemoglobin A1c, and creatinine. Conclusion: The proportion of blood glucose in TIR is closely related to the severity of UAER in patients with T2DM.
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Miller RG, Orchard TJ, Costacou T. 30-Year Cardiovascular Disease in Type 1 Diabetes: Risk and Risk Factors Differ by Long-term Patterns of Glycemic Control. Diabetes Care 2022; 45:142-150. [PMID: 34782353 PMCID: PMC8753768 DOI: 10.2337/dc21-1381] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/07/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We hypothesized that there is heterogeneity in long-term patterns of glycemic control with respect to cardiovascular disease (CVD) development in type 1 diabetes and that risk factors for CVD differ by glycemic control pattern. Thus, we estimated associations between data-derived latent HbA1c trajectories and 30-year CVD risk in the Pittsburgh Epidemiology of Diabetes Complications (EDC) study of childhood-onset (<17 years old) type 1 diabetes. RESEARCH DESIGN AND METHODS Participants (n = 536 with two or more HbA1c measurements [median 6] and CVD-free at baseline; mean age 27 and diabetes duration 18 years) were followed from 1986 to 1988 to 2016 to 2018 to ascertain CVD incidence (CVD death, myocardial infarction, stroke, coronary revascularization or blockage ≥50%, ischemic electrocardiogram, or angina). Latent HbA1c trajectories and their association with time-to-CVD incidence were simultaneously assessed using joint latent class mixed models. RESULTS Two HbA1c trajectories with respect to differential CVD risk were identified: low (HbA1c ∼8% [64 mmol/mol] and improving over follow-up, 76% of cohort) and high (HbA1c ∼10% [86 mmol/mol] and stable, 24%). Overall, 30-year CVD incidence was 47.4% (n = 253); major adverse cardiovascular event incidence was 31.0% (n = 176). High HbA1c was associated with threefold increased CVD risk versus low HbA1c. Both groups had similar age and diabetes duration. Non-HDL cholesterol and estimated glomerular filtration rate were associated with CVD risk only in low HbA1c; albumin excretion rate was associated with CVD risk only in high HbA1c. CONCLUSIONS These risk factor differences suggest that pathways to CVD may differ by glycemic control, potentially resulting in important implications for prognosis in type 1 diabetes.
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Affiliation(s)
- Rachel G. Miller
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Trevor J. Orchard
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Tina Costacou
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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Park YJ, Yang PS, Yu HT, Kim TH, Jang E, Uhm JS, Pak HN, Lee MH, Lip GY, Joung B. Association of proteinuria and hypertension with incident atrial fibrillation in an elderly population: nationwide data from a community-based elderly cohort. J Hypertens 2022; 40:128-135. [PMID: 34857705 PMCID: PMC8654251 DOI: 10.1097/hjh.0000000000002987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/26/2021] [Accepted: 07/17/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The excess risk of atrial fibrillation in relation to the presence of proteinuria associated with hypertension has not been well elucidated. We aimed to determine the effect of hypertension and/or proteinuria on the incidence of atrial fibrillation. Second, we evaluated whether the associations with temporal changes in proteinuria status on the incidence of atrial fibrillation. METHODS AND RESULTS A total of 85 434 participants with hypertension and 125 912 participants without hypertension with age at least 60 years from the Korea National Health Insurance Service-Senior cohort were included. Amongst controls (participants without proteinuria and hypertension), hypertension only, proteinuria only, and hypertension with proteinuria groups, the adjusted incidences of atrial fibrillation were 0.51, 0.69. 0.78 and 0.99 per 100 person-years, respectively after inverse probability of treatment weighting. Compared with controls, the weighted risks of atrial fibrillation in the hypertension only, proteinuria only and hypertension with proteinuria groups were increased by 37% (hazard ratio 1.37, 95% confidence interval, CI 1.30-1.44, P = 0.001), 55% (hazard ratio 1.55, 95% CI 1.28-1.88, P < 0.001), and 98% (hazard ratio 1.98, 95% CI 1.62-2.43, P < 0.001), respectively. Populations who had proteinuria in the first examination had an increased risk of atrial fibrillation even in the group whereby the proteinuria was resolved on the second examination (hazard ratio 1.36, 95% CI 1.12-2.31, P < 0.001). The presence of proteinuria in first and second analysis had the highest risk of incident atrial fibrillation (hazard ratio 1.61, 95% CI 1.12-2.31). CONCLUSION In conclusion, hypertension and/or proteinuria were associated with increased risk of atrial fibrillation, with the greatest risks when both are present. Proteinuria could be a useful factor for predicting atrial fibrillation development.
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Affiliation(s)
- Yoon Jung Park
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul
| | - Pil-Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul
| | - Eunsun Jang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul
| | - Gregory Y.H. Lip
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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27
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Trajectories of kidney function in diabetes: a clinicopathological update. Nat Rev Nephrol 2021; 17:740-750. [PMID: 34363037 DOI: 10.1038/s41581-021-00462-y] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 02/06/2023]
Abstract
Diabetic nephropathy has been traditionally diagnosed based on persistently high albuminuria and a subsequent decline in glomerular filtration rate (GFR), which is widely recognized as the classical phenotype of diabetic kidney disease (DKD). Several studies have emphasized that trajectories of kidney function in patients with diabetes (specifically, changes in GFR and albuminuria over time) can differ from this classical DKD phenotype. Three alternative DKD phenotypes have been reported to date and are characterized by albuminuria regression, a rapid decline in GFR, or non-proteinuric or non-albuminuric DKD. Although kidney biopsies are not typically required for the diagnosis of DKD, a few studies of biopsy samples from patients with DKD have demonstrated that changes in kidney function associate with specific histopathological findings in diabetes. In addition, various clinical and biochemical parameters are related to trajectories of GFR and albuminuria. Collectively, pathological and clinical characteristics can be used to predict trajectories of GFR and albuminuria in diabetes. Furthermore, cohort studies have suggested that the risks of kidney and cardiovascular outcomes might vary among different phenotypes of DKD. A broader understanding of the clinical course of DKD is therefore crucial to improve risk stratification and enable early interventions that prevent adverse outcomes.
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28
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Hanouneh M, Echouffo Tcheugui JB, Jaar BG. Recent advances in diabetic kidney disease. BMC Med 2021; 19:180. [PMID: 34399760 PMCID: PMC8369797 DOI: 10.1186/s12916-021-02050-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 06/30/2021] [Indexed: 01/23/2023] Open
Affiliation(s)
- Mohamad Hanouneh
- Department of Medicine, Johns Hopkins University School of Medicine, 5601 Loch Raven Boulevard, Suite 3 North, Baltimore, MD, 21239, USA.,Nephrology Center of Maryland, Baltimore, MD, USA
| | - Justin B Echouffo Tcheugui
- Department of Medicine, Johns Hopkins University School of Medicine, 5601 Loch Raven Boulevard, Suite 3 North, Baltimore, MD, 21239, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD, USA
| | - Bernard G Jaar
- Department of Medicine, Johns Hopkins University School of Medicine, 5601 Loch Raven Boulevard, Suite 3 North, Baltimore, MD, 21239, USA. .,Nephrology Center of Maryland, Baltimore, MD, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD, USA.
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29
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Diabetic kidney disease: new clinical and therapeutic issues. Joint position statement of the Italian Diabetes Society and the Italian Society of Nephrology on "The natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function". J Nephrol 2021; 33:9-35. [PMID: 31576500 PMCID: PMC7007429 DOI: 10.1007/s40620-019-00650-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aims This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents. Data Synthesis Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., “nonalbuminuric renal impairment” and “progressive renal decline”, suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered. Conclusions The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.
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Abstract
Diabetes mellitus is a disease of dysregulated blood glucose homeostasis. The current pandemic of diabetes is a significant driver of patient morbidity and mortality, as well as a major challenge to healthcare systems worldwide. The global increase in the incidence of diabetes has prompted researchers to focus on the different pathogenic processes responsible for type 1 and type 2 diabetes. Similarly, increased morbidity due to diabetic complications has accelerated research to uncover pathological changes causing these secondary complications. Albuminuria, or protein in the urine, is a well-recognised biomarker and risk factor for renal and cardiovascular disease. Albuminuria is a mediator of pathological abnormalities in diabetes-associated conditions such as nephropathy and atherosclerosis. Clinical screening and diagnosis of diabetic nephropathy is chiefly based on the presence of albuminuria. Given the ease in measuring albuminuria, the potential of using albuminuria as a biomarker of cardiovascular diseases is gaining widespread interest. To assess the benefits of albuminuria as a biomarker, it is important to understand the association between albuminuria and cardiovascular disease. This review examines our current understanding of the pathophysiological mechanisms involved in both forms of diabetes, with specific focus on the link between albuminuria and specific vascular complications of diabetes.
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Affiliation(s)
- Pappitha Raja
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, Northern Ireland, BT9 7BL, UK
| | - Alexander P Maxwell
- Nephrology Research, Centre for Public Health, Queen's University of Belfast, Northern Ireland Regional Nephrology Unit, Belfast City Hospital, Belfast, Northern Ireland, UK
| | - Derek P Brazil
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, Northern Ireland, BT9 7BL, UK.
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31
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Zheng XM, Yang FY, Chen X, Yang YH, Zhu XR, Chen C, Yang JK. Development of a sensitive and reliable ELISA kit of urinary haptoglobin to predict progress of diabetic kidney disease. Diabetes Metab Res Rev 2021; 37:e3432. [PMID: 33400837 DOI: 10.1002/dmrr.3432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/26/2020] [Accepted: 12/14/2020] [Indexed: 01/01/2023]
Abstract
AIMS Urinary haptoglobin (UHp) is a potential biomarker for predicting progress of diabetic kidney disease (DKD) to remedy the defects of currently used urinary albumin. The clinical application of UHp is however limited, owing to the extremely low level in urine. This study aims to establish an enzyme-linked immunosorbent assay (ELISA) kit specifically for detecting UHp in urine samples of patients with diabetes and DKD. MATERIALS AND METHODS Supersensitive human haptoglobin antibodies were generated for ELISA kit development, and the sensitivity, specificity and reproducibility of the kit was evaluated. This kit was used to detect UHp in 246 healthy individuals and 83 patients with type 2 diabetes (T2D). The interference of blood haptoglobin genotypes on UHp measurement was analysed. RESULTS The UHp ELISA kit had a standard curve ranging from 5 to 200 ng/ml. The low detection limit was 0.11 ng/ml. The coefficients of variation of intra- and interassay were 5.5% and 8.3%, respectively. The kit showed high accuracy with 100.9% mean recovery rate, and linearity R2 = 0.999. The reference range of UHp was 0-42.3 ng/g creatinine (0-Q95) in the healthy individuals. UHp level was significantly higher in T2D patients with microalbuminuria and macroalbuminuria than that in T2D without microalbuminuria (p < 0.01). The UHp concentration measured by this kit was not affected by haptoglobin genotypes. CONCLUSIONS We have generated an ELISA kit to accurately detect UHp levels, which is potentially a reliable biomarker of DKD.
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Affiliation(s)
- Xiao-Min Zheng
- Beijing Diabetes Institute, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Department of Endocrinology, Chui Yang Liu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Fang-Yuan Yang
- Beijing Diabetes Institute, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xing Chen
- Shijiazhuang Heya Biotechnology Co., Ltd., Shijiazhuang, China
| | - Yan-Hui Yang
- Shijiazhuang Heya Biotechnology Co., Ltd., Shijiazhuang, China
| | - Xiao-Rong Zhu
- Beijing Diabetes Institute, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chen Chen
- Endocrinology, Faculty of Medicine, School of Biomedical Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Jin-Kui Yang
- Beijing Diabetes Institute, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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32
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Moon S, Tsay JJ, Lampert H, Md Dom ZI, Kostic AD, Smiles A, Niewczas MA. Circulating short and medium chain fatty acids are associated with normoalbuminuria in type 1 diabetes of long duration. Sci Rep 2021; 11:8592. [PMID: 33883567 PMCID: PMC8060327 DOI: 10.1038/s41598-021-87585-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/30/2021] [Indexed: 11/08/2022] Open
Abstract
A substantial number of subjects with Type 1 Diabetes (T1D) of long duration never develop albuminuria or renal function impairment, yet the underlying protective mechanisms remain unknown. Therefore, our study included 308 Joslin Kidney Study subjects who had T1D of long duration (median: 24 years), maintained normal renal function and had either normoalbuminuria or a broad range of albuminuria within the 2 years preceding the metabolomic determinations. Serum samples were subjected to global metabolomic profiling. 352 metabolites were detected in at least 80% of the study population. In the logistic analyses adjusted for multiple testing (Bonferroni corrected α = 0.000028), we identified 38 metabolites associated with persistent normoalbuminuria independently from clinical covariates. Protective metabolites were enriched in Medium Chain Fatty Acids (MCFAs) and in Short Chain Fatty Acids (SCFAs) and particularly involved odd-numbered and dicarboxylate Fatty Acids. One quartile change of nonanoate, the top protective MCFA, was associated with high odds of having persistent normoalbuminuria (OR (95% CI) 0.14 (0.09, 0.23); p < 10-12). Multivariable Random Forest analysis concordantly indicated to MCFAs as effective classifiers. Associations of the relevant Fatty Acids with albuminuria seemed to parallel associations with tubular biomarkers. Our findings suggest that MCFAs and SCFAs contribute to the metabolic processes underlying protection against albuminuria development in T1D that are independent from mechanisms associated with changes in renal function.
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Affiliation(s)
- Salina Moon
- Research Division, Joslin Diabetes Center, One Joslin Place, Boston, MA, 02215, USA
| | - John J Tsay
- Research Division, Joslin Diabetes Center, One Joslin Place, Boston, MA, 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Medicine, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Heather Lampert
- Research Division, Joslin Diabetes Center, One Joslin Place, Boston, MA, 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Family Medicine, Brown University, Providence, RI, USA
| | - Zaipul I Md Dom
- Research Division, Joslin Diabetes Center, One Joslin Place, Boston, MA, 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Aleksandar D Kostic
- Research Division, Joslin Diabetes Center, One Joslin Place, Boston, MA, 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Microbiology, Harvard Medical School, Boston, MA, USA
| | - Adam Smiles
- Research Division, Joslin Diabetes Center, One Joslin Place, Boston, MA, 02215, USA
| | - Monika A Niewczas
- Research Division, Joslin Diabetes Center, One Joslin Place, Boston, MA, 02215, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
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Cosentino F, Grant PJ, Aboyans V, Bailey CJ, Ceriello A, Delgado V, Federici M, Filippatos G, Grobbee DE, Hansen TB, Huikuri HV, Johansson I, Jüni P, Lettino M, Marx N, Mellbin LG, Östgren CJ, Rocca B, Roffi M, Sattar N, Seferović PM, Sousa-Uva M, Valensi P, Wheeler DC. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J 2021; 41:255-323. [PMID: 31497854 DOI: 10.1093/eurheartj/ehz486] [Citation(s) in RCA: 2354] [Impact Index Per Article: 784.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Liew A, Bavanandan S, Prasad N, Wong MG, Chang JM, Eiam-Ong S, Hao CM, Lim CY, Lim SK, Oh KH, Okada H, Susantitaphong P, Lydia A, Tran HTB, Villanueva R, Yeo SC, Tang SCW. ASIAN PACIFIC SOCIETY OF NEPHROLOGY CLINICAL PRACTICE GUIDELINE ON DIABETIC KIDNEY DISEASE. Nephrology (Carlton) 2020; 25 Suppl 2:12-45. [PMID: 33111477 DOI: 10.1111/nep.13785] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Adrian Liew
- The Kidney & Transplant Practice, Mount Elizabeth Novena Hospital, Singapore
| | | | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Muh Geot Wong
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia.,Division of Renal and Metabolic, The George Institute for Global Health, Sydney, Australia
| | - Jer Ming Chang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Taiwan
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chuan-Ming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | | | - Soo Kun Lim
- Renal Division, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University, Seoul, Republic of Korea
| | - Hirokazu Okada
- Department of Nephrology, Saitama Medical University, Saitama, Japan
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Aida Lydia
- Division of Nephrology and Hypertension, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Huong Thi Bich Tran
- Renal Division, Department of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | | | - See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
| | - Sydney C W Tang
- Division of Nephrology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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de Boer IH, Caramori ML, Chan JC, Heerspink HJ, Hurst C, Khunti K, Liew A, Michos ED, Navaneethan SD, Olowu WA, Sadusky T, Tandon N, Tuttle KR, Wanner C, Wilkens KG, Zoungas S, Rossing P. KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int 2020; 98:S1-S115. [PMID: 32998798 DOI: 10.1016/j.kint.2020.06.019] [Citation(s) in RCA: 569] [Impact Index Per Article: 142.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 12/13/2022]
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Cardiovascular disease in type 1 diabetes: A review of epidemiological data and underlying mechanisms. DIABETES & METABOLISM 2020; 46:442-449. [PMID: 32998054 DOI: 10.1016/j.diabet.2020.09.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/27/2020] [Accepted: 09/05/2020] [Indexed: 12/15/2022]
Abstract
Cardiovascular disease (CVD) is highly prevalent in patients with type 1 diabetes (T1D) and a major cause of mortality. CVD arises earlier in life in T1D patients and is responsible for a significant reduction of at least 11 years' life expectancy. Also, the incidence of CVD is much more pronounced in patients with T1D onset at an earlier age. However, the factors responsible for increased atherosclerosis and CVD in T1D are not yet totally clarified. In addition to the usual cardiovascular (CV) risk factors, chronic hyperglycaemia plays an important role by promoting oxidative stress, vascular inflammation, monocyte adhesion, arterial wall thickening and endothelial dysfunction. Diabetic nephropathy and cardiac autonomic neuropathy are also associated with increased CVD in T1D. In fact, the CVD risk remains significantly increased even in well-controlled T1D patients who have no additional CV risk factors, indicating that other potential factors are likely to be involved. Hypoglycemia and glucose variability could enhance CV disease by promoting oxidative stress, vascular inflammation and endothelial dysfunction. Furthermore, even well-controlled T1D patients show significant qualitative and functional abnormalities of lipoproteins that are likely to be implicated in the development of atherosclerosis and premature CVD. In addition, recent data suggest that a dysfunctional immune system, which is typical of autoimmune T1D, might also promote CVD possibly through inflammatory pathways. Moreover, overweight and obese T1D patients can manifest additional CV risk through pathophysiological mechanisms resembling those observed in type 2 diabetes (T2D).
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Błaszkowska M, Shalimova A, Wolnik B, Orłowska-Kunikowska E, Graff B, Hoffmann M, Nilsson P, Wolf J, Narkiewicz K. Subclinical macroangiopathic target organ damage in type 1 diabetes mellitus patients. Blood Press 2020; 29:344-356. [PMID: 32460564 DOI: 10.1080/08037051.2020.1770054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE We have summarized key studies regarding the assessment of subclinical macroangiopathic target organ damage (TOD) in type 1 diabetes mellitus (T1DM). RESULTS Although chronic complications resulting from hyperglycemia, in particular macroangiopathies, are still the first cause of death in T1DM, there has been growing recognition of the role of hypoglycemia in cardiovascular morbidity and mortality. Subclinical TOD diagnosis ensures early implementation of the complex management aiming at either partial reversal of these complications or at least its downturn. To better identify patients with early TODs, several non-invasive diagnostic techniques are employed, including the ultrasonographic assessment of the intima-media thickness (IMT), computed tomography (CT) for coronary artery calcium (CAC) scores, and pulse wave velocity (PWV) measurement for arterial stiffness evaluation. Various studies reported that T1DM patients present an increased IMT. An increasing IMT fairly correlates with the cardiovascular (CV) events risk even after the adjustment to age, diabetes duration, quality of glucose control as well as the presence of hypertension, and chronic complications. Another, well established marker of the organ damage - CAC score is recommended by ACC/AHA guidelines to assess the overall CV risk in T1DM. Also, the arterial stiffness evaluation with PWV may further improve CV risk prediction, which has been reported in multiple studies including the Framingham Heart Study. CONCLUSIONS There is shortage of data from prospective studies which could confirm the benefits of early treatment initiation based on the presence of the subclinical organ damage in T1DM. Most evidence comes from T2DM trials, where effective preventive measures were identified i.e.: smoking cessation, reasonable blood glucose control, efficacious hypertension treatment, and dyslipidemia management, as well as renoprotection. There is still a field for further research to see if routine assessment of asymptomatic vascular damage and early implementation of aggressive treatment would reduce mortality excess from CVD in T1DM.
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Affiliation(s)
- Magdalena Błaszkowska
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| | - Anna Shalimova
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland.,Department of Internal Medicine N1, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Bogumił Wolnik
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| | | | - Beata Graff
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| | - Michał Hoffmann
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| | - Peter Nilsson
- Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Jacek Wolf
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
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Shuvy M, Zwas DR, Lotan C, Keren A, Gotsman I. Albuminuria: Associated With Heart Failure Severity and Impaired Clinical Outcomes. Can J Cardiol 2020; 36:527-534. [DOI: 10.1016/j.cjca.2019.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/15/2019] [Accepted: 09/02/2019] [Indexed: 01/17/2023] Open
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Pugliese G, Penno G, Natali A, Barutta F, Di Paolo S, Reboldi G, Gesualdo L, De Nicola L. Diabetic kidney disease: New clinical and therapeutic issues. Joint position statement of the Italian Diabetes Society and the Italian Society of Nephrology on "The natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function". Nutr Metab Cardiovasc Dis 2019; 29:1127-1150. [PMID: 31586514 DOI: 10.1016/j.numecd.2019.07.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 02/06/2023]
Abstract
AIMS This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents. DATA SYNTHESIS Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., "nonalbuminuric renal impairment" and "progressive renal decline", suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered. CONCLUSIONS The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.
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Affiliation(s)
- Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Endocrine and Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy.
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Diabetes Unit, University Hospital, Pisa, Italy
| | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Unit of Internal Medicine, University Hospital, Pisa, Italy
| | - Federica Barutta
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | | | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Nephrology, Dialysis and Transplantation Unit, "Policlinico" University Hospital, Bari, Italy
| | - Luca De Nicola
- Nephrology and Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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41
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Márquez DF, Ruiz-Hurtado G, Segura J, Ruilope L. Microalbuminuria and cardiorenal risk: old and new evidence in different populations. F1000Res 2019; 8. [PMID: 31583081 PMCID: PMC6758838 DOI: 10.12688/f1000research.17212.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2019] [Indexed: 01/13/2023] Open
Abstract
Since the association of microalbuminuria (MAU) with cardiovascular (CV) risk was described, a huge number of reports have emerged. MAU is a specific integrated marker of CV risk and targets organ damage in patients with hypertension, chronic kidney disease (CKD), and diabetes and its recognition is important for identifying patients at a high or very high global CV risk. The gold standard for diagnosis is albumin measured in 24-hour urine collection (normal values of less than 30 mg/day, MAU of 30 to 300 mg/day, macroalbuminuria of more than 300 mg/day) or, more practically, the determination of urinary albumin-to-creatinine ratio in a urine morning sample (30 to 300 mg/g). MAU screening is mandatory in individuals at risk of developing or presenting elevated global CV risk. Evidence has shown that intensive treatment could turn MAU into normoalbuminuria. Intensive treatment with the administration of an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, in combination with other anti-hypertensive drugs and drugs covering other aspects of CV risk, such as mineralocorticoid receptor antagonists, new anti-diabetic drugs, and statins, can diminish the risk accompanying albuminuria in hypertensive patients with or without CKD and diabetes.
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Affiliation(s)
- Diego Francisco Márquez
- Unidad de Hipertensión Arterial-Servicio de Clínica Médica, Hospital San Bernardo, Salta, Argentina
| | - Gema Ruiz-Hurtado
- Instituto de Investigación Imas12 and Unidad de Hipertensión, Hospital 12 de Octubre, Madrid, Spain
| | - Julian Segura
- Instituto de Investigación Imas12 and Unidad de Hipertensión, Hospital 12 de Octubre, Madrid, Spain
| | - Luis Ruilope
- Instituto de Investigación Imas12 and Unidad de Hipertensión, Hospital 12 de Octubre, Madrid, Spain.,Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma, Madrid, Spain.,Escuela de Estudios Postdoctorales and Investigación, Universidad de Europa de Madrid, Madrid, Spain
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Marcovecchio ML, Dalton RN, Daneman D, Deanfield J, Jones TW, Neil HAW, Dunger DB. A new strategy for vascular complications in young people with type 1 diabetes mellitus. Nat Rev Endocrinol 2019; 15:429-435. [PMID: 30996294 DOI: 10.1038/s41574-019-0198-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetes vascular complications, including cardiovascular disease, diabetic nephropathy and retinopathy, have a negative effect on the long-term prognosis of young people with type 1 diabetes mellitus (T1DM). Poor glycaemic control and consequent increased HbA1c levels are major risk factors for the development of vascular complications. HbA1c levels are the main focus of current management strategies; however, the recommended target is rarely achieved in adolescents. Thus, a clear need exists for improved biomarkers to identify high-risk young people early and to develop new intervention strategies. Evidence is accumulating that early increases in urinary albumin excretion could be predictive of adolescents with T1DM who are at an increased risk of developing vascular complications, independent of HbA1c levels. These findings present an opportunity to move towards the personalized care of adolescents with T1DM, which takes into consideration changes in albumin excretion and other risk factors in addition to HbA1c levels.
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Affiliation(s)
| | - R Neil Dalton
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Denis Daneman
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - John Deanfield
- Vascular Physiology Unit, Institute of Cardiovascular Science, University College London, London, UK
| | - Timothy W Jones
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - H Andrew W Neil
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - David B Dunger
- Department of Paediatrics, University of Cambridge, Cambridge, UK.
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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Changes in albuminuria and renal outcome in patients with type 2 diabetes and hypertension: a real-life observational study. J Hypertens 2019; 36:1719-1728. [PMID: 29677050 DOI: 10.1097/hjh.0000000000001749] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To assess the predictive role of changes in albuminuria on the loss of renal function under antihypertensive treatment in patients with type 2 diabetes (T2D). METHODS Clinical records from a total of 12 611 patients with hypertension and T2D, attending 100 antidiabetic centers in Italy, with normal estimated glomerular filtration rate (eGFR) at baseline and regular visits during a 4-year period were retrieved and analyzed. We assessed the association between changes in albuminuria status during a 1-year baseline period and time updated blood pressure (BP) and eGFR loss over the subsequent 4-year follow-up. RESULTS Mean age at baseline was 65 ± 9 years, known duration of diabetes11 ± 8 years, eGFR 85 ± 13 ml/min and BP 142 ± 17/81 ± 9 mmHg. Patients with persistent albuminuria showed the highest 4-year risk of eGFR loss more than 30% from baseline or onset of stage 3 chronic kidney disease (eGFR < 60 ml/min) as compared with those with persistent normal albuminuria (odds ratio 2.00, confidence interval 1.71-2.34; P < 0.001). Female sex, age, disease duration, BMI, low baseline eGFR, lipid profile, the number of antihypertensive drugs and variations in albuminuria status were associated with renal risk in the whole study population. Furthermore, lower time updated BP values and the use of renin-angiotensin-aldosterone-system-inhibitors were related to the occurrence of renal endpoints only in the subgroup of patients without albuminuria. CONCLUSION In patients with hypertension and T2D under real-life clinical conditions, changes in albuminuria parallel changes of renal risk. Albuminuria status could be a guide to optimize therapeutic strategy.
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Miller RG, Costacou T, Orchard TJ. Risk Factor Modeling for Cardiovascular Disease in Type 1 Diabetes in the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study: A Comparison With the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study (DCCT/EDIC). Diabetes 2019; 68:409-419. [PMID: 30409781 PMCID: PMC6341302 DOI: 10.2337/db18-0515] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 11/03/2018] [Indexed: 12/20/2022]
Abstract
In a recent Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) study report, mean HbA1c was the strongest predictor of cardiovascular disease (CVD) after age. In DCCT/EDIC, mean diabetes duration was 6 years (median 4) at baseline and those with high blood pressure or cholesterol were excluded. We now replicate these analyses in the Pittsburgh Epidemiology of Diabetes Complications (EDC) prospective cohort study of childhood-onset (at <17 years of age) type 1 diabetes, with similar age (mean 27 years in both studies) but longer diabetes duration (mean 19 years and median 18 years) and no CVD risk factor exclusion at baseline. CVD incidence (CVD death, myocardial infarction (MI), stroke, revascularization, angina, or ischemic electrocardiogram) was associated with diabetes duration, most recent albumin excretion rate (AER), updated mean triglycerides, baseline hypertension, baseline LDL cholesterol, and most recent HbA1c Major atherosclerotic cardiovascular events (CVD death, MI, or stroke) were associated with diabetes duration, most recent AER, baseline systolic blood pressure, baseline smoking, and updated mean HbA1c Compared with findings in DCCT/EDIC, traditional risk factors similarly predicted CVD; however AER predominates in EDC and HbA1c in DCCT/EDIC. Thus, the relative impact of HbA1c and kidney disease in type 1 diabetes varies according to diabetes duration.
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Affiliation(s)
- Rachel G Miller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Tina Costacou
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Trevor J Orchard
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
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45
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Affiliation(s)
- David M Maahs
- 1 Stanford Medical Center, Department of Pediatrics, Division of Endocrinology and Diabetes, Stanford, CA
| | - Rayhan Lal
- 1 Stanford Medical Center, Department of Pediatrics, Division of Endocrinology and Diabetes, Stanford, CA
| | - Shlomit Shalitin
- 2 Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- 3 Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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46
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Kahkoska AR, Isom S, Divers J, Mayer-Davis EJ, Dolan L, Shah AS, Afkarian M, Pettitt DJ, Lawrence JM, Marcovina S, Saydah SH, Dabelea D, Maahs DM, Mottl AK. The early natural history of albuminuria in young adults with youth-onset type 1 and type 2 diabetes. J Diabetes Complications 2018; 32:1160-1168. [PMID: 30316542 PMCID: PMC6289668 DOI: 10.1016/j.jdiacomp.2018.09.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/27/2018] [Accepted: 09/29/2018] [Indexed: 12/14/2022]
Abstract
AIMS To determine among adolescents and young adults with youth-onset type 1 diabetes and type 2 diabetes the rates and risk factors for albuminuria regression and progression. METHODS Data from SEARCH, a longitudinal observational study of youth-onset type 1 diabetes (N = 1316) and type 2 diabetes (N = 143) were analyzed. Urine albumin:creatinine ratio (UACR) was measured from random urine specimens at baseline and follow-up visits (mean 7 years later). Albuminuria regression was defined as halving of baseline UACR when baseline UACR was ≥30 μg/mg; progression was defined as doubling of baseline UACR when follow-up UACR was ≥30 μg/mg, respectively. Multivariable regression assessed risk factors associated with low-risk albuminuria category (combined persistently-low albuminuria and regression) versus moderate-risk albuminuria category (combined persistently-high albuminuria and progression). RESULTS Albuminuria progression was more common in type 2 diabetes versus type 1 diabetes (15.4% versus 6.0%, p<0.001). Moderate-risk albuminuria was associated with increasing HbA1c (adjusted OR (aOR) = 1.3, 95% CI 1.1-1.6) and lack of private health insurance (aOR = 2.7, 95%CI 1.1-6.5) in type 1 diabetes; and African American race (OR = 4.6, 95% CI 1.2-14.2), lower estimated insulin sensitivity score (aOR = 2.1, 95% CI 1.4-3.3), baseline UACR (aOR = 3.2, 95% CI 1.7-5.8), and follow-up estimated glomerular filtration rate (eGFR) (10-unit increase aOR = 1.3, 95% CI 1.0, 1.5) in type 2 diabetes. CONCLUSIONS In the first decade of diabetes duration, kidney complications in type 2 diabetes are significantly more aggressive than in type 1 diabetes and may be associated with less modifiable risk factors including race, insulin sensitivity, and eGFR. Early interventions may help reduce long-term kidney complications.
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Affiliation(s)
- Anna R Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599, USA.
| | - Scott Isom
- Dept. of Biostatistical Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Jasmin Divers
- Dept. of Biostatistical Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Elizabeth J Mayer-Davis
- Department of Medicine, University of North Carolina at Chapel Hill, 321 S. Columbia St, Chapel Hill, NC 27516, USA
| | - Lawrence Dolan
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, USA
| | - Amy S Shah
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, USA
| | - Maryam Afkarian
- Division of Nephrology, Department of Medicine, University of California, Davis, 4610 X St, Sacramento, CA 95817, USA
| | | | - Jean M Lawrence
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Santica Marcovina
- Northwest Lipid Metabolism and Diabetes Research Laboratories, Dept. of Medicine, University of Washington, 401 Queen Anne Avenue North, UW Mailbox 359119, Seattle, WA 98109, USA
| | - Sharon H Saydah
- Division of Diabetes Translation, US Centers for Disease Control and Prevention, National Center for Health Statistics, 3311 Toledo Rd, Hyattsville, MD 20782, USA
| | - Dana Dabelea
- Department of Epidemiology, School of Public Health, University of Colorado Denver, 13001 E 17th Pl, Aurora, CO 80045, USA
| | - David M Maahs
- Division of Pediatric Endocrinology, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - Amy K Mottl
- University of North Carolina Kidney Center, UNC School of Medicine, 101 Manning Dr, Chapel Hill, NC 27514, USA
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Lovshin JA, Bjornstad P, Lovblom LE, Bai JW, Lytvyn Y, Boulet G, Farooqi MA, Santiago S, Orszag A, Scarr D, Weisman A, Keenan HA, Brent MH, Paul N, Bril V, Perkins BA, Cherney DZI. Atherosclerosis and Microvascular Complications: Results From the Canadian Study of Longevity in Type 1 Diabetes. Diabetes Care 2018; 41:2570-2578. [PMID: 30275283 PMCID: PMC6245210 DOI: 10.2337/dc18-1236] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 09/02/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Type 1 diabetes carries a significant risk for cardiovascular mortality, but it is unclear how atherosclerosis associates with microvascular complications. We aimed to determine the relationships between atherosclerotic burden and neuropathy, retinopathy, and diabetic kidney disease (DKD) in adults with a ≥50-year history of type 1 diabetes. RESEARCH DESIGN AND METHODS Adults with type 1 diabetes (n = 69) underwent coronary artery calcification (CAC) volume scoring by wide-volume computerized tomography. Microvascular complications were graded as follows: neuropathy by clinical assessment, electrophysiology, vibration and cooling detection thresholds, heart rate variability, and corneal confocal microscopy; retinopathy by ultra-wide-field retinal imaging; and DKD by renal hemodynamic function measured by inulin and para-aminohippurate clearance at baseline and after intravenous infusion of angiotensin II. The cohort was dichotomized to high (≥300 Agatston units [AU]) or low (<300 AU) CAC and was stratified by diabetes status. A comparator group without diabetes (n = 73) matched for age and sex also underwent all study procedures except for retinal imaging. RESULTS CAC scores were higher in participants with type 1 diabetes (median Agatston score 1,000 [interquartile range = 222, 2,373] AU vs. 1 [0.75] AU in comparators, P < 0.001). In participants with type 1 diabetes, high CAC scores associated with markers of neuropathy and retinopathy, but not with DKD, or renal hemodynamic function at baseline or in response to angiotensin II. CONCLUSIONS The presence of high CAC in adults with longstanding type 1 diabetes was associated with large nerve fiber neuropathy and retinopathy but not with renal hemodynamic function, suggesting that neuropathy, retinopathy, and macrovascular calcification share common risk factors.
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Affiliation(s)
- Julie A Lovshin
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada .,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Petter Bjornstad
- Division of Endocrinology, Department of Pediatrics, University of Colorado, Aurora, CO.,Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Leif E Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Johnny-Wei Bai
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Geneviève Boulet
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Mohammed A Farooqi
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sam Santiago
- Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network, Toronto, Ontario, Canada
| | - Andrej Orszag
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alanna Weisman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Michael H Brent
- Department of Ophthalmology and Vision Sciences, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Narinder Paul
- Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network, Toronto, Ontario, Canada
| | - Vera Bril
- The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Krembil Neuroscience Centre, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Harrison TG, Tam-Tham H, Hemmelgarn BR, Elliott M, James MT, Ronksley PE, Jun M. Change in Proteinuria or Albuminuria as a Surrogate for Cardiovascular and Other Major Clinical Outcomes: A Systematic Review and Meta-analysis. Can J Cardiol 2018; 35:77-91. [PMID: 30595186 DOI: 10.1016/j.cjca.2018.10.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/04/2018] [Accepted: 10/25/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND There is ongoing controversy around the surrogacy of proteinuria or albuminuria, particularly for cardiovascular (CV) outcomes, which remain the leading cause of morbidity and mortality among patients with chronic kidney disease. We performed a systematic review and meta-analysis of the literature to assess the surrogacy of changing proteinuria or albuminuria for CV events, end-stage renal disease (ESRD), and all-cause mortality. METHODS CENTRAL, EMBASE, and MEDLINE were searched (from inception to October 2017). All randomized controlled trials in adults that reported change in proteinuria or albuminuria and ≥ 10 CV, ESRD, or all-cause mortality events were included. We calculated treatment effect ratios (TERs), defined as the ratio of the treatment effect on a clinical outcome and the effect on the change in the surrogate outcome. TERs close to 1 indicate greater agreement between the clinical outcome and changing proteinuria or albuminuria. RESULTS Thirty-six trials were included in the meta-analysis. We observed inconsistent treatment effects for proteinuria and CV events (20 trials; TER 1.11 [95% confidence interval (CI), 1.01-1.22]) with moderate heterogeneity (I2 = 51%, P = 0.005). Treatment effects on proteinuria or albuminuria were also inconsistent with the effects on all-cause mortality (21 trials; TER 1.17 [95% CI, 1.07-1.28]; I2 = 35%, P for heterogeneity = 0.06), although they were similar with the effects on ESRD (23 trials; TER 0.99 [95% CI, 0.88-1.13]; I2 = 9%, P for heterogeneity = 0.337). CONCLUSIONS Change in proteinuria or albuminuria might be a suitable surrogate outcome for ESRD. However, overall treatment effects on these potential surrogates are inconsistent and overestimate the treatment effects on CV events and all-cause mortality.
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Affiliation(s)
- Tyrone G Harrison
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Helen Tam-Tham
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meghan Elliott
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T James
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Min Jun
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; The George Institute for Global Health, University of New South Wales, Sydney, Australia.
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Wang YZ, Zhu DY, Xie XM, Ding M, Wang YL, Sun LL, Zhang N, Shen E, Wang XX. EA15, MIR22, LINC00472 as diagnostic markers for diabetic kidney disease. J Cell Physiol 2018; 234:8797-8803. [PMID: 30317603 DOI: 10.1002/jcp.27539] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 09/13/2018] [Indexed: 02/06/2023]
Abstract
This study aimed to investigate the molecular mechanisms of diabetic kidney disease (DKD) and to explore new potential therapeutic strategies and biomarkers for DKD. First we analyzed the differentially expressed changes between patients with DKD and the control group using the chip data in Gene Expression Omnibus (GEO) database. Then the gene chip was subjected to be annotated again, so as to screen long noncoding RNAs (lncRNAs) and study expression differences of these lncRNAs in DKD and controlled samples. At last, the function of the differential lncRNAs was analyzed. A total of 252 lncRNAs were identified, and 14 were differentially expressed. In addition, there were 1,629 differentially expressed messenger RNAs (mRNAs) genes, and proliferation and apoptosis adapter protein 15 (PEA15), MIR22, and long intergenic nonprotein coding RNA 472 ( LINC00472) were significantly differentially expressed in DKD samples. Through functional analysis of the encoding genes coexpressed by the three lncRNAs, we found these genes were mainly enriched in type 1 diabetes and autoimmune thyroid disease pathways, whereas in Gene Ontology (GO) function classification, they were also mainly enriched in the immune response, type I interferon signaling pathways, interferon-γ mediated signaling pathways, and so forth. To summary, we identified EA15, MIR22, and LINC00472 may serve as the potential diagnostic markers of DKD.
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Affiliation(s)
- Yan-Zhe Wang
- Department of Nephrology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ding-Yu Zhu
- Department of Nephrology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin-Miao Xie
- Department of Nephrology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Miao Ding
- Department of Nephrology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong-Lan Wang
- Department of Nephrology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin-Lin Sun
- Department of Nephrology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Nan Zhang
- Department of Nephrology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - E Shen
- Department of Ultrasound in Medicine, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Xia Wang
- Department of Nephrology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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50
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Rossing P, Persson F, Frimodt-Møller M. Prognosis and treatment of diabetic nephropathy: Recent advances and perspectives. Nephrol Ther 2018; 14 Suppl 1:S31-S37. [PMID: 29606261 DOI: 10.1016/j.nephro.2018.02.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/01/2018] [Indexed: 12/21/2022]
Abstract
Approximately 20 to 40% of patients with type 1 or type 2 diabetes develop diabetic kidney disease. It is a clinical syndrome characterized by persistent albuminuria (>300mg/24h, or 300mg/g creatinine), a relentless decline in glomerular filtration rate, raised arterial blood pressure and enhanced cardiovascular morbidity and mortality. The natural course of classical diabetic nephropathy is initially microalbuminuria or moderately increased urine albumin excretion (30-300mg/g creatinine). Untreated microalbuminuria may then rise gradually, reaching severely increased albuminuric (macroalbuminuria) over 5 to 15 years. Glomerular filtration rate then begins to decline and end-stage renal failure is reached without treatment in 5 to 7 years. Regular, systematic screening for diabetic kidney disease is needed to identify patients at risk for, or with presymptomatic stages of diabetic kidney disease. Multifactorial intervention targeting glucose, lipids and blood pressure including blockade of renin angiotensin system and lifestyle, has improved renal and cardiovascular prognosis and reduced mortality with 50%. Recent data suggest beneficial pleiotropic effects on renal endpoint with new glucose lowering agents. It is also being investigated if blocking aldosterone could be an option as a potential new treatment. Thus, although diabetic nephropathy remains a major burden, prognosis has improved and new options for further improvements are currently tested in phase 3 clinical renal outcome studies.
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Affiliation(s)
- Peter Rossing
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, 2820 Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark.
| | - Frederik Persson
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, 2820 Gentofte, Denmark
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