Diabetic Kidney Disease: Challenges, Progress, and Possibilities

TGF-β: elusive target in diabetic kidney disease

Transforming growth factor-beta (TGF-β), a cytokine with near omnipresence, is an integral part of many vital cellular processes across the human body. The family includes three isoforms: Transforming growth factor-beta 1, 2, and 3. These cytokines play a significant role in the fibrosis cascade. Diabetic kidney disease (DKD), a major complication of diabetes, is increasing in prevalence daily, and the classical diagnosis of diabetes is based on the presence of albuminuria. The occurrence of nonalbuminuric DKD has provided new insight into the pathogenesis of this disease. The emphasis on multifactorial pathways involved in developing DKD has highlighted some markers associated with tissue fibrosis. In diabetic nephropathy, TGF-β is significantly involved in its pathology. Its presence in serum and urine means that it could be a diagnostic tool while its regulation provides potential therapeutic targets. Completely blocking TGF-β signaling could reach untargeted regions and cause unanticipated effects. This paper reviews the basic details of TGF-β as a cytokine, its role in DKD, and updates on research carried out to validate its candidacy.

Nailfold capillary abnormalities as indicators of diabetic nephropathy progression: a cross-sectional study in type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus (DM) leads to chronic hyperglycemia and microvascular complications, including diabetic nephropathy (DN). Nailfold videocapillaroscopy (NVC) is a non-invasive method for assessing the microvascular abnormalities and may aid in early DN detection. This study investigates the correlation between DN and nailfold capillary abnormalities in type 2 DM.

METHODS

This prospective cross-sectional study involved 453 participants with type 2 DM, divided into 3 groups based on estimated glomerular filtration rate (eGFR) or albumin-to-creatinine (A/C) ratio. Chronic kidney disease (CKD) risk categories based on the 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines. Participants underwent structured interviews, clinical assessments, and laboratory tests. NVC was performed to assess capillary morphology, distribution, density, and blood flow.

RESULTS

Significant differences in NVC measurements were observed across eGFR groups, with higher NVC scores and more severe capillary abnormalities noted in lower eGFR groups. The 'comma-like' capillary distribution pattern (23.08%, p = 0.016), more ratio of ramified capillaries (p = 0.0137) were observed in the eGFR <30 ml/min/1.73m2 group. Reduced fundus transparency (p = 0.0015) and impaired visibility of the sub-venous plexus (p = 0.0016) were noted in the lower eGFR groups. Capillary lengths, both input and mean, were shorter in the A/C ratio > 300 mg/g group (p = 0.0382 and p = 0.0478, respectively). The NVC score was higher in the A/C ratio > 300 mg/g groups (p = 0.0028).

CONCLUSION

Nailfold capillary abnormalities correlate with DN severity, indicating their potential as a non-invasive biomarker for early DN detection and monitoring in type 2 DM.

Integration of transcriptome and Mendelian randomization analyses in exploring the extracellular vesicle-related biomarkers of diabetic kidney disease

BACKGROUND

Diabetic Kidney Disease (DKD) is a common complication in patients with diabetes, and its pathogenesis remains incompletely understood. Recent studies have suggested that extracellular vesicles (EVs) may play a significant role in the initiation and progression of DKD. This study aimed to identify biomarkers associated with EVs in DKD through bioinformatics and Mendelian randomization (MR) analysis.

METHODS

This study utilized two DKD-related datasets, GSE96804 and GSE30528, alongside 121 exosome-related genes (ERGs) and 200 inflammation-related genes (IRGs). Differential analysis, co-expression network construction, and MR analysis were conducted to identify candidate genes. Machine learning techniques and expression validation were then employed to determine biomarkers. Finally, the potential mechanisms of action of these biomarkers were explored through Immunohistochemistry (IHC) staining, enrichment analysis, immune infiltration analysis, and regulatory network construction.

RESULTS

A total of 22 candidate genes were identified as causally linked to DKD. CMAS and RGS10 were identified as biomarkers, with both showing reduced expression in DKD. IHC confirmed low RGS10 expression, providing new insights into DKD management. CMAS was involved primarily in mitochondria-related pathways, while RGS10 was enriched in the extracellular matrix and associated pathways. Significant differences were observed in neutrophils and M2 macrophages between DKD and normal groups, correlating strongly with the biomarkers.

CONCLUSION

This study identified two EV-associated biomarkers, CMAS and RGS10, linked to DKD and elucidated their potential roles in disease progression. These results offer valuable insights for further exploration of DKD pathogenesis and the development of new therapeutic targets.

Analysis of correlation between dietary fiber intake and risk of diabetic kidney disease in adults with type 2 diabetes mellitus: results from the United States National Health and Nutrition Examination Surveys 2009-2018

OBJECTIVE

Given the significant impact of diabetic kidney disease (DKD) on morbidity and mortality in patients with type 2 diabetes mellitus (T2DM) and the potential preventive role of dietary factors, particularly dietary fiber, this study aimed to investigate the relationship between dietary fiber intake and the risk of DKD in adults with T2DM.

METHODS

The medical records and other relevant data from patients with T2DM were retrieved from the United States National Health and Nutrition Examination Surveys (U.S. NHANES) from 2009 to 2018. Multivariate logistic regression and restricted cubic spline (RCS) regression were employed to investigate the relationship between dietary fiber intake and the risk of DKD in adult T2DM patients.

RESULTS

The study involved 4,520 T2DM patients with a mean age of 59.16 years, consisting of 2,346 male patients (51.9%) and 2,174 female patients (48.1%). The prevalence of T2DM patients with DKD was 37.92% in the overall population. Regression analyses, after adjusting for confounders, showed that dietary fiber intake was negatively correlated with the prevalence of DKD. RCS analysis demonstrated a nonlinear negative correlation between the level of dietary fiber intake and the prevalence of DKD, with a threshold inflection point of 13.96 g/day. Subgroup analyses revealed that age, gender, race, smoking status, body mass index, hypertension, diabetes duration, glycosylated hemoglobin, and ACEI/ARB medication use did not significantly affect the negative correlations (p > 0.05).

CONCLUSIONS

Dietary fiber intake was negatively correlated with the prevalence of DKD in T2DM patients.

Dietary habits and risk of diabetic kidney disease: a two-sample and multivariate Mendelian randomization study

OBJECTIVE

We explored the causal relationship between certain dietary habits and the risk of developing diabetic kidney disease (DKD) using two-sample Mendelian randomization and multivariate Mendelian randomization.

RESEARCH DESIGN AND METHODS

This study is based on pooled data from a genome-wide association study (GWAS) of 83 dietary habits in a European population. We performed a two-sample Mendelian randomization analysis using GAWS data on diabetic nephropathy in a European population. Validation was then performed against positive results (p < 0.05) in different GAWS data on diabetic nephropathy of European origin. Finally, multivariate Mendelian randomization analyses were performed on dietary habits with positive results (p < 0.05) in both datasets and GWAS data on postprandial glucose in the European population.

RESULTS

This study showed causal relationships between 18 dietary habits and the risk of developing DKD. After validation, causal relationships were found between the risk of DKD and two dietary habits: abstaining from sugar consumption (OR 2.86; 95%CI 1.35, 6.08; p = 0.006) and consuming whole grain/multigrain bread (OR 0.53; 95%CI 0.32, 0.89; p = 0.016). Correcting for the effect of postprandial glucose, the multivariate MR results showed that never eating sugar increased the risk of developing DKD (OR 0.08; 95%CI 0.018, 0.36; p = 0.001), whereas eating whole grain/multigrain bread did not reduce the risk of developing DKD (OR 1.37; 95%CI 0.55, 3.41; p = 0.50).

CONCLUSIONS

Our MR results suggest a causal relationship between never eating sugar and an increased risk of developing DKD. Therefore, people with diabetes need a reasonable range of sugar intake.

Implementing novel complete blood count-derived inflammatory indices in the diabetic kidney diseases diagnostic models

Objectives

Hemogram inflammatory markers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), red-cell distribution width (RDW), and mean platelet volume (MPV) have been associated with type 2 diabetes mellitus (T2DM) and its complications, namely diabetic kidney diseases (DKD). We aimed to develop and validate logistic regression (LR) and CatBoost diagnostic models and study the role of adding these markers to the models.

Methods

All individuals who were managed in our secondary care center from March 2020 to December 2023 were identified. After excluding the ineligible patients, train-test splitting, and data preprocessing, two baseline LR and CatBoost-based models were developed using demographic, clinical, and laboratory features. The AUC-ROC of the models with biomarkers (NLR, PLR, RDW, and MPV) was compared to the baseline models. We calculated net reclassification improvement (NRI) and integrated discrimination index (IDI).

Results

One thousand and eleven T2DM patients were eligible. The AUC-ROC of both LR (0.738) and CatBoost (0.715) models was comparable. Adding target inflammatory markers did not significantly change the AUC-ROC in both LR and CatBoost models. Adding RDW to the baseline LR model reclassified 41.7% of patients without DKD, in the cost of misclassification of 38.4% of DKD cases. This change was absent in CatBoost models, and other markers did not achieve improved NRI or IDI.

Conclusion

The basic models with demographical and clinical features had acceptable performance. Adding RDW to the basic LR model improved the reclassification of the non-DKD participants. However, adding other hematological indices did not significantly improve the LR and CatBoost models' performance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01523-2.

Urinary DcR2/Cr level predicts renal outcomes in patients with diabetic kidney disease

In diabetic kidney disease (DKD), urinary decoy receptor 2 (uDcR2) levels are associated with tubulointerstitial fibrosis; however, whether uDcR2 can predict renal outcomes remains unclear. Herein, we analyzed the association between uDcR2 and renal outcomes (defined as a composite of a serum creatinine (SCr) increase of 50 % from baseline, or initiation of dialysis for end-stage renal disease) in 153 patients with biopsy-proven DKD. Patients were divided into the composite (n = 67) and no composite (n = 86) outcome groups. uDcR2 levels were measured using ELISA. The area under the receiver operating characteristic curve (AUC) for uDcR2 in discriminating DKD renal outcomes was calculated. Kaplan-Meier survival analysis and multifactorial Cox regression models evaluated the association between uDcR2 levels and renal outcomes. Renal DcR2 mRNA and protein expression were detected using in situ hybridization and immunohistochemical staining. Immunofluorescence revealed DcR2 and α-SMA colocalization. uDcR2/Cr levels were higher in patients in the composite than the no composite outcome group. uDcR2/Cr levels positively correlated with ACR, SCr, interstitial fibrosis and tubular atrophy (IFTA), and negatively correlated with eGFR. uDcR2/Cr had an AUC of 0.825 at the optimal cut-off value of 389 ng/gCr. Addition of uDcR2/Cr to ACR, eGFR, or IFTA improved renal outcome predictions. Renal survival was significantly lower at uDcR2/Cr ≥ 389 ng/gCr. Patients in the composite group had higher tubular DcR2 mRNA and protein level percentages. α-SMA was significantly increased in DcR2-positive renal tubules and their surroundings. Overall, uDcR2/Cr is an independent predictor of renal outcomes, with potential for improving the prevention and treatment of DKD.

Correlation of hsa-mirna-342-3p and SOX 6 Expression with Diabetic Nephropathy Classification, Prognostic Histomorphological Parameters and Laboratory Findings in Diabetic Nephropathy

Diabetic nephropathy (DN) is one of the leading causes of end-stage renal disease. The most popular biomarkers in current research on DN are microRNAs. There are studies showing that while the expression of SOX6 increases, hsa-miR-342-3p expression decreases in kidney tissues with DN. The current study evaluated hsa-miR-342-3p expression by Real Time PCR and SOX6 expression by immunohistochemistry in a cohort of 110 DN biopsies, as well as their relationship with various clinical and histomorphological parameters. An inverse relationship between expression of hsa-miR-342-3p and SOX6 was demonstrated. SOX6 genetic expression was correlated with serum creatinine and tubular basement membrane thickening. Immunohistochemically, SOX6 staining was observed in mesangial cells and podocytes in 21 patients, with tubular staining in 45, and interstitial staining in 27 patients. Tubular staining was associated with proteinuria, interstitial fibrosis and inflammation; interstitial staining was associated with creatinine; and staining in the glomerular compartment was associated with advanced DN class. Our study is the first in the literature in which SOX6 was applied immunohistochemically in human kidney tissue, and its relation with DN classes was examined. We demonstrate its correlation with laboratory and histomorphological parameters, and provide a rational basis for future studies on larger patient groups that may result in the development of new biomarkers to predict the progression of DN and enhance its treatment.

Short-term effect of atorvastatin on renal oxidative stress, inflammation, and fibrosis in a rat model of streptozotocin-induced diabetes

Objectives

Diabetes mellitus (DM) contributes to the development and progression of nephropathy and kidney diseases. Statins are known to have anti-inflammatory and antifibrotic effects. We aimed to test the short-term effect of atorvastatin on renal biomarkers of oxidative damage, inflammation, and fibrosis in a rat model of streptozotocin-induced DM.

Methods

Wistar rats were divided into; control rats, rats treated with atorvastatin (Ator, oral 40 mg/kg for 6 weeks), DM rats (DM, one intraperitoneal 40 mg/kg streptozotocin), and atorvastatin-treated DM rats (DM + Ator). Renal oxidative stress markers, inflammatory and mitogenic factors were measured.

Results

Streptozotocin induced an increase in serum glucose, blood urea nitrogen, and creatinine levels. A marked increase in kidney to body weight ratio was found in DM groups. Diabetes resulted in an elevation in inflammatory biomarkers of galectin-3 and endothelin-1. Hyperglycemia induced an increase in lipid peroxides and a decrease in the superoxide dismutase (SOD) antioxidant level in the DM group. A significant increase in the fibrotic factor platelet derived factor-BB (PDGF-BB) expression was documented in the DM group. Six weeks use of atorvastatin normalized kidney endothelin-1, galectin-3, and the PDGF-BB, and attenuated the increase in lipid peroxides and the reduction in SOD levels.

Conclusion

Our findings suggest that short-term use of atorvastatin may attenuate the substrates for diabetic nephropathy via partial decrease of renal markers of inflammation, oxidative stress, and fibrosis.

Unfolded protein response-activated NLRP3 inflammasome contributes to pyroptotic and apoptotic podocyte injury in diabetic kidney disease via the CHOP-TXNIP axis

BACKGROUND

Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease and end-stage renal disease worldwide. Podocyte injury and death is a key event in DKD progression. Emerging evidence has indicated that crosstalk between unfolded protein response (UPR) and NLR family pyrin domain containing 3 (NLRP3) inflammasome plays an essential role in DKD progression. However, the involvement of these pathways in podocyte injury and death during DKD remains unclear.

RESULTS

Here, we found that inositol-requiring enzyme 1 (IRE1) and protein kinase RNA-like ER kinase (PERK) branches of the UPR, NLRP3 inflammasome, and apoptosis were activated in podocytes under DKD and high glucose (HG) conditions. In vitro, inducing ER stress by thapsigargin, and IRE1 or PERK overexpression upon HG treatment stimulated NLRP3 inflammasome-mediated pyroptosis and apoptosis, whereas inhibiting IRE1 or PERK suppressed them. Importantly, we discovered that the newly identified NLRP3-binding partner, thioredoxin-interacting protein (TXNIP), upon activation by the transcription factor (TF) PERK/CCAAT-enhancer-binding protein homologous protein (CHOP), served as a link between IRE1 or PERK branches with NLRP3 inflammasome-mediated pyroptosis and apoptosis. TXNIP expression was promoted in podocytes from DKD patients and db/db mice, as well as in HG-exposed conditionally immortalized human podocyte (HPC). In HG-exposed HPC, IRE1 or PERK overexpression upregulated TXNIP expression, while IRE1 or PERK inhibition downregulated it. TXNIP or CHOP silencing both inhibited HG-upregulated TXNIP, further blocking NLRP3 inflammasome-mediated pyroptosis and apoptosis. Furthermore, NLRP3 overexpression aggravated HG-induced pyroptosis and apoptosis, whereas additional TXNIP silencing reversed them without affecting IRE1 or PERK branches.

CONCLUSION

In conclusion, our results suggested that UPR/NLRP3 inflammasome-mediated pyroptosis/apoptosis pathway was involved in diabetic podocyte injury, and that targeting the CHOP-TXNIP axis may serve as a promising therapeutic target for DKD.

Impact of urinary tract infection requiring hospital admission on short-term, mid-term and long-term renal outcomes in adult CKD patients - A potentially modifiable factor for CKD progression

BACKGROUND

Urinary tract infection (UTI) or acute pyelonephritis can lead to renal scarring and impact the subsequent renal function progression. The aims of this study were to investigate the changes in renal function related to UTI requiring hospital admission (UTI/HA) and the association between UTI/HA and long-term renal outcomes in patients with chronic kidney disease (CKD).

METHODS

This was a multicenter, retrospective observational study. Renal events and renal function before and after UTI/HA in CKD patients were analyzed for short-term and mid-term renal outcomes. A case-control study with multivariate logistic regression analysis was used to investigate the association between clinical characteristics and risk of long-term renal outcomes (kidney replacement therapy or death, KRT/death) in adult CKD patients.

RESULTS

This study included 1062 adult CKD patients, with 340 KRT and 76 deaths identified during a median follow-up of 105 months. Among 174 patients with UTI/HA, 59 (33.9 %) had bacteremia, 90 (51.7 %) acute kidney injury (AKI), and one in-hospital mortality. There was a faster decline rate of estimated glomerular filtration rate (eGFR) after UTI/HA compared to the pre-UTI/HA period [median (IQR) 0.37 (0.17-0.72) versus 0.19 (0.06-0.36) ml/min/1.73 m2 per month, P < 0.0001]. The incidence of UTI/HA was similar between the KRT/death and the CKD non-dialysis groups. Multivariate logistic regression analysis showed that baseline eGFR, baseline eGFR decline rate and number of hospital admission were significantly associated with an increased risk of KRT/death.

CONCLUSIONS

This study highlights the impact of UTI/HA on renal function and renal outcomes in adult CKD patients. It demonstrates a high incidence of in-hospital AKI but low mortality, and accelerated deterioration of renal function following UTI/HA. Long-term renal outcomes were influenced by the baseline renal function and progression rate, and the frequency of hospital admission. UTI/HA may be regarded as a potentially modifiable factor for CKD progression. However, there is a need for further analysis to isolate the impact of UTI/HA from pre-existing renal function decline on long-term renal outcomes.

MC16 promotes mitochondrial biogenesis and ameliorates acute and diabetic nephropathy

BACKGROUND AND PURPOSE

Kidney disease (KD) is a leading cause of mortality worldwide, affecting 〉10% of the global population. Two of the most common causes of KD are diabetes and acute kidney injury (AKI), both of which induce mitochondrial dysfunction resulting in renal proximal tubular damage/necrosis. Thus, pharmacological induction of mitochondrial biogenesis (MB) may provide a therapeutic strategy to block the onset/progression of KD. Here, we evaluated the pharmacological and potential therapeutic effects of a novel MB-inducing oxindole agent, MC16.

EXPERIMENTAL APPROACH

Primary cultures of rabbit renal proximal tubule cells (RPTCs) were used to evaluate the cellular signalling and MB-inducing effects of MC16. Mice were used to determine the MB-inducing effects of MC16 in vivo, and the metabolic effects of MC16 on the renal cortical metabolome. Mouse models of AKI and diabetic kidney disease (DKD) were used to demonstrate the therapeutic potential of MC16 to ameliorate acute and diabetic nephropathy.

KEY RESULTS

MC16 activated the PI3K-AKT-eNOS-FOXO1 axis and induced MB in RPTCs. MC16 induced MB and altered the renal cortical metabolome of mice. MC16 accelerated renal recovery, reduced vascular permeability, and diminished mitochondrial dysfunction following AKI. MC16 decreased diabetes-induced renal swelling, improved renal and mitochondrial function, and diminished interstitial fibrosis in DKD mouse models.

CONCLUSION AND IMPLICATIONS

MC16 is a novel compound that induces MB and ameliorates acute and diabetic nephropathy in mice. This study underscores that targeting MB following the onset of renal/metabolic insults may provide a therapeutic strategy to mitigate the onset and/or progression of KD.

Association of normal range of urinary albumin-to-creatinine ratio with all-cause mortality among diabetic adults with preserved kidney function: National Health and Nutrition Examination Survey (NHANES) 2003-2018

AIM

To ascertain the connection between normal-range urinary albumin-to-creatinine ratio (UACR) and all-cause mortality (ACM) among diabetic adults with preserved eGFR.

METHODS

We used data from the 2003-2018 National Health and Nutrition Examination Survey. Nationally representative cross-sectional survey data linked with mortality outcomes from the National Death Index. Restricted cubic spline curves (RCS) and multivariable Cox regression models alongside subgroup analyses were utilised for estimating hazard ratios (HRs) and 95% confidence intervals (Cls) for UACR-ACM interplay, adjusting for demographic, socioeconomic, biochemical, medication and medical history factors. The UACR's predictive accuracy for survival outcomes was determined through receiver operating characteristic analysis.

RESULTS

The RCS regression analysis showcased that there was no significant evidence to support a nonlinear relationship between normal-range UACR and ACM (p = 0.080 for nonlinearity) in participants with diabetes mellitus (DM). In the model 2 adjusted for multiple confounding variables, the HR for ACM was 1.22 (95% CI, 1.06-1.40) per 10 mg/g raise in continuous UACR and 1.50 (95%CI, 1.18-1.91) for the high UACR tertile compared to the low. Kaplan-Meier analysis showed significantly lower survival rates in the medium and high UACR groups (p < 0.001). Subgroup analysis manifested a significant UACR-body mass index (BMI) interaction (p = 0.033 for interaction).

CONCLUSIONS

In DM adults without overt kidney dysfunction, elevated normal-range UACR was independently related to escalated ACM, particularly in those with normal BMI. To conclude, we underscore the significance of early risk assessment in DM patients with normal-range albuminuria, even without overt kidney dysfunction.

Apelin/APJ alleviates diabetic nephropathy by improving glomerular endothelial cells dysfunction via SIRT3‑KLF15

Glomerular basement membrane (GBM) thickening, the earliest morphological change of diabetic nephropathy (DN), is related to glomerular endothelial cells (GECs) dysfunction which increase extracellular matrix (ECM) synthesizing. Apelin, the endogenous ligand for apelin/apelin receptor (APJ), is reported to alleviate endothelial cell dysfunction in DN. Therefore, it was hypothesized that apelin/APJ reduced GBM thickening by decreasing the synthesis of ECM in GECs. The results showed that apelin reduced glomerular fibrosis and GBM thickening by decreasing the expression of laminin and collagen IV in diabetic mice, which were cancelled following APJ knockout in GECs. Furthermore, apelin/APJ inhibited the synthesis of laminin and collagen IV in GECs by increasing the expression and activity of SIRT3, which promoted KLF15 deacetylation and translocation into nucleus. In conclusion, apelin/APJ reduced GBM thickening in diabetes mellitus by preventing laminin and collagen IV synthesizing via SIRT3‑KLF15 pathway in GECs.

Exploring a novel mechanism for targeting β-arrestin-2 in the management of diabetic nephropathy

Diabetic nephropathy (DN) is a well-known microvascular complication in patients with diabetes mellitus, which is characterized by the accumulation of extracellular matrix in the glomerular and tubulointerstitial compartments, along with the hyalinization of intrarenal vasculature. DN has recently emerged as a leading cause of chronic and end-stage renal disease. While the pathobiology of other diabetic microvascular complications, such as retinopathy, is largely understood and has reasonable therapeutic options, the mechanisms and management strategies for DN remain incompletely elucidated. In this editorial, we comment on the article by Liu et al, focusing on the mechanisms underlying the detrimental impact of β-arrestin-2 on the kidneys in the context of DN. The authors suggest that inhibiting β-arrestin-2 could alleviate renal damage through suppressing apoptosis of glomerular endothelial cells (GENCs), highlighting β-arrestin-2 as a promising therapeutic target for DN. The study proposed that β-arrestin-2 triggers endoplasmic reticulum (ER) stress via the ATF6 signaling pathway, thereby promoting GENC apoptosis and exacerbating DN progression. Given the novel and crucial role of β-arrestin-2 in ER stress-related DN, it is imperative to further explore β-arrestin-2, its roles in ER stress and the potential therapeutic implications in DN.

Association of non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and chronic kidney disease in elderly insights from NHANES

The non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) is a novel lipid index. Prior research has established a connection between lipid irregularities and chronic kidney disease (CKD). This study aims to establish a possible link between NHHR and CKD. Data from the National Health and Nutrition Examination Survey (NHANES) spanning from 2003 to 2016 was used to examine the relationship between NHHR and CKD among the elderly population. This research utilized weighted logistic regression, smoothed curve fitting and subgroup analyses along with interaction tests to evaluate the association between NHHR and CKD. The findings reveal a positive correlation between NHHR and CKD in fully adjusted Model 3. Besides, NHHR had a J-curve relationship with CKD. Subgroup analysis indicated that compared with those with lower body mass index (BMI), individuals with higher BMI are more prone to CKD. Research has shown that increased NHHR levels are associated with a higher likelihood of developing CKD in individuals aged above 60 in the United States. NHHR's role in lipid metabolism suggests it might be an effective marker for tracking CKD's progression.

Predicting diabetic kidney disease with serum metabolomics and gut microbiota

This study aims to identify biomarkers for reliably predicting diabetic kidney disease (DKD), systematically characterize serum metabolites and gut microbiota in DKD patients, and investigate the correlation between differential serum metabolites and gut microbiota. From September 2021 to January 2023, 90 subjects were recruited: 30 with DKD, 30 with type 2 diabetes mellitus (T2DM), and 30 normal controls (NCs). Serum metabolites, including 180 different metabolites, were analyzed using untargeted metabolomics UPLC-MS/MS, and gut microbiota were assessed via 16S rRNA sequencing. Differential metabolites were identified through univariate (t-test or Mann-Whitney U-test, P < 0.05) and multivariate analyses (OPLS-DA model, VIP > 1, P < 0.05), followed by selection using the least absolute shrinkage and selection operator (LASSO). The selected overlapping serum metabolites, along with DKD-associated differential gut microbiota, were used to develop a logistic regression prediction model for DKD based on six markers. In the DKD group compared to the DM and NC groups, 39 and 60 differential serum metabolites were identified, respectively (VIP > 1, P < 0.01). Among these, 36 serum metabolites, including alpha-Hydroxyisobutyric acid, were significantly elevated in DKD patients compared to those with DM. Of these, 28 metabolites showed a negative correlation with estimated glomerular filtration rate (eGFR), while 29 showed a positive correlation with urine albumin creatinine ratio (UACR). Patients with DKD were further categorized into subgroups (DKD middle and DKD early) based on eGFR (eGFR < 90 ml/min/1.73m2, eGFR ≥ 90 ml/min/1.73m2), revealing 23 differential metabolites. Dysbiosis of the gut microbiota was evident in DKD patients, with lower relative abundances of g_Prevotella and g_Faecalibacterium compared to the DM and NC groups. Subgroup analysis indicated decreased relative abundances of g_Prevotella and g_Faecalibacterium in the DKD middle group, along with a decrease in g_Klebsiella compared to the DKD early group, which correlated positively with DKD patients' eGFR. There were 11 common metabolites among the three groups of differential metabolites. Among these, three serum metabolites-imidazolepropionic acid, adipoylcarnitine, and 1-methylhistidine-were identified as predictive serum metabolic markers. Disease prediction models (logistic regression models) were constructed based on these three metabolites combined with three genera of bacteria. These models demonstrated strong discriminatory power for diagnosing patients with DKD compared to patients with DM (area under the receiver operating characteristic curve (AUROC) = 0.939 and precision-recall curve (AUPR) = 0.940). The models also effectively discriminated between patients with DKD and NCs (0.976, 0.973). This study revealed distinctive serum metabolites and gut microbiota in patients with DKD. It demonstrated the potential utility of three specific serum metabolites and three genera of bacteria in diagnosing patients with DKD and assessing their renal dysfunction.

Using guideline-directed medical therapies to improve kidney and cardiovascular outcomes in patients with chronic kidney disease

PURPOSE

An estimated 37 million people currently live with chronic kidney disease in the US, which places them at increased risk for kidney disease progression, cardiovascular disease, and mortality. This review discusses current standard-of-care management of patients with chronic kidney disease, identifies key gaps in care, and briefly highlights how pharmacists can address gaps in care as members of the multidisciplinary care team.

SUMMARY

Recent advances in guideline-directed medical therapies for patients with chronic kidney disease, including agents from the sodium-glucose cotransporter, glucagon-like peptide-1 receptor agonist, and nonsteroidal mineralocorticoid receptor antagonist classes, can dramatically improve cardiovascular-kidney-metabolic care and outcomes. Unfortunately, gaps in screening, diagnosis, and implementation of recommended therapies persist. Team-based models of care-inclusive of the person with chronic kidney disease-have the potential to significantly improve care and outcomes for people with chronic kidney disease by addressing current gaps in care.

CONCLUSION

As members of the multidisciplinary care team, pharmacists can play a critical role in addressing current gaps in care, including optimized use of guideline-directed medical therapies, in patients with chronic kidney disease.

Isoquercitrin Alleviates Diabetic Nephropathy by Inhibiting STAT3 Phosphorylation and Dimerization

At the convergence point of multiple cytokine signals, signal transducer and activator of transcription 3 (STAT3) is a highly promising therapeutic target for diabetic nephropathy. Isoquercitrin, a natural small-molecule inhibitor of STAT3, may have beneficial effects on diabetic nephropathy; however, the underlying mechanism remains unclear. Isoquercitrin significantly mitigated renal inflammation and fibrosis by inhibiting STAT3 activity in mice with diabetic nephropathy. Moreover, STAT3 is a direct molecular target of isoquercitrin, which as corroborated by tight and stable noncovalent binding between them. This interaction is mechanistically supported by the affinity of isoquercitrin for the Ser668-Gln635-Gln633 region within the pY+1 binding pocket of the SH2 domain. This binding obstructs pivotal processes like STAT3 phosphorylation and dimerization, thereby suppressing its transcriptional function. Finally, a kidney-targeted nanocarrier, Iso@PEG-GK, is developed to load isoquercitrin, thus enhancing its therapeutic precision for diabetic nephropathy. Iso@PEG-GK significantly improved the absorption and renal distribution of isoquercitrin. This study is the first to demonstrate that isoquercitrin exerts a significant protective effect against diabetic nephropathy and may provide a novel therapeutic drug for this disease.

Ketone Bodies in Renal Function and Diabetic Kidney Disease

Diabetes, as a leading cause of chronic kidney disease (CKD) and diabetic kidney disease (DKD), underscores a significant concern, especially due to its association with health decline and mortality. In this context, the roles of ketone bodies, especially beta-hydroxybutyrate are increasingly recognized for their impact in renal physiology and the pathology of DKD. Moving beyond their conventional perception as metabolic by products, ketone bodies have been found to play a crucial role in renal health, particularly under the stresses of diabetic conditions. Serving as alternative energy sources during periods of glucose scarcity, they also function as important signaling molecules. These ketones significantly influence oxidative stress, nutrient-sensing pathways, and mitochondrial function within the kidneys. The adaptability of renal cells to utilize ketone bodies in diabetes highlights a dynamic metabolic interplay, essential for understanding renal health. The exploration of ketone body metabolism modulation, particularly through interventions like SGLT2 inhibitors and ketogenic diets, opens new avenues in managing DKD. Such insights pave the way for rethinking the role of ketone bodies in renal pathology and diabetes, pointing to novel research directions and therapeutic potentials.

Association between daily coffee intake and diabetic kidney disease: evidence from the 2007 to 2016 NHANES

PURPOSE

Regular coffee intake is recognized as a protective factor against various chronic diseases, particularly diabetes. However, the correlation between coffee intake-both the act of drinking coffee and the amount consumed-and diabetic kidney disease (DKD) remains uncertain. The goal of this study is to measure the correlation between coffee intake and DKD.

METHODS

This cross-sectional study was based on data from the 2007 to 2016 National Health and Nutrition Examination Survey (NHANES). DKD was characterized by the coexistence of diabetes combined with impaired glomerular filtration rate (eGFR < 60 mL/min/1.73 m2) or ACR ≥ 30 mg/g. Weighted logistic regression and restricted cubic spline (RCS) analyses were adopted to evaluate the correlation between coffee intake and DKD. The subgroup analyses were implemented to assess the reliability of the results.

RESULTS

The study included 13,177 participants, representing a weighted population of 125,388,198 individuals. Among them, 8198 (64%) participants consumed coffee and 1430 (7.6%) were classified as having DKD. After controlling for covariates, multivariable logistic regression showed a negative correlation between moderate coffee intake and DKD (OR = 0.68; 95% CI: 0.55-0.83; P < 0.001). The RCS analysis suggested a U-shaped, non-linear correlation between coffee intake and DKD (P overall = 0.013; P nonlinear = 0.047). The subgroup analyses further supported the stability and reliability of these findings.

CONCLUSION

The results indicate a U-shaped correlation between coffee intake and diabetic kidney disease.

Mediterranean diet and diabetic microvascular complications: a systematic review and meta-analysis

BACKGROUND

Diabetic microvascular complications, including diabetic retinopathy (DR), diabetic nephropathy (DN), and diabetic peripheral neuropathy (DPN), contribute significantly to morbidity and healthcare burdens among individuals with diabetes. The Mediterranean diet (MD) has been associated with improved metabolic health, but its role in mitigating microvascular complications remains unclear. This systematic review and meta-analysis aimed to assess the impact of MD adherence on the risk and progression of these complications.

METHODS

A comprehensive search of PubMed, Web of Science, Embase, and Scopus was conducted through February 12, 2025 to identify studies evaluating MD adherence and diabetic microvascular complications. Meta-analysis was performed where possible, with effect sizes reported as odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

Fourteen studies, encompassing 138 to 71,392 participants, were included. Meta-analysis indicated a significant reduction in DR risk among individuals adhering to the MD (HR: 0.69, 95% CI: 0.49-0.97, p = 0.03; OR: 0.32, 95% CI: 0.12-0.82, p = 0.02). A lower likelihood of DN development was observed (HR: 0.85, 95% CI: 0.73-0.99, p = 0.04; OR: 0.49, 95% CI: 0.25-0.96, p = 0.04). However, results for diabetic neuropathy were inconclusive due to study heterogeneity. Sensitivity analyses revealed notable heterogeneity and publication bias was detected in some analyses.

CONCLUSION

Adherence to the Mediterranean diet is associated with a reduced risk of diabetic nephropathy and retinopathy, supporting its potential as a dietary intervention for diabetes management. However, the evidence for neuropathy remains inconclusive. Future well-controlled randomized trials are needed to strengthen causal inferences and refine clinical recommendations for MD-based interventions in diabetic microvascular complications.

Oxybaphus himalaicus alleviates diabetic kidney disease by suppressing the lipid metabolism and inflammation via PPARα signaling

Diabetic kidney disease (DKD) is a common complication in patients with diabetes, and glycolipid metabolism disorders are an important cause of DKD. The root of Oxybaphus himalaicus (Edgew.) Heimerl is a traditional Tibetan medicine commonly used to treat kidney-related diseases. Nevertheless, contemporary pharmacological investigations into O. himalaicus, especially those associated with the treatment of renal disorders, remain scarce. The objective of this research was to explore the pharmaceutical impacts and mechanisms of action of O. himalaicus in the treatment of DKD. The active fraction and potential pharmacological effects of O. himalaicus were determined through network pharmacology. Then, in vivo and in vitro efficacy and mechanism studies were conducted through streptozotocin-induced DKD mice and high glucose-induced HK-2 cells. Network pharmacology research speculated the ethyl acetate (EA) fraction as the main active component of O. himalaicus for treating DKD. In vivo and in vitro experiments showed that EA reduces renal lipotoxicity by upregulating PPARα pathway proteins, enhancing fatty acid oxidation (FAO), and downregulating inflammatory factors such as TNF-α and IL-6. Molecular docking studies revealed that the active components of EA with a high affinity for PPARα are mainly rotenoid compounds. EA mitigates DKD through the activation of PPARα, which serves to augment FAO, abate lipid accumulation, and impede the expression of inflammatory factors. Among these, rotenoids may be the main active components that exert pharmacological effects.

Application of raman spectroscopy in the non-invasive diagnosis of urological diseases via urine

OBJECTIVES

The objective of this review is to provide a comprehensive overview of the utilization of Raman spectroscopy in urinary system diseases, highlighting its potential in non-invasive diagnostic methodologies for early diagnosis and prognostic assessment of urinary ailments.

METHODS

We searched PubMed, Web of Science, and Google Scholar using 'raman,' 'bladder,' 'kidney,' 'prostate,' 'cancer,' 'infection,' 'stone or urinary calculi,' and 'urine or urinary,' along with 'AND' and 'OR' to refine our search. We excluded irrelevant articles and screened potential ones based on titles and abstracts before assessing the full texts for relevance and quality.

FINDINGS

The findings indicate that RS can furnish data on biomolecules in urine, which is significant for non-invasive diagnostic approaches. It has shown potential within non-invasive diagnostic methodologies and is expected to play a pivotal role in the early diagnosis and prognostic assessment of urinary system diseases, such as malignancies, urinary tract infections, kidney diseases, urolithiasis, and other urinary conditions.

CONCLUSIONS

Raman spectroscopy has demonstrated significant potential in providing precise and rapid diagnostic approaches for clinical use in the context of urinary system diseases. Its ability to analyze biomolecules non-invasively positions it as an increasingly important tool in the early diagnosis and prognostic assessment of these conditions.

Hemoglobin glycation index and rapid kidney function decline in diabetes patients: Insights from CHARLS

AIMS

This study aimed to assess the relationship between hemoglobin glycation index (HGI) and risk of rapid kidney function decline (RKFD) in diabetic patients.

METHODS

HGI was calculated as actual measured HbA1c minus predicted HbA1c. RKFD was defined as a 30 % decline in estimated glomerular filtration rate during follow-up. Participants were categorized into three groups based on HGI levels: lower (HGI ≤ -0.55), medium (-0.55 < HGI ≤ 0.22) and higher (HGI > 0.23). To understand the association between HGI and risk of RKFD in diabetic patients, directed acyclic graph were drawn and multivariate Cox proportional hazards models were used to adjust for covariates.

RESULTS

During a median follow-up of 4.0 years, RKFD occurred in 43 patients (6.3 %) with diabetes. After adjusting for potential confounders, Compared to the lower-HGI group, the hazard ratios for RKFD were 1.75 (95 % confidence interval [95 % CI]: 0.72, 4.25) and 2.64 (95 % CI: 1.12, 6.21) in the medium- and higher-HGI groups, respectively. HGI showed a linearly associated with RKFD (Pfor nonlinear = 0.383). The magnitude of associations was not materially altered in all sensitivity analyses, but with none significantly.

CONCLUSION

Higher HGI may be associated with an increased risk of RKFD in diabetic patients.

Comparative effectiveness of insulin glargine, glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors in veterans with type 2 diabetes

AIMS

To compare the risk of all-cause death and cardiovascular events in new users of insulin glargine, glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i), particularly in subgroups defined by baseline haemoglobin A1C (HbA1C), body mass index (BMI) and estimated glomerular filtration rate (eGFR).

MATERIALS AND METHODS

We conducted an active comparator, new user design study in a national cohort of 161 405 veterans with type 2 diabetes (T2D) on metformin and initiated insulin glargine (n = 54 375), GLP-1RA (n = 22 145) or SGLT2i (n = 84 885) between 1 January 2018 and 31 December 2021. Patients were followed until 31 March 2023. Inverse probability weighted Cox regression models were used for treatment comparisons on all-cause deaths and cardiovascular events in the entire cohort and above subgroups.

RESULTS

There were 20 788 cardiovascular events/414 414 person-years and 15 268 all-cause deaths/446 458 person-years. Insulin glargine had a higher hazard of all-cause death compared to GLP-1RA (hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.48-1.67) or SGLT2i (HR 1.55, 95% CI 1.48-1.61) in the entire cohort and across subgroups, especially in those with HbA1C levels <9.0%. Results were similar for secondary outcomes. Compared to GLP-1RA, SGLT2i had similar risk of all-cause death (HR 1.03, 95% CI 0.97-1.10) but higher hazard of cardiovascular events (HR 1.13, 95% CI 1.08-1.19). Across subgroups, GLP-1RA and SGLT2i had generally similar effects, with SGLT2i showing a slightly higher risk in some cases.

CONCLUSIONS

Insulin glargine might be deleterious particularly in those with HbA1C <9.0%. There was no clear evidence for prioritization of SGLT2i versus GLP-1RA across subgroups.

Dapagliflozin in diabetic kidney disease patients with different filtration status

BACKGROUND

Few studies have discussed the effects and mechanism of dapagliflozin on diabetic kidney disease (DKD) with different glomerular filtration rate (GFR) and systolic blood pressure (SBP). This study aimed to investigate the variation in the eGFR and proteinuria after dapagliflozin treatment in DKD patients with different filtration status and SBP levels.

METHODS

First, we conducted a cross-sectional study to determined hyperfiltration threshold for the DKD trial. Then, we enrolled 259 DKD patients with an eGFR greater than 70 mL/min/1.73m2 and an albumin-to-creatinine ratio (ACR) between 30 and 200 mg/g to receive treatment with dapagliflozin. Hyperfiltration was defined as the 95th percentile of eGFR above the age- and gender- specific in healthy subjects, DKD patients were divided into hyperfiltration and non-hyperfiltration groups, and SBP > 120 mmHg and ≤ 120 mmHg groups. The eGFR, ACR, and blood and urine electrolytes were measured before and after treatment.

RESULTS

The mean eGFR change at 2 weeks in the hyperfiltration with SBP > 120 mmHg group was greater than in the non-hyperfiltration with SBP ≤ 120 mmHg group (P = 0.048). The mean ACR reduction values were greater in the non-hyperfiltration with SBP ≤ 120 mmHg group than in the hyperfiltration with SBP > 120 mmHg group at 12 weeks (P = 0.042). There was no difference in other blood or urine electrolytes before and after treatment, except for the fractional excretion of sodium (FENa), which significantly increased after 2 weeks (P < 0.001) and recovered after 8 weeks (P = 0.305).

CONCLUSION

DKD with non-hyperfiltration with SBP ≤ 120 mmHg had a lower mean eGFR decline and greater decrease in the ACR after treatment. The initial increase in FENa and subsequent decrease after dapagliflozin treatment may be the main mechanism behind the eGFR variation.

Renoprotective mechanisms of glucagon-like peptide-1 receptor agonists

Glucagon-like peptide-1 (GLP-1) is an incretin hormone, secreted from gut endocrine cells, which acts to potentiate nutrient-induced insulin secretion. Activation of its receptor, GLP-1R, decreases glucagon secretion and gastric emptying, thereby decreasing blood glucose and body weight. It is largely through these mechanisms that Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have transformed the treatment of type 2 diabetes. More recently, preclinical and clinical studies have reported that these agents have potent extra-pancreatic effects, exhibiting cardioprotective and renoprotective actions. The recent FLOW trial was the first multicentre clinical trial investigating the effect of GLP-1RAs on a primary renal outcome and reported robust evidence that GLP-1RAs are renoprotective. Studies in rodent models of renal injury have shown that gain and loss of GLP-1R signalling improves or deteriorates kidney function. However, the precise mechanisms responsible for renal benefits of GLP-1RAs are not yet fully understood. While prolonged activation of GLP-1 receptors (GLP-1R) has been shown to reverse diabetes-related disruptions in gene expression across various renal cell populations, GLP-1R expression in both rodent and human kidneys is thought to be primarily confined to certain vascular smooth muscle cells. This review discusses recent advances in our understanding of the effects of GLP-1 medicines on the kidney with a focus on indirect and direct mechanisms of action.

Mechanism of LncRNA-MiRNA in Renal Intrinsic Cells of Diabetic Kidney Disease and Potential Therapeutic Direction

The occurrence of diabetic kidney disease (DKD), a critical microvascular issue in diabetes, is progressively on the rise. In recent years, long noncoding RNAs (lncRNAs) have garnered considerable attention as a novel and critical layer of biological regulation. Our knowledge regarding the roles and underlying mechanisms of lncRNAs in various diseases, including DKD, continues to evolve. Similarly, microRNAs (miRNAs), which are small noncoding RNAs, have been recognized as crucial contributors to cellular processes and disease pathogenesis. Emerging studies have highlighted the complex interactions between lncRNAs and miRNAs, particularly in the context of DKD, underscoring their importance in complex human diseases. Renal intrinsic cell damage is an important cause of inducing DKD. Persistent high glucose stimulation leads to remodeling of renal intrinsic cells and a cascade of pathological changes. This article aims to review recent literature on the lncRNAs-mediated regulation of miRNAs affecting renal intrinsic cells in DKD and to propose novel molecular-level therapeutic strategies for DKD. Through in-depth investigation of this dynamic molecular interaction, we can gain a profound understanding of the potential mechanisms underlying diabetic nephropathy, potentially identifying new targets for therapeutic intervention and paving the way for personalized and effective treatments.

Impact of Empagliflozin on Cardiac Arrhythmias and Heart Rate Variability in Kidney Transplant Recipients

AIM

We aimed to investigate the effects of Empagliflozin on cardiac arrhythmias and heart rate variability in kidney transplant recipients (KTRs).

METHODS

Twenty-seven diabetic patients who underwent kidney transplantation between August 2020 and August 2023 were included. Patients with HbA1c >8% were received Empagliflozin treatment. A 24-hour Holter ECG monitoring was performed before and one year after beginning Empagliflozin. Holter ECGs were evaluated by a single cardiologist, comparing ventricular ectopic beats (VEB) and supraventricular ectopic beats (SEB) arrhythmias and heart rate variability parameters before and after one year of Empagliflozin treatment.

RESULTS

Twenty-seven patients completed the study, and the mean patient age was 56.1 ± 10 years. Fifteen of the patients (55.6%) were male. The mean duration since transplant before starting Empagliflozin was 62.8 ± 46.2 months. In follow-up, HbA1c decreased from 8.2% to 7.7%(P = .075), urine protein/creatinine ratio reduced from 0.437 ± 0.428 to 0.267 ± 0.146 gr/g (P = .056), and platelet count increased significantly (P = .004). After one year of treatment, the number of VEBs and SEBs in the patients decreased compared to pretreatment. They decreased from 173.5 ± 460.8 and 514.8 ± 265 beats before treatment to 125.1 ± 231.7 and 125.1 ± 231.7 beats after treatment, respectively, but did not reach statistical significance (P > .05). No significant changes were found in heart rate variability parameters (P > .05). No significant correlation was found between VEBs and SEBs and cardiac inflammation indicators (P > .05).

CONCLUSION

This study, for the first time, investigated the effect of Empagliflozin on cardiac arrhythmias and heart rate variability in diabetic KTRs. Empagliflozin did not significantly affect cardiac arrhythmias and heart rate variability in KTRs.

Effects of dietary oxidative balance score on diabetic nephropathy and renal function: insights from retrospective and cross-sectional studies

Background

The relationship between dietary oxidative balance score (DOBS) and diabetes-related renal events remains unclear.

Methods

In this study, the associations between serum micronutrients and diabetic nephropathy (DN) in participants matched by propensity score (PSM) were retrospectively analyzed. And next, a cross-sectional analysis was performed with the National Health and Nutritional Examination Survey (NHANES) database. Weighted multivariate adjusted logistic regression models, dose-response curves, subgroup analysis, and mediation analysis were the main methods of this study. Finally, sensitivity analyses were performed by PSM and multiple imputation (MI).

Results

Retrospective findings suggest that single antioxidants may not be representative of an individual's overall antioxidant levels. The results of the cross-sectional study indicated that the higher the DOBS, the greater the beneficial effects on DN [Q4 vs. Q1: OR (95% CI): 0.78 (0.63, 0.96), p for trend = 0.008] and renal function in DN [Q4 vs. Q1: β (95% CI): 5.395 (1.590, 9.199), p for trend = 0.004]. The above correlations were linear negative correlation (p for nonlinear = 0.989) and linear positive correlation (p for nonlinear = 0.593) respectively. Chronic inflammation mediated the above associations to some extent. The results of sensitivity analysis were consistent with the original analysis.

Conclusion

Higher dietary antioxidant exposure has a positive effect on DN and renal function in DN, mediated partially by chronic inflammation.

Proximal tubular deletion of superoxide dismutase-2 reveals disparate effects on kidney function in diabetes

There is a large body of evidence implicating mitochondrial reactive oxygen species (ROS) overproduction and oxidative stress in the development of diabetic kidney disease and the deficiency of mitochondrial antioxidant systems in the kidney, such as manganese superoxide dismutase (MnSOD/SOD2) have been identified. The proximal tubules of the kidney are densely packed with mitochondria thereby providing energy via oxidative phosphorylation in order to drive active transport for proximal tubular reabsorption of solutes from the glomerular filtrate. We hypothesized that maintenance of MnSOD function in the proximal tubules would be critical to maintain kidney health in diabetes. Here, we induced targeted deletion of SOD2 in the proximal tubules of the kidney in Ins2Akita diabetic mice (SODptKO mice) and show that 20 weeks of SOD2 deletion leads to no major impairment of kidney function and structure, despite these mice displaying enhanced albuminuria and kidney lipid peroxidation (8-isoprostanes). Plasma cystatin C, which is a surrogate marker of glomerular filtration was not altered in SODptKO diabetic mice and histological assessment of the kidney cortex revealed no change in kidney fibrosis. Thus, our findings suggest that deletion of SOD2 in the proximal tubular compartment of the kidney induces a more subtle phenotype than expected, shedding light on the involvement of SOD2 and the proximal tubular compartment in the pathogenesis of diabetic kidney disease.

Spirit Interim Analysis: A Multicenter Prospective Observational Study of Outpatients with CKD and Decreased eGFR to Assess Therapeutic Algorithms, Disease Management and Quality of Life in Greece

Background: Chronic Kidney Disease (CKD) affects 8-16% of the population worldwide and is characterized by an estimated Glomerular Filtration Rate (eGFR) of less than 60 mL/min/1.73 m2 for more than 3 months. The main purpose of the study is to record the treatment algorithms and disease management of patients presenting for the first time to hospital-based nephrologists with a reduced eGFR and CKD diagnosis, under real-world clinical practice in Greece. Methods: This is the 6-month interim analysis of an ongoing, multicenter, observational, prospective, national study, which included 178 patients, with an eGFR between <60 and 15 mL/min/1.73 m2, presenting for the first time to nephrologists at 15 public hospital units. Results: The median age of the patients was 71 years old, with 39.6% of them categorized as CKD stage G3b. Of these patients, 71.6% and 33.7% suffered from arterial hypertension and type 2 diabetes mellitus, respectively; 78.7% of patients received antihypertensive and 38.5% antidiabetic medications. Calcium channel blocker usage increased with disease progression (from 52.2% at G3a, to 67.9% and 67.6% at G3b and G4, respectively), while that of angiotensin II receptor antagonists decreased (from 78.3% at G3a, to 41.5% and 17.6% at G3b and G4, respectively). A decrease in metformin usage and an increase in Dipeptidyl peptidase-4 inhibitor (DPP4i) usage was also observed upon disease progression. Furthermore, 18.5%, 32.0% and 7.7% of patients received Sodium-glucose cotransporter-2 inhibitors (SGLT2i) at the G3a, G3b and G4 stages, respectively. Conclusions: The interim analysis results contributed to the collection of real-world data for the therapeutic patterns and the management of CKD in Greece.

Extracellular vesicles derived from mesenchymal stem cells alleviate renal fibrosis via the miR-99b-5p/mTOR/autophagy axis in diabetic kidney disease

BACKGROUND

Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease (ESRD) globally, presenting a significant therapeutic challenge. Extracellular vesicles (EVs) from mesenchymal stem cells (MSCs) have emerged as promising therapeutic agents. This study explored the therapeutic effects and mechanisms of EVs derived from human placental mesenchymal stem cells (hP-MSCs) on DKD.

METHODS

EVs were isolated from cultured hP-MSCs and administered to streptozotocin (STZ)-induced diabetic mice and high glucose-treated glomerular mesangial cells. The therapeutic impact of EVs was assessed through histological analysis and biochemical assays. miR-99b-5p expression in EVs and its role in modulating the mechanistic target of rapamycin (mTOR)/autophagy pathway were examined via western blotting and RT‒qPCR.

RESULTS

Treatment with hP-MSC-derived EVs significantly alleviated renal fibrosis and improved renal function in DKD models. These EVs were enriched with miR-99b-5p, which targeted and inhibited mTOR signaling, thereby increasing autophagic activity and reducing cellular proliferation and extracellular matrix accumulation in renal tissues.

CONCLUSIONS

hP-MSC-derived EVs can mitigate renal injury in DKD by modulating the miR-99b-5p/mTOR/autophagy pathway. These findings suggest a potential cell-free therapeutic strategy for managing DKD.

Targeting Diabetic Atherosclerosis: The Role of GLP-1 Receptor Agonists, SGLT2 Inhibitors, and Nonsteroidal Mineralocorticoid Receptor Antagonists in Vascular Protection and Disease Modulation

Atherosclerosis is a closely related complication of diabetes mellitus (DM), driven by endothelial dysfunction, inflammation, and oxidative stress. The progression of atherosclerosis is accelerated by hyperglycemia, insulin resistance, and hyperlipidemia. Novel antidiabetic agents, SGLT2 inhibitors, and GLP-1 agonists improve glycemic control and offer cardiovascular protection, reducing the risk of major adverse cardiovascular events (MACEs) and heart failure hospitalization. These agents, along with nonsteroidal mineralocorticoid receptor antagonists (nsMRAs), promise to mitigate metabolic disorders and their impact on endothelial function, oxidative stress, and inflammation. This review explores the potential molecular mechanisms through which these drugs may prevent the development of atherosclerosis and cardiovascular disease (CVD), supported by a summary of preclinical and clinical evidence.

Comparative performance of CKD-EPI equations in people with diabetes: An international pooled analysis of individual participant data

AIM

This study assessed the concordance and misclassification of chronic kidney disease (CKD) stages between directly measured glomerular filtration rate (mGFR) and estimates of GFR (eGFR) using the creatinine-based CKD-EPI-2009 and the CKD-EPI-2021 equations in individuals with diabetes.

METHODS

Data from 5,177 individuals across six international diabetes cohorts included mGFR measurements using exogenous filtration markers. We calculated an intra-class correlation coefficient (ICC), bias, precision and accuracy between mGFR and CKD-EPI estimates using a four-level mixed-effect linear variance component model.

RESULTS

The pooled cohort included people with type 1 (n = 1,748, median age: 33 years [IQR: 27, 40], mGFR = 104.2 ml/min per 1.73 m2) and type 2 diabetes (n = 3,429, median age: 66 years [IQR: 58, 73], mGFR = 58.4 ml/min per 1.73 m2). Both CKD-EPI equations showed good agreement (2009 ICC: 0.90; 2021 ICC: 0.87) but substantial bias (2009: 3.7 ml/min/1.73 m2; 2021: 8.6 ml/min/1.73 m2), low precision (2009: 12.4 ml/min/1.73 m2; 2021: 13.91 ml/min/1.73 m2), and limited accuracy (2009 p30: 77 %; 2021 p30: 70 %) compared to mGFR.

CONCLUSION

The use of CKD-EPI equations has the potential for misdiagnosis and suboptimal CKD management in people with diabetes. Alternative methods of estimating kidney function for people with diabetes are needed to optimally manage diabetes-related kidney disease.

NR4A1 silencing alleviates high-glucose-stimulated HK-2 cells pyroptosis and fibrosis via hindering NLRP3 activation and PI3K/AKT pathway

BACKGROUND

The pathophysiology of diabetic kidney disease (DKD) is complex. Interfering with the processes of pyroptosis and fibrosis is an effective strategy for slowing DKD progression. Previous studies have revealed that nuclear receptor subfamily 4 group A member 1 (NR4A1) may serve as a novel pathogenic element in DKD; however, the specific mechanism by which it contributes to pyroptosis and fibrosis in DKD is unknown.

AIM

To investigate the role of NR4A1 in renal pyroptosis and fibrosis in DKD and possible molecular mechanisms.

METHODS

Streptozotocin 60 mg/kg was injected intraperitoneally to establish a rat model of DKD. Typically, 45 mmol/L glucose [high glucose (HG)] was used to activate HK-2 cells to mimic the DKD model in vitro. HK-2 cells were transfected with NR4A1 siRNA to silence NR4A1.

RESULTS

NR4A1 was elevated in renal tissues of DKD rats and HG-stimulated HK-2 cells. Concurrently, NOD-like receptor protein 3 (NLRP3) and phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT) pathways were triggered, and pyroptosis and expression of fibrosis-linked elements was increased in vivo and in vitro. These alterations were significantly reversed via NR4A1 silencing.

CONCLUSION

Inhibition of NR4A1 mitigated pyroptosis and fibrosis via suppressing NLRP3 activation and the PI3K/AKT pathway in HG-activated HK-2 cells.

Association between endocrine disrupting chemicals exposure and diabetic kidney disease in adults: A national cross-sectional NHANES study

BACKGROUND

Diabetic kidney disease (DKD) is a global public health concern. Environmental factors are increasingly recognized as significant risk factors that cannot be overlooked, and certain environmental pollutants exhibit endocrine-disrupting properties. Previous research on the association between endocrine-disrupting chemicals (EDCs) and DKD has been notably limited.

METHODS

This study investigated the association between exposure to 25 EDC metabolites and DKD in 1421 U.S. adults from the 2015-2018 National Health and Nutrition Examination Survey (NHANES). We used logistic regression, restricted cubic spline regression, weighted quantile sum (WQS) regression, and bayesian kernel machine regression (BKMR) models to assess the association between individual and co-exposure to multiple EDCs and DKD. Subgroup analyses and interaction tests were performed to investigate whether this association was stable across the population. Additionally, mediation analysis was used to explore the mediating role of serum globulins in the association between Pb exposure and DKD.

RESULTS

In logistic regression models, N-Acetyl-S-(2-hydroxypropyl)-L-cysteine (2HPMA), N-Acetyl-S-(4-hydroxy-2-butenyl)-L-cysteine (MHBMA3), Phenylglyoxylic acid (PGA), and lead (Pb) were significantly positively associated with diabetes. Restricted cubic spline (RCS) analyses also revealed significant non-linear positive associations between 2HPMA, MHBMA3, and DKD. Perfluorohexane sulfonic acid (PFHxS), n-perfluorooctanoic acid (n-PFOA), n-perfluorooctane sulfonic acid (n-PFOS), and Perfluoromethylheptane sulfonic acid isomers (Sm-PFOS) were significantly negatively associated with DKD. Furthermore, co-exposure to metals and metalloid was positively associated with DKD in both the WQS regression and the BKMR models, with Pb as the primary contributing factor. Mediation analysis showed that globulin mediated the association between Pb exposure and DKD, with a mediation proportion of 7.25 % (P = 0.046). Co-exposure to perfluoroalkyl and polyfluoroalkyl substances (PFASs) was negatively correlated with DKD, and subgroup analyses revealed that this correlation was more pronounced in the obese group (BMI ≥30 kg/m²). The BKMR analysis revealed potential interactions among various chemical compounds, such as N-Acetyl-S-(2-hydroxypropyl)-L-cysteine (2HPMA), 2-Methylhippuric acid (2MHA), N-Acetyl-S-(4-hydroxy-2-methyl-2-butenyl)-L-cysteine (IPM3), mercury (Hg), and cadmium (Cd), in a model simulating co-exposure to metals and metalloid, as well as to volatile organic compound metabolites (mVOCs).

CONCLUSION

The findings suggest an association between individual or co-exposure to EDC metabolites and DKD, providing valid evidence for DKD prevention from the perspective of EDCs exposure. However, more prospective studies are needed to elucidate the potential mechanisms underlying these findings.

SGLT2 Inhibitors and the Risk of Urogenital Infections: A Concise Review

Diabetes mellitus has become a major public health problem due to aspects such as an alarming increase in prevalence, the morbidity and mortality associated with its complications and, not least, the economic burden. SGLT2 inhibitors are a relatively new but valuable class of drugs that demonstrated multifaceted effects in addition to hypoglycemic action. Moreover, these drugs demonstrated cardiovascular and renal benefits, even in individuals without diabetes, being recommended by current guidelines to patients with a history of cardiovascular disease, or at high risk for it, as well as to patients with chronic kidney disease. The prescription of this class of drugs is limited by the risk of urogenital infections, despite their multiple demonstrated benefits. Data regarding the prevalence of SGLT2 inhibitors associated with urogenital infections depend on several factors related to the study carried out and to other additional conditions that could precipitate such infections. While SGLT2 inhibitors have a well-established association with the risk of genital infections, the association with urinary tract infections remains controversial and uncertain. This review will be focused on urogenital infections associated with the administration of SGLT2 inhibitors, highlighting their prevalence, risk factors, mechanisms involved, clinical relevance and particularities of management.

Effects of Holothuria leucospilota polysaccharide on alleviating diabetic kidney disease through regulating inflammation

Diabetic kidney disease (DKD) is a severe metabolic disorder that typically results from diabetes mellitus and culminates in chronic kidney disease and renal failure. It has been reported that Holothuria leucospilota polysaccharide (HLP) has an improvement effect on type 2 diabetes mellitus (T2DM) rats. This study aimed to explore the impact of HLP on DKD further and reveal its mechanism. The spontaneous Goto-Kakizaki (GK) rats were used as a model of the DKD group, and Wistar rats were used as a normal control group, treated with intragastric administration for 4 weeks. The results showed that after HLP intervention, the renal index was reduced. Scr, BUN, and UA levels increased in the DKD group, and the HLP-H group was significantly decreased by 15.44 μmol/L, 1.11 mmol/L, and 0.08 mmol/L (p < 0.05). HLP also alleviated renal pathological damage and kidney fibrosis, decreased MIF, CD74, and IL-6 mRNA expression levels, enhanced PI3K, AKT, and PCX levels. These results indicated that HLP effectively relieved DKD by regulating inflammation and metabolism.

A novel index evaluating left atrioventricular coupling function in chronic kidney disease with diabetes patients

The left atrioventricular coupling index (LACI) evaluates the coupling function between the left atrial (LA) and left ventricular (LV) chambers. However, little is known about LACI in chronic kidney disease (CKD) patients. This study aimed to assess the impact of concurrent CKD and type 2 diabetes mellitus (T2DM) on left atrioventricular coupling function compared to CKD patients without T2DM. A retrospective analysis included 173 CKD 4-5 stage patients who underwent echocardiographic examinations. The study comprised 75 CKD patients with T2DM (CKD + DM) and 98 CKD patients without T2DM (CKD-DM). During the follow-up, major adverse cardiac events (MACE) were tracked until June 30, 2024, or death, with a median duration of 21 (18, 27) months, 20.8% of patients experienced MACE, and 10.4% passed away. This study employed speckle tracking echocardiography to evaluate LA and LV strain, alongside the LACI, analyzing its role in predicting MACE. CKD + DM patients showed a notable rise in LACI compared to CKD-DM patients, hinting at a link between diabetes and impaired left atrioventricular coupling in CKD. Patients with lower LACI had superior clinical outcomes during follow-up (P < 0.001). Univariate and multivariate Cox regression analyses underscored LACI as an independent predictor for heightened MACE risk in CKD 4-5 stage patients. This study highlights a potential association between diabetes and impaired left atrioventricular coupling function in CKD 4-5 stage patients, with LACI independently linked to an increased risk of MACE.

Cornuside as a promising therapeutic agent for diabetic kidney disease: Targeting regulation of Ca2+ disorder-mediated renal tubular epithelial cells apoptosis

Renal tubular epithelial cells (RTECs) apoptosis is the key factor in the development of diabetic kidney disease (DKD). Endoplasmic reticulum stress (ERS) leading to mitochondrial Ca2+ overload is one of the causes of apoptosis in RTECs. Corni Fructus (CF) is an herbal medicine, developed and applied as a functional food, and it is commonly used to treat DKD. Cornuside (Cor) is one of the main chemical components in CF. This research seeks to investigate the function of Cor in DKD and delve into its possible mechanisms. Cor significantly improved renal function and ameliorated renal pathological changes of db/db mice. Bioinformatics analyses suggested that the modulation of endoplasmic reticulum-induced intrinsic apoptosis pathway was a primary mechanism by which Cor ameliorated DKD. TUNEL assays and flow cytometry assays indicated that Cor effectively inhibited RTECs apoptosis in db/db mice and AGE-induced HK-2 cells. Further experimental studies showed that Cor mitigated ERS by inhibiting the activation of PERK/ATF4/CHOP signal pathway and down-regulation of VDAC1 protein expression, thus alleviating mitochondrial Ca2+ overload. More importantly, Cor directly targeted NEDD4 to facilitate VDAC1 degradation. Notably, the silencing of NEDD4 nearly abolished Cor's inhibitory effects on mitochondrial Ca2+ overload and apoptosis. In conclusion, Cor modulated Ca2+ homeostasis by alleviating ERS and targeting NEDD4, thus mitigating apoptosis of RTECs in DKD. These findings indicate that Cor has the potential for the treatment and drug development of DKD.

Nuciferine Restores Autophagy via the PI3K-AKT-mTOR Pathway to Alleviate Renal Fibrosis in Diabetic Kidney Disease

Diabetic kidney disease (DKD) is one of the complications of diabetes mellitus, which triggers kidney fibrosis and eventually develops into end-stage renal disease. Nuciferine (NF) is one of the most important functional components in lotus leaves (LL), but its role and mechanism for the treatment of DKD are unclear. A high-fat-diet (HFD)-induced DKD model in KK-AY mice was established in this study. NF treatment significantly improved blood glucose and blood biochemical indices in DKD mice. Furthermore, NF reduced the levels of mALB, UCRE, Scr, and BUN in mice urine. Further, the extent of renal lesions in the mice in this study was at stage IV according to the Mogensen staging method. NF treatment was effective in ameliorating renal injury during this period. Concurrently, the protein levels of FN, N-cadherin, TGFβ, p-Smad3, p-PI3K, p-AKT, p-mTOR, and p62 were decreased. In contrast, the level of expression of Beclin-1 was increased. In the high glucose-exposed HK-2 cell model, the expression of p-PI3K, p-AKT, and p-mTOR was all downregulated, and autophagy proteins were increased after NF intervention. In addition, HK-2 cells were treated with high glucose in combination with Wortmannin and 3-MA, respectively. The results demonstrated that NF inhibited the expression of TGFβ and p-Smad3 by regulating autophagy through the PI3K-AKT-mTOR pathway, thereby ameliorating renal fibrosis at stage IV in mice. Therefore, LL can be used as a dietary component for the prevention of renal fibrosis in DKD patients.

Network pharmacology and molecular docking technology-based predictive study and potential targets analysis of icariin for the treatment of diabetic nephropathy

OBJECTIVE

Epimedium glycoside is a flavonoid compound in Epimedium, which has been found to alleviate various chronic diseases. The effect and mechanism of icariin on the treatment of diabetes nephropathy still need to be clarified. In this study, we conducted network pharmacology and molecular docking analysis to reveal the mechanism of icariin treating DKD, and then validated its efficacy using a cell model.

METHOD

The structure and targets of icariin were screened using Traditional Chinese Medicine Systems Pharmacology (TCMSP), and their targets were annotated. Retrieve DKD targets from OMIM, GeneCards, and TTD databases. We constructed a protein-protein interaction (PPI) network using the STRING platform and visualized the results using Cytoscape 3.9.1 software. We also conducted GO and KEGG enrichment analysis on icariin and then performed molecular docking between icariin and key targets. Finally, we established a cell model of DKD to evaluate the efficacy of icariin in treating DKD.

RESULT

A total of 77 icariin targets were associated with DKD. The GO and KEGG enrichment results showed that the therapeutic effect of icariin on DKD was significantly correlated with inflammatory response, cell apoptosis, epithelial-mesenchymal transition, and PI3K/AKT signaling pathway. The molecular docking results indicate that icariin has a high affinity for key targets EGER, AKT1, and IGF1. Cell experiments showed that icariin inhibited high glucose-induced EMT, fibrosis-related proteins, levels of inflammatory factors TGF-β1, IL-6, and TNF-α, as well as phosphorylation of phosphatidylinositol 3-kinase (PI3K) and protein kinase B (AKT) in renal tubular epithelial cells. In addition, icariin inhibited the increase in EGER and AKT1 mRNA levels caused by high glucose and alleviated the decrease in IGF1 mRNA levels.

CONCLUSION

Epimedium glycoside may protect DKD by targeting EGER, AKT1, and IGF1 to inhibit PI3K/AKT signaling, but the specific mechanism needs further exploration.

Machine learning-based risk predictive models for diabetic kidney disease in type 2 diabetes mellitus patients: a systematic review and meta-analysis

Background

Machine learning (ML) models are being increasingly employed to predict the risk of developing and progressing diabetic kidney disease (DKD) in patients with type 2 diabetes mellitus (T2DM). However, the performance of these models still varies, which limits their widespread adoption and practical application. Therefore, we conducted a systematic review and meta-analysis to summarize and evaluate the performance and clinical applicability of these risk predictive models and to identify key research gaps.

Methods

We conducted a systematic review and meta-analysis to compare the performance of ML predictive models. We searched PubMed, Embase, the Cochrane Library, and Web of Science for English-language studies using ML algorithms to predict the risk of DKD in patients with T2DM, covering the period from database inception to April 18, 2024. The primary performance metric for the models was the area under the receiver operating characteristic curve (AUC) with a 95% confidence interval (CI). The risk of bias was assessed using the Prediction Model Risk of Bias Assessment Tool (PROBAST) checklist.

Results

26 studies that met the eligibility criteria were included into the meta-analysis. 25 studies performed internal validation, but only 8 studies conducted external validation. A total of 94 ML models were developed, with 81 models evaluated in the internal validation sets and 13 in the external validation sets. The pooled AUC was 0.839 (95% CI 0.787-0.890) in the internal validation and 0.830 (95% CI 0.784-0.877) in the external validation sets. Subgroup analysis based on the type of ML showed that the pooled AUC for traditional regression ML was 0.797 (95% CI 0.777-0.816), for ML was 0.811 (95% CI 0.785-0.836), and for deep learning was 0.863 (95% CI 0.825-0.900). A total of 26 ML models were included, and the AUCs of models that were used three or more times were pooled. Among them, the random forest (RF) models demonstrated the best performance with a pooled AUC of 0.848 (95% CI 0.785-0.911).

Conclusion

This meta-analysis demonstrates that ML exhibit high performance in predicting DKD risk in T2DM patients. However, challenges related to data bias during model development and validation still need to be addressed. Future research should focus on enhancing data transparency and standardization, as well as validating these models' generalizability through multicenter studies.

Systematic Review Registration

https://inplasy.com/inplasy-2024-9-0038/, identifier INPLASY202490038.

Comparison of Renal Adverse Events Between Intravitreal Anti-Vascular Endothelial Growth Factor Agents: A Meta-Analysis

PURPOSE

To compare the risk of renal adverse events, particularly acute kidney injury (AKI), between intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents.

DESIGN

Meta-analysis.

METHODS

A systematic literature search was conducted on Ovid Medline, Embase, and the Cochrane Library for randomized controlled trials (RCTs) published from January 2005 to February 2024 involving adult patients receiving anti-VEGF intravitreal injections for age-related macular degeneration, diabetic macular edema, and macular edema secondary to retinal vein occlusion. The primary outcome was the comparative risk of AKI between anti-VEGF agents and sham injections. Secondary outcomes involved other renal adverse events. Subgroup analyses were conducted by specific disease indications. A random-effects model was used for meta-analysis to estimate risk ratios (RRs) and their 95% confidence intervals, with a P value of <.05 representing statistical significance. Risk of bias was assessed using the Cochrane Risk of Bias 2 (ROB2) tool, and the certainty of evidence was evaluated through the Cochrane Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework.

RESULTS

A total of 10,031 eyes from 11 RCTs were included. No significant differences were found in the risk of acute or chronic renal conditions, obstructive uropathies, neoplasia, or infectious processes between anti-VEGF agents and sham therapy. AKI was reported in 5.4% (n = 10/185) of patients treated with bevacizumab, 1.3% (n = 6/456) with sham, 1.0% (n = 48/4724) with aflibercept, 0.8% (n = 15/1929) with faricimab, 0.5% (n = 5/1098) with brolucizumab, and 0.3% (n = 5/1639) with ranibizumab. No significant differences in AKI risk were observed between any of the anti-VEGF agents and sham (P > .05 for all comparisons). However, there was an increased risk of patient-reported symptoms with 1.25 mg bevacizumab compared to 2 mg aflibercept (RR = 3.26, 95% CI = 1.07-9.93, P = .04), driven primarily by reports of hematuria: 4.3% (bevacizumab), 0.7% (sham), 0.2% (aflibercept), 0.1% (faricimab), and 0.1% (ranibizumab).

CONCLUSIONS

US Food and Drug Administration (FDA)-approved intravitreal anti-VEGF agents do not significantly increase the risk of AKI compared to sham injections. Nevertheless, variations in patient-reported renal symptoms were observed across different anti-VEGF drugs. These variations were influenced primarily by differences in hematuria events, which may be a result of differential systemic absorption by these agents. These results underscore the importance of continuous monitoring and pharmacovigilance.

Association between fatty liver disease and risk of microvascular complications in Type-2 diabetes mellitus: A systematic review and meta-analysis

Objective

To summarize the existing evidence on the association between non-alcoholic fatty liver disease (NAFLD) and the probability of microvascular complications in Type-2 diabetes mellitus (T2DM).

Methods

PubMed, EMBASE and Scopus databases search (from inception until October 31, 2023) was done for reports with cross-sectional, cohort or case-control design that included adult participants with T2DM and a documented NAFLD status. The selected studies were required to report on at least one microvascular outcome. Studies reporting adjusted associations were included. Random-effects models were used for all analysis. The pooled effect sizes for the associations were reported as odds ratio (OR) with 95% confidence intervals (CI).

Results

Sixteen studies were analysed. T2DM patients with associated NAFLD had similar risk of neuropathy (OR 1.08, 95% CI: 0.97, 1.21), compared to those without NALFD. NAFLD was associated with slightly lower risk of retinopathy (OR 0.86, 95% CI: 0.75, 0.98; N=10, I2=82.6%) an increased incidence of nephropathy (OR 1.21, 95% CI: 1.14, 1.29; N=12, I2=82.5%), compared to patients with T2DM but no NAFLD.

Conclusion

Diagnosis of NAFLD in patients with T2DM appears to increase the incidence of nephropathy and decrease the risk of retinopathy. Future studies are needed to confirm these observations.

mTOR pathway: A key player in diabetic nephropathy progression and therapeutic targets

Diabetic nephropathy is a prevalent complication of diabetes and stands as the primary contributor to end-stage renal disease. The global prevalence of diabetic nephropathy is on the rise, however, due to its intricate pathogenesis, there is currently an absence of efficacious treatments to enhance renal prognosis in affected patients. The mammalian target of rapamycin (mTOR), a serine/threonine protease, assumes a pivotal role in cellular division, survival, apoptosis delay, and angiogenesis. It is implicated in diverse signaling pathways and has been observed to partake in the progression of diabetic nephropathy by inhibiting autophagy, promoting inflammation, and increasing oxidative stress. In this academic review, we have consolidated the understanding of the pathological mechanisms associated with four distinct resident renal cell types (podocytes, glomerular mesangial cells, renal tubular epithelial cells, and glomerular endothelial cells), as well as macrophages and T lymphocytes, within a diabetic environment. Additionally, we highlight the research progress in the treatment of diabetic nephropathy with drugs and various molecules interfering with the mTOR signaling pathway, providing a theoretical reference for the treatment and prevention of diabetic nephropathy.

Identifying subgroups benefiting from intensive glycaemic treatment to improve renal outcomes in type 2 diabetes: Insights from the ACCORD trial

AIMS

The ACCORD trial showed that intensive glucose-lowering therapy has a limited impact on renal function decline. We aimed to identify subgroups in the ACCORD population that might derive renal benefits from intensive glucose-lowering therapy.

MATERIALS AND METHODS

The primary renal outcome included a ≥50% decline in baseline estimated glomerular filtration rate or end-stage renal disease (ESRD). Using the causal tree model, we employed internal cross-validation to identify five pivotal variables influencing the renal efficacy of intensive glycaemic control. These variables were integrated into the model-based recursive partitioning approach, yielding a visualizable tree model that depicted benefitting subgroups.

RESULTS

Node 4, characterized by no cardiovascular history, systolic blood pressure (SBP) ≤142.67 mm Hg, and triglycerides ≤172 mg/dL, showed significantly reduced hazards of the composite renal outcome (fully adjusted hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.49-0.89; p = 0.006) and doubling of serum creatinine (fully adjusted HR 0.59, 95% CI 0.36-0.98; p = 0.041). Node 7 (no cardiovascular history and SBP 142.67-154 mm Hg) showed reduced hazards of the primary renal outcome (fully adjusted HR 0.67, 95% CI 0.49-0.93; p = 0.016) and ESRD (fully adjusted HR 0.35, 95% CI 0.17-0.74; p = 0.0057). Encouragingly, neither node 4 nor node 7 displayed elevated cardiovascular risk or hypoglycaemic events.

CONCLUSIONS

Through innovative machine learning, we identified ACCORD subgroups benefitting significantly from intensive glycaemic therapy for renal outcomes, without increased cardiovascular or hypoglycaemic risks.