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Cohen RV, Pereira TV, Aboud CM, Zanata Petry TB, Lopes Correa JL, Schiavon CA, Pompílio CE, Quirino Pechy FN, Calmon da Costa Silva AC, Cunha da Silveira LP, Paulo de Paris Caravatto P, Halpern H, de Lima Jacy Monteiro F, da Costa Martins B, Kuga R, Sarian Palumbo TM, Friedman AN, le Roux CW. Gastric bypass versus best medical treatment for diabetic kidney disease: 5 years follow up of a single-centre open label randomised controlled trial. EClinicalMedicine 2022; 53:101725. [PMID: 36467457 PMCID: PMC9716325 DOI: 10.1016/j.eclinm.2022.101725] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We compared the albuminuria-lowering effects of Roux-en-Y gastric bypass (RYGB) to best medical treatment in patients with diabetic kidney disease and obesity to determine which treatment is better. METHODS A 5 year, open-label, single-centre, randomised trial studied patients with diabetic kidney disease and class I obesity after 1:1 randomization to best medical treatment (n = 49) or RYGB (n = 51). The primary outcome was the proportion of patients achieving remission of microalbuminuria after 5 years. Secondary outcomes included improvements in diabetic kidney disease, glycemic control, quality of life, and safety. For efficacy outcomes, we performed an intention-to-treat (ITT) analysis. This study was registered with ClinicalTrials.gov, NCT01821508. FINDINGS 88% of patients (44 per arm) completed 5-year follow-up. Remission of albuminuria occurred in 59.6% (95% CI = 45.5-73.8) after best medical treatment and 69.7% (95% CI = 59.6-79.8) after RYGB (risk difference: 10%, 95% CI, -7 to 27, P = 0.25). Patients after RYGB were twice as likely to achieve an HbA1c ≤ 6.5% (60.2% versus 25.4%, risk difference, 34.9%; 95% CI = 15.8-53.9, P < 0.001). Quality of life after five years measured by the 36-Item Short Form Survey questionnaire (standardized to a 0-to-100 scale) was higher in the RYGB group than in the best medical treatment group for several domains. The mean differences were 13.5 (95% CI, 5.5-21.6, P = 0.001) for general health, 19.7 (95% CI, 9.1-30.3, P < 0.001) for pain, 6.1 (95% CI, -4.8 to 17.0, P = 0.27) for social functioning, 8.3 (95% CI, 0.23 to 16.3, P = 0.04) for emotional well-being, 12.2 (95% CI, 3.9-20.4, P = 0.004) for vitality, 16.8 (95% CI, -0.75 to 34.4, P = 0.06) for mental health, 21.8 (95% CI, 4.8-38.7, P = 0.01) for physical health and 11.1 (95% CI, 2.24-19.9, P = 0.01) for physical functioning. Serious adverse events were experienced in 7/46 (15.2%) after best medical treatment and 11/46 patients (24%) after RYGB (P = 0.80). INTERPRETATION Albuminuria remission was not statistically different between best medical treatment and RYGB after 5 years in participants with diabetic kidney disease and class 1 obesity, with 6-7 in ten patients achieving remission of microalbuminuria (uACR <30 mg/g) in both groups. RYGB was superior in improving glycemia, diastolic blood pressure, lipids, body weight, and quality of life. FUNDING The study was supported by research grants from Johnson & Johnson Brasil, Oswaldo Cruz German Hospital, and by grant 12/YI/B2480 from Science Foundation Ireland (Dr le Roux) and grant 2015-02733 from the Swedish Medical Research Council (Dr le Roux). Dr Pereira was funded by the Chevening Scholarship Programme (Foreign and Commonwealth Office, UK).
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Affiliation(s)
- Ricardo V. Cohen
- The Center for Obesity and Diabetes, Oswaldo Cruz German Hospital, São Paulo, Brazil
- Corresponding author. The Center for Obesity and Diabetes Hospital Alemão Oswaldo Cruz, R. Treze de Maio, 1815, Bloco D, 1° andar, Bela Vista, São Paulo - SP, CEP 01327-001, Brazil.
| | - Tiago Veiga Pereira
- Applied Health Research Centre, St. Michael's Hospital, Toronto, Canada
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | | | | | | | | | | | | | | | | | | | - Helio Halpern
- The Center for Obesity and Diabetes, Oswaldo Cruz German Hospital, São Paulo, Brazil
| | | | | | - Rogerio Kuga
- The Center for Obesity and Diabetes, Oswaldo Cruz German Hospital, São Paulo, Brazil
| | | | - Allon N. Friedman
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carel W. le Roux
- Diabetes Complications Research Centre, UCD Conway Institute, School of Medicine, University College Dublin, Dublin, Ireland
- Diabetes Research Centre, Ulster University, Coleraine, United Kingdom
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Wang JW, Ke JF, Zhang ZH, Lu JX, Li LX. Albuminuria but not low eGFR is closely associated with atherosclerosis in patients with type 2 diabetes: an observational study. Diabetol Metab Syndr 2022; 14:50. [PMID: 35413936 PMCID: PMC9006541 DOI: 10.1186/s13098-022-00824-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 04/03/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There is still controversy regarding the associations of urinary albumin excretion (UAE) and estimated glomerular filtration rate (eGFR) with atherosclerosis in patients with type 2 diabetes mellitus (T2DM). Therefore, it is necessary to explore the correlation between them in T2DM patients. METHODS We conducted a survey involving 2565 T2DM patients from a single center. The study cohort was classified into three groups based on the levels of albuminuria: normal UAE (UAE < 30 mg/24 h), moderate UAE (UAE between 30 and 299 mg/24 h) and high UAE (UAE ≥ 300 mg/24 h). Additionally, the patients were divided into three separate groups according to eGFR levels, including low eGFR (eGFR < 60 ml/min/1.73 m2), intermediate eGFR (eGFR 60-89 ml/min/1.73 m2) and normal eGFR (eGFR ≥ 90 ml/min/1.73 m2) groups. Atherosclerotic lesions were compared among the three UAE and eGFR groups. Regression analyses were used to assess the associations of atherosclerotic lesions with UAE and eGFR in T2DM. RESULTS After controlling for age, sex and diabetes duration, the prevalence of atherosclerotic plaque and stenosis were significantly increased from the normal to high UAE groups (plaque: 72.2%, 78.6% and 87.3%, respectively, p = 0.016 for trend; stenosis: 14.0%, 25.5% and 37.3%, respectively, p < 0.001 for trend). Likewise, the values of carotid intima-media thickness (CIMT) and femoral intima-media thickness (FIMT) were also obviously increased from the normal to high UAE groups (CIMT: p < 0.001 for trend; FIMT: p = 0.001 for trend). Conversely, only the FIMT value was clearly increased from the low to normal eGFR groups (p = 0.001 for trend). Fully adjusted regression analyses revealed that UAE was closely associated with the presence of atherosclerotic plaque (OR 1.20, 95% CI 1.03-1.40, p = 0.020) and stenosis (OR 1.17, 95% CI 1.01-1.35, p = 0.036), and with the values of CIMT (β 0.05, 95% CI 0.01-0.10, p = 0.029) and FIMT (β 0.07, 95% CI 0.03-0.11, p = 0.001) in T2DM patients. However, there was no significant association between eGFR levels and atherosclerotic lesions in T2DM after adjustment for multiple confounding factors. CONCLUSIONS Overall, albuminuria rather than low eGFR is closely associated with atherosclerotic lesions in T2DM patients. Albuminuria is an independent risk factor for carotid and femoral atherosclerotic lesions in T2DM. Therefore, albuminuria may be a potential early marker to predict the development of atherosclerosis in patients with T2DM.
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Affiliation(s)
- Jun-Wei Wang
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Jiang-Feng Ke
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Zhi-Hui Zhang
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Jun-Xi Lu
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Lian-Xi Li
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
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Sheer R, Nair R, Pasquale MK, Evers T, Cockrell M, Gay A, Singh R, Schmedt N. Predictive Risk Models to Identify Patients at High-Risk for Severe Clinical Outcomes With Chronic Kidney Disease and Type 2 Diabetes. J Prim Care Community Health 2022; 13:21501319211063726. [PMID: 35068244 PMCID: PMC8796116 DOI: 10.1177/21501319211063726] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction/Objective: Predictive risk models identifying patients at high risk for specific outcomes may provide valuable insights to providers and payers regarding points of intervention and modifiable factors. The goal of our study was to build predictive risk models to identify patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) at high risk for progression to end stage kidney disease (ESKD), mortality, and hospitalization for cardiovascular disease (CVD), cerebrovascular disease (CeVD), and heart failure (HF). Methods: This was a retrospective observational cohort study utilizing administrative claims data in patients with CKD (stage 3-4) and T2D aged 65 to 89 years enrolled in a Medicare Advantage Drug Prescription plan offered by Humana Inc. between 1/1/2012 and 12/31/2017. Patients were enrolled ≥1 year pre-index and followed for outcomes, including hospitalization for CVD, CeVD and HF, ESKD, and mortality, 2 years post-index. Pre-index characteristics comprising demographic, comorbidities, laboratory values, and treatment (T2D and cardiovascular) were evaluated and included in the models. LASSO technique was used to identify predictors to be retained in the final models followed by logistic regression to generate parameter estimates and model performance statistics. Inverse probability censoring weighting was used to account for varying follow-up time. Results: We identified 169 876 patients for inclusion. Declining estimated glomerular filtration rate (eGFR) increased the risk of hospitalization for CVD (38.6%-61.8%) and HF (2-3 times) for patients with eGFR 15 to 29 mL/min/1.73 m2 compared to patients with eGFR 50 to 59 mL/min/1.73 m2. Patients with urine albumin-to-creatinine ratio (UACR) ≥300 mg/g had greater chance for hospitalization for CVD (2.0 times) and HF (4.9 times), progression to ESKD (2.9 times) and all-cause mortality (2.4 times) than patients with UACR <30 mg/g. Elevated hemoglobin A1c (≥8%) increased the chances for hospitalization for CVD (21.3%), CeVD (45.4%), and death (20.6%). Among comorbidities, history of HF increased the risk for ESKD, mortality, and hospitalization for CVD, CeVD, and HF. Conclusions: The predictive models developed in this study could potentially be used as decision support tools for physicians and payers, and the risk scores from these models can be applied to future outcomes studies focused on patients with T2D and CKD.
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Affiliation(s)
- Richard Sheer
- Humana Healthcare Research, Inc., Louisville, KY, USA
| | - Radhika Nair
- Humana Healthcare Research, Inc., Louisville, KY, USA
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Komuro I, Kadowaki T, Bodegård J, Thuresson M, Okami S, Yajima T. Lower heart failure and chronic kidney disease risks associated with sodium-glucose cotransporter-2 inhibitor use in Japanese type 2 diabetes patients without established cardiovascular and renal diseases. Diabetes Obes Metab 2021; 23 Suppl 2:19-27. [PMID: 33835641 DOI: 10.1111/dom.14119] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/11/2020] [Accepted: 06/14/2020] [Indexed: 12/11/2022]
Abstract
AIMS To examine heart failure (HF) and chronic kidney disease (CKD) risks reduction associated with sodium-glucose cotransporter-2 inhibitors (SGLT-2i) compared to other glucose-lowering drugs (oGLD) in the early stage of type 2 diabetes patients without established cardiovascular or renal diseases (CVRD-free T2D). MATERIALS AND METHODS We performed an observational cohort study using a Japanese hospital claims registry, Medical Data Vision. CVRD-free T2D patients were identified between 1 April 2014 and 30 September 2018. SGLT-2i and oGLD new users (and dipeptidyl peptidase 4 inhibitors [DPP-4i] separately) were subjected to 1:1 propensity-score matching analysis. Hazard ratios (HRs) of cardiorenal disease (HF and/or CKD), HF, CKD, stroke, myocardial infarction (MI), and all-cause mortality, were estimated using unadjusted Cox regression. RESULTS A total of 108 362 CVRD-free patients including 54 181 SGLT-2i and 54 181 oGLD users were matched. Baseline characteristics were well balanced (mean age 59.1 years, 63% male, and follow-up 1.50 years [162 970 patient-years]). Compared to oGLD group, SGLT-2i group had lower risk of cardiorenal disease, HF, CKD, stroke, and all-cause mortality with HRs (95% confidence intervals) 0.55 (0.49-0.61), 0.73 (0.61-0.87), 0.45 (0.39-0.52), 0.69 (0.59-0.81), and 0.52 (0.46-0.58), respectively, while no difference in MI. These were consistent in 1:1 propensity-score matching analysis between SGLT-2i and DPP-4i users (n = 17 232 in each group). CONCLUSIONS In Japanese CVRD-free T2D patients, SGLT-2i initiation was associated with lower risk of cardiorenal diseases, stroke, and all-cause mortality compared to oGLD, suggesting preventive effect of SGLT-2i treatment in the early stage of T2D patients without CVRD manifestation.
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Affiliation(s)
- Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | | | | | - Suguru Okami
- Cardiovascular, Renal, and Metabolism, Medical Affairs, AstraZeneca K.K., Osaka, Japan
| | - Toshitaka Yajima
- Cardiovascular, Renal, and Metabolism, Medical Affairs, AstraZeneca K.K., Osaka, Japan
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Scholtes RA, van Baar MJB, Kok MD, Bjornstad P, Cherney DZI, Joles JA, van Raalte DH. Renal haemodynamic and protective effects of renoactive drugs in type 2 diabetes: Interaction with SGLT2 inhibitors. Nephrology (Carlton) 2021; 26:377-390. [PMID: 33283420 PMCID: PMC8026736 DOI: 10.1111/nep.13839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/05/2020] [Accepted: 11/24/2020] [Indexed: 12/25/2022]
Abstract
Diabetic kidney disease remains the leading cause of end‐stage kidney disease and a major risk factor for cardiovascular disease. Large cardiovascular outcome trials and dedicated kidney trials have shown that sodium‐glucose cotransporter (SGLT)2 inhibitors reduce cardiovascular morbidity and mortality and attenuate hard renal outcomes in patients with type 2 diabetes (T2D). Underlying mechanisms explaining these renal benefits may be mediated by decreased glomerular hypertension, possibly by vasodilation of the post‐glomerular arteriole. People with T2D often receive several different drugs, some of which could also impact the renal vasculature, and could therefore modify both renal efficacy and safety of SGLT2 inhibition. The most commonly prescribed drugs that could interact with SGLT2 inhibitors on renal haemodynamic function include renin‐angiotensin system inhibitors, calcium channel blockers and diuretics. Herein, we review the effects of these drugs on renal haemodynamic function in people with T2D and focus on studies that measured glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) with gold‐standard techniques. In addition, we posit, based on these observations, potential interactions with SGLT2 inhibitors with an emphasis on efficacy and safety. This invited review describes the renal haemodynamic and protective effects of commonly prescribed drugs in people with type 2 diabetes and their interaction with SGLT2 inhibitors.
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Affiliation(s)
- Rosalie A Scholtes
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Michaël J B van Baar
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Megan D Kok
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Petter Bjornstad
- Department of Pediatrics, Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Medicine, Division of Nephrology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David Z I Cherney
- Department of Medicine and Department of Physiology, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center, Utrecht, The Netherlands
| | - Daniël H van Raalte
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands.,Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
Endothelial cells form the inner lining of all blood vessels and play a vital role in regulating vascular permeability. This applies to the circulation in general and also to specific capillary beds including the renal glomerular capillaries. Endothelial dysfunction, including increased permeability, is a key component of diabetes-induced organ damage. Endothelial cells together with their glycocalyx, grown on porous membranes, provide an excellent model to study endothelial permeability properties. Here we describe the measurement of two characteristics of glomerular endothelial cell (GEnC) monolayers: electrical resistance and macromolecular passage. Trans-endothelial electrical resistance provides a measure of small-pore pathways across the endothelium and provides an index of monolayer confluence and cell-cell junction integrity. Measurement of macromolecular passage provides an index of large-pore pathways and use of labeled albumin provides direct relevance to the clinically important parameter of albuminuria. The combination of the two approaches provides a fantastic tool to elucidate endothelial barrier function in vitro including in response to cytokines, pathological stimuli, and potential therapeutic agents.
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Arman Rabbani S, Belagodu Sridhar S, Gm Rao P, Javed N, Thomas Kurian M, Mahtab A, Sharma S. Prevalence and associations of moderately increased albuminuria in patients with type 2 diabetes in United Arab Emirates. Diabetes Metab Syndr 2020; 14:1865-1870. [PMID: 32980790 DOI: 10.1016/j.dsx.2020.09.021] [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: 08/19/2020] [Revised: 09/11/2020] [Accepted: 09/13/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Our study sought to investigate the prevalence of moderately increased albuminuria in United Arab Emirates (UAE) nationals with type 2 diabetes, and to identify the associated factors. METHODS This prospective cross-sectional study was conducted in two hundred and seven UAE nationals with type 2 diabetes mellitus attending the internal medicine department of a secondary care hospital. Moderately increased albuminuria was estimated in random spot urine samples and was defined as urinary albumin-to-creatinine ratio (UACR) of 3-30 mg/mmoL. Prevalence and associations of moderately increased albuminuria were evaluated. RESULTS The study population had a mean UACR of 7.2 ± 10.2 mg/mmoL with mean eGFR of 94.5 ± 11.7 mL/min/1.73 m2. Prevalence of moderately increased albuminuria in our study population was found to be 44.0%. Multivariate logistic regression analysis showed that duration of diabetes (OR:1.72, 95% CI:1.34-2.19; p<0.001), presence of hypertension (OR:3.42, 95% CI:0.96-12.20; p=0.050) and neuropathy (OR:2.85, 95% CI:1.03-7.84; p=0.042), BMI (OR:1.08, 95% CI:1.01-1.16; p=0.019), HbA1c (OR:1.39, 95% CI:1.00-1.93; p=0.045), CRP (OR:1.10, 95% CI:1.00-1.22; p=0.035), serum creatinine (OR:1.04, 95% CI:1.02-1.06; p<0.001) and HDL-C (OR:0.10, 95% CI:0.01-0.28; p<0.001) were independently correlated with moderately increased albuminuria. Stepwise multiple linear regression analysis demonstrated that duration of diabetes, HbA1c, CRP and serum creatinine were independent predictors of UACR. CONCLUSION We report a high prevalence of moderately increased albuminuria in UAE nationals with type 2 diabetes in a secondary care setting. Routine screening and timely management of moderately increased albuminuria in type 2 diabetes mellitus can lead to better patient outcomes.
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Affiliation(s)
- Syed Arman Rabbani
- Department of Clinical Pharmacy and Pharmacology, RAK College of Pharmaceutical Sciences, RAK Medical and Health Sciences University, Ras Al-Khaimah, United Arab Emirates.
| | - Sathvik Belagodu Sridhar
- Department of Clinical Pharmacy and Pharmacology, RAK College of Pharmaceutical Sciences, RAK Medical and Health Sciences University, Ras Al-Khaimah, United Arab Emirates
| | - Padma Gm Rao
- Department of Clinical Pharmacy and Pharmacology, RAK College of Pharmaceutical Sciences, RAK Medical and Health Sciences University, Ras Al-Khaimah, United Arab Emirates
| | - Nadeem Javed
- Ibrahim Bin Hamad Obaidallah Hospital, Ras al Khaimah, United Arab Emirates
| | | | - Asiya Mahtab
- School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Shrestha Sharma
- School of Medical and Allied Sciences, K. R. Mangalam University, Gurgaon, Haryana, India
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Borunda Duque T, Dodd M, Mwithi A, VanNess R, Swanson K. Opportunity for Real-Time, Longitudinal Clinical Laboratory Data to Enhance Diabetes Disease Surveillance: A Cross-Sectional, Laboratory Database–Enabled Population Study. J Appl Lab Med 2020; 5:967-977. [DOI: 10.1093/jalm/jfaa106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/22/2020] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Population disease surveillance can contribute to focused interventions to promote better disease management and prevention of noncommunicable diseases.
Methods
HbA1c results in TriCore Reference Laboratories’ (TriCore) data repository from residents in New Mexico (NM) from January 2014 to May 2019 were used in the study. Using the Behavioral Risk Factor Surveillance System (BRFSS) as the gold standard, a linear regression model was used to develop a model to estimate NM’s diabetes prevalence from HbA1cs. The American Diabetes Association guidelines HbA1c ranges were used to divide the population into groups according to their last HbA1c result, and patients were tracked by their TriCore identification number over the selected time period.
Results
The derived NM diabetes rate of 10.63%, 95% CI [10.1%–11.1%] was compared to the derived 10.4%, 95% CI [9.8%–11%] by the CDC. Moreover, TriCore’s longitudinal data were able to track a large number of patients’ transition between the different HbA1cs cut offs from 2014 to 2019.
Conclusion
Findings of this study substantiate the value of the laboratory outside of the traditional fee per service lab result model and support a possible novel role for clinical laboratories to play in population health.
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Affiliation(s)
| | - Monique Dodd
- TriCore Reference Laboratories, Albuquerque NM
- Rhodes Group, Albuquerque, NM
| | | | - Richard VanNess
- TriCore Reference Laboratories, Albuquerque NM
- Rhodes Group, Albuquerque, NM
| | - Kathleen Swanson
- TriCore Reference Laboratories, Albuquerque NM
- Rhodes Group, Albuquerque, NM
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Nichols GA, Déruaz-Luyet A, Brodovicz KG, Kimes TM, Rosales AG, Hauske SJ. Kidney disease progression and all-cause mortality across estimated glomerular filtration rate and albuminuria categories among patients with vs. without type 2 diabetes. BMC Nephrol 2020; 21:167. [PMID: 32380961 PMCID: PMC7203828 DOI: 10.1186/s12882-020-01792-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 04/01/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Studies of progression of kidney dysfunction typically focus on renal replacement therapy or percentage decline in estimated glomerular filtration rate (eGFR) as outcomes. Our aim was to compare real-world patients with and without T2D to estimate progression from and to clinically defined categories of kidney disease and all-cause mortality. METHODS This was an observational cohort study of 31,931 patients with and 33,201 age/sex matched patients without type 2 diabetes (T2D) who had a serum creatinine and urine albumin-to-creatinine ratio (UACR) or dipstick proteinuria (DP) values. We used the first available serum creatinine value between 2006 and 2012 to calculate baseline eGFR and categorized them and the corresponding UACR/DP values using the Kidney Disease Improving Global Outcomes (KDIGO) categories. To assess our primary outcomes, we extracted probabilities of eGFR progression or mortality from life-table analyses and conducted multivariable Cox regression analyses of relative risk adjusted for age, sex, race/ethnicity, smoking, ischemic heart disease, heart failure, and use of renal-angiotensin-aldosterone system inhibitors. RESULTS Patterns of eGFR decline were comparable among patients with vs. without T2D with larger percentage declines at higher albuminuria levels across all eGFR categories. eGFR decline was generally larger among T2D patients, particularly in those with severely increased albuminuria. Across all CKD categories, risk of progression to the next higher category of eGFR was substantially increased with increasing albuminuria. For example, the risk was 23.5, 36.2, and 65.1% among T2D patients with eGFR 30-59 ml/min/1.73m2 and UACR < 30, 30-299, and > 300 mg/dL, respectively (p < 0.001). Other comparisons were similarly significant. Among patients with low eGFR and normal to mildly increased albuminuria, the relative risk was up to 8-fold greater for all-cause mortality compared with the non-CKD subgroup (eGFR> 60 ml/min/1.73m2 with normal to mildly increased albuminuria). CONCLUSIONS Presence of albuminuria was associated with accelerated eGFR decline independent of T2D. Risk for adverse outcomes was remarkably high among patients with CKD and normal to mildly increased albuminuria levels. Independent of T2D or albuminuria, a substantial risk for adverse outcomes exists for CKD patients in a routine care setting.
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Affiliation(s)
- Gregory A Nichols
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, Oregon, USA.
| | | | | | - Teresa M Kimes
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, Oregon, USA
| | - A Gabriela Rosales
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, Oregon, USA
| | - Sibylle J Hauske
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
- Vth Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Heidelberg, Germany
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Laszczyńska O, Severo M, Mascarenhas J, Paiva JA, Azevedo A. Serum creatinine trajectories in real-world hospitalized patients: clinical context and short-term mortality. J Investig Med 2020; 68:870-881. [DOI: 10.1136/jim-2019-001185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2020] [Indexed: 12/27/2022]
Abstract
Fluctuations in serum creatinine (SCr) during hospitalization may provide additional prognostic value beyond baseline renal function. This study aimed to identify groups of patients with distinct creatinine trajectories over hospital stay and assess them in terms of clinical characteristics and short-term mortality. This retrospective study included 35 853 unique adult admissions to a tertiary referral center between January 2012 and January 2016 with at least three SCr measurements within the first 9 days of stay. Individual SCr courses were determined using linear regression or linear-splines model and grouped into clusters. SCr trajectories were described as median SCr courses within clusters. Almost half of the patients presented with changing, mainly declining SCr concentration during hospitalization. In comparison to patients with an increase in SCr, those with a significant decline were younger, more often admitted via the emergency department, more often required a higher level of care, had fewer comorbidities and the more pronounced the fall in SCr, the greater the observed difference. Regardless of baseline renal function, an increase in SCr was related to the highest in-hospital mortality risk among compared clusters. Also, patients with normal renal function at admission followed by decreasing SCr were at higher risk of inpatient death, but lower 90-day postdischarge mortality than patients with a stable SCr. Acute changes in inpatient SCr convey important prognostic information and can only be interpreted by looking at their evolution over time. Recognizing underlying causes and providing adequate care is crucial for improving adverse prognosis.
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Singh S, Sonkar SK, Sonkar GK, Mahdi AA. Diabetic kidney disease: A systematic review on the role of epigenetics as diagnostic and prognostic marker. Diabetes Metab Res Rev 2019; 35:e3155. [PMID: 30892801 DOI: 10.1002/dmrr.3155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 01/26/2019] [Accepted: 03/14/2019] [Indexed: 12/13/2022]
Abstract
Diabetic kidney disease is one of the most serious microvascular complications and among the leading causes of end stage renal disease. Persistently increasing albuminuria has been considered to be the central hallmark of nephropathy. However, albuminuria can indicate kidney damage for clinicians; it is not a specific biomarker for prediction of diabetic kidney disease prior to the onset of this devastating complication, and in fact all individuals with microalbuminuria do not progress to overt nephropathy. Controlled glycemia is unable to prevent nephropathy in all diabetic individuals indicating the role of other factors in progression of diabetic kidney disease. There are numerous cellular and molecular defects persisting prior to appearance of clinical symptoms. So, there is an urgent need to look for easy, novel, and accurate way to detect diabetic kidney disease prior to its beginning or at the infancy stage so that its progression can be slowed or arrested. It is now accepted that initiation and progression of diabetic kidney disease are a result of complex interactions between genetic and environmental factors. Environmental signals can alter the intracellular pathways by chromatin modifiers and regulate gene expression patterns leading to diabetes and its complications. In the present review, we have discussed a possible link between aberrant DNA methylation and altered gene expression in diabetic kidney disease. Drugs targeting to reverse epigenetic alteration can retard or stop the development of this devastating disease, just by breaking the chain of events occurring prior to the development of this microvascular complication in patients with diabetes.
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Affiliation(s)
- Sangeeta Singh
- Department of Biochemistry, King George's Medical University, U.P., Lucknow, India
| | | | | | - Abbas Ali Mahdi
- Department of Biochemistry, King George's Medical University, U.P., Lucknow, India
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Jia Y, Zheng Z, Xue M, Zhang S, Hu F, Li Y, Yang Y, Zou M, Li S, Wang L, Guan M, Xue Y. Extracellular Vesicles from Albumin-Induced Tubular Epithelial Cells Promote the M1 Macrophage Phenotype by Targeting Klotho. Mol Ther 2019; 27:1452-1466. [PMID: 31208912 DOI: 10.1016/j.ymthe.2019.05.019] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 05/16/2019] [Accepted: 05/21/2019] [Indexed: 12/22/2022] Open
Abstract
Albumin absorbed by renal tubular epithelial cells induces inflammation and plays a key role in promoting diabetic kidney disease (DKD) progression. Macrophages are prominent inflammatory cells in the kidney, and their role there is dependent on their phenotypes. However, whether albuminuria influences macrophage phenotypes and underlying mechanisms during the development of DKD is still unclear. We found that M1 macrophage-related markers were increased in diabetes mellitus (DM) mouse renal tissues with the development of DKD, and coculture of extracellular vesicles (EVs) from human serum albumin (HSA)-induced HK-2 cells with macrophages induced macrophage M1 polarization in the presence of lipopolysaccharide (LPS). Through a bioinformatic analysis, miR-199a-5p was selected and found to be increased in EVs from HSA-induced HK-2 cells and in urinary EVs from DM patients with macroalbuminuria. Tail-vein injection of DM mice with EVs from HSA-induced HK-2 cells induced kidney macrophage M1 polarization and accelerated the progression of DKD through miR-199a-5p. miR-199a-5p exerted its effect by targeting Klotho, and Klotho induced macrophage M2 polarization through the Toll-like receptor 4 (TLR4) pathway both in vivo and in vitro. In summary, miR-199a-5p from HSA-stimulated HK-2 cell-derived EVs induces M1 polarization by targeting the Klotho/TLR4 pathway and further accelerates the progression of DKD.
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Affiliation(s)
- Yijie Jia
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zongji Zheng
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Meng Xue
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Endocrinology and Metabolism, Shenzhen People's Hospital, Second Affiliated Hospital of Jinan University, Shenzhen, Guangdong, China
| | - Shuting Zhang
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Endocrinology, Guangdong General Hospital/Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Fang Hu
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Endocrinology and Metabolism, The Fifth Affiliated Hospital Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Yang Li
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanlin Yang
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Meina Zou
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shuangshuang Li
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ling Wang
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Meiping Guan
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yaoming Xue
- Department of Endocrinology & Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Ghith N, Merlo J, Frølich A. Albuminuria measurement in diabetic care: a multilevel analysis measuring the influence of accreditation on institutional performance. BMJ Open Qual 2019; 8:e000449. [PMID: 30729192 PMCID: PMC6340563 DOI: 10.1136/bmjoq-2018-000449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 11/27/2018] [Accepted: 12/03/2018] [Indexed: 11/24/2022] Open
Abstract
Background Studies assessing institutional performance regarding quality of care are frequently performed using single-level statistical analyses investigating differences between provider averages of various quality indicators. However, such analyses are insufficient as they do not consider patients’ heterogeneity around those averages. Hence, we apply a multilevel analysis of individual-patient heterogeneity that distinguishes between ‘general’ (‘latent quality’ or measures of variance) and ‘specific’ (measures of association) contextual effects. We assess general contextual effects of the hospital departments and the specific contextual effect of a national accreditation programme on adherence to the standard benchmark for albuminuria measurement in Danish patients with diabetes. Methods From the Danish Adult Diabetes Database, we extracted data on 137 893 patient cases admitted to hospitals between 2010 and 2013. Applying multilevel logistic and probit regression models for every year, we quantified general contextual effects of hospital department by the intraclass correlation coefficient (ICC) and the area under the receiver operating characteristic curve (AUC) values. We evaluated the specific effect of hospital accreditation using the ORs and the change in the department variance. Results In 2010, the department context had considerable influence on adherence with albuminuria measurement (ICC=21.8%, AUC=0.770), but the general effect attenuated along with the implementation of the national accreditation programme. The ICC value was 16.5% in 2013 and the rate of compliance with albuminuria measurement increased from 91.6% in 2010 to 96% in 2013. Conclusions Parallel to implementation of the national accreditation programme, departments’ compliance with the standard benchmark for albuminuria measurement increased and the ICC values decreased, but remained high. While those results indicate an overall quality improvement, further intervention focusing on departments with the lowest compliance could be considered.
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Affiliation(s)
- Nermin Ghith
- Research Unit of Chronic Conditions, Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg University Hospital, Frederiksberg, Denmark.,Unit for Social Epidemiology, Lunds Universitet, Lund, Sweden
| | - Juan Merlo
- Unit for Social Epidemiology, Lunds Universitet, Lund, Sweden
| | - Anne Frølich
- Research Unit of Chronic Conditions, Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg University Hospital, Frederiksberg, Denmark
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Bjornstad P, Karger AB, Maahs DM. Measured GFR in Routine Clinical Practice-The Promise of Dried Blood Spots. Adv Chronic Kidney Dis 2018; 25:76-83. [PMID: 29499891 DOI: 10.1053/j.ackd.2017.09.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/17/2017] [Accepted: 09/20/2017] [Indexed: 12/31/2022]
Abstract
Accurate determination of glomerular filtration rate (GFR) is crucial for the diagnosis of kidney disease. Estimated GFR (eGFR) calculated by serum creatinine and/or cystatin C is a mainstay in clinical practice and epidemiologic research but lacks precision and accuracy until GFR <60 mL/min/1.73 m2. Furthermore, eGFR may not precisely and accurately represent changes in GFR longitudinally. The lack of precision and accuracy is of concern in populations at high risk for kidney disease, as the dissociation between changes in eGFR and GFR may lead to missed diagnoses of early kidney disease. Therefore, improved methods to quantify GFR are needed. Whereas direct measures of GFR have been too cumbersome for screening and ambulatory care, a practical method of measuring GFR by iohexol clearance using dried capillary blood spots exists. In this review, we examine the current literature and data addressing GFR measurements by dried capillary blood spots and its potential application in high-risk groups.
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15
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Leong A, Ekinci EI, Nguyen C, Milne M, Hachem M, Dobson M, MacIsaac RJ, Jerums G. Long-term intra-individual variability of albuminuria in type 2 diabetes mellitus: implications for categorization of albumin excretion rate. BMC Nephrol 2017; 18:355. [PMID: 29207965 PMCID: PMC5717840 DOI: 10.1186/s12882-017-0767-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 11/20/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease in the Western world. Early and accurate identification of DKD offers the best chance of slowing the progression of kidney disease. An important method for evaluating risk of progressive DKD is abnormal albumin excretion rate (AER). Due to the high variability in AER, most guidelines recommend the use of more than or equal to two out of three AER measurements within a 3- to 6-month period to categorise AER. There are recognised limitations of using AER as a marker of DKD because one quarter of patients with type 2 diabetes may develop kidney disease without an increase in albuminuria and spontaneous regression of albuminuria occurs frequently. Nevertheless, it is important to investigate the long-term intra-individual variability of AER in participants with type 2 diabetes. METHODS Consecutive AER measurements (median 19 per subject) were performed in 497 participants with type 2 diabetes from 1999 to 2012 (mean follow-up 7.9 ± 3 years). Baseline clinical characteristics were collected to determine associations with AER variability. Participants were categorised as having normo-, micro- or macroalbuminuria according to their initial three AER measurements. Participants were then categorised into four patterns of AER trajectories: persistent, intermittent, progressing and regressing. Coefficients of variation were used to measure intra-individual AER variability. RESULTS The median coefficient of variation of AER was 53.3%, 76.0% and 67.0% for subjects with normo-, micro- or macroalbuminuria at baseline. The coefficient of variation of AER was 37.7%, 66% and 94.8% for subjects with persistent, intermittent and progressing normoalbuminuria; 43%, 70.6%, 86.1% and 82.3% for subjects with persistent, intermittent, progressing and regressing microalbuminuria; and 55.2%, 67% and 82.4% for subjects with persistent, intermittent and regressing macroalbuminuria, respectively. CONCLUSION High long-term variability of AER suggests that two out of three AER measurements may not always be adequate for the optimal categorisation and prediction of AER.
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Affiliation(s)
- Amanda Leong
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
| | - Elif Ilhan Ekinci
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia.
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
- Menzies School of Health Research, Red 9, Casuarina Campus, University Drive North, Casuarina, Northern Territory, 0811, Australia.
| | - Cattram Nguyen
- Murdoch Children's Research Institute, Flemington Road, Melbourne, Victoria, 3052, Australia
| | - Michele Milne
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
| | - Mariam Hachem
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew Dobson
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, 41 Victoria Parade, Melbourne, Victoria, 3065, Australia
| | - George Jerums
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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16
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Budoff MJ, Wilding JPH. Effects of canagliflozin on cardiovascular risk factors in patients with type 2 diabetes mellitus. Int J Clin Pract 2017; 71:e12948. [PMID: 28508457 PMCID: PMC5488174 DOI: 10.1111/ijcp.12948] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/12/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Cardiovascular disease is the most common cause of morbidity and mortality among people with type 2 diabetes mellitus (T2DM). The main contributors to cardiovascular risk in T2DM are chronic hyperglycaemia, reduced insulin sensitivity, hypertension and dyslipidaemia. Other cardiovascular risk factors include obesity and visceral adiposity, increased arterial stiffness and renal dysfunction. Results from clinical trials, including a long-term cardiovascular outcome study, have shown that sodium glucose co-transporter 2 (SGLT2) inhibitors can provide multiple cardiometabolic benefits beyond glycaemic control including inducing mild osmotic diuresis, natriuresis and weight loss. This review article describes the effects of canagliflozin on cardiovascular risk factors based on results from its clinical development programme. METHODS This review is based on structured searches to identify literature related to the effects of canagliflozin on cardiovascular risk factors in patients with T2DM. DISCUSSION AND CONCLUSIONS Canagliflozin treatment has been shown to provide glycaemic improvements as well as reductions in blood pressure and body weight across a broad range of patients with T2DM, including those with elevated cardiovascular risk. Other observed effects of canagliflozin that may contribute to improved cardiometabolic outcomes include reduction in uric acid levels, decreased albuminuria and increases in serum magnesium. Results of ongoing long-term cardiovascular outcomes studies of canagliflozin are expected to provide additional evidence on the cardiometabolic effects of canagliflozin treatment.
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Affiliation(s)
- Matthew J. Budoff
- Division of CardiologyLos Angeles Biomedical Research InstituteTorranceCAUSA
| | - John P. H. Wilding
- Obesity and Endocrinology Clinical ResearchInstitute of Ageing and Chronic DiseaseUniversity of LiverpoolLiverpoolUK
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Lee HW, Jo AR, Yi DW, Kang YH, Son SM. Prevalent Rate of Nonalbuminuric Renal Insufficiency and Its Association with Cardiovascular Disease Event in Korean Type 2 Diabetes. Endocrinol Metab (Seoul) 2016; 31:577-585. [PMID: 28029027 PMCID: PMC5195835 DOI: 10.3803/enm.2016.31.4.577] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/26/2016] [Accepted: 10/10/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Nonalbuminuric renal insufficiency is a unique category of diabetic kidney diseases. The objectives of the study were to evaluate prevalent rate of nonalbuminuric renal insufficiency and to investigate its relationship with previous cardiovascular disease (CVD) event in Korean patients with type 2 diabetes mellitus (T2DM). METHODS Laboratory and clinical data of 1,067 subjects with T2DM were obtained and reviewed. Study subjects were allocated into four subgroups according to the CKD classification. Major CVD events were included with coronary, cerebrovascular, and peripheral vascular events. RESULTS Nonalbuminuric stage ≥3 CKD group, when compared with albuminuric stage ≥3 CKD group, had shorter diabetic duration, lower concentrations of glycated hemoglobin, high density lipoprotein cholesterol, and high-sensitivity C-reactive protein, lower prevalent rates of retinopathy and previous CVD, and higher rate of treatment with angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers. Nonalbuminuric stage ≥3 CKD group showed a greater association with prior CVD events than no CKD group; however, albuminuric stage ≥3 CKD group made addition to increase prevalence of prior CVD events significantly when CKD categories were applied as covariates. Association of prior CVD events, when compared with normal estimated glomerular filtration rate (eGFR) and nonalbuminuria categories, became significant for declined eGFR, which was higher for eGFR of <30 mL/min/1.73 m², and albuminuria. CONCLUSION The results show that subjects with nonalbuminuric stage ≥3 CKD is significantly interrelated with occurrence of prior CVD events than those with normal eGFR with or without albuminuria. Comparing with normal eGFR and nonalbuminuria categories, the combination of increased degree of albuminuria and declined eGFR is becoming significant for the association of prior CVD events.
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Affiliation(s)
- Hye Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Diabetes Center, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - A Ra Jo
- Department of Internal Medicine, Pusan National University School of Medicine and Diabetes Center, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dong Won Yi
- Department of Internal Medicine, Pusan National University School of Medicine and Diabetes Center, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yang Ho Kang
- Department of Internal Medicine, Pusan National University School of Medicine and Diabetes Center, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seok Man Son
- Department of Internal Medicine, Pusan National University School of Medicine and Diabetes Center, Pusan National University Yangsan Hospital, Yangsan, Korea.
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18
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Gensicke H, Frih AA, Strbian D, Zini A, Pezzini A, Padjen V, Haueter M, Seiffge DJ, Mäkitie L, Traenka C, Poli L, Martinez-Majander N, Putaala J, Bonati LH, Sibolt G, Giovannini G, Curtze S, Beslac-Bumbasirevic L, Vandelli L, Lyrer PA, Nederkoorn PJ, Tatlisumak T, Engelter ST. Prognostic significance of proteinuria in stroke patients treated with intravenous thrombolysis. Eur J Neurol 2016; 24:262-269. [DOI: 10.1111/ene.13179] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/16/2016] [Indexed: 11/27/2022]
Affiliation(s)
- H. Gensicke
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - A. A. Frih
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - D. Strbian
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - A. Zini
- Stroke Unit; Department of Neuroscience; Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena; Modena Italy
| | - A. Pezzini
- Department of Clinical and Experimental Sciences; Neurology Clinic; University of Brescia; Modena Italy
| | - V. Padjen
- Neurology Clinic; Clinical Centre of Serbia; Beograd Serbia
| | - M. Haueter
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
- Neurorehabilitation Unit; Felix Platter Hospital; University of Basel and University Center for Medicine of Aging; Basel Switzerland
| | - D. J. Seiffge
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - L. Mäkitie
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - C. Traenka
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - L. Poli
- Department of Clinical and Experimental Sciences; Neurology Clinic; University of Brescia; Modena Italy
| | - N. Martinez-Majander
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - J. Putaala
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - L. H. Bonati
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - G. Sibolt
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - G. Giovannini
- Stroke Unit; Department of Neuroscience; Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena; Modena Italy
| | - S. Curtze
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | | | - L. Vandelli
- Stroke Unit; Department of Neuroscience; Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena; Modena Italy
| | - P. A. Lyrer
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - P. J. Nederkoorn
- Department of Neurology; Academic Medical Center Amsterdam; The Netherlands
| | - T. Tatlisumak
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
- Institute of Neuroscience and Physiology; Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
- Department of Neurology; Sahlgrenska University Hospital; Gothenburg Sweden
| | - S. T. Engelter
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
- Neurorehabilitation Unit; Felix Platter Hospital; University of Basel and University Center for Medicine of Aging; Basel Switzerland
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Rabelink TJ, de Zeeuw D. The glycocalyx--linking albuminuria with renal and cardiovascular disease. Nat Rev Nephrol 2015; 11:667-76. [PMID: 26460356 DOI: 10.1038/nrneph.2015.162] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Albuminuria is commonly used as a marker of kidney disease progression, but some evidence suggests that albuminuria also contributes to disease progression by inducing renal injury in specific disease conditions. Studies have confirmed that in patients with cardiovascular risk factors, such as diabetes and hypertension, endothelial damage drives progression of kidney disease and cardiovascular disease. A key mechanism that contributes to this process is the loss of the glycocalyx--a polysaccharide gel that lines the luminal endothelial surface and that normally acts as a barrier against albumin filtration. Degradation of the glycocalyx in response to endothelial activation can lead to albuminuria and subsequent renal and vascular inflammation, thus providing a pathophysiological framework for the clinical association of albuminuria with renal and cardiovascular disease progression. In this Review, we examine the likely mechanisms by which glycocalyx dysfunction contributes to kidney injury and explains the link between cardiovascular disease and albuminuria. Evidence suggests that glycocalyx dysfunction is reversible, suggesting that these mechanisms could be considered as therapeutic targets to prevent the progression of renal and cardiovascular disease. This possibility enables the use of existing drugs in new ways, provides an opportunity to develop novel therapies, and indicates that albuminuria should be reconsidered as an end point in clinical trials.
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Affiliation(s)
- Ton J Rabelink
- Department of Medicine, Division of Nephrology, Einthoven Laboratory for Experimental Vascular Medicine, LUMC, Leiden University Medical Centre, Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, Netherlands
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20
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Hinnen D. Glucuretic effects and renal safety of dapagliflozin in patients with type 2 diabetes. Ther Adv Endocrinol Metab 2015; 6:92-102. [PMID: 26137213 PMCID: PMC4480550 DOI: 10.1177/2042018815575273] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Dapagliflozin is a selective sodium-glucose cotransporter 2 (SGLT2) inhibitor approved as a treatment for type 2 diabetes mellitus (T2DM) in the United States, the European Union and other countries. Dapagliflozin increases renal glucose excretion in an insulin-independent manner, and its mechanism of action is complementary to those of other antidiabetes medications. When used as monotherapy or in combination with other oral antidiabetes medications or insulin, dapagliflozin improves glycemic measures in patients with T2DM. Dapagliflozin treatment is also associated with weight reduction and a decrease in blood pressure, both of which may be beneficial in patients with T2DM. Because of its mechanism of action, dapagliflozin has a low intrinsic propensity to cause hypoglycemia. Overall, dapagliflozin is well tolerated, with the frequency of most adverse events similar to that seen with placebo. Cases of genital infections and, in some studies, urinary tract infections have been more frequent in dapagliflozin-treated groups compared with placebo groups. In the clinical development program, more cases of newly diagnosed bladder cancer were reported for patients treated with dapagliflozin (0.17%) compared with placebo or comparator (0.03%). Although there were not enough cases to determine causality, dapagliflozin should not be used in patients with bladder cancer and should be used with caution in patients with a history of bladder cancer. Dapagliflozin may decrease glomerular filtration rate (GFR), especially in elderly patients and patients with impaired renal function. Renal function should be monitored before initiation of dapagliflozin. Dapagliflozin should not be used in patients with an estimated GFR <60 ml/min/1.73 m(2). No cardiovascular safety signals have been detected for dapagliflozin, and a long-term cardiovascular outcomes study is ongoing. Evidence from clinical trials suggests that dapagliflozin is a promising new treatment option for T2DM.
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Affiliation(s)
- Deborah Hinnen
- Memorial Hospital Diabetes Center, University of Colorado Health, 175 South Union Boulevard, Suite 305, Colorado Springs, CO 80190, USA
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21
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Schernthaner G, Mogensen CE, Schernthaner GH. The effects of GLP-1 analogues, DPP-4 inhibitors and SGLT2 inhibitors on the renal system. Diab Vasc Dis Res 2014; 11:306-23. [PMID: 25116004 PMCID: PMC4230539 DOI: 10.1177/1479164114542802] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Diabetic nephropathy (DN) affects an estimated 20%-40% of patients with type 2 diabetes mellitus (T2DM). Key modifiable risk factors for DN are albuminuria, anaemia, dyslipidaemia, hyperglycaemia and hypertension, together with lifestyle factors, such as smoking and obesity. Early detection and treatment of these risk factors can prevent DN or slow its progression, and may even induce remission in some patients. DN is generally preceded by albuminuria, which frequently remains elevated despite treatment in patients with T2DM. Optimal treatment and prevention of DN may require an early, intensive, multifactorial approach, tailored to simultaneously target all modifiable risk factors. Regular monitoring of renal function, including urinary albumin excretion, creatinine clearance and glomerular filtration rate, is critical for following any disease progression and making treatment adjustments. Dipeptidyl peptidase (DPP)-4 inhibitors and sodium-glucose cotransporter 2 (SGLT2) inhibitors lower blood glucose levels without additional risk of hypoglycaemia, and may also reduce albuminuria. Further investigation of the potential renal benefits of DPP-4 and SGLT2 inhibitors is underway.
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Affiliation(s)
| | - Carl Erik Mogensen
- Medical Department M (Diabetes & Endocrinology), Aarhus University Hospital, Aarhus, Denmark
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22
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Groop PH, Del Prato S, Taskinen MR, Owens DR, Gong Y, Crowe S, Patel S, von Eynatten M, Woerle HJ. Linagliptin treatment in subjects with type 2 diabetes with and without mild-to-moderate renal impairment. Diabetes Obes Metab 2014; 16:560-8. [PMID: 24612167 PMCID: PMC4288982 DOI: 10.1111/dom.12281] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 02/04/2014] [Accepted: 02/18/2014] [Indexed: 12/13/2022]
Abstract
AIMS Renal disease is a frequent comorbidity of type 2 diabetes mellitus (T2DM) and an important factor complicating the choice of glucose-lowering drugs. The aim of this analysis was to evaluate the efficacy and safety of the dipeptidyl peptidase (DPP)-4 inhibitor linagliptin (5 mg/day) in mono, dual or triple oral glucose-lowering regimens in subjects with T2DM and mild or moderate renal impairment (RI). METHODS In this pooled analysis of three 24-week, placebo-controlled, phase 3 trials, subjects with mild (estimated glomerular filtration rate (eGFR) 60-<90 ml/min/1.73 m(2) , n = 838) or moderate RI (30-<60 ml/min/1.73 m(2), n = 93) were compared with subjects with normal renal function (≥90 ml/min/1.73 m(2), n = 1212). RESULTS Subjects with RI were older, had longer duration of diabetes, and increased prevalence of diabetes-related comorbidities. After 24 weeks, linagliptin achieved consistent placebo-corrected mean glycated haemoglobin (HbA1c) changes across the three renal function categories: normal (-0.63%; p < 0.0001), mild RI (-0.67%; p < 0.0001) and moderate RI (-0.53%; p < 0.01), with no inter-group difference (p = 0.74). Renal function with linagliptin remained stable across all categories. In linagliptin-treated subjects, overall adverse event (AE) rates and serious AE rates were similar to placebo. The incidence of hypoglycaemia with linagliptin and placebo was 11.1 versus 6.9%, 11.9 versus 9.0% and 15.9 versus 12.0% in the normal, mild RI and moderate RI categories, respectively. CONCLUSIONS This pooled analysis provides evidence that linagliptin is an effective, well-tolerated and convenient treatment in subjects with T2DM and mild or moderate RI.
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Affiliation(s)
- P-H Groop
- Division of Nephrology, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland; Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland; Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
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23
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Bentata Y, Abouqal R. Does albuminuria predict renal risk and/or cardiovascular risk in obese type 2 diabetic patients? AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2014; 4:26-30. [PMID: 24551483 PMCID: PMC3925884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 11/23/2013] [Indexed: 06/03/2023]
Abstract
Increased urinary albumin excretion (UAE) is a marker of renal and cardiovascular risk in patients with type 2 diabetes (DT2). What about the obese patient with DT2? Does albuminuria predict the progression of renal disease and/or cardiovascular disease? The objective of this study is to determine the link between albuminuria, renal risk and cardiovascular risk in a cohort of obese DT2 patients. This is a prospective study begun in September 2006. It included DT2 patients presenting obesity defined by a body mass index (BMI)>30 Kg/m(2). Three groups of patients were defined: normo-albuminuria (Urinary Albumin Excretion UAE<30 mg/day or Albumin Creatinine Ratio ACR<30 mg/g), micro-albuminuria (UAE=30-300 mg/day or ACR=30-300 mg/g) and macro-albuminuria (UAE>300 mg/day or ACR>300 mg/g). Data on 144 obese DT2 patients were compiled: The mean age of our patients was 59 ± 9 years and the sex ratio 0.26. The incidence of ESRD was higher in the macro-albuminuria group than in the two other groups (26.5% vs. 1.2%, p<0.001). The incidence of cardiovascular events was 15.4%, 14.3% and 23.5% in the normo, micro and macro-albuminuria groups (p=0.48). A history of cardiovascular comorbidities was the main cardiovascular risk in multivariate analysis (0R=15.07; 95% CI=5.30-42.82; p<0.001) and the low admission GFR (0R=5.67; 95% CI=1.23-9.77; p=0.008) was the main factor for progression of kidney disease in multivariate analysis. Albuminuria may be a better marker of kidney disease progression than of cardiovascular risk in the obese DT2 patient, according to our results. However, to accurately demonstrate the link albuminuria - renal risk and albuminuria - cardiovascular risk in the obese DT2 patient, additional studies using very strict criteria of selection and judgment are needed.
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Affiliation(s)
- Yassamine Bentata
- Department of Nephrology, Medical School of Oujda, University Mohammed FirstOujda, Morocco
| | - Redouane Abouqal
- Department of Medical Emergency, Ibn Sina University Hospital10000, Rabat, Morocco
- Laboratory of Biostatistics, Clinical and Epidemiological Research, Medical School University Mohamed V Souissi10000, Rabat, Morocco
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Kopf S, Oikonomou D, von Eynatten M, Kieser M, Zdunek D, Hess G, Morcos M, Forsblom C, Bierhaus A, Groop PH, Nawroth PP, Humpert PM. Urinary excretion of high molecular weight adiponectin is an independent predictor of decline of renal function in type 2 diabetes. Acta Diabetol 2014; 51:479-89. [PMID: 24366425 DOI: 10.1007/s00592-013-0542-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 12/05/2013] [Indexed: 12/11/2022]
Abstract
Adiponectin and urinary adiponectin excretions have been ascribed a function in glomerular physiology and seem to indicate vascular disease in diabetes. The aim of this study was to compare the urinary excretion of albumin and adiponectin as predictors for decline of renal function in patients with type 2 diabetes and early kidney disease. Over 141 patients were screened for renal function (estimated GFR, ml/min*1.73 m(2)), albumin excretion rate (AER, mg/24 h), total as well as high molecular weight (HMW) urinary adiponectin excretion (ng/mol u-creatinine). AER and adiponectin excretion were studied as predictors of renal function after 1 year. After 1 year, 36 patients were in the upper quartile of eGFR decline and defined as progressors (delta eGFR = - 12.3 ± 6.3) while the remaining 105 patients were defined as non-progressors (delta eGFR = 1.4 ± 6.0). At baseline, HMW-adiponectin excretion was positively correlated with HbA1c (p < 0.001) and negatively with eGFR (p < 0.001), but not with AER (p = 0.14). Progressors showed increased urinary HMW-adiponectin at baseline (158[IQR41/479] vs. 65[24/168] ng/mol; p < 0.01), while total adiponectin (182[101/1534] vs. 345[118/1361] ng/mol) and AER (48[23/109] vs. 46[25/108] mg/24 h) excretion showed no differences between the groups. Multivariate logistic regression showed that HMW-adiponectin excretion was an independent predictor of renal progression in all patients (OR 1.86 [95 % CI 1.34-2.59]; p < 0.01), especially in those (n = 45) with normal AER at baseline (OR 2.16 [95 % CI 1.1-4.56]; p < 0.05). Urinary HMW-adiponectin but not AER improved the prediction of progressors in ROC analysis (AUC 0.72 [95 % CI 0.63-0.81] vs. 0.80 [95 % CI 0.71-0.90], p < 0.05). In conclusion, urinary HMW-adiponectin excretion may identify diabetes patients at increased risk for progression of kidney disease.
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Affiliation(s)
- Stefan Kopf
- Department of Medicine 1 and Clinical Chemistry, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany,
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Stephenson DT, Jandeleit-Dahm K, Balkau B, Cohen N. Improvement in albuminuria in patients with type 2 diabetes after laparoscopic adjustable gastric banding. Diab Vasc Dis Res 2013; 10:514-9. [PMID: 23975723 DOI: 10.1177/1479164113498083] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To determine the effects of laparoscopic adjustable gastric banding (LAGB) on albuminuria in patients with obesity, type 2 diabetes mellitus (T2DM) and established diabetic nephropathy. METHODS A retrospective analysis of clinical records from a tertiary diabetes service identified obese patients with T2DM who had micro- or macroalbuminuria prior to LAGB surgery. Clinical data from follow-up appointments including albuminuria were analysed. RESULTS A total of 23 T2DM patients were included in the final study. Of 7 patients with macroalbuminuria at baseline, 2 reverted to normoalbuminuria, 2 reverted to microalbuminuria and 3 remained with macroalbuminuria on their final recording in the 36-month period of follow-up. Of 16 patients with microalbuminuria, 9 reverted to normoalbuminuria, while 6 remained with microalbuminuria. CONCLUSION This study demonstrates significant improvements in albuminuria in patients with established diabetic nephropathy following LAGB. These results suggest the potential for LAGB to improve or reverse renal damage in patients with T2DM.
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Pasko N, Toti F, Strakosha A, Thengjilli E, Shehu A, Dedej T, Ylli A, Thereska N. Prevalence of microalbuminuria and risk factor analysis in type 2 diabetes patients in Albania: the need for accurate and early diagnosis of diabetic nephropathy. Hippokratia 2013; 17:337-341. [PMID: 25031513 PMCID: PMC4097415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Microalbuminuria is often the first sign of renal dysfunction in diabetes. This study aimed to investigate the prevalence of microalbuminuria in Albanian type 2 diabetes patients and its association with other cardiovascular risk factors. METHODS Three hundred and twenty-one patients with type 2 diabetes attending, diabetes centers in Albania were enrolled in this cross-sectional, multicenter study. The subjects, aged 40-70 years, had no known proteinuria or other kidney disease. Pregnant women and patients with acute infections were excluded. Data including waist circumference, duration of diabetes and history of hypertension were obtained by questionnaire. Blood samples were drawn after 12 h overnight fasting to measure glycosylated hemoglobin (HbA1c), serum cholesterol, triglyceride and creatinine. Microalbuminuria was assessed using dipstick kits in early morning urine samples. RESULTS The prevalence of normoalbuminuria was 56.3%, microalbuminuria 40.8% and macroalbuminuria 2.8%. Systolic and diastolic blood pressure (p<0.01), HbA1c (p<0.01) and fasting plasma glucose (p<0.001) were significantly higher in microalbuminuric than in normoalbuminuric subjects. Independent risk factors for microalbuminuria were duration of diabetes (OR: 2.785, 95% CI: 1.156-3.759), systolic blood pressure (OR: 2.88, 95% CI: 1.85-6.85) and waist circumference (OR: 2.15, 95% CI: 1.01-5.45) in males and poor glycemic control (OR: 4.51, 95% CI: 1.45-13.98), duration of diabetes (OR: 2.568, 95% CI: 1.702-3.778) and waist circumference (OR: 4.87, 95% CI: 1.80-13.11) in females. CONCLUSIONS The high proportion of type 2 diabetes patients with microalbuminuria raises implications for health policy in Albania. Screening programs and optimized control of modifiable risk factors are needed to reduce the risk of diabetic nephropathy.
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Affiliation(s)
- N Pasko
- Department of Nephrology Dialysis and Transplant, University Hospital Center, Tirana, Albania
| | - F Toti
- Department of Endocrinology, University Hospital Center, Tirana, Albania
| | - A Strakosha
- Department of Nephrology Dialysis and Transplant, University Hospital Center, Tirana, Albania
| | - E Thengjilli
- Department of Internal Medicine, Regional Hospital, Pogradec, Albania
| | - A Shehu
- Laboratory "Intermedica", Tirana, Albania
| | - T Dedej
- Service of Clinical and Biochemical Laboratory, University Hospital Center, Tirana, Albania
| | - A Ylli
- Department of Endocrinology, University Hospital Center, Tirana, Albania
| | - N Thereska
- Department of Nephrology Dialysis and Transplant, University Hospital Center, Tirana, Albania
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Hayes AJ, Leal J, Gray AM, Holman RR, Clarke PM. UKPDS outcomes model 2: a new version of a model to simulate lifetime health outcomes of patients with type 2 diabetes mellitus using data from the 30 year United Kingdom Prospective Diabetes Study: UKPDS 82. Diabetologia 2013; 56:1925-33. [PMID: 23793713 DOI: 10.1007/s00125-013-2940-y] [Citation(s) in RCA: 280] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
Abstract
AIMS/HYPOTHESIS The aim of this project was to build a new version of the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model (UKPDS-OM1), a patient-level simulation tool for predicting lifetime health outcomes of people with type 2 diabetes mellitus. METHODS Data from 5,102 UKPDS patients from the 20 year trial and the 4,031 survivors entering the 10 year post-trial monitoring period were used to derive parametric proportional hazards models predicting absolute risk of diabetes complications and death. We re-estimated the seven original event equations and estimated new equations for diabetic ulcer and some second events. The additional data permitted inclusion of new risk factor predictors such as estimated GFR. We also developed four new equations for all-cause mortality. Internal validation of model predictions of cumulative incidence of all events and death was carried out and a contemporary patient-level dataset was used to compare 10 year predictions from the original and the new models. RESULTS Model equations were based on a median 17.6 years of follow-up and up to 89,760 patient-years of data, providing double the number of events, greater precision and a larger number of significant covariates. The new model, UKPDS-OM2, is internally valid over 25 years and predicts event rates for complications, which are lower than those from the existing model. CONCLUSIONS/INTERPRETATION The new UKPDS-OM2 has significant advantages over the existing model, as it captures more outcomes, is based on longer follow-up data, and more comprehensively captures the progression of diabetes. Its use will permit detailed and reliable lifetime simulations of key health outcomes in people with type 2 diabetes mellitus.
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Affiliation(s)
- A J Hayes
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia.
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de Zeeuw D, Akizawa T, Agarwal R, Audhya P, Bakris GL, Chin M, Krauth M, Lambers Heerspink HJ, Meyer CJ, McMurray JJ, Parving HH, Pergola PE, Remuzzi G, Toto RD, Vaziri ND, Wanner C, Warnock DG, Wittes J, Chertow GM. Rationale and trial design of Bardoxolone Methyl Evaluation in Patients with Chronic Kidney Disease and Type 2 Diabetes: the Occurrence of Renal Events (BEACON). Am J Nephrol 2013; 37:212-22. [PMID: 23467003 DOI: 10.1159/000346948] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/22/2012] [Indexed: 01/03/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) associated with type 2 diabetes mellitus constitutes a global epidemic complicated by considerable renal and cardiovascular morbidity and mortality, despite the provision of inhibitors of the renin-angiotensin-aldosterone system (RAAS). Bardoxolone methyl, a synthetic triterpenoid that reduces oxidative stress and inflammation through Nrf2 activation and inhibition of NF-κB was previously shown to increase estimated glomerular filtration rate (eGFR) in patients with CKD associated with type 2 diabetes mellitus. To date, no antioxidant or anti-inflammatory therapy has proved successful at slowing the progression of CKD. METHODS Herein, we describe the design of Bardoxolone Methyl Evaluation in Patients with Chronic Kidney Disease and Type 2 Diabetes: the Occurrence of Renal Events (BEACON) trial, a multinational, multicenter, double-blind, randomized, placebo-controlled Phase 3 trial designed to determine whether long-term administration of bardoxolone methyl (on a background of standard therapy, including RAAS inhibitors) safely reduces renal and cardiac morbidity and mortality. RESULTS The primary composite endpoint is time-to-first occurrence of either end-stage renal disease or cardiovascular death. Secondary endpoints include the change in eGFR and time to occurrence of cardiovascular events. CONCLUSION BEACON will be the first event-driven trial to evaluate the effect of an oral antioxidant and anti-inflammatory drug in advanced CKD.
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Affiliation(s)
- Dick de Zeeuw
- Department of Clinical Pharmacology, University of Groningen, University Medical Center, Groningen, The Netherlands.
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Abstract
Excess total and cardiovascular morbidity and mortality remain very high among those with type 2 diabetes versus those without diabetes. Clinical trials to lower blood glucose have been disappointing probably because the participants were too late in the natural history of diabetes and already had extensive vascular disease. Insulin resistance measured simply by elevated fasting blood insulin is an early marker of β-cell stress and peripheral insulin resistance. Metformin will prevent development of diabetes among patients with impaired fasting glucose but only for the short term. Metformin reduces risk of coronary heart disease. The drug is safe, low cost, and may also prevent cancer. The combination of diet and exercise followed by metformin in the early phase of "insulin resistance" may reduce or delay both atherosclerosis and arteriosclerosis complications associated with diabetes. Preventive therapy must begin much earlier than before clinical diagnosis of diabetes and aim to initially lower blood insulin levels or insulin resistance.
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Affiliation(s)
- Lewis H Kuller
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 North Bellefield Avenue, Pittsburgh, PA 15261, USA.
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