Factors affecting progression of renal failure in patients with type 2 diabetes

Association between change in serum uric acid and rapid decline in kidney function in China

While the elevation of serum uric acid (SUA) is acknowledged as a risk factor for chronic kidney disease, the independent extent to which variations in SUA levels are correlated with temporal changes in estimated glomerular filtration rate (eGFR) remains uncertain. In light of this uncertainty, our research endeavored to elucidate the temporal associations between change in SUA and rapid eGFR decline in China. In this longitudinal study of China's middle-aged and elderly between 2011 and 2015, we analyzed 5421 individuals with complete SUA and eGFR data. Logistic regression was applied to evaluate the risk factors associated with a rapid eGFR decline (defined by a 5 mL/min/1.73 m2 decrease or falling to less than 15 mL/min/1.73 m2 by 2015), adjusted for age, gender, marital, residence, income, BMI, hypertension, diabetes, dyslipidemia, CRP, Hba1c, baseline eGFR and baseline SUA. Linear regression was used to evaluate the relationship between variations in SUA and changes in eGFR. After multivariable adjustments, the risk factors of a rapid eGFR decline included aging (OR per 1-year increase: 1.1, 95% CI 1.08-1.12, P < 0.001), being female, being single, having hypertension, a higher baseline eGFR, a higher baseline SUA (OR per-1 mg/dL increase: 1.68, 95% CI 1.48-1.90, P < 0.001), and increase in change in SUA (OR per-1 mg/ dL increase: 1.92,95% CI 1.71-2.16, P < 0.001). Pearson's analysis showed a significant inverse correlation between SUA changes and eGFR decline, particularly pronounced in females, with correlation coefficients of - 0.349 for females and - 0.306 for males (95% CI - 0.347 to - 0.299, P < 0.001). A significant correlation was found between the change in SUA and the rapid decline in eGFR, with this association being particularly pronounced in females.

Personalized Prediction of Change in Fasting Blood Glucose Following Basal Insulin Adjustment in People With Type 2 Diabetes: A Proof-of-Concept Study

AIMS

For people with type 2 diabetes treated with basal insulin, suboptimal glycemic control due to clinical inertia is a common issue. Determining the optimal basal insulin dose can be difficult, as it varies between individuals. Thus, insulin titration can be slow and cautious which may lead to treatment fatigue and non-adherence. A model that predicts changes in fasting blood glucose (FBG) after adjusting basal insulin dose may lead to more optimal titration, reducing some of these challenges.

OBJECTIVE

To predict the change in FBG following adjustment of basal insulin in people with type 2 diabetes using a machine learning framework.

METHODS

A multiple linear regression model was developed based on 786 adults with type 2 diabetes. Data were divided into training (80%) and testing (20%) sets using a ranking approach. Forward feature selection and fivefold cross-validation were used to select features.

RESULTS

Participants had a mean age of approximately 59 years, a mean duration of diabetes of 12 years, and a mean HbA1c at screening of 65 mmol/mol (8.1%). Chosen features were FBG at week 2, basal insulin dose adjustment from week 2 to 7, trial site, hemoglobin level, and alkaline phosphatase level. The model achieved a relative absolute error of 0.67, a Pearson correlation coefficient of 0.74, and a coefficient of determination of 0.55.

CONCLUSIONS

A model using FBG, insulin doses, and blood samples can predict a five-week change in FBG after adjusting the basal insulin dose in people with type 2 diabetes. Implementation of such a model can potentially help optimize titration and improve glycemic control.

Mediators between canagliflozin and renoprotection vary depending on patient characteristics: Insights from the CREDENCE trial

AIM

To identify the mediators between canagliflozin and renoprotection in patients with type 2 diabetes at a high risk of end-stage kidney disease (ESKD).

METHODS

In this post hoc analysis of the CREDENCE trial, the effect of canagliflozin on potential mediators (42 biomarkers) at 52 weeks and the association between changes in mediators and renal outcomes were evaluated using mixed-effects and Cox models, respectively. The renal outcome was a composite of ESKD, serum creatinine doubling or renal death. The percentage of the mediating effect of each significant mediator was calculated based on changes in the hazard ratios of canagliflozin after additional adjustment of the mediator.

RESULTS

Changes in haematocrit, haemoglobin, red blood cell (RBC) count and urinary albumin-to-creatinine ratio (UACR) at 52 weeks significantly mediated 47%, 41%, 40% and 29% risk reduction with canagliflozin, respectively. Further, 85% mediation was attributed to the combined effect of haematocrit and UACR. A large variation in mediating effects by haematocrit change existed among the subgroups, ranging from 17% in those patients with a UACR of more than 3000 mg/g to 63% in patients with a UACR of 3000 mg/g or less. In the subgroups with a UACR of more than 3000 mg/g, UACR change was the highest mediating factor (37%), driven by the strong association between UACR decline and renal risk reduction.

CONCLUSIONS

The renoprotective effects of canagliflozin in patients at a high risk of ESKD can be significantly explained by changes in RBC variables and UACR. The complementary mediating effects of RBC variables and UACR may support the renoprotective effect of canagliflozin in different patient groups.

Association between hemoglobin and chronic kidney disease progression: a secondary analysis of a prospective cohort study in Japanese patients

OBJECTIVE

Anemia has been reported as a risk factor for chronic kidney disease (CKD) progression. However, there are still few studies examining the relationship between specific hemoglobin (Hb) levels and renal prognosis and renal function decline simultaneously. Meanwhile, the possible non-linear relationship between Hb and CKD progression also deserves further exploration. On that account, our primary goal is to explore the link of Hb on renal prognosis and renal function decline in patients with CKD.

METHODS

This study was a secondary analysis of a prospective cohort study, which consecutively and non-selectively collected 962 participants from the research of CKD-ROUTE in Japan from November 2010 to December 2011. We used the Cox proportional-hazards and linear regression models to evaluate the independent association between baseline Hb and renal prognosis (renal composite endpoint, initiation of dialysis during follow-up or 50% decline in eGFR from baseline) and renal function decline(annual eGFR decline), respectively. A multivariate Cox proportional hazards regression analysis with cubic spline functions model and smooth curve fitting (penalized spline method) were conducted to address Hb and CKD prognosis's non-linearity. At the same time, a generalized additive model (GAM) and smooth curve fitting (penalized spline method) was conducted to explore the exact shape of the curve between Hb and renal function decline. Additionally, we did a series of sensitivity analyses to ensure the robustness of the results. Moreover, we conducted subgroup analyses.

RESULTS

The mean age of the included patients was 67.35 ± 13.56 years old, and 69.65% were male. The mean baseline Hb and estimated glomerular filtration rate (eGFR) was 12.06 ± 2.21 g/dL and 33.04 ± 18.01 ml/min per 1.73 m². The annual decline in eGFR was 2.09 mL/min/1.73 m²/year. During a median follow-up time of 33.5 months, 252(26.2%) people experienced renal composite endpoint. After adjusting covariates, the results showed that Hb was negatively associated with renal composite endpoint (HR = 0.836, 95%CI: 0.770, 0.907) and renal function decline (β = -0.436, 95%CI: -0.778, -0.093). There was also a non-linear relationship between Hb and renal composite endpoint, and the inflection point of Hb was 8.6 g/dL. The effect sizes(HR) on the left and right sides of the inflection point were 1.257 (0.841, 1.878) and 0.789 (0.715, 0.870), respectively. And the sensitive analysis demonstrated the robustness of the results. Subgroup analysis showed that Hb was more strongly associated with the renal composite endpoint in non-hypertensive, SBP < 140 mmHg, urine protein-to-creatinine ratio (UPCR) < 0.5 g/gCr, and diuretic use patients. In contrast, the weaker association was probed in hypertensive and non-diuretic use patients and the patients with SBP ≥ 140 mmHg, and UPCR ≥ 0.5 g/gCr.

CONCLUSION

This study demonstrates a negative and non-linear relationship between Hb and renal prognosis and renal function decline in Japanese CKD patients. Hb is strongly related to renal prognosis when Hb is above 8.6 g/dL.

[Challenges in drug discovery research and the effects of SGLT2 inhibitor against diabetic kidney disease]

Diabetic kidney disease is an important diabetic complication as a causative disease for the progression of dialysis. However, the current therapeutic option has not been fully satisfied for completely suppressing the progression of renal injury. One of the reasons is that the model animals are limited that exhibit progressive renal injury similar to those of patients such as advanced urinary protein excretion, glomerular sclerosis, renal interstitial fibrosis and decreased glomerular filtration rate. And also, this is one of the important factors that pathophysiology of diabetic kidney disease has not yet been fully clarified. SGLT2 inhibitors are medicines that promote the excretion of glucose into the urine by suppressing the reabsorption of glucose from the renal proximal tubule and induce a blood glucose lowering effect. In order to verify the effect of SGLT2 inhibitors on diabetic complications, we examined the effects of luseogliflozin using two kinds of animal models expressing the progressive renal injury including the advanced features of diabetic kidney disease similar to patients. Luseogliflozin and combination therapy with ACE inhibitor prevented the progression of renal injury in these animal models, and the result suggests that treatment with SGLT2 inhibitors could be a candidate of therapeutic option for diabetic kidney disease.

Anemia in Diabetes and Pre-Diabetes with Normal Kidney Function: Prevalence and Clinical Outcomes

OBJECTIVE

Anemia is a known complication of diabetes mellitus (DM); however, its prevalence and prognostic relevance in patients with DM and pre-DM with normal kidney function is not well-defined. This study assessed the prevalence of anemia in DM and pre-DM patients and evaluated its association with clinical outcomes during 4-years' follow-up.

METHODS

This retrospective analysis included patients with DM and pre-DM referred to the Meir Medical Center Endocrine Institute during 2015. Patients with estimated glomerular filtration rate (eGFR) <60 ml/min or other recognized cause of anemia were excluded. The risk of developing microvascular or macrovascular complications, or death during four years follow-up was determined.

RESULTS

A total of 622 patients (408 with DM and 214 with pre-DM) were included. Mean age was 64±10.6 years, and 70% were women. Baseline HbA1c was 7.1±1.7% and eGFR was 86.1±15.3 ml/min. At inclusion 77 (19%) patients with DM and 23 (11%) with pre-DM, had anemia (hemoglobin 11.9±0.8 and 11.8±0.8 g/dl, respectively) vs. normal hemoglobin levels of 13.8±0.9 and 13.7±0.9 g/dl, respectively in the others. Multivariable analysis demonstrated an inverse correlation between baseline hemoglobin (as a continuous variable) and mortality (P=0.035), microvascular complications (P=0.003) and eGFR decline (P<0.001), but not with macrovascular complications (P=0.567).

CONCLUSION

This study found a significant prevalence of anemia unrelated to renal failure, both in DM and pre-DM. Anemia in these patients is associated with development of microvascular complications, eGFR decline and mortality. These results underscore the need for intensive lifestyle and pharmacological interventions among these patients.

Drug-drug interactions and inappropriate medicines impact on glycemic control and kidney function in older adults with diabetes-attending specialty care institution

PURPOSE

To describe and assess the impact of polypharmacy, and its potential adverse reactions; serious clinically relevant drug-drug interactions (DDIs) and inappropriate medicines (PIMs) on glycemic target, and kidney function in a sample of older adults with type 2 diabetes (T2D).

METHODS

Cross-sectional study was performed in a real-world database including 444 elderly people with T2D from the Portuguese Diabetes Association, aged ≥ 65 years, and registered in 2018. DDIs were analyzed using Micromedex drug-interaction platform and PIMs identified using STOPP criteria version-2.

RESULTS

Polypharmacy was identified in 43.6% of patients. This group of patients has shown to be more females (50 vs. 39.6%, P=0.0208), higher HbA1c targets (P=0.0275), longer diabetes duration (66.4 vs. 54.4%, P=0.0019), more hypertensive (87 vs. 62.9%, P<0.0001), using more insulin (38.1 vs. 26%, P=0.0062), sulfonylureas (37.1 vs. 15.6%, P<0.0001), GLP-1 receptor-agonists (9.7 vs. 3.6%, P=0.0077), metformin-DPP-4 inhibitors (41.2 vs. 29.2%, P=0.0081), and SGLT2 inhibitors (19 vs. 9.6%, P=0.0040). A total of 8.7% of patients had potentially serious clinically relevant DDIs, mainly due to interacting medicine pairs dexamethasone and fluoroquinolones. Furthermore, 23.4% had PIMs, and cardiovascular medicines accounted for largest therapeutic group associated. Polypharmacy found to be associated with twofold greater odds of having HbA1c ≤8%, whereas PIMs associated with 2.5-fold greater odds of having HbA1c ≤9%, and 5.5-folds greater odds of having severe kidney function.

CONCLUSIONS

These findings suggested that there is a potential association between polypharmacy and PIMs and altered glycemic control, and PIMs with the deterioration of kidney function.

The Impact of CKD Anaemia on Patients: Incidence, Risk Factors, and Clinical Outcomes-A Systematic Literature Review

Anaemia is a common consequence of chronic kidney disease (CKD); however, the risk factors for its development and its impact on outcomes have not been well synthesised. Therefore, we undertook a systematic review to fully characterise the risk factors associated with the presence of anaemia in patients with CKD and a contemporary synthesis of the risks of adverse outcomes in patients with CKD and anaemia. We searched MEDLINE, EMBASE, and the Cochrane Library from 2002 until 2018 for studies reporting the incidence or prevalence of anaemia and associated risk factors and/or associations between haemoglobin (Hb) or anaemia and mortality, major adverse cardiac events (MACE), hospitalisation, or CKD progression in adult patients with CKD. Extracted data were summarised as risk factors related to the incidence or prevalence of anaemia or the risk (hazard ratio (HR)) of outcome by Hb level (<10, 10-12, >12 g/dL) in patients not on dialysis and in those receiving dialysis. 191 studies met the predefined inclusion criteria. The risk factor most associated with the prevalence of anaemia was CKD stage, followed by age and sex. Mean HRs (95% CI) for all-cause mortality in patients with CKD on dialysis with Hb <10, 10-12, and >12 g/dL were 1.56 (1.43-1.71), 1.17 (1.09-1.26), and 0.91 (0.87-0.96), respectively. Similar patterns were observed for nondialysis patients and for the risks of hospitalisation, MACE, and CKD progression. This is the first known systematic review to quantify the risk of adverse clinical outcomes based on Hb level in patients with CKD. Anaemia was consistently associated with greater mortality, hospitalisation, MACE, and CKD progression in patients with CKD, and risk increased with anaemia severity. Effective treatments that not only treat the anaemia but also reduce the risk of adverse clinical outcomes are essential to help reduce the burden of anaemia and its management in CKD.

Rate of kidney function decline and factors predicting progression of kidney disease in type 2 diabetes mellitus patients with reduced kidney function: A nationwide retrospective cohort study

Currently, the data on independent risk factors for the progression of kidney disease in type 2 diabetes mellitus (T2DM) patients with CKD are limited. This study aimed to investigate CKD progression in T2DM patients who have reduced kidney function with baseline estimated glomerular filtration rate (eGFRs) between 15 and 59 mL/min/1.73 m² . This study was composed of a nationwide retrospective cohort of adult T2DM patients from 831 public hospitals in Thailand during the year 2015. T2DM patients with CKD stages 3 and 4 were followed up, until development of CKD stage 5, requirement of chronic dialysis, loss to follow-up, death, or 31 May 2018, whichever came first. Cox proportional hazard regression was utilized for analysis. A total of 8464 participants were included; 30.4% were male. The mean age was 69 ± 10 years. The mean eGFR was 45 ± 11 mL/min/1.73 m² . The incidence of CKD stage 5 or the need for chronic dialysis was 16.4 per 1000 person-years. The annual rate of eGFR decline during a mean follow-up of 29 months was -2.3 mL/min/1.73 m² ; 14.4% had a rapid decline in eGFR. The risk factors associated with progression to CKD stage 5 or the need for chronic dialysis were diabetes duration, systolic blood pressure, serum uric acid, albuminuria, and baseline eGFR. Conversely, older age and the use of renin-angiotensin aldosterone system blockade were associated with decreased risks for rapid CKD progression and incidence CKD stage 5 or dialysis. This study identifies multiple predictive risk factors that support a multifaceted approach to prevent progression of advanced CKD.

Low erythropoietin levels predict faster renal function decline in diabetic patients with anemia: a prospective cohort study

Elevated erythropoietin (EPO) levels have been reported to predict poor survival in various populations including diabetic patients. However, data regarding its impact on renal outcomes are scarce. We conducted a single-center, prospective cohort study of 339 type 2 diabetic patients with anemia. The primary outcome was the estimated glomerular filtration rate (eGFR) slope for two years. We performed multiple linear regression and restricted cubic spline analyses to assess the association of serum EPO levels with the renal outcome. Chronic kidney disease (CKD) was defined as eGFR <60 mL/min/1.73 m2 or urine albumin-to-creatinine ratio >30 mg/g creatinine. Median baseline EPO and eGFR level were 14.4 IU/L and 53 mL/min/1.73 m², respectively. Inappropriately low EPO levels were observed in 73% of anemic patients and 59% of anemic patients even without CKD, suggesting that EPO deficiency precedes the onset of CKD in diabetes mellitus. Multivariable analysis revealed that iron status and hemoglobin levels were major determinants of EPO levels. Median eGFR slope was −1.3 mL/min/1.73 m²/year. We found that low EPO levels, but not low hemoglobin levels, were associated with a faster decline in eGFR, independent of clinically relevant factors. The eGFR decline was steeper, particularly when the EPO level was below the upper limit of normal. Lower EPO concentrations were associated with rapid eGFR decline, especially in patients with iron deficiency (P for interaction = 0.01). Relative EPO deficiency should be considered as a culprit in anemia of unknown etiology in diabetic patients, even those without CKD. Low EPO levels, especially when accompanied by poor iron status, are predictive of rapid loss of renal function.

Prevalence of anemia in diabetic adult outpatients in Northeast Ethiopia

Background

Anemia is a common finding in patients with diabetes, even in the absence of kidney disease and is a risk factor for adverse outcomes, including all-cause and cardiovascular mortality. Despite this, relatively little is known about the burden of anemia among adults with diabetes in sub-Saharan Africa. The aim of this study was to determine the prevalence of anemia and its association with renal disease among diabetic adult outpatients attending a hospital in Northeast Ethiopia.

Methods

A cross-sectional study was conducted among 412 diabetic adults at the diabetes clinic of Dessie Referral hospital in Northeast Ethiopia, from January to April 2018. Each patient provided a blood sample for hemoglobin and serum creatinine levels and urine for albuminuria. Anemia was defined by World Health Organization criteria (<13 g/dl for men and <12 g/dl for women). Glomerular filtration rate (GFR) was estimated using the 4-variable Modification of Diet in Renal Disease (MDRD) equation. Chronic kidney disease (CKD) was classified into 5 stages based on the eGFR and albuminuria.

Results

Anemia was present in 26.7% of the participants, and CKD in 43.0%. Anemia was more prevalent in patients with CKD (39.5%) than those without CKD (17.0%; P < 0.001). The prevalence of anemia increased with stage of CKD, from 22.6% at stage 1 to 100% at stage 4. Fifteen percent of the patients had anemia below the treatment threshold of 11 g ⁄dl. In multivariate analysis, older age (AOR = 2.41, 95% CI 1.11–5.21); type 2 diabetes (AOR = 2.40, 95% CI 1.14–5.08); presence of hypertension (AOR = 3.78, 95% CI 1.35–10.57); high systolic BP (AOR = 1.05, 95% CI 1.02–1.08); serum creatinine (AOR = 12.80, 95% CI 3.90–87.98) and low GFR (AOR = 9.50, 95% CI 4.05–22.28) were independently associated with greater odds for the presence of anemia

Conclusions

Anemia is commonly present among diabetic adults attending our diabetes outpatient clinic in Northeast Ethiopia, including those without kidney disease. Our findings highlight the need for incorporating anemia screening into routine diabetes care to enable early detection and treatment of anemia and hence improve the overall care of patients with diabetes.

Robust clinical marker identification for diabetic kidney disease with ensemble feature selection

Objective

Diabetic kidney disease (DKD) is one of the most frequent complications in diabetes associated with substantial morbidity and mortality. To accelerate DKD risk factor discovery, we present an ensemble feature selection approach to identify a robust set of discriminant factors using electronic medical records (EMRs).

Material and Methods

We identified a retrospective cohort of 15 645 adult patients with type 2 diabetes, excluding those with pre-existing kidney disease, and utilized all available clinical data types in modeling. We compared 3 machine-learning-based embedded feature selection methods in conjunction with 6 feature ensemble techniques for selecting top-ranked features in terms of robustness to data perturbations and predictability for DKD onset.

Results

The gradient boosting machine (GBM) with weighted mean rank feature ensemble technique achieved the best performance with an AUC of 0.82 [95%-CI, 0.81-0.83] on internal validation and 0.71 [95%-CI, 0.68-0.73] on external temporal validation. The ensemble model identified a set of 440 features from 84 872 unique clinical features that are both predicative of DKD onset and robust against data perturbations, including 191 labs, 51 visit details (mainly vital signs), 39 medications, 34 orders, 30 diagnoses, and 95 other clinical features.

Discussion

Many of the top-ranked features have not been included in the state-of-art DKD prediction models, but their relationships with kidney function have been suggested in existing literature.

Conclusion

Our ensemble feature selection framework provides an option for identifying a robust and parsimonious feature set unbiasedly from EMR data, which effectively aids in knowledge discovery for DKD risk factors.

The Saudi Diabetic Kidney Disease study (Saudi-DKD): clinical characteristics and biochemical parameters

BACKGROUND

Saudi Arabia is facing an epidemic of type 2 diabetes that is complicated by a high rate of chronic complications such as kidney disease, which have a major impact on the healthcare system and economy. The Saudi diabetic kidney disease (SAUDI-DKD) study was launched to understand the implications of chronic diabetic kidney disease .

OBJECTIVES

Examine the hematological, biochemical and metabolic parameters of the selected cohorts to look for biomarkers of diabetic nephropathy.

DESIGN

Cross-sectional, hospital-based.

SETTING

Four general hospitals and two dialysis centers in Riyadh.

PATIENTS AND METHODS

We recruited adult type 2 diabetic patients aged between 35 and 70 years, with a duration of diabetes > 10 years, including subjects with microalbuminuria, macroalbuminuria and end stage renal disease (ESRD). They were compared with subjects with normal albumin excretion classified according to American Diabetes Association (ADA) criteria.

MAIN OUTCOME MEASURES

The effect of different stages of diabetic nephropathy on hematological and biochemical parameters.

RESULTS

Of 427 subjects with nephropathy, 184 (43%) had microalbuminuria, 83 (19%) had macroalbu.minuria and 160 (37%) had end stage renal disease (ESRD). The remaining 213 (50%) subjects did not have nephropathy. Patients with nephropathy were older with a mean age (SD) of 55.62 (6.00) years and had a longer duration of diabetes (mean [SD], 19.04 [6.33]) years), and had a lower monthly income and body mass index (BMI) than patients without nephropathy. Insulin resistance, elevated uric acid level, low red blood cells (RBCs) count and low hemoglobin level were associated with significantly increased risk of macroalbuminuria and ESRD. Elevated uric acid and LDH were associated with significantly increased risk of microalbuminuria and ESRD, while elevated red blood cell distribution width was significantly associated with an increased risk of ESRD.

CONCLUSION

Diabetic nephropathy is associated with insulin resistance, changes in liver enzymes and uric acid in addition to abnormalities in the red blood cell count and red blood cell shape that warrant frequent monitoring among patients with diabetic kidney disease.

LIMITATIONS

Cross-sectional study design and exclusion of patients with some risk factors.

Diabetes and Anemia: International Diabetes Federation (IDF) - Southeast Asian Region (SEAR) position statement

Anemia is often associated with diabetes mellitus and is known to intensify the risk of developing diabetes-related microvascular and macrovascular complications. There is paucity in understanding of co-existence of these conditions, especially in Southeast Asian countries. Iron and/or erythropoietin deficiencies are the major causes of anemia in diabetes, and diabetic kidney disease plays a key role. Patients with diabetes need to be screened for anemia along with other risk factors and anemia should be corrected appropriately to improve overall clinical outcomes. This position statement aims to provide a comprehensive overview and an algorithm for appropriate management of anemia in patients with diabetes.

Iron deficiency anemia and glucose metabolism

Iron deficiency anemia (IDA) is a global public health problem affecting both developing and developed countries with major consequences for human health as well as social and economic development. It occurs at all stages of the life cycle, but is more prevalent in pregnant women and young children. IDA appears to be more common in diabetic patients compared to non-diabetic population. Iron deficiency (ID) and IDA can impair glucose homeostasis in animals and human and may negatively affect glycemic control and predispose to more complications in diabetic patients. On the other hand diabetes and its complications are associated with anemia and its correction improves diabetes control and may prevent or delay the occurrence of complications. Physicians treating this form of anemia should be aware of its negative effect on glycemic control in normal and diabetic patients (both type 1 and type 2). They should prevent ID and treat early all those with IDA.This brief review aims to enlighten the different effects of IDA on glucose metabolism in normal and diabetic patients.

Coronary Artery Disease Is a Predictor of Progression to Dialysis in Patients With Chronic Kidney Disease, Type 2 Diabetes Mellitus, and Anemia: An Analysis of the Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT)

BACKGROUND

Although clear evidence shows that chronic kidney disease is a predictor of cardiovascular events, death, and accelerated coronary artery disease (CAD) progression, it remains unknown whether CAD is a predictor of progression of chronic kidney disease to end-stage renal disease. We sought to assess whether CAD adds prognostic information to established predictors of progression to dialysis in patients with chronic kidney disease, diabetes, and anemia.

METHODS AND RESULTS

Using the previously described Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT) population, we compared baseline characteristics of patients with and without CAD. Cox proportional hazards models were used to assess the association between CAD and the outcomes of end-stage renal disease and the composite of death or end-stage renal disease. Of the 4038 patients, 1791 had a history of known CAD. These patients were older (mean age 70 versus 65 years, P<0.001) and more likely to have other cardiovascular disease. CAD patients were less likely to have marked proteinuria (29% versus 39%, P<0.001), but there was no significant difference in estimated glomerular filtration rate between the 2 groups. After adjusting for age, sex, race, estimated glomerular filtration rate, proteinuria, treatment group, and 14 other renal risk factors, patients with CAD were significantly more likely to progress to end-stage renal disease (adjusted hazard ratio 1.20 [95% CI 1.01-1.42], P=0.04) and to have the composite of death or end-stage renal disease (adjusted hazard ratio 1.15 [95% CI 1.01-1.30], P=0.03).

CONCLUSIONS

In patients with chronic kidney disease, diabetes, and anemia, a history of CAD is an independent predictor of progression to dialysis. In patients with diabetic nephropathy, a history of CAD contributes important prognostic information to traditional risk factors for worsening renal disease.

Secondary hyperparathyroidism prevalence and profile, between diabetic and non-diabetic patients with stage 3 to 4 chronic kidney disease attended in internal medicine wards. MiPTH study

AIMS

Secondary hyperparathyroidism (SHPTH) is a leading cause of renal osteodystrophy, and an independent risk factor for all-cause and cardiovascular mortality. Our aim is to establish differences in prevalence and profile of SHPTH, regarding diabetics or non-diabetics with chronic kidney disease (CKD).

METHODS

Cross-sectional multicenter study which included patients with stages 3 to 4 CKD. SHPTH was considered when the intact PTH levels (iPTH) were equal or higher than 70pg/ml. We divided the sample into two groups (diabetics and non-diabetics). We used robust statistical methods.

RESULTS

409 patients (214 diabetics) were studied. HPTH was found in 60.4% of diabetics vs 65% of non-diabetics (P=0.42). Diabetics with HPTH were younger (79.5 vs 82.3 years-old, P=0.005), and had more hypertension (P=0.0014), dyslipidemia (P=0.0001) and comorbidities. In multivariate analysis, we found a significant relationship in case of diabetics, with age (OR: 1.04, 95%CI 1.005-1.09 P=0.02 ), and with statins treatment (OR 2.3, 95%CI 1.17-4.54, P=0.01).

DISCUSSION

The prevalence of SHPTH between the groups was similar, however, diabetics had more presence of hypertension and dyslipidemia, and SHPTH in this case was also related with moderate microalbuminuria and lower levels of vitamin D. An association with statins was also found in this group.

Serum uric acid levels are associated with a high risk of rapid chronic kidney disease progression among patients with type 2 diabetes: a prospective cohort study [Diabetes Distress and Care Registry at Tenri (DDCRT 12)]

Background

We assessed the prospective association between baseline serum uric acid (SUA) concentrations and consequent risk of chronic kidney disease (CKD) progression in type 2 diabetes patients.

Methods

Longitudinal data from a Japanese diabetes registry including 3454 type 2 diabetes patients were obtained. To assess the independent correlations between SUA and rapid CKD progression [i.e., 30 % reduction in estimated glomerular filtration rate (eGFR) over 2 years], participants were divided into five groups based on SUA levels: <5.0, ≥5.0-6.0, ≥6.0-7.0, ≥7.0-8.0, and ≥8.0 mg/dl. Cox proportional hazards model adjusted for potential confounders was used for analysis.

Results

After 2 years, rapid CKD progression was recognized in 169 patients (4.89 %) who showed longer duration of type 2 diabetes (15.5 vs. 13.5 years, p = 0.005); higher systolic blood pressure (142.0 vs. 138.3 mmHg, p = 0.016), SUA (6.15 vs. 5.32 mg/dl, p < 0.001), and urinary albumin-creatinine ratio (1127.4 vs. 184.7 mg/gCr, p < 0.001); and lower diastolic blood pressure (69.7 vs. 72.8 mmHg, p = 0.003). Multivariate ratios for rapid CKD progression were 1.19 (p = 0.371), 1.02 (p = 0.937), 1.18 (p = 0.625), and 3.04 (p = 0.004), respectively, for the first, third, fourth, and fifth serum UA range groups; a second group was used as a reference.

Conclusions

Higher SUA levels, independent of possible confounders, were associated with rapid eGFR decline and CKD progression in type 2 diabetes patients. SUA may be a useful biomarker for predicting future risk of rapid diabetic CKD progression.

Carotid Intima-Media Thickness and Visit-to-Visit HbA1c Variability Predict Progression of Chronic Kidney Disease in Type 2 Diabetic Patients with Preserved Kidney Function

Background/Aims. Subclinical atherosclerosis and long-term glycemic variability have been reported to predict incident chronic kidney disease (CKD) in the general population. However, these associations have not been investigated in patients with type 2 diabetes with preserved kidney function. Methods. We prospectively followed up 162 patients with type 2 diabetes (mean age, 62.3 years; 53.6% men) and assessed whether carotid intima-media thickness (IMT) measured by B-mode ultrasound and visit-to-visit HbA1c variability are associated with deterioration of CKD (incident CKD defined as estimated GFR [eGFR] < 60 mL/min/1.73 m² and progression of CKD stages) over a median follow-up of 6.0 years. At baseline, 25 patients (15.4%) had CKD. Cox proportional hazards regression models were used for identifying associated factors of CKD deterioration. Results. Estimated GFR decreased from 75.8 ± 16.3 to 67.4 ± 18.2 mL/min/1.73 m² (p < 0.01). Of 162 patients, 32 developed CKD and 8 made a progression of CKD stages. Multivariate Cox regression analysis revealed that carotid IMT (HR: 4.0, 95% CI: 1.1-14.226.7, and p = 0.03) and coefficient of variation of HbA1c (HR: 1.12, 95%: 1.04-1.21, and p = 0.003) were predictors of deterioration of CKD independently of age, mean HbA1c, urinary albumin/creatinine ratio, baseline eGFR, uric acid, and leucocyte count. Conclusions. Subclinical atherosclerosis and long-term glycemic variability predict deterioration of chronic kidney disease (as defined by incident or worsening CKD) in type 2 diabetic patients with preserved kidney function.

Renoprotective effects of combined SGLT2 and ACE inhibitor therapy in diabetic Dahl S rats

This study examined whether control of hyperglycemia with a new SGLT2 inhibitor, luseogliflozin, given alone or in combination with lisinopril could prevent the development of renal injury in diabetic Dahl salt-sensitive (Dahl S) rats treated with streptozotocin (Dahl-STZ). Blood glucose levels increased from normoglycemic to hyperglycemic levels after treatment of STZ in Dahl S rats. Chronic treatment of Dahl-STZ rats with luseogliflozin (10 mg/kg/day) increased the fractional excretion of glucose and normalized blood glucose and HbA1c levels. Lisinopril (20 mg/kg/day) reduced blood pressure from 145 ± 9 to 120 ± 5 mmHg in Dahl-STZ rats, while luseogliflozin had no effect on blood pressure. Combination therapy reduced blood pressure more than that seen in the rats treated with luseogliflozin or lisinopril alone. Dahl-STZ rats exhibited hyperfiltration, mesangial matrix expansion, severe progressive proteinuria, focal glomerulosclerosis and interstitial fibrosis. Control of hyperglycemia with luseogliflozin reduced the degree of hyperfiltration and renal injury but had no effect on blood pressure or the development of proteinuria. Treatment with lisinopril reduced hyperfiltration, proteinuria and renal injury in Dahl-STZ rats. Combination therapy afforded greater renoprotection than administration of either drug alone. These results suggest that long-term control of hyperglycemia with luseogliflozin, especially in combination with lisinopril to lower blood pressure, attenuates the development of renal injury in this rat model of advanced diabetic nephropathy.

Association between Hemoglobin Concentration and the Progression or Development of Albuminuria in Diabetic Kidney Disease

AIMS

Anemia, which might contribute to pathogenesis of kidney dysfunction, is a common finding in patients with type 2 diabetes. The aim of this study was to investigate if hemoglobin concentration is associated with the degree of change in urinary albumin-creatinine ratio or the development of albuminuria in patients with type 2 diabetes.

METHODS

We measured hemoglobin concentration in 470 (296 men and 174 women) consecutive type 2 diabetic patients without albuminuria. We performed a follow-up study to assess the progression or development of albuminuria, the interval of which was 3.0 years. Then we evaluated relationships between hemoglobin concentration and albuminuria, using multivariate linear regression analyses and logistic regression analyses.

RESULTS

Eighty four patients developed albuminuria during follow-up duration. In multivariate analyses, hemoglobin concentration was negatively associated with a change in urinary albumin-creatinine ratio in men (ß = -0.259, P = 0.0002) and women (ß = -0.194, P = 0.030). Moreover, multivariate adjusted odds ratio associated with 1 g/L in hemoglobin for the development of albuminuria was 0.93 (95% confidence interval; 0.89-0.96) in men and 0.94 (95% confidence interval; 0.88-0.99) in women, respectively. And, multivariate analyses revealed that adjusted odds ratios for the development of albuminuria were 4.78 (95% confidence interval; 1.65-13.91) in men and 4.62 (95% confidence interval; 1.34-16.68) in women with anemia (hemoglobin < 130 g/L for men and < 120 g/L for women), which were higher than those without anemia.

CONCLUSIONS

Low hemoglobin concentration could be a predictor for the progression and development of albuminuria in patients with type 2 diabetes.

Charlson comorbidity index helps predict the risk of mortality for patients with type 2 diabetic nephropathy

Our intent is to examine the predictive role of Charlson comorbidity index (CCI) on mortality of patients with type 2 diabetic nephropathy (DN). Based on the CCI score, the severity of comorbidity was categorized into three grades: mild, with CCI scores of 1-2; moderate, with CCI scores of 3-4; and severe, with CCI scores ≥5. Factors influencing mortality and differences between groups stratified by CCI were determined by logistical regression analysis and one-way analysis of variance (ANOVA). The impact of CCI on mortality was assessed by the Kaplan-Meier analysis. A total of 533 patients with type 2 DN were enrolled in this study, all of them had comorbidity (CCI score >1), and 44.7% (238/533) died. The mortality increased with CCI scores: 21.0% (50/238) patients with CCI scores of 1-2, 56.7% (135/238) patients with CCI scores of 3-4, and 22.3% (53/238) patients with CCI scores ≥5. Logistical regression analysis showed that CCI scores, hemoglobin, and serum albumin were the potential predictors of mortality (P<0.05). One-way ANOVA analysis showed that DN patients with higher CCI scores had lower levels of hemoglobulin, higher levels of serum creatinine, and higher mortality rates than those with lower CCI scores. The Kaplan-Meier curves showed that survival time decreased when the CCI scores and mortality rates went up. In conclusion, CCI provides a simple, readily applicable, and valid method for classifying comorbidities and predicting the mortality of type 2 DN. An increased awareness of the potential comorbidities in type 2 DN patients may provide insights into this complicated disease and improve the outcomes by identifying and treating patients earlier and more effectively.

Diabetes mellitus with normal renal function is associated with anaemia

BACKGROUND

Anaemia is a common complication of diabetes mellitus (DM), usually related to renal failure. There is scarce information as to the levels of haemoglobin (Hb) and the rate of anaemia in diabetic patients with normal renal function. We, therefore, evaluated haemoglobin levels and the rate of anaemia in diabetic subjects with normal renal functions [estimated glomerular filtration rate (eGFR) > 60 mL/min].

METHODS

The charts of 9250 subjects who attended the Institute of Periodic Medical Examinations at the Chaim Sheba Medical Center for a routine yearly check-up were reviewed. Four hundred and forty-five subjects with type 2 DM and normal renal function were indentified and compared with those without DM who were routinely examined at the same time. Subjects' electronic records were used to build a biochemical and clinical database.

RESULTS

Mean haemoglobin levels were lower in subjects with DM than in those without (14.2 vs. 14.7 g/dL, respectively; p < 0.001). Anaemia was observed in 48 (10.8%) subjects in the diabetic group and in only 12 (2.7%) in the nondiabetic group (p < 0.001). Multivariate analysis revealed that age, gender, history of gastrointestinal disease, use of beta blockers, renal function and DM were independent determinants of haemoglobin levels. After adjustment for age, gender, history of gastrointestinal tract diseases and renal function, DM remained a significant determinant of anaemia with an odds ratio of 2.15 (confidence interval: 1.07-4.31).

CONCLUSIONS

Anaemia is more common in diabetic patients even when eGFR > 60 mL/min.

Effects of a new SGLT2 inhibitor, luseogliflozin, on diabetic nephropathy in T2DN rats

This study examined the effect of long-term control of hyperglycemia with a new sodium glucose cotransporter 2 inhibitor, luseogliflozin, given alone or in combination with lisinopril on the progression of renal injury in the T2DN rat model of type 2 diabetic nephropathy. Chronic treatment with luseogliflozin (10 mg/kg/day) produced a sustained increase in glucose excretion and normalized blood glucose and glycosylated hemoglobin levels to the same level as seen in the rats treated with insulin. It had no effect on blood pressure. In contrast, lisinopril (10 mg/kg/day) reduced mean blood pressure from 140 to 113 mmHg. Combination therapy significantly reduced blood pressure more than that seen in the rats treated with lisinopril. T2DN rats treated with vehicle exhibited progressive proteinuria, a decline in glomerular filtration rate (GFR), focal glomerulosclerosis, renal fibrosis, and tubular necrosis. Control of hyperglycemia with luseogliflozin prevented the fall in GFR and reduced the degree of glomerular injury, renal fibrosis, and tubular necrosis. In contrast, control of hyperglycemia with insulin had no effect on the progression of renal disease in T2DN rats. Reducing blood pressure with lisinopril prevented the fall in GFR and reduced proteinuria and the degree of glomerular injury and tubular necrosis. Combination therapy reduced the degree of glomerular injury, renal fibrosis, and tubular necrosis to a greater extent than administration of either drug alone. These results suggest that control of hyperglycemia with luseogliflozin slows the progression of diabetic nephropathy more than that seen with insulin, and combination therapy is more renoprotective than administration of either compound alone.

Associations between hemoglobin concentrations and the clinical characteristics of patients with type 2 diabetes

BACKGROUND/AIMS

Many studies have demonstrated an association between hemoglobin levels and cardiovascular disease in diabetic patients. The aim of this study was to determine whether there is an association between hemoglobin concentrations and various clinical parameters, including metabolic factors, plasma C-peptide response after a meal tolerance test, and microvascular complications, in Korean patients with type 2 diabetes.

METHODS

In total, 337 male patients with type 2 diabetes were recruited. All subjects were subjected to a meal tolerance test and underwent assessment of hemoglobin levels, fasting and postprandial β-cell responsiveness, and microvascular complications.

RESULTS

Patients with lower hemoglobin concentrations had a longer duration of diabetes, a lower body mass index, and lower concentrations of total cholesterol, triglycerides, and low-density lipoprotein cholesterol. They also had lower levels of postprandial C-peptide, Δ C-peptide, and postprandial β-cell responsiveness. They had a higher prevalence of retinopathy and nephropathy. In multivariate analyses, there was a significant association between nephropathy and hemoglobin concentration. Also, hemoglobin concentrations were independently associated with Δ C-peptide levels and postprandial β-cell responsiveness.

CONCLUSIONS

Hemoglobin concentrations are associated with postprandial C-peptide responses and diabetic nephropathy in patients with type 2 diabetes.

Hyperglycemia and renal mass ablation synergistically augment albuminuria in the diabetic subtotally nephrectomized rat: implications for modeling diabetic nephropathy

Background/AimsBackground/Aims

While experimental models that emulate diabetic nephropathy are valuable tools for elucidating pathogenetic mechanisms and developing novel therapies, existing models imperfectly recapitulate human disease. In diabetes, hyperglycemia and hemodynamic forces act in concert to induce renal injury. Accordingly, in the present study, we combined streptozotocin-induced diabetes with surgical ablation of 5/6 of the kidney mass with the aim of evaluating their additive effects on renal function and glomerular morphology.

Methods

Female F344 rats were randomized to undergo subtotal nephrectomy (SNx) either at baseline or following 4 weeks of diabetes.

Results

In comparison to sham rats, rats with diabetes or rats after SNx surgery, diabetic subtotally nephrectomized (DM-SNx) rats demonstrated an increase in systolic blood pressure, glomerular volume and mesangial matrix. Albuminuria was synergistically increased by hyperglycemia and renal mass ablation associated with decreased nephrin expression. In contrast, glomerular capillary rarefaction and glomerular filtration rate were similarly reduced in SNx and DM-SNx rats.

Conclusion

The DM-SNx rat recapitulates some of the features of human disease, most notably augmented albuminuria. Since this model avoids the deletion or overexpression of gene(s) linked to the pathogenesis of nephropathy, the DM-SNx rat model represents a complementary tool for the trial of novel therapies.

Predictors of estimated GFR decline in patients with type 2 diabetes and preserved kidney function

BACKGROUND AND OBJECTIVES

This study examined predictors of the annual decline in estimated GFR (eGFR) in patients with type 2 diabetes and preserved kidney function.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a prospective, observational cohort study, 1682 individuals with type 2 diabetes and baseline eGFR ≥60 ml/min per 1.73 m(2) (as estimated by the Chronic Kidney Disease Epidemiology Collaboration equation) were followed for 10 years. Linear regression was used to estimate participants' changes in eGFR over time.

RESULTS

During follow-up, 263 (15.6%) individuals had a rapid eGFR decline defined as >4.0% per year. Average eGFR decline was -5.8 ± 3 and -0.6 ± 2 ml/min per 1.73 m(2) per year in rapid decliners and nondecliners, respectively. Compared with normotensive, normoalbuminuric patients (-0.2 ± 0.2 ml/min per 1.73 m(2) per year), those with hypertension (-1.0 ± 0.1 ml/min per 1.73 m(2) per year), hemoglobin A(1c)≥7% (-1.0 ± 0.1 ml/min per 1.73 m(2) per year), longer diabetes duration (-1.0 ± 0.1 ml/min per 1.73 m(2) per year), obesity (-1.2 ± 0.1 ml/min per 1.73 m(2) per year), insulin treatment (-1.5 ± 0.1 ml/min per 1.73 m(2) per year), microalbuminuria (-1.3 ± 0.2 ml/min per 1.73 m(2) per year), or macroalbuminuria (-2.7 ± 0.4 ml/min per 1.73 m(2) per year) had significantly faster age-adjusted annual eGFR declines. Multivariable linear regression analyses revealed that albuminuria (P<0.001) was the strongest predictor of annual eGFR decline. Other independent predictors of annual eGFR decline were older age, hypertension, insulin treatment, and lower baseline eGFR.

CONCLUSIONS

Annual eGFR decline is predicted by multiple modifiable risk factors in patients with type 2 diabetes and preserved kidney function.

A study of the natural history of diabetic kidney disease (DKD)

BACKGROUND

In view of the alarming increase in the number of people with diabetes mellitus (DM), a rising number of patients with diabetic kidney disease (DKD), end-stage renal disease (ESRD) and cardiovascular disease (CVD) is forecasted. It is therefore imperative to re-visit the natural history of DKD and to identify potential risk factors, which may enhance the progression of the disease and its complications.

METHODS

The medical records of 270 Type 2 diabetic chronic kidney disease patients followed up at the Sheffield Kidney Institute between 2000 and 2008 were reviewed. Various socio-demographic, clinical and biochemical parameters (baseline and follow-up parameters) were retrospectively collected from the patients' database. Progression of DKD was evaluated by evaluation of the rate of decline of estimated glomerular filtration rate (eGFR) as calculated from the simplified Modification of Diet in Renal Disease formula [progressors: loss of glomerular filtration rate (GFR) >2 mL/min/1.73m(2)/year] as well as by the progression pattern based on the slope of GFR changes. Variables associated with progression in univariate analysis were examined by multivariate analysis to determine the factors independently associated with DKD progression.

RESULTS

The majority of the study populations were males (66.7%) and Caucasians (88%). Ninety-four patients (34.8%) had progressive, whereas 176 (65.2%) had non-progressive DKD. The rate of eGFR decline in progressors was -3.57 ± 1.45 mL/min/1.73m(2)/year compared to -1.31 ± 0.23 mL/min/1.73m(2)/year in non-progressors. The following parameters discriminated progressors from non-progressors by univariate analysis: baseline-blood pressure (BP) parameters, eGFR and proteinuria as well as serum uric acid. We also observed that area under the curve for follow-up systolic blood pressure (SBP), glycosylated haemoglobin (HbA1c) and proteinuria were significantly higher among the progressors (P = 0.043, P = 0.02 and P = 0.001, respectively). Independent determinants of DKD progression in this study in an adjusted logistic regression model were baseline HbA1c [odds ratio (OR), 2.27; 95% confidence interval (CI), 1.14-4.54], baseline SBP (OR, 1.23; 95% CI, 1.06-1.41), baseline proteinuria (OR, 3.24; 95% CI, 2.1-5.38), baseline serum uric acid (OR, 1.16; 95% CI, 1.09-1.39) and vascular co-morbidities (OR, 1.61; 95% CI, 1.02-2.54). Percentage changes in the key parameters (BP, HbA1c and proteinuria) during the first year of the study did not affect the rate of eGFR decline.

CONCLUSIONS

Baseline HbA1c, SBP, proteinuria and serum uric acid together with the presence of vascular co-morbidities are strongly and independently associated with faster DKD progression. A further prospective observational study is currently undertaken to evaluate these findings and to determine the predictive value of other biochemical peptides and cellular markers on DKD outcome.

[TREAT or not to treat: anemia in type 2 diabetes and chronic kidney disease at stages 3 and 4]

Anemia is associated with an increased risk of cardiovascular and renal events among patients with type 2 diabetes and chronic kidney disease (CKD). Although erythropoiesis-stimulating agents (ESA) can effectively increase hemoglobin (Hb) levels, their effect on clinical outcomes has not been demonstrated in CKD patients. The TREAT study is the first randomized, double-blind, placebo-controlled trial with the aim to evaluate the effect of a Hb level of 13 g/dL on the risk of death, cardiovascular events and progression to end-stage renal disease (ESRD) in type 2 diabetes with stage 3 to 4 CKD. Four thousand and thirty-eight patients were included. Death, cardiovascular events and progression to ESRD were not different between the two groups. Stroke occurred in 101 patients assigned to DA and 53 patients assigned to placebo (p<0.001), and red-cell transfusions were administered in 14.8% patients in the DA group and in 24.5% patients assigned to placebo (p<0.001). There was a modest improvement in patient-reported fatigue in the DA group. Studies performed in CKD patients who were not undergoing dialysis failed to show a benefit of the use of ESA to target a Hb level of 13 g/dl or more, on the risk of death, cardiovascular morbidity and progression to ESRD. Post hoc analysis of randomized studies suggest that the increase cardiovascular risk induced by targeting a high Hb level is more related to the resistance state of patients who failed to increase their Hb level under high ESA doses and by the rate of change in Hb concentration over time. After the release of the TREAT study, the recommendations of a Hb level of 10 to 12 g/dl in CKD patients seems adequate. This target needs to be tailored for each patient taking into account the comorbidity, age and physical activity.

Increased risk of renal deterioration associated with low e-GFR in type 2 diabetes mellitus only in albuminuric subjects

OBJECTIVE

The significance of estimated glomerular filtration rate (e-GFR) in diabetic nephropathy has yet to be clearly determined. We therefore compared albuminuria and e-GFR for usefulness in predicting progressive decline in renal function.

METHODS

A total of 1,303 subjects with type 2 diabetes mellitus whose e-GFR was more than 30 mL/min/1.73 m(2) were followed for three years. Associations of clinical staging based on AER and that based on e-GFR with progression of renal insufficiency (e-GFR <30 mL/min/1.73 m(2)) were evaluated.

RESULTS

On univariate analysis, both clinical stages based on e-GFR and AER were significant variables (p<0.05). On multiple logistic regression analysis, the odds ratio for macroalbuminuria was 132.3, and that for microalbuminuria was 10.3 while that for e-GFR less than 60 mL/min/1.73 m(2) was 9.0 for further deterioration of renal function. On the other hand, subjects without albuminuria exhibited a rate of disease progression of less than 1% irrespective of e-GFR level.

CONCLUSIONS

Both albuminuria and reduced e-GFR are significant and independent risk factors for further deterioration of diabetic nephropathy, though albuminuria had a greater odds ratio than reduced e-GFR for deterioration of renal function over a three-year period. e-GFR exhibited additive risk for deterioration of diabetic nephropathy within three years only when albuminuria was present.

Clinical and subclinical cardiovascular disease and kidney function decline in the elderly

OBJECTIVE

Kidney function decline in elderly persons may be the result of microvascular atherosclerosis. As a proxy for the renovascular system, we evaluated the association of clinical and subclinical cardiovascular disease (CVD) with kidney function decline.

METHODS

This study included 4380 subjects from the Cardiovascular Health Study, a longitudinal, community-based cohort of persons aged >or=65 from 4 U.S. communities. Creatinine and cystatin C were measured at baseline, year 3, and year 7; eligible subjects had at least two measures. Creatinine-based estimated glomerular filtration rate (eGFR(creat)) was calculated using the MDRD equation. Rapid kidney function decline was defined as an annual eGFR loss >3 mL/min/1.73 m(2). Predictors of rapid kidney decline included prevalent and subclinical measures of CVD.

RESULTS

Mean decline in eGFR(creat) was 0.4+/-2.6/year; 714 (16%) had rapid progression. In multivariate models adjusted for demographics, cardiovascular risk factors, and inflammation, prevalent stroke (OR, 95% CI: 1.55, 1.16-2.08) and heart failure (OR, 95% CI: 1.80, 1.40-2.31) were independent predictors of rapid kidney decline. Among persons without clinical CV, the subclinical disease measures ankle-arm index <0.9 (OR, 95% CI: 1.67, 1.25-2.24), common carotid intima-media thickness (>or=1.14 mm) (OR, 95% CI: 1.52, 1.12-2.06) and internal carotid intima-media thickness (>1.82 mm) (OR, 95% CI: 1.50, 1.12-2.02) had independent associations with rapid kidney function decline. Results were similar using cystatin C.

CONCLUSION

Clinical atherosclerosis and heart failure and subclinical measures of CVD have independent associations with kidney function decline progression in the elderly, suggesting an underlying role of renal atherosclerosis.

Prevalence of anaemia in patients with diabetes mellitus

BACKGROUND

Anaemia is an increasingly recognised entity in patients with diabetes mellitus.

AIMS

We aimed to determine the prevalence of anaemia in our population of patients with diabetes, and to examine the factors associated with anaemia.

METHODS

The haemoglobin (Hb) levels in a consecutive series of patients attending for annual review of their diabetes over a three-month period were measured. Patients were classified as anaemic as per the WHO criteria.

RESULTS

During the period of study, 270 patients attended for review. Eleven per cent of males and 16% of females were anaemic. Seventy four per cent of anaemic patients had a serum creatinine <110micromol/l and 72% of anaemic patients had a calculated creatinine clearance of >60ml/min.

CONCLUSIONS

Anaemia was relatively common in patients attending for routine outpatient diabetes clinic review. The high prevalence of anaemia supports the routine screening for anaemia in the diabetes out-patient clinic, including in those without overt nephropathy.

Normoalbuminuric renal-insufficient diabetic patients: a lower-risk group

OBJECTIVE

About 20% of diabetic patients with chronic kidney disease (CKD) detected from the new American Diabetes Association recommendations (albumin excretion rate >30 mg/24 h or estimated glomerular filtration rate [GFR] <60 ml/min per 1.73 m2) may be normoalbuminuric. Do the characteristics and outcome differ for subjects with and without albuminuria?

RESEARCH DESIGN AND METHODS

A total of 89 patients with diabetes and a modification of diet in renal disease (MDRD) estimated GFR (e-GFR) <60 ml/min per 1.73 m2 underwent a 51Cr-EDTA B-isotopic GFR determination and were followed up for 38 +/- 11 months.

RESULTS

The mean MDRD e-GFR (41.3 +/- 13.1 ml/min per 1.73 m2) did not significantly differ from the i-GFR (45.6 +/- 29.7). Of the subjects, 15 (17%) were normoalbuminuric. Their i-GFR did not differ from the albuminuric rate and from their MDRD e-GFR, although their serum creatinine was lower (122 +/- 27 vs. 160 +/- 71 micromol/l, P < 0.05): 71% would not have been detected by measuring serum creatinine (sCr) alone. They were less affected by diabetic retinopathy, and their HDL cholesterol and hemoglobin were higher (P < 0.05 vs. albuminuric). None of the CKD normoalbuminuric subjects started dialysis (microalbuminuric: 2/36, macroalbuminuric: 10/38) or died (microalbuminuric: 3/36, macroalbuminuric: 7/38) during the follow-up period (log-rank test: P < 0.005 for death or dialysis), and their albumin excretion rate and sCr values were stable after 38 months, whereas the AER increased in the microalbuminuric patients (P < 0.05), and the sCr increased in the macroalbuminuric patients (P < 0.01).

CONCLUSIONS

Although their sCr is usually normal, most of the normoalbuminuric diabetic subjects with CKD according to an MDRD e-GFR below 60 ml/min per 1.73 m2 do really have a GFR below 60 ml/min per 1.73 m2. However, as expected, because of normoalbuminuria and other favorable characteristics, their risk for CKD progression or death is lower.

The high prevalence of anemia in diabetes is linked to functional erythropoietin deficiency

Anemia is a common finding in diabetes, particularly in patients with albuminuria or renal impairment. We recently showed that at least 1 in 5 outpatients with type 1 or type 2 diabetes in tertiary clinics have anemia, in whom it constitutes a significant additional burden. Anemia is associated strongly with an increased risk of diabetic complications including nephropathy, retinopathy, and heart failure. Although a number of factors contribute to an increased prevalence of anemia in diabetes, an uncoupling of hemoglobin concentration and renal erythropoietin synthesis associated with tubular dysfunction appears to be the dominant factor. In our patients with diabetes and anemia, more than three quarters had functional erythropoietin deficiency. This association was most pronounced in patients with renal impairment, in whom nearly half of all patients had anemia. However, 70% of anemic patients without renal impairment also had inappropriately low erythropoietin levels. Consequently, the likelihood of functional erythropoietin deficiency, as a cause of anemia in patients with diabetes, is not dependent on the severity of renal impairment. Although there is a clear rationale for correction of anemia in diabetes, it remains to be established whether this will lead to improved outcomes. Some small studies suggest improvement in cardiac outcomes and hospitalization. It is anticipated that large ongoing studies will help define the optimal approach to the management of anemia in diabetes.

Anemia in diabetes: marker or mediator of microvascular disease?

Anemia is a common finding in patients with diabetes due to the high burden of chronic kidney disease in this population. Anemia is more prevalent and is found earlier in patients with diabetes than in those with kidney disease from other causes. The increased risk of anemia in diabetes probably reflects changes in the renal tubulointerstitium associated with diabetic kidney disease, which disrupt the delicate interaction between interstitial fibroblasts, capillaries and tubular cells required for normal hemopoietic function. In particular, the uncoupling of the hemoglobin concentration from renal erythropoietin synthesis seems to be the key factor underlying the development of anemia. Systemic inflammation, functional hematinic deficiencies, erythropoietin resistance and reduced red cell survival also drive anemia in the setting of impaired renal compensation. Although anemia can be considered a marker of kidney damage, reduced hemoglobin levels independently identify diabetic patients with an increased risk of microvascular complications, cardiovascular disease and mortality. Nevertheless, a direct role in the development or progression of diabetic complications remains to be clearly established and the clinical utility of correcting anemia in diabetic patients has yet to be demonstrated in randomized controlled trials. Correction of anemia certainly improves performance and quality of life in diabetic patients. In the absence of additional data, treatment should be considered palliative, and any functional benefits must be matched against costs to the patient and the health system.

Prevalence and severity of anaemia in patients with type 2 diabetic nephropathy and different degrees of chronic renal insufficiency

BACKGROUND/AIM

Type 2 diabetes mellitus is the single most common cause of chronic kidney disease (CKD); however its real impact on renal anaemia has not been established. The aim of this study was to evaluate whether onset, severity, and prevalence of anaemia during the course of CKD is different between type 2 diabetic and non-diabetic patients.

METHODS

We enrolled 281 patients with: (1) type 2 diabetes and no CKD (n = 75); (2) type 2 diabetes plus CKD (n = 106), and (3) CKD without type 2 diabetes (n = 100). According to K/DOQI guidelines, the patients with renal insufficiency (i.e., those with a glomerular filtration rate <60 ml/min) were subgrouped into three tertiles of CKD: (1) stage 3 (creatinine clearance 60-30 ml/min); (2) stage 4 (creatinine clearance 29-15 ml/min), and (3) stage 5 (creatinine clearance <15 ml/min).

RESULTS

Anaemia was observed in 16% of the diabetic patients without CKD; it was more frequent in the diabetic patients with CKD than in the non-diabetic patients with CKD (61.7 vs. 52%, p < 0.05). The comparison among the tertiles showed that the prevalence of anaemia was significantly higher only in diabetic CKD patients of stages 4 and 5. The prevalence was higher in females independently of type 2 diabetes mellitus. In diabetics with a normal renal function, the haemoglobin levels were higher than in diabetics and non-diabetics with CKD, but the diabetics showed lower levels of haemoglobin than non-diabetics at stage 3 and stage 4 of CKD.

CONCLUSIONS

Diabetic patients with CKD of stages 4 and 5 have a higher prevalence of anaemia than non-diabetic patients with comparable glomerular filtration rate. A higher awareness of this risk will allow earlier diagnosis and treatment.

End-stage renal disease risk equations for Hong Kong Chinese patients with type 2 diabetes: Hong Kong Diabetes Registry

AIMS/HYPOTHESIS

The objective of the study was to investigate risk factors and develop risk equations for end-stage renal disease (ESRD) in Chinese patients with type 2 diabetes.

SUBJECTS AND METHODS

A prospective cohort of 4,438 patients with type 2 diabetes mellitus and without ESRD (median observation period 2.9 years, interquartile range 1.6-4.1 years) was included in the analysis. The end-point (ESRD) was defined by: (1) death due to diabetes with renal manifestations or renal failure; (2) hospitalisation due to renal failure; (3) estimated GFR (eGFR) <15 ml min(-1) 1.73 m(-2). Cox proportional hazards regression was used to develop risk equations. The data were randomly and evenly divided into the training data for development of the risk equations and the test data for validation. The validation was performed using the area under the receiver operating characteristic curve (aROC), which takes into account follow-up time and censoring.

RESULTS

During the observation period, 159 patients or 12.45 per 1,000 person-years (95% CI 10.52-14.37 per 1,000 person-years) developed ESRD. Known duration of diabetes, systolic blood pressure, log(10) total cholesterol:HDL cholesterol ratio and retinopathy were significant predictors of ESRD. After further adjusting for eGFR, log(10) spot albumin:creatinine ratio (ACR) and haematocrit, only eGFR, haematocrit and log(10) ACR remained as independent predictors of ESRD. The risk equation derived from these three independent predictors had good discrimination, with an aROC of 0.97.

CONCLUSIONS/INTERPRETATION

Estimated GFR, haematocrit and ACR were independent predictors of ESRD and the derived risk equation performed well in Chinese patients with type 2 diabetes.

Anemia and the role of erythropoietin in diabetes

Anemia is more common in patients with diabetes than without diabetes, and the problem is magnified in patients with renal impairment. Diabetic patients with anemia may be at increased risk of adverse outcomes from diabetic retinopathy, nephropathy, neuropathy, and cardiovascular disease. The etiology of anemia in diabetes is multifactorial and includes inflammation, nutritional deficiencies, concomitant autoimmune diseases, drugs, and hormonal changes in addition to kidney disease. Anemia that is associated with erythropoietin deficiency may have prognostic significance for persons with nephropathy or heart failure. In early diabetic nephropathy, damage to the peritubular fibroblasts can occur and lead to erythropoietin deficiency and anemia prior to the loss of filtration. Correction of the anemia not only leads to less fatigue, greater exercise tolerance, and an improved quality of life but also to a reduction in mortality and hospital admissions for congestive heart failure (CHF). Data are accumulating that suggest that treatment of anemia will slow the progression of microvascular and macrovascular complications, including postural hypotension from autonomic neuropathy, retinopathy, and loss of renal function from diabetic nephropathy. Promptly diagnosing and treating anemia in patients with diabetes may result in an improved quality of life and decreased morbidity and mortality.

Glucose control influences glomerular filtration rate and its prediction in diabetic subjects

OBJECTIVE

Hyperglycemia increases glomerular filtration rate (GFR), but the influence of HbA(1c) (A1C) on GFR and GFR's prediction by recommended equations remains to be determined.

RESEARCH DESIGN AND METHODS

In 193 diabetic patients, we searched for an association between A1C and isotopically measured GFR (51Cr-EDTA) and their predictions by the Cockcroft and Gault formula (CG) and the modification of diet in renal disease (MDRD) equation. Their accuracy for the diagnosis of moderate (GFR <60 ml/min per 1.73 m(2)) or severe (GFR <30 ml/min per 1.73 m(2)) renal failure was compared from receiver operating characteristic (ROC) curves, before and after categorizing the patients as well (A1C <or=8%) or poorly controlled.

RESULTS

The mean GFR was 57.0 +/- 34.8 ml/min per 1.73 m(2) and was well correlated with both estimations (CG r = 0.75, MDRD r = 0.83; P < 0.05). The areas under the ROC curves were higher with the MDRD (P < 0.05). A1C was correlated (P < 0.001) with the GFR (r = 0.29), MDRD (r = 0.38), CG (r = 0.26), and the absolute differences between the GFR and their CG but not MDRD estimations (r = 0.17, P < 0.05). Each +1% A1C was associated with +6.0 ml/min per 1.73 m(2) GFR (CG +5.6, MDRD +5.3). After separating well-controlled (n = 88, A1C 7.0 +/- 0.7%) and poorly controlled (n = 105, 9.6 +/- 1.3%) patients, the diagnostic accuracies were better (P < 0.05) for the MDRD, except for the diagnosis of moderate renal failure in well-controlled patients (NS).

CONCLUSIONS

GFR and its estimations correlate with A1C. Although the relations between GFR and its estimations were not affected by the degree of glucose control, the precision and diagnostic accuracy of the CG formula were diminished for A1C >8%. The MDRD equation was more accurate and robust in diabetic patients with impaired renal function.

Lower haemoglobin level and subsequent decline in kidney function in type 2 diabetic adults without clinical albuminuria

AIMS/HYPOTHESIS

Anaemia has been suggested to be an independent risk factor for subsequent progression of advanced diabetic nephropathy; however, the relationship between haemoglobin levels and progression of nephropathy in patients without clinical albuminuria is unknown.

METHODS

We conducted this prospective hospital-based cohort study of 464 type 2 diabetic patients (149 women and 315 men, 55+/-13 [mean+/-SD] years of age) with serum creatinine <177 micromol/l (2.00 mg/dl) and urinary albumin : creatinine ratio <300 mg/g creatinine. GFR was estimated using the equation formulated by the Modification of Diet in Renal Disease Study group, refitted for Japanese individuals. Most patients had haemoglobin concentrations in the normal range (144+/-15 g/l), only modest renal impairment (GFR: 74.8+/-14.5 ml min(-1) 1.73 m(-2)), and normal urinary albumin levels (81.5/18.5% with normo-/microalbuminuria). The primary outcome measurement was the rate of change in GFR determined by regression analysis with GFR as a function of time. Patients were followed up for a mean observation period of 5.0+/-0.9 (range: 2.5 to 6.2) years.

RESULTS

Univariate and multiple regression analyses yielded a significant association between the rate of change in GFR and baseline haemoglobin concentration. After adjusting for covariates, the rate of decline in GFR was significantly greater in patients in the lowest haemoglobin quartile (-3.27 ml min(-1) 1.73 m(-2) year(-1)) than in the third (-2.71 ml min(-1) 1.73 m(-2) year(-1), p = 0.024) and highest quartiles (-2.78 ml min(-1) 1.73 m(-2) year(-1), p = 0.046).

CONCLUSIONS/INTERPRETATION

Lower haemoglobin concentrations in type 2 diabetic patients without clinical albuminuria may be a significant predictor of subsequent decline in GFR.

Anaemia in diabetes: Is there a rationale to TREAT?

BACKGROUND

Anaemia is a common finding in patients with diabetes, particularly in those with overt nephropathy or renal impairment. In tertiary clinics, at least one outpatient in five with diabetes has anaemia, for whom it constitutes a significant additional burden.

DISCUSSION

Anaemia is associated with an increased risk of diabetic complications including nephropathy, retinopathy and macrovascular disease. Anaemia may also be significant in determining the outcome of heart failure and hypoxia-induced organ damage in diabetes. While several factors contribute to the increased prevalence of anaemia in diabetes, the failure of the kidney to increase erythropoietin in response to falling haemoglobin appears to be the dominant factor. Although there is a clear rationale for correcting anaemia in people with diabetes, it remains to be established whether this will lead to improved outcomes. Moreover, the balance of risks, costs, and benefits remains to be established in patients with diabetes. The Trial to Reduce Cardiovascular Events with Aranesp (darbepoetin alpha) Therapy (TREAT) is a randomised controlled trial designed to determine the impact of anaemia correction on mortality and non-fatal cardiovascular events in patients with type 2 diabetes and stage 3-4 nephropathy.

CONCLUSION

It is anticipated that TREAT will help to define the optimal approach to the management of anaemia in diabetes.

Concealed renal failure and adverse drug reactions in older patients with type 2 diabetes mellitus

BACKGROUND

In elderly patients serum creatinine may be normal despite decreased glomerular filtration rate (GFR). The aim of this study was to evaluate the prevalence of this "concealed" renal failure, i.e., renal failure with normal serum creatinine levels, in elderly diabetic patients, and to verify whether it is a risk factor for adverse drug reactions (ADR) to hydrosoluble drugs.

METHODS

We used data on 2257 hospitalized patients with type 2 diabetes mellitus enrolled in the Gruppo Italiano di Farmacovigilanza nell'Anziano study. On the basis of serum creatinine and calculated GFR, patients were grouped as follows: normal renal function (normal serum creatinine levels and normal GFR), concealed (normal serum creatinine levels and reduced GFR), or overt (increased creatinine levels and reduced GFR) renal failure. GFR was calculated using the Modification of Diet in Renal Disease (MDRD) equation. The outcome of the study was the incidence of ADR to hydrosoluble drugs during the hospital stay. The relationship between renal function and ADR was evaluated using Cox regression analysis including potential confounders.

RESULTS

Concealed renal failure was observed in 363 (16.1%) of patients studied. Patients with concealed or overt renal failure were older, had more frequently cognitive impairment and polypharmacy, and had lower serum albumin levels than did those with normal renal function. Both concealed (hazard ratio = 1.90; 95% confidence interval, 1.04-3.48; p =.036) and overt (hazard ratio = 2.23; 95% confidence interval, 1.40-3.55; p =.001) renal failure were significantly associated with ADR to hydrosoluble drugs. The use of more than four drugs also qualified as an independent risk factor for ADRs to hydrosoluble drugs during hospital stay.

CONCLUSIONS

Older diabetic patients should be systematically screened to ascertain the presence of concealed renal failure in an attempt to optimize the pharmacological treatment and reduce the risk of ADRs.

Prospective study of lipoprotein(a) as a risk factor for deteriorating renal function in type 2 diabetic patients with overt proteinuria

OBJECTIVE

The effect of lipoprotein(a) [Lp(a)] on the progression of diabetic nephropathy has not been evaluated yet. The aim of this study was to determine whether Lp(a) is an independent risk factor for deteriorating renal function in type 2 diabetic patients with nephropathy.

RESEARCH DESIGN AND METHODS

We conducted this prospective study in type 2 diabetic patients with overt proteinuria. Patients were divided into two groups according to their baseline serum Lp(a) level. Group 1 had Lp(a) levels < or =30 mg/dl (n = 40) and group 2 had Lp(a) levels >30 mg/dl (n = 41). Patients were followed for 2 years. Progression of diabetic nephropathy was defined as a greater than twofold increase of follow-up serum creatinine concentration from the baseline value.

RESULTS

At baseline and during the follow-up, there was no difference in HbA(1c) and lipid profile between groups 1 and 2. However, serum creatinine was significantly higher in group 2 than in group 1 after 1 year (148.3 +/- 78.0 vs. 108.1 +/- 34.9 micromol/l, P = 0.004) and after 2 years (216.9 +/- 144.5 vs. 131.3 +/- 47.3 micromol/l, P = 0.001), although baseline serum creatinine did not differ significantly between groups. In all, 13 of 14 patients with progression of diabetic nephropathy (progressors) were from group 2. Baseline Lp(a) levels were higher in the progressors than in the nonprogressors (62.9 +/- 26.7 vs. 33.5 +/- 27.5 mg/dl, P < 0.001). Multiple logistic regression showed that baseline Lp(a) level was a significant and independent predictor of the progression of diabetic nephropathy.

CONCLUSIONS

Our study demonstrated that Lp(a) is an independent risk factor for the progression of diabetic nephropathy in type 2 diabetic patients with overt proteinuria.

Progression of kidney disease in type 2 diabetes - beyond blood pressure control: an observational study

BACKGROUND

The risk factors for progression of chronic kidney disease (CKD) in type 2 diabetes mellitus (DM) have not been fully elucidated. Although uncontrolled blood pressure (BP) is known to be deleterious, other factors may become more important once BP is treated.

METHODS

All patients seen in the outpatient clinics of our hospital between January 1993 and September 2002 with type 2 DM and clinical evidence of CKD were evaluated. Progression of kidney disease was evaluated by rate of decline of glomerular filtration rate (GFR) as estimated from the simplified MDRD formula. Variables associated with progression in univariate analyses were examined by multivariate analysis to determine the factors independently associated with kidney disease progression.

RESULTS

343 patients (mean age 69 years; all male; 77% Caucasian) were studied. Mean BP, glycated hemoglobin, and serum cholesterol during the study period were 138/72 mmHg, 8.1%, and 4.8 mmol/L, respectively. Mean decline of GFR was 4.5 ml min-1 1.73 m2-1 yr-1 (range -14 to +32). Low initial serum albumin (p < 0.001), black race (p < 0.001), and degree of proteinuria (p = 0.002), but not blood pressure, glycated hemoglobin, or serum cholesterol, were independently associated with progression.

CONCLUSION

In a cohort of diabetic patients with CKD in whom mean BP was < 140/80 mmHg, the potentially remediable factors hypoalbuminemia and proteinuria but not blood pressure were independently associated with progression of kidney disease. Further understanding of the relationship between these factors and kidney disease progression may lead to beneficial therapies in such patients.

Progression of nephropathy in type 2 diabetic patients

BACKGROUND

Nephropathy in type 2 diabetes is the single most common cause of end-stage renal disease (ESRD), but the decline in kidney function varies considerably between individuals, and determinants of renal function loss, early in the course of renal disease, have not been clearly identified.

METHODS

In a prospective observational study, we followed 227 (60 female) Caucasian type 2 diabetic patients with nephropathy for 6.5 (range 3 to 17) years from a baseline glomerular filtration rate (GFR) of 83 (SD30) mL/min/1.73m(2) with 7 (range 3 to 22) measurements of GFR ((51)Cr-EDTA) per patient. We evaluated determinants of (1) rate of decline in GFR, (2) risk of doubling in serum creatinine or ESRD, and (3) mortality using potential risk factors at baseline and during follow-up.

RESULTS

The mean (SD) rate of decline in GFR was 5.2 (4.1) mL/min/year. In multivariate regression analysis, higher baseline albuminuria, systolic blood pressure (SBP), hemoglobin A1c, GFR, age, and degree of diabetic retinopathy were significantly associated with increased rate of decline in GFR (R(2) (adj) 0.24). During follow-up, elevated mean albuminuria, SBP, hemoglobin A1c, and lower hemoglobin, heavy smoking, and presence of diabetic retinopathy were significantly associated with increased decline in GFR (R(2) (adj) 0.26). During follow-up, 63 patients had a doubling in serum creatinine or developed ESRD, and 79 patients died, primarily due to cardiovascular disease. In Cox regression analysis, higher baseline albuminuria, hemoglobin A1c, and SBP, together with lower GFR and hemoglobin, were significantly associated with shorter time to doubling of serum creatinine or ESRD. Higher baseline albuminuria, hemoglobin A1c, SBP, and age were significantly associated with increased mortality.

CONCLUSION

Our long-term prospective study of type 2 diabetic patients with nephropathy has revealed several modifiable risk factors of enhanced progression in kidney disease and increased mortality.

Anemia and diabetes

World Health Organization statistics identify 150 million people with diabetes mellitus worldwide and suggest that this figure may double by 2025. In countries with a western lifestyle, the number of patients admitted for renal replacement therapy with diabetes as a co-morbid condition has increased significantly up to three to four times in a period of 10 years. Diabetes and renal failure are thus tightly linked diseases, and so is anemia. However, whether anemia may be worsened and/or directly, at least in part, caused by diabetes is not clearly elucidated yet. In this article, we review the prevalence, pathophysiology and consequences of anemia in diabetic patients.