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El-Ashmawy HM, Ahmed AM. Serum cathelicidin as a marker for diabetic nephropathy in patients with type 1 diabetes. Diabetes Metab Res Rev 2018; 34:e3057. [PMID: 30091508 DOI: 10.1002/dmrr.3057] [Citation(s) in RCA: 2] [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: 05/01/2018] [Revised: 06/22/2018] [Accepted: 07/29/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND The aim of the study was to evaluate the relationship between serum cathelicidin level and diabetic nephropathy (DN) in patients with type 1 diabetes mellitus (T1DM). METHODS The study group consisted of 76 patients with T1DM (47 men), aged 36 ± 7 years, and with duration of T1DM 14 (7-18) years. Serum cathelicidin was measured by ELISA test in healthy controls (n = 20) and in 76 T1DM patients grouped as follows: G1 = patients with normal urinary albumin excretion (n = 20), G2 = patients with microalbumin excretion (n = 19), G3 = patients with macroalbumin excretion but normal serum creatinine level (n = 19), and G4 = patients with macroalbumin excretion with increased serum creatinine (n = 18). RESULTS There was no significant difference in serum cathelicidin levels between healthy controls and G1 diabetic patients, but serum levels were progressively increased from the stage of microalbuminuria to frank nephropathy (P < .001). Positive correlation between serum cathelicidin level and the presence of DN, thyroid-stimulating hormone, total cholesterol, and negative with male sex and fasting plasma glucose, was found. In multiple regression analysis, serum cathelicidin level was associated with the presence of DN after adjustment of sex, waist-to-hip ratio, total cholesterol, and thyroid-stimulating hormone. CONCLUSIONS Patients with T1DM and DN are characterized by increased serum cathelicidin level. There was an independent relationship between serum cathelicidin level and DN. Serum cathelicidin level can be used as an early marker for the presence and progression of DN in T1DM patients.
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Affiliation(s)
- Hazem M El-Ashmawy
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Azza M Ahmed
- Department of Clinical Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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2
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Currie GE, von Scholten BJ, Mary S, Flores Guerrero JL, Lindhardt M, Reinhard H, Jacobsen PK, Mullen W, Parving HH, Mischak H, Rossing P, Delles C. Urinary proteomics for prediction of mortality in patients with type 2 diabetes and microalbuminuria. Cardiovasc Diabetol 2018; 17:50. [PMID: 29625564 PMCID: PMC5889591 DOI: 10.1186/s12933-018-0697-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/02/2018] [Indexed: 01/01/2023] Open
Abstract
Background The urinary proteomic classifier CKD273 has shown promise for prediction of progressive diabetic nephropathy (DN). Whether it is also a determinant of mortality and cardiovascular disease in patients with microalbuminuria (MA) is unknown. Methods Urine samples were obtained from 155 patients with type 2 diabetes and confirmed microalbuminuria. Proteomic analysis was undertaken using capillary electrophoresis coupled to mass spectrometry to determine the CKD273 classifier score. A previously defined CKD273 threshold of 0.343 for identification of DN was used to categorise the cohort in Kaplan–Meier and Cox regression models with all-cause mortality as the primary endpoint. Outcomes were traced through national health registers after 6 years. Results CKD273 correlated with urine albumin excretion rate (UAER) (r = 0.481, p = <0.001), age (r = 0.238, p = 0.003), coronary artery calcium (CAC) score (r = 0.236, p = 0.003), N-terminal pro-brain natriuretic peptide (NT-proBNP) (r = 0.190, p = 0.018) and estimated glomerular filtration rate (eGFR) (r = 0.265, p = 0.001). On multivariate analysis only UAER (β = 0.402, p < 0.001) and eGFR (β = − 0.184, p = 0.039) were statistically significant determinants of CKD273. Twenty participants died during follow-up. CKD273 was a determinant of mortality (log rank [Mantel-Cox] p = 0.004), and retained significance (p = 0.048) after adjustment for age, sex, blood pressure, NT-proBNP and CAC score in a Cox regression model. Conclusion A multidimensional biomarker can provide information on outcomes associated with its primary diagnostic purpose. Here we demonstrate that the urinary proteomic classifier CKD273 is associated with mortality in individuals with type 2 diabetes and MA even when adjusted for other established cardiovascular and renal biomarkers. Electronic supplementary material The online version of this article (10.1186/s12933-018-0697-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gemma E Currie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| | | | - Sheon Mary
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Jose-Luis Flores Guerrero
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | | | | | | | - William Mullen
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | | | - Harald Mischak
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.,Mosaiques Diagnostics, Hanover, Germany
| | - Peter Rossing
- Steno Diabetes Center, Gentofte, Copenhagen, Denmark.,HEALTH, University of Aarhus, Aarhus, Denmark.,Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
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3
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Feldt-Rasmussen B, Hegedüs L, Mathiesen ER, Deckert T. Kidney volume in type 1 (insulin-dependent) diabetic patients with normal or increased urinary albumin excretion: effect of long-term improved metabolic control. Scandinavian Journal of Clinical and Laboratory Investigation 2018. [DOI: 10.1080/00365513.1991.11978686] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
| | - L. Hegedüs
- Department of Internal Medicine and Endocrinology and Department of Ultrasound, Herlev Hospital, DK-2730 Herlev, Denmark
| | | | - T. Deckert
- Steno Memorial Hospital, DK-2820 Gentofte, Herlev, Denmark
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4
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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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5
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Østergaard JA, Thiel S, Hoffmann-Petersen IT, Hovind P, Parving HH, Tarnow L, Rossing P, Hansen TK. Incident microalbuminuria and complement factor mannan-binding lectin-associated protein 19 in people with newly diagnosed type 1 diabetes. Diabetes Metab Res Rev 2017; 33. [PMID: 28303635 DOI: 10.1002/dmrr.2895] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/09/2017] [Accepted: 02/24/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Evidence links the lectin pathway of complement activation to diabetic kidney disease. Upon carbohydrate-recognition by pattern-recognition molecules, eg, mannan-binding lectin (MBL), the MBL-associated serine protease (MASP-2) is activated and initiates the complement cascade. The MASP2 gene encodes MASP-2 and the alternative splice product MBL-associated protein 19 (MAp19). Both MAp19 and MASP-2 circulate in complex with MBL. We tested the hypothesis that MAp19 and MASP-2 concentrations predict the risk of incident microalbuminuria. METHODS Baseline MAp19 and MASP-2 were measured in 270 persons with newly diagnosed type 1 diabetes tracked for incidence of persistent microalbuminuria in a prospective observational 18-year-follow-up study. RESULTS Seventy-five participants (28%) developed microalbuminuria during follow-up. MBL-associated protein 19 concentrations were higher in participants that later progressed to microalbuminuria as compared with those with persistent normoalbuminuria (268 ng/mL [95% CI, 243-293] vs 236 ng/mL [95% CI, 223-250], P = .02). Participants with MAp19 concentration within the highest quartile of the cohort had an increased risk of microalbuminuria as compared with participants with MAp19 concentration within the combined lower 3 quartiles in unadjusted Cox analysis, hazard ratio 1.86 ([95% CI, 1.17-2.96], P = .009). This remained significant in adjusted models, eg, adjusting for age, sex, HbA1c , systolic blood pressure, urinary albumin excretion, smoking, serum creatinine, and serum cholesterol. MBL-associated serine protease concentration was not associated with incidence of microalbuminuria. CONCLUSIONS In conclusion, the results show an association between baseline MAp19 concentration and the incidence of microalbuminuria in an 18-year-follow-up study on persons with newly diagnosed type 1 diabetes.
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Affiliation(s)
- J A Østergaard
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital and Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- The Danish Diabetes Academy, Odense, Denmark
| | - S Thiel
- Department of Biomedicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - I T Hoffmann-Petersen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital and Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - P Hovind
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - H-H Parving
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - L Tarnow
- Steno Diabetes Center, Gentofte, Denmark
- Nordsjaellands Hospital, Hillerød, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - P Rossing
- Steno Diabetes Center, Gentofte, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - T K Hansen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital and Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Zobel EH, von Scholten BJ, Lajer M, Jorsal A, Tarnow L, Rasmussen LM, Holstein P, Parving HH, Hansen TW, Rossing P. High osteoprotegerin is associated with development of foot ulcer in type 1 diabetes. J Diabetes Complications 2016; 30:1603-1608. [PMID: 27469295 DOI: 10.1016/j.jdiacomp.2016.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/24/2016] [Accepted: 07/14/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM The bone-related peptide osteoprotegerin has been linked to vascular calcification and peripheral vascular disease. We investigated the association between osteoprotegerin and development of foot complications in persons with type 1 diabetes. MATERIALS AND METHODS Prospective observational study of 573 persons with type 1 diabetes, 225 women; age [mean±SD] 42.3±10.3years. Plasma osteoprotegerin was measured by ELISA. RESULTS Median (IQR) osteoprotegerin was 2.80(2.35-3.63)μg/L and follow-up time (median (range)) was 12.7(0.1-15.6)years. Endpoints included: new foot ulceration (n=153), Charcot foot (n=14), vascular surgery/amputation (n=53), loss of foot pulse (n=57), and peripheral neuropathy (n=99). In unadjusted analyses, higher osteoprotegerin was associated with development of all endpoints (p≤0.026). Higher osteoprotegerin remained associated with development of foot ulcer, and the combination of vascular surgery/amputation, loss of foot pulse and neuropathy (p≤0.001) in a sex and age adjusted model. After further adjustment (nephropathy status, smoking, HbA1c, systolic blood pressure, serum cholesterol, high sensitivity C-reactive protein, eGFR, and presence of neuropathy and/or claudication and/or foot ulcer at baseline), higher osteoprotegerin remained associated with development of foot ulcer (HR (95% CI) per doubling: 1.75 (1.04-2.97); p=0.037). CONCLUSION Higher osteoprotegerin levels were associated with development of foot ulcer, even after comprehensive adjustment.
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Affiliation(s)
| | | | | | - Anders Jorsal
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Lise Tarnow
- Department of Clinical Research, Nordsjællands Hospital, University of Copenhagen, Hillerød, Denmark; Health, Aarhus University, Aarhus, Denmark
| | - Lars M Rasmussen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; Center for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, Odense, Denmark
| | - Per Holstein
- Steno Diabetes Center, Gentofte, Denmark; Department of Dermato-venerology and Copenhagen Wound Healing Center, Bispebjerg Hospital, University Hospital of Copenhagen, Denmark
| | - Hans-Henrik Parving
- Department of Medical Endocrinology, Rigshospitalet, University of Copenhagen, Denmark
| | - T W Hansen
- Steno Diabetes Center, Gentofte, Denmark
| | - P Rossing
- Steno Diabetes Center, Gentofte, Denmark; Health, Aarhus University, Aarhus, Denmark; Novo Nordisk Foundation Center for Metabolic Research, Copenhagen, Denmark
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7
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Østergaard JA, Thiel S, Lajer M, Steffensen R, Parving HH, Flyvbjerg A, Rossing P, Tarnow L, Hansen TK. Increased all-cause mortality in patients with type 1 diabetes and high-expression mannan-binding lectin genotypes: a 12-year follow-up study. Diabetes Care 2015; 38:1898-903. [PMID: 26180106 DOI: 10.2337/dc15-0851] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/17/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Mannan-binding lectin (MBL) is a complement-activating carbohydrate-recognizing molecule associated with diabetic nephropathy. MBL is associated with all-cause mortality in type 2 diabetes, but whether MBL is associated with mortality in type 1 diabetes remains unknown. We therefore aimed to investigate this. RESEARCH DESIGN AND METHODS We studied an existing 12-year prospective cohort with type 1 diabetes with 198 patients with diabetic nephropathy (121 men, age 41 years [95% CI 40-42], estimated glomerular filtration rate [eGFR] 67 mL/min/1.73 m(2) [95% CI 63-70]) and 174 normoalbuminuric patients (103 men, age 43 years [95% CI 41-44], eGFR 93 mL/min/1.73 m(2) [95% CI 91-95]). Mortality rates were compared according to the concentration-determining MBL2 genotype or the MBL concentration. Patients were classified as having high or low MBL expression genotypes. The effect of MBL concentration was estimated by comparing patients with MBL concentrations above or below the median. RESULTS Ninety-eight patients died during follow-up. The unadjusted hazard ratio (HR) for all-cause mortality was 1.61 (95% CI 1.07-2.43) for patients with high MBL expression genotypes versus patients with low MBL expression genotypes (P = 0.023). All-cause mortality was higher in patients with MBL concentrations above the median than in patients with MBL concentrations below the median (unadjusted HR 1.90 [95% CI 1.26-2.87], P = 0.002). CONCLUSIONS High MBL expression genotypes and high MBL concentrations are both associated with increased mortality rates in type 1 diabetes compared with low MBL expression genotypes and low MBL concentrations.
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Affiliation(s)
- Jakob A Østergaard
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark The Danish Diabetes Academy, Odense, Denmark
| | - Steffen Thiel
- Department of Biomedicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | | | - Rudi Steffensen
- Department of Clinical Immunology, Aalborg University Hospital, Aalborg, Denmark
| | - Hans-Henrik Parving
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Allan Flyvbjerg
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Peter Rossing
- Steno Diabetes Center, Gentofte, Denmark Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Lise Tarnow
- Steno Diabetes Center, Gentofte, Denmark Faculty of Health, Aarhus University, Aarhus, Denmark Nordsjællands Hospital, Hillerød, Denmark
| | - Troels K Hansen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Al-Saffar HB, Nassir H, Mitchell A, Philipp S. Microalbuminuria in non-diabetic patients with unstable angina/non ST-segment elevation myocardial infarction. BMC Res Notes 2015; 8:371. [PMID: 26362770 PMCID: PMC4567814 DOI: 10.1186/s13104-015-1347-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/13/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Microalbuminuria (MAU) is defined as an urinary albumin excretion rate between 20-200 mg/l or 30-300 mg/day. It is a surrogate marker for endothelial dysfunction and is independently associated with atherosclerotis in diabetic and in non-diabetic patients. We assessed the prevalence of MAU in non-diabetic patients who presented with UA/NSTEMI and the relation of MAU to the severity of coronary artery disease in patients at a cardiac care center in Iraq. METHODS Seventy non-diabetic patients referred to the Iraqi Center for Heart Disease, Baghdad, between November 1st 2010 and June 1st 2011 with the diagnosis of UA/NSTEMI were included in this study. Physical examination, ECG and echocardiography were performed on all patients. TIMI ("Thrombolysis in Myocardial Infarction") risk score was obtained. Urine samples were collected and sent for quantitative determination of MAU. All patients underwent diagnostic coronary angiography. Data are give as mean (quantitative and percent) ± SD. RESULTS Fifty-three men (76%) and 17 (24%) women (mean age 56 ± 12 years) were investigated. Overall 37 (53%) individuals presented with arterial hypertension and 41 (59%) with a history of smoking. 58 patients (83%) had ischemic ECG changes (defined as ST segment depression more than 1 mm from baseline, and/or T wave inversion), 52 (74%) had echocardiographic findings indicative of ischemia (defined as segmental wall motion abnormalities). Twenty-one (30%) patients tested positive for MAU. There was a significant correlation of echocardiographic signs of ischemia and MAU, (n = 20 (38%), p < 0.01). There was a clear relationship between MAU and TIMI risk score. Additionally, MAU was more common in patients with multivessel coronary artery disease (CAD) (p < 0.001). There was no statistically significant correlation between MAU and mean age, sex, smoking, and blood pressure. CONCLUSION In this analysis of patients with UA/NSTEMI we found a strong correlation of microalbuminuria with echocardiographic changes and findings in coronary angiography.
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Affiliation(s)
| | | | - Anna Mitchell
- Department of Nephrology, Essen University Hospital, University of Duisburg-Essen, Essen, Germany.
| | - Sebastian Philipp
- Department of Cardiology, Elbeklinikum Stade, Bremervörderstr. 111, 21682, Stade, Germany.
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9
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von Scholten BJ, Reinhard H, Hansen TW, Lindhardt M, Petersen CL, Wiinberg N, Hansen PR, Parving HH, Jacobsen PK, Rossing P. Additive prognostic value of plasma N-terminal pro-brain natriuretic peptide and coronary artery calcification for cardiovascular events and mortality in asymptomatic patients with type 2 diabetes. Cardiovasc Diabetol 2015; 14:59. [PMID: 25990319 PMCID: PMC4489401 DOI: 10.1186/s12933-015-0225-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 05/06/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In patients with type 2 diabetes, cardiovascular disease (CVD) is the major cause of morbidity and mortality. We evaluated the combination of NT-proBNP and coronary artery calcium score (CAC) for prediction of combined fatal and non-fatal CVD and mortality in patients with type 2 diabetes and microalbuminuria (>30 mg/24-h), but without known coronary artery disease. Moreover, we assessed the predictive value of a predefined categorisation of patients into a high- and low-risk group at baseline. METHODS Prospective study including 200 patients. All received intensive multifactorial treatment. Patients with baseline NT-proBNP > 45.2 ng/L and/or CAC ≥ 400 were stratified as high-risk patients (n = 133). Occurrence of fatal- and nonfatal CVD (n = 40) and mortality (n = 26), was traced after 6.1 years (median). RESULTS High-risk patients had a higher risk of the composite CVD endpoint (adjusted hazard ratio [HR] 10.6 (95 % confidence interval [CI] 2.4-46.3); p = 0.002) and mortality (adjusted HR 5.3 (95 % CI 1.2-24.0); p = 0.032) compared to low-risk patients. In adjusted continuous analysis, both higher NT-proBNP and CAC were strong predictors of the composite CVD endpoint and mortality (p ≤ 0.0001). In fully adjusted models mutually including NT-proBNP and CAC, both risk factors remained associated with risk of CVD and mortality (p ≤ 0.022). There was no interaction between NT-proBNP and CAC for the examined endpoints (p ≥ 0.31). CONCLUSIONS In patients with type 2 diabetes and microalbuminuria but without known coronary artery disease, NT-proBNP and CAC were strongly associated with fatal and nonfatal CVD, as well as with mortality. Their additive prognostic capability holds promise for identification of patients at high risk.
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Affiliation(s)
| | - Henrik Reinhard
- Steno Diabetes Center, Niels Steensens Vej 1, Gentofte, 2820, Denmark.
| | | | - Morten Lindhardt
- Steno Diabetes Center, Niels Steensens Vej 1, Gentofte, 2820, Denmark.
| | - Claus Leth Petersen
- Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, University of Copenhagen, Compenhagen, Denmark.
| | | | | | - Hans-Henrik Parving
- Rigshospitalet, Copenhagen, Denmark. .,University of Copenhagen, Copenhagen, Denmark.
| | - Peter Karl Jacobsen
- The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Peter Rossing
- Steno Diabetes Center, Niels Steensens Vej 1, Gentofte, 2820, Denmark. .,University of Copenhagen, Copenhagen, Denmark. .,Aarhus University, Aarhus, Denmark.
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10
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Østergaard JA, Thiel S, Hovind P, Holt CB, Parving HH, Flyvbjerg A, Rossing P, Hansen TK. Association of the pattern recognition molecule H-ficolin with incident microalbuminuria in an inception cohort of newly diagnosed type 1 diabetic patients: an 18 year follow-up study. Diabetologia 2014; 57:2201-7. [PMID: 25064124 DOI: 10.1007/s00125-014-3332-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 06/30/2014] [Indexed: 01/01/2023]
Abstract
AIMS/HYPOTHESIS Increasing evidence links complement activation through the lectin pathway to diabetic nephropathy. Adverse complement recognition of proteins modified by glycation has been suggested to trigger complement auto-attack in diabetes. H-ficolin (also known as ficolin-3) is a pattern recognition molecule that activates the complement cascade on binding to glycated surfaces, but the role of H-ficolin in diabetic nephropathy is unknown. We aimed to investigate the association between circulating H-ficolin levels and the incidence of microalbuminuria in type 1 diabetes. METHODS We measured baseline H-ficolin levels and tracked the development of persistent micro- and macroalbuminuria in a prospective 18 year observational follow-up study of an inception cohort of 270 patients with newly diagnosed type 1 diabetes. RESULTS Patients were followed for a median of 18 years (range 1-22 years). During follow-up, 75 patients developed microalbuminuria, defined as a persistent urinary albumin excretion rate (UAER) above 30 mg/24 h. When H-ficolin levels were divided into quartile groups an unadjusted Cox proportional hazards regression model showed a significant association with risk of incident microalbuminuria during follow-up (HR, fourth vs first quartile, 2.45; 95% CI 1.24, 4.85) (p = 0.01). This remained significant after adjusting for HbA1c, systolic blood pressure, smoking and baseline UAER (HR 2.09; 95% CI 1.03, 4.25) (p = 0.04). CONCLUSIONS/INTERPRETATION Our data suggest that high levels of the complement activating molecule H-ficolin are associated with an increased risk of future progression to microalbuminuria in patients with newly diagnosed type 1 diabetes.
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Affiliation(s)
- Jakob A Østergaard
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 2, DK-8000, Aarhus C, Denmark,
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Damm JA, Asbjörnsdóttir B, Callesen NF, Mathiesen JM, Ringholm L, Pedersen BW, Mathiesen ER. Diabetic nephropathy and microalbuminuria in pregnant women with type 1 and type 2 diabetes: prevalence, antihypertensive strategy, and pregnancy outcome. Diabetes Care 2013; 36:3489-94. [PMID: 24009298 PMCID: PMC3816914 DOI: 10.2337/dc13-1031] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the prevalence of diabetic nephropathy and microalbuminuria in pregnant women with type 2 diabetes in comparison with type 1 diabetes and to describe pregnancy outcomes in these women following the same antihypertensive protocol. RESEARCH DESIGN AND METHODS Among 220 women with type 2 diabetes and 445 women with type 1 diabetes giving birth from 2007-2012, 41 women had diabetic nephropathy (albumin-creatinine ratio ≥300 mg/g) or microalbuminuria (albumin-creatinine ratio 30-299 mg/g) in early pregnancy. Antihypertensive therapy was initiated if blood pressure ≥135/85 mmHg or albumin-creatinine ratio ≥300 mg/g. RESULTS The prevalence of diabetic nephropathy was 2.3% (5 of 220) in women with type 2 diabetes and 2.5% (11 of 445) in women with type 1 diabetes (P = 1.00). The figures for microalbuminuria were 4.5 (10 of 220) vs. 3.4% (15 of 445) (P = 0.39). Baseline glycemic control was comparable between women with type 2 diabetes (n = 15) and type 1 diabetes (n = 26). Blood pressure at baseline was median 128 (range 100-164)/81 (68-91) vs. 132 (100-176)/80 (63-100) mmHg (not significant) and antihypertensive therapy in type 2 versus type 1 diabetes was used in 0 and 62%, respectively, at baseline, increasing to 33 and 96%, respectively, in late pregnancy. Pregnancy outcome was comparable regardless type of diabetes; gestational age at delivery: 259 days (221-276) vs. 257 (184-271) (P = 0.19); birth weight 3,304 g (1,278-3,914) vs. 2,850 (370-4,180) (P = 0.67). CONCLUSIONS The prevalence of diabetic nephropathy and microalbuminuria in early pregnancy was similar in type 2 and type 1 diabetes. Antihypertensive therapy was used more frequently in type 1 diabetes. Pregnancy outcome was comparable regardless type of diabetes.
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Jorsal A, Petersen EH, Tarnow L, Hess G, Zdunek D, Frystyk J, Flyvbjerg A, Lajer M, Rossing P. Urinary adiponectin excretion rises with increasing albuminuria in type 1 diabetes. J Diabetes Complications 2013; 27:604-8. [PMID: 23969018 DOI: 10.1016/j.jdiacomp.2013.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 06/03/2013] [Accepted: 06/27/2013] [Indexed: 10/26/2022]
Abstract
AIM Urinary adiponectin (u-adiponectin) excretion has been suggested to reflect early glomerular damage. Inspired by this, we studied the levels of u-adiponectin in type 1 diabetic patients with different levels of urinary albumin excretion (UAE). METHODS U-adiponectin was analysed by ELISA in type 1 diabetic patients: Fifty-eight with normoalbuminuria (<30mg albumin/24h), 43 with persistent microalbuminuria (30-300mg/24h) and 44 with persistent macroalbuminuria (>300mg/24h). For comparison, a control group of 55 healthy individuals was included. RESULTS U-adiponectin increased with increasing levels of UAE (p<0.01). U-adiponectin median (interquartile range): Normoalbuminuria 0.38 (0.14-1.31), microalbuminuria 1.12 (0.20-2.68), macroalbuminuria 9.20 (1.10-23.35) and controls 0.09 (0.06-0.24) μg/g creatinine. Levels were unrelated to sex, age, cholesterol, diastolic BP and BMI. U-adiponectin was weakly associated with increasing systolic BP and HbA1c (r(2)<0.1, p<0.05), but strongly related to increasing UAE (r(2)=0.57, p<0.001) and decreasing eGFR (r(2)=0.26, p<0.001). The relationship between UAE and u-adiponectin was significant in all groups and independent of eGFR, BMI, BP and HbA1c. Furthermore, u-adiponectin was associated with markers of tubular damage (p<0.01). CONCLUSION U-adiponectin rises with increasing levels of UAE in patients with type 1 diabetes. This is in accordance with the hypothesis that loss of adiponectin may reflect glomerular and/or tubular damage.
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Affiliation(s)
- Anders Jorsal
- Steno Diabetes Center, Gentofte, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
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Kramer CK, Retnakaran R. Concordance of retinopathy and nephropathy over time in Type 1 diabetes: an analysis of data from the Diabetes Control and Complications Trial. Diabet Med 2013; 30:1333-41. [PMID: 23909911 DOI: 10.1111/dme.12296] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2013] [Indexed: 12/18/2022]
Abstract
AIMS Little is known about the dynamic relationship over time between diabetic retinopathy and nephropathy. Thus, we sought to evaluate the concordance over time of retinopathy and nephropathy in patients with Type 1 diabetes during the Diabetes Control and Complications Trial. METHODS This analysis was conducted in patients with Type 1 diabetes participating in the Diabetes Control and Complications Trial. Only participants with urinary albumin excretion rate < 40 mg/24 h were included in the analysis (n = 1365). We evaluated the relationship between the progression of retinopathy and the development of nephropathy over a mean 6.5 years of follow-up. Progression of retinopathy was defined by 3-step change in Early Treatment Diabetic Retinopathy Study score on consecutive annual evaluations. Development of nephropathy was defined as incidence of urinary albumin excretion rate ≥ 40 mg/24 h on annual evaluation. RESULTS Over a mean 6.5 years of follow-up, the incidence of progression of retinopathy was higher in those who developed nephropathy than in those who did not (36.2 vs. 13.4%; P < 0.001). The development of nephropathy independently increased the risk for progression of retinopathy (hazard ratio 1.62, 95% CI 1.23-2.13, P = 0.001), after adjustment for age, gender, diabetes duration, treatment, HbA1c , BMI, HDL cholesterol and blood pressure. Similarly, the incidence of nephropathy was higher in participants who had progression of retinopathy than in those who did not (40.7 vs. 15.7%; P < 0.001). Furthermore, progression of retinopathy independently increased the risk for development of nephropathy (hazard ratio 1.72, 95% CI 1.30-2.27, P < 0.001). CONCLUSIONS Progression of retinopathy and development of nephropathy each increase the risk for incidence of the other, independent of established risk factors for microvascular complications, supporting the notion of a shared aetiologic basis.
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Affiliation(s)
- C K Kramer
- Leadership Sinai Centre for Diabetes, Mount Sinai Hospital; Division of Endocrinology, University of Toronto
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Guidone C, Gniuli D, Castagneto-Gissey L, Leccesi L, Arrighi E, Iaconelli A, Mingrone G. Underestimation of urinary albumin to creatinine ratio in morbidly obese subjects due to high urinary creatinine excretion. Clin Nutr 2011; 31:212-6. [PMID: 22030400 DOI: 10.1016/j.clnu.2011.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 09/15/2011] [Accepted: 10/14/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND & AIMS Albuminuria, a chronic kidney and/or cardiovascular disease biomarker, is currently measured as albumin-to-creatinine ratio (ACR). We hypothesize that in severely obese individuals ACR might be abnormally low in spite of relatively high levels of urinary albumin due to increased creatininuria. METHODS One-hundred-eighty-four subjects were divided into tertiles based on their BMI. Fat-free mass (FFM) and fat-mass were assessed by DEXA; 24-h creatinine and albumin excretion, ACR, lipid profile and blood pressure were measured. RESULTS Twenty-four-hour creatinine highly correlated (R = 0.75) with FFM. Since both creatininuria and albuminuria increased with the BMI, being the increase in creatininuria preponderant in subjects with BMI>35, their ratio (AC-ratio) did not change significantly from that of subjects in the lower BMI tertile. ACR only correlated with the systolic blood pressure, while both albuminuria and cretininuria correlated (P = 0.01) with the absolute 10-year CHD risk. In subjects with BMI>35, 100 mg of albumin excreted with urine increased the CHD risk of 2%. CONCLUSIONS Albumin-to-creatinine ratio is underestimated in severely obese individuals as a consequence of the large creatininuria, which is proportional to the increased FFM. Therefore, at least in this population 24-h albuminuria should be more reliable than ACR.
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Affiliation(s)
- Caterina Guidone
- Department of Internal Medicine, Catholic University, Largo A. Gemelli 8, 00168 Rome, Italy
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Reinhard H, Hansen PR, Persson F, Tarnow L, Wiinberg N, Kjaer A, Petersen CL, Winther K, Parving HH, Rossing P, Jacobsen PK. Elevated NT-proBNP and coronary calcium score in relation to coronary artery disease in asymptomatic type 2 diabetic patients with elevated urinary albumin excretion rate. Nephrol Dial Transplant 2011; 26:3242-9. [DOI: 10.1093/ndt/gfr009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Taskiran M, Iversen A, Klausen K, Jensen GB, Jensen JS. The association of microalbuminuria with mortality in patients with acute myocardial infarction. A ten-year follow-up study. Heart Int 2010; 5:e2. [PMID: 21977287 PMCID: PMC3184708 DOI: 10.4081/hi.2010.e2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 01/15/2010] [Accepted: 01/15/2010] [Indexed: 11/24/2022] Open
Abstract
Our study evaluates the long-term effect of microalbuminuria on mortality among patients with acute myocardial infarction. We followed 151 patients from 1996 to 2007 to investigate if microalbuminuria is a risk factor in coronary heart disease. All patients admitted with acute myocardial infarction in 1996 were included. At baseline, we recorded urinary albumin/creatinine concentration ratio, body mass index, blood pressure, left ventricle ejection fraction by echocardiography, smoking status, medication, diabetes, age, and gender. Deaths were traced in 2007 by means of the Danish Personal Identification Register. Microalbuminuria, defined as a urinary albumin/creatinine concentration ratio above 0.65 mg/mmoL, occurred in 50% of the patients and was associated with increased all-cause mortality. Thus, 68% of the patients with microalbuminuria versus 48% of the patients without microalbuminuria had died during the 10 years of follow-up (P=0.04). The crude hazard ratio for death associated with microalbuminuria was 1.78 (CI: 1.18–2.68) (P=0.006), whereas the gender- and age-adjusted hazard ratio was 1.71 (CI: 1.03–2.83) (P=0.04). We concluded that microalbuminuria in hospitalized patients with acute myocardial infarction is prognostic for increased long-term mortality. We recommend measurement of microalbuminuria to be included as a baseline risk factor in patients with acute myocardial infarction and in future trials in patients with coronary heart disease.
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Rasmussen KL, Laugesen CS, Ringholm L, Vestgaard M, Damm P, Mathiesen ER. Progression of diabetic retinopathy during pregnancy in women with type 2 diabetes. Diabetologia 2010; 53:1076-83. [PMID: 20225131 DOI: 10.1007/s00125-010-1697-9] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Accepted: 01/22/2010] [Indexed: 11/25/2022]
Abstract
AIMS/HYPOTHESIS We studied the progression of diabetic retinopathy during pregnancy in women with type 2 diabetes. METHODS Fundus photography was performed at median 10 (range 6-21) and 28 (27-37) gestational weeks in 80 of 110 (73%) consecutively referred pregnant women with type 2 diabetes. Diabetic retinopathy was classified in five stages. Progression was defined as at least one stage of deterioration of diabetic retinopathy and/or development of macular oedema on at least one eye between the two examinations. Macular oedema was defined as retinal thickening and/or hard exudates within a diameter of 1,500 microm in the macula area. RESULTS Diabetic retinopathy, mainly mild, was present in 11 (14%) women in early pregnancy. Median duration of diabetes was 3 years (range 0-16 years). At baseline, HbA(1c) was 6.4% (1.0) (mean [SD]), systolic BP 121 (13) and diastolic BP 72 (9) mmHg. Prior to pregnancy, 22 (28%) women had been on insulin treatment. During pregnancy 74 women (93%) were treated with insulin and 11 (14%) with antihypertensive medication. Progression of diabetic retinopathy was observed in 11 (14%) women. Progression was mainly mild, but one woman with poor glycaemic control and uncontrolled hypertension progressed from mild retinopathy to sight-threatening retinopathy with proliferations, clinically significant macular oedema and impaired vision in both eyes. Progression of diabetic retinopathy was associated with a longer duration of diabetes (p = 0.03) and insulin treatment before pregnancy (p = 0.004). CONCLUSIONS/INTERPRETATION Despite a low risk of progression of retinopathy in pregnant women with type 2 diabetes, sight-threatening deterioration did occur.
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Affiliation(s)
- K L Rasmussen
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 København Ø, Denmark.
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Chadban S, Howell M, Twigg S, Thomas M, Jerums G, Cass A, Campbell D, Nicholls K, Tong A, Mangos G, Stack A, MacIsaac RJ, Girgis S, Colagiuri R, Colagiuri S, Craig J. Assessment of kidney function in type 2 diabetes. Nephrology (Carlton) 2010; 15 Suppl 1:S146-61. [DOI: 10.1111/j.1440-1797.2010.01239.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
The evaluation of diabetic nephropathy from research and clinical viewpoints depends on the assessment of two continuous variables, albumin excretion rate (AER) and glomerular filtration rate (GFR). These two parameters form the basis of both the European classification of five stages of diabetic nephropathy, assessed according to changes in AER and GFR (hyperfiltration, normoalbuminuria, microalbuminuria, macroalbuminuria and end-stage renal disease), and the National Kidney Foundation classification of five stages of chronic kidney disease based on categories of estimated GFR. Although increases in AER generally precede a decline in GFR, some patients follow a non-albuminuric pathway to renal impairment. In addition, studies indicate that GFR decreases in a linear fashion from normal or above-normal levels. Whether hyperfiltration is part of the pathogenetic process leading to diabetic nephropathy remains unclear. Ideally, both AER and GFR should be assessed at an early stage in patients being evaluated for diabetic nephropathy. New methods such as the use of cystatin-C-based equations for estimating GFR should be considered because current creatinine-based estimates are inaccurate at normal or high GFRs. Serial assessments of both AER and GFR might allow diabetic nephropathy to be diagnosed at early stages of the disease process that are selectively responsive to new interventions. The successful integration of AER categories with the recently defined stages of GFR represents a new challenge in the management of diabetic nephropathy.
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Hovind P, Rossing P, Tarnow L, Johnson RJ, Parving HH. Serum uric acid as a predictor for development of diabetic nephropathy in type 1 diabetes: an inception cohort study. Diabetes 2009; 58:1668-71. [PMID: 19411615 PMCID: PMC2699868 DOI: 10.2337/db09-0014] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Experimental and clinical studies have suggested that uric acid may contribute to the development of hypertension and kidney disease. Whether uric acid has a causal role in the development of diabetic nephropathy is not known. The objective of the present study is to evaluate uric acid as a predictor of persistent micro- and macroalbuminuria. RESEARCH DESIGN AND METHODS This prospective observational follow-up study consisted of an inception cohort of 277 patients followed from onset of type 1 diabetes. Of these, 270 patients had blood samples taken at baseline. In seven cases, uric acid could not be determined; therefore, 263 patients (156 men) were available for analysis. Uric acid was measured 3 years after onset of diabetes and before any patient developed microalbuminuria. RESULTS During a median follow-up of 18.1 years (range 1.0-21.8), 23 of 263 patients developed persistent macroalbuminuria (urinary albumin excretion rate >300 mg/24 h in at least two of three consecutive samples). In patients with uric acid levels in the highest quartile (>249 micromol/l), the cumulative incidence of persistent macroalbumnuria was 22.3% (95% CI 10.3-34.3) compared with 9.5% (3.8-15.2) in patients with uric acid in the three lower quartiles (log-rank test, P = 0.006). In a Cox proportional hazards model with sex and age as fixed covariates, uric acid was associated with subsequent development of persistent macroalbuminuria (hazard ratio 2.37 [95% CI 1.04-5.37] per 100 micromol/l increase in uric acid level; P = 0.04). Adjustment for confounders did not change the estimate significantly. CONCLUSIONS Uric acid level soon after onset of type 1 diabetes is independently associated with risk for later development of diabetic nephropathy.
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Klausen KP, Parving HH, Scharling H, Jensen JS. Microalbuminuria and obesity: impact on cardiovascular disease and mortality. Clin Endocrinol (Oxf) 2009; 71:40-5. [PMID: 18803675 DOI: 10.1111/j.1365-2265.2008.03427.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Microalbuminuria and obesity are both associated with cardiovascular disease (CVD). The aim of this study was to determine the association between obesity (measured by body mass index, waist-to-hip ratio, waist circumference) and different levels of microalbuminuria. We also aimed to determine the risk of death and CVD at different levels of microalbuminuria and obesity. DESIGN Population-based observational study based on 2696 men and women, 30-70 years of age. Urinary albumin excretion (UAE), body mass index, waist-to-hip ratio, waist circumference and other cardiovascular risk factors were measured during the years 1992-1994 at the Copenhagen City Heart Study. End-points were registered until 1999-2000 with respect to CVD and until 2004 with respect to death. RESULTS There was a strong association between microalbuminuria and obesity. Microalbuminuria and obesity had additive effects on the relative risk of death independently of other risk factors. In contrast there was no statistically significant association between microalbuminuria and risk of CVD when stratified by obesity. CONCLUSIONS Microalbuminuria (UAE > 5 microg/min) confers increased risk of death and to a similar extent as obesity. This effect is independent of concomitant obesity. We suggest microalbuminuria to be included in health examinations besides measurements of obesity.
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Affiliation(s)
- Klaus Peder Klausen
- The Copenhagen City Heart Study, Epidemiological Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark.
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Nielsen LR, Damm P, Mathiesen ER. Improved pregnancy outcome in type 1 diabetic women with microalbuminuria or diabetic nephropathy: effect of intensified antihypertensive therapy? Diabetes Care 2009; 32:38-44. [PMID: 18945922 PMCID: PMC2606826 DOI: 10.2337/dc08-1526] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To describe pregnancy outcome in type 1 diabetic women with normoalbuminuria, microalbuminuria, or diabetic nephropathy after implementation of an intensified antihypertensive therapeutic strategy. RESEARCH DESIGN AND METHODS Prospective study of 117 pregnant women with type 1 diabetes. Antihypertensive therapy, mainly methyldopa, was given to obtain blood pressure <135/85 mmHg and urinary albumin excretion <300 mg/24 h. Blood pressure and A1C were recorded during pregnancy. The pregnancy outcome was compared with recently published studies of pregnant women with microalbuminuria or diabetic nephropathy. RESULTS Antihypertensive therapy was given in 14 of 100 women with normoalbuminuria, 5 of 10 women with microalbuminuria, and all 7 women with diabetic nephropathy. Mean systolic blood pressure during pregnancy was 120 mmHg (range 101-147), 122 mmHg (116-135), and 135 mmHg (111-145) in women with normoalbuminuria, microalbuminuria, and diabetic nephropathy, respectively (P = 0.0095). No differences in mean diastolic blood pressure or A1C were detected between the groups. No women with microalbuminuria developed preeclampsia. The frequency of preterm delivery was 20% in women with normoalbuminuria and microalbuminuria in contrast to 71% in women with diabetic nephropathy (P < 0.01) where the median gestational age was 258 days (220-260). Compared with previous studies using less stringent antihypertensive therapeutic strategy and less strict metabolic control, gestational age was longer and birth weight was larger in our study. CONCLUSIONS With intensified antihypertensive therapy and strict metabolic control, comparable pregnancy outcome was seen in type 1 diabetic women with microalbuminuria and normoalbuminuria. Although less severe than in previous studies, diabetic nephropathy was associated with more adverse pregnancy outcome.
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Affiliation(s)
- Lene Ringholm Nielsen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Faculty of Health Sciences, Copenhagen, Denmark.
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Jorsal A, Tarnow L, Flyvbjerg A, Parving HH, Rossing P, Rasmussen LM. Plasma osteoprotegerin levels predict cardiovascular and all-cause mortality and deterioration of kidney function in type 1 diabetic patients with nephropathy. Diabetologia 2008; 51:2100-7. [PMID: 18719882 DOI: 10.1007/s00125-008-1123-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2008] [Accepted: 07/16/2008] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS The bone-related peptide osteoprotegerin is produced by vascular cells and is involved in the process of vascular calcification. The aim of this study was to investigate the predictive value of plasma levels of osteoprotegerin in relation to mortality, cardiovascular events and deterioration in kidney function in patients with type 1 diabetes. METHODS This prospective observational follow-up study included 397 type 1 diabetic patients with overt diabetic nephropathy (243 men; age [mean+/-SD] 42.1 +/- 10.6 years, duration of diabetes 28.3 +/- 9.9 years, GFR 67 +/- 28 ml min(-1) 1.73 m(2)) and a group of 176 patients with longstanding type 1 diabetes and persistent normoalbuminuria (105 men; age 42.6 +/- 9.7 years, duration of diabetes 27.6 +/- 8.3 years). RESULTS The median (range) follow-up period was 11.3 (0.0-12.9) years. Among patients with diabetic nephropathy, individuals with high osteoprotegerin levels (fourth quartile) had significantly higher all-cause mortality than patients with low levels (first quartile) (covariate-adjusted hazard ratio [HR] 3.00 [1.24-7.27]). High osteoprotegerin levels also predicted cardiovascular mortality (covariate-adjusted HR 4.88 [1.57-15.14]). Furthermore, patients with high osteoprotegerin levels had significantly higher risk of progression to end-stage renal disease than patients with low levels (covariate-adjusted HR 4.32 [1.45-12.87]). In addition, patients with high levels of plasma osteoprotegerin had an elevated rate of decline in GFR. CONCLUSIONS/INTERPRETATION High levels of osteoprotegerin predict all-cause and cardiovascular mortality in patients with diabetic nephropathy. Furthermore, high levels of osteoprotegerin predict deterioration of kidney function towards end-stage renal disease.
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Affiliation(s)
- A Jorsal
- Steno Diabetes Center, Niels Steensens Vej 2, 2820, Gentofte, Denmark.
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Ekbom P, Damm P, Feldt-Rasmussen B, Feldt-Rasmussen U, Jensen DM, Mathiesen ER. Elevated third-trimester haemoglobin A 1c predicts preterm delivery in type 1 diabetes. J Diabetes Complications 2008; 22:297-302. [PMID: 18413167 DOI: 10.1016/j.jdiacomp.2007.03.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Revised: 03/07/2007] [Accepted: 03/26/2007] [Indexed: 10/22/2022]
Abstract
The prevalence of preterm delivery is considerably elevated in women with type 1 diabetes. The aim of the study was to evaluate haemoglobin A(1c) (HbA(1c)) as a predictor of preterm delivery. Two hundred thirteen consecutive pregnant women with type 1 diabetes and normal urinary albumin excretion were included prospectively. HbA(1c) was analyzed at 10, 20 and 28 weeks of gestation. Seventy-one women (33%) delivered pre term and 142 at term. At 10 weeks of gestation, HbA(1c) was 7.3% (S.D. 1.0) vs. 6.9% (S.D. 0.9) (P<.01), at 20 weeks of gestation 6.6% (S.D. 0.7) vs. 6.1% (S.D. 0.7) (P<.001) and at 28 weeks of gestation 6.7% (S.D. 0.8) vs. 6.1% (S.D. 0.7) (P<.001). When comparing HbA(1c) at 10, 20 and 28 weeks of gestation, HbA(1c) at 28 weeks of gestation (P<.001) was the best predictor of preterm delivery. The adjusted odds ratio per 1% increment in HbA(1c) at 28 weeks of gestation was 2.8 (95% CI 1.7-4.4). HbA(1c) at 28 weeks of gestation was a clinical significant predictor of preterm delivery in type 1 diabetes.
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Affiliation(s)
- Pia Ekbom
- Endocrine Clinic, The National University Hospital, Rigshospitalet, Copenhagen, Denmark
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Jorsal A, Tarnow L, Lajer M, Ek J, Hansen T, Pedersen O, Parving HH. The PPAR gamma 2 Pro12Ala variant predicts ESRD and mortality in patients with type 1 diabetes and diabetic nephropathy. Mol Genet Metab 2008; 94:347-51. [PMID: 18467141 DOI: 10.1016/j.ymgme.2008.03.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 03/25/2008] [Accepted: 03/25/2008] [Indexed: 11/28/2022]
Abstract
UNLABELLED The Pro12Ala polymorphism in the peroxisome proliferator-activated receptor-gamma 2 gene is suggested to associate with diabetic nephropathy and cardiovascular disease in type 2 diabetes. The aim of this study was to investigate the polymorphism in relation to diabetic nephropathy, end-stage renal disease (ESRD), mortality and cardiovascular (CVD) events in type 1 diabetic patients. This prospective observational follow-up study included 415 type 1 diabetic patients with overt diabetic nephropathy (252 men; age 42.2+/-10.4 years [mean+/-SD], duration of diabetes 28.3+/-8.8 years, GFR 66+/-8.8 ml/min) and 428 patients with longstanding type 1 diabetes and persistent normoalbuminuria (230 men; age 45.4+/-11.6 years, duration of diabetes 27.8+/-10.1 years). FOLLOW-UP 8.1 (0.0-12.8) years (median [range]). There where no significant differences between cases and controls in genotype (p=0.51) or allele frequencies (p=0.25). Cox regression analysis revealed a covariate-adjusted hazard ratio (HR) for all-cause mortality in patients with the Ala/Ala genotype of 2.44 (1.23-4.84). The Pro12Ala polymorphism did not predict CVD events. However, the Ala/Ala genotype predicts ESRD (covariate-adjusted HR 2.60 (1.11-6.07)). Furthermore, Carriers of the Ala-allele had a higher rate of decline in GFR (p=0.040). In conclusion, the Pro12Ala polymorphism is not associated with type 1 diabetic nephropathy. The Ala-allele is associated with enhanced decline in GFR and predicts ESRD and all-cause mortality in patients with nephropathy.
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Affiliation(s)
- A Jorsal
- Steno Diabetes Center, Niels Steensens Vej 2, 2820 Gentofte, Denmark.
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Predictors of mortality in patients with type 2 diabetes with or without diabetic nephropathy: a follow-up study. J Hypertens 2008; 25:2479-85. [PMID: 17984670 DOI: 10.1097/hjh.0b013e3282f06428] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the prognostic significance of cardiovascular risk factors including 24-h ambulatory blood pressure level and rhythm for all-cause mortality in type 2 diabetic patients. METHODS In a prospective observational study, 104 patients with type 2 diabetes were followed: 51 patients with diabetic nephropathy and 53 patients with persistent normoalbuminuria. At baseline, 24-h ambulatory blood pressure, left ventricular hypertrophy, glomerular filtration rate and cardiac autonomic neuropathy were measured. Blood samples were taken and patients answered a World Health Organization questionnaire. Dipping was calculated as the average nocturnal reduction in systolic and diastolic blood pressure. RESULTS Mean follow-up was 9.2 years (range 0.5-12.9). During follow-up, 54 of 104 patients died. Sixteen patients (15%) had higher blood pressure at night than during the day (reversed pattern); 14 of these patients died (88%), compared to 40 of 88 patients (45%) with reduced dipping or normal dipping; log rank P = 0.001. In a Cox regression analysis, predictors of all-cause mortality were: age, male sex, presence of left ventricular hypertrophy, glycated haemoglobin A1c (HbA1c), daytime systolic blood pressure, cardiac autonomic neuropathy, glomerular filtration rate and dipping (1% increase; hazard ratio 0.97, 95% confidence interval 0.94-0.998, P = 0.033). CONCLUSION Type 2 diabetes patients with non-dipping of night blood pressure were at higher risk of death as compared to dippers, independent of known cardiovascular risk factors. Since non-dipping has a high prevalence in patients with diabetic nephropathy, 24-h ambulatory blood pressure should be used to assess a full risk profile and blood pressure-lowering therapy in these patients.
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Astrup AS, Tarnow L, Christiansen M, Hansen PR, Parving HH, Rossing P. Pregnancy-associated plasma protein A in a large cohort of Type 1 diabetic patients with and without diabetic nephropathy-a prospective follow--up study. Diabet Med 2007; 24:1381-5. [PMID: 17971180 DOI: 10.1111/j.1464-5491.2007.02283.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM Pregnancy-associated plasma protein A (PAPP-A) has been implicated in the aetiology of acute coronary syndromes and carotid and peripheral artherosclerosis. Diabetic nephropathy is characterized by increased cardiovascular risk. We investigated the prognostic value of PAPP-A in a large cohort of Type 1 diabetic patients. METHODS In a prospective observational follow-up study, 197 Type 1 diabetic patients with diabetic nephropathy and a matched group of 178 patients with normoalbuminuria were followed for 10.1 (0-10.3) years. PAPP-A was determined at baseline. RESULTS In patients with diabetic nephropathy, plasma PAPP-A was elevated 3.6 (0.4-51.1) mIU/l [median (range)] vs. 2.1 (0.4-46.6) mIU/l in normoalbuminuric patients, P < 0.0001. For acute coronary syndromes, a PAPP-A threshold of 10 mIU/l has been suggested. Thirty-seven patients were above the threshold and of these 13 patients (35%) died, compared with 60 of 338 patients (18%) below the threshold; log rank test P = 0.007. PAPP-A significantly predicted mortality after adjustment for presence of nephropathy; hazard ratio for dying when PAPP-A was above the threshold 2.1 (95% CI 1.13-3.9); P = 0.019. After adjusting for traditional risk factors, the results were attenuated. When only patients with nephropathy were analysed, PAPP-A was significantly predictive of all-cause mortality [P = 0.008; 2.43 (1.26-4.67)] in unadjusted analysis. After adjustment, the predictive value of PAPP-A for all-cause mortality was attenuated (P = 0.064). CONCLUSION We find PAPP-A to be associated with increased mortality in Type 1 diabetic patients with nephropathy in unadjusted analysis. After adjustment for traditional risk factors, the prognostic value of PAPP-A was no longer significant.
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Affiliation(s)
- A S Astrup
- Steno Diabetes Center, Gentofte, Denmark.
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Klausen KP, Parving HH, Scharling H, Jensen JS. The association between metabolic syndrome, microalbuminuria and impaired renal function in the general population: impact on cardiovascular disease and mortality. J Intern Med 2007; 262:470-8. [PMID: 17875184 DOI: 10.1111/j.1365-2796.2007.01839.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Microalbuminuria and metabolic syndrome are both associated with cardiovascular disease (CVD). The aim of this study was to determine the potential association between numbers of components in the metabolic syndrome, different levels of microalbuminuria and renal function. We also aimed to determine the risk of death and CVD at different levels of microalbuminuria and renal function and numbers of components in the metabolic syndrome. DESIGN Population-based observational follow-up study. SETTING Epidemiological research unit (Copenhagen City Heart Study). SUBJECTS A total of 2,696 men and women, 30-70 years of age. BASELINE MEASURES: Urinary albumin excretion (UAE), creatinine clearance and metabolic risk factors were measured in 1992-1994. MAIN OUTCOME MEASUREMENTS The participants were followed prospectively by registers until 1999-2000 with respect to CVD, and until 2004 with respect to death. RESULTS We found a strong association between microalbuminuria and the metabolic syndrome: 2% with none and 18% with five metabolic risk factors had microalbuminuria (P < 0.001). No association between impaired renal function defined as creatinine clearance <60 mL min(-1) and the metabolic syndrome was found. Microalbuminuria was associated with increased risk of death and CVD to a similar extend as the metabolic syndrome, irrespective of concomitant presence of metabolic syndrome (RR approximately 2; P < 0.001). Impaired renal function was not associated with increased risk of death and CVD in subjects with the metabolic syndrome. CONCLUSIONS Microalbuminuria (UAE >5 microg min(-1)) confers increased risk of death and CVD to a similar extent as the metabolic syndrome.
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Affiliation(s)
- K P Klausen
- Copenhagen City Heart Study, Epidemiological Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark.
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Clausen P, Ekbom P, Damm P, Feldt-Rasmussen U, Nielsen B, Mathiesen ER, Feldt-Rasmussen B. Signs of maternal vascular dysfunction precede preeclampsia in women with type 1 diabetes. J Diabetes Complications 2007; 21:288-93. [PMID: 17825752 DOI: 10.1016/j.jdiacomp.2006.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2005] [Revised: 03/17/2006] [Accepted: 03/21/2006] [Indexed: 10/22/2022]
Abstract
AIM This study aims to test the hypothesis that vascular dysfunction is present early in pregnancy in women with type 1 diabetes who subsequently develop preeclampsia. METHODS Eighty-three women with type 1 diabetes of more than 10 years duration were followed up prospectively during pregnancy. External ultrasound was used to measure the dilatory response of the brachial artery to postischemic increased blood flow (endothelium-dependent, flow-associated dilatation) and to nitroglycerin (NTG) [endothelium-independent, NTG-induced dilatation (NID)] at Gestational Weeks 11 and 29. Plasma concentrations of the vascular markers vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), E-selectin, and von Willebrand factor antigen were also measured together with 24-h urinary albumin excretion (UAE), blood pressure (BP), and HbA(1C). RESULTS Fourteen (17%) of the 83 women developed preeclampsia. NID was significantly impaired at Week 29 in women prone to preeclampsia (108.8+/-7.0% vs. 116.8+/-8.9%, mean+/-S.D., P<.05), and the plasma concentrations of VCAM-1 and ICAM-1 were significantly elevated at Gestational Week 11 (612+/-82 vs. 516+/-109 microg/l, P<.005 and 293+/-67 vs. 255+/-57 microg/l, P<.05, respectively). Women who later developed preeclampsia were also characterized by higher UAE, higher BP, and higher HbA(1C) than women who did not [Gestational Week 11: 194 (3-1104) vs. 7 (0-412) mg/24 h, median (range), P=.0003; 122+/-12/75+/-6 vs. 111+/-11/69+/-9 mmHg, mean+/-S.D., P<.01; and 8.2% (5.9-10.5%) vs. 7.2% (5.3-10.9%), P=.008, respectively]. CONCLUSION This prospective study indicates that signs of maternal vascular dysfunction precede development of preeclampsia in women with type 1 diabetes.
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Affiliation(s)
- Peter Clausen
- Department of Nephrology and Endocrinology, Copenhagen University Hospital, Rigshospitalet, DK-2100, Copenhagen, Denmark.
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Spijkerman AMW, Gall MA, Tarnow L, Twisk JWR, Lauritzen E, Lund-Andersen H, Emeis J, Parving HH, Stehouwer CDA. Endothelial dysfunction and low-grade inflammation and the progression of retinopathy in Type 2 diabetes. Diabet Med 2007; 24:969-76. [PMID: 17593241 DOI: 10.1111/j.1464-5491.2007.02217.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To study whether microalbuminuria, endothelial dysfunction and low-grade inflammation are associated with the presence and progression of diabetic retinopathy. METHODS Patients with Type 2 diabetes (n = 328) attending a diabetes clinic were followed for 10 years and examined annually during the last 7 years. Retinopathy was assessed after pupillary dilatation by direct ophthalmoscopy (baseline) and two-field 60 degrees fundus photography (follow-up). Urinary albumin excretion, and markers of endothelial function (von Willebrand factor, tissue-type plasminogen activator, soluble E-selectin (sE-selectin), and soluble vascular cell adhesion molecule 1) and inflammatory activity (C-reactive protein and fibrinogen) were determined. RESULTS The prevalence of retinopathy was 33.8%. The median diabetes duration at baseline was 7 years (interquartile range 2-12 years). The highest tertiles of baseline urinary albumin excretion and glycated haemoglobin (HbA(1c)) were associated with prevalent retinopathy: odds ratio (OR) 95% confidence interval (CI) 2.80 (1.44-5.46) and 2.19 (1.11-4.32), respectively. Progression of retinopathy occurred in 188 patients. The second and third tertiles of baseline sE-selectin were associated with progression of retinopathy [1.44 (1.04-2.01) and 1.61 (1.19-2.18)] but not independently of HbA(1c). None of the other markers was significantly associated with the presence or progression of retinopathy. High baseline HbA(1c) was significantly associated with progression of retinopathy: 1.65 (1.21-2.25). CONCLUSIONS In this population of patients with Type 2 diabetes who attended a diabetes clinic, there was some evidence for a role of endothelial dysfunction in the progression of retinopathy. We could not demonstrate a role for low-grade inflammation. Our study emphasizes the importance of glycaemic control in the development and progression of retinopathy.
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Affiliation(s)
- A M W Spijkerman
- Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Hovind P, Lamberts S, Hop W, Deinum J, Tarnow L, Parving HH, Janssen JAMJL. An IGF-I gene polymorphism modifies the risk of developing persistent microalbuminuria in type 1 diabetes. Eur J Endocrinol 2007; 156:83-90. [PMID: 17218729 DOI: 10.1530/eje.1.02308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Derangements of the GH-IGF-I axis have been associated with microalbuminuria (MA) in type 1 diabetes. The aim of this study was to investigate whether an IGF-I gene promoter polymorphism influenced the development of persistent MA in type 1 diabetes. DESIGN A prospective follow-up study of a cohort of 277 patients with newly diagnosed type 1 diabetes consecutively enrolled between September 1979 and August 1984. METHODS Urinary albumin excretion rate over 24 h was measured in each patient at least once a year. Persistent MA was defined as a urinary albumin excretion rate between 30 and 300 mg/24 h. RESULTS During a median follow-up of 18.0 years (range 1.0-21.5), 79 of 277 patients developed persistent MA. IGF-I gene genotype was available for 216 subjects; in 73% of the subjects, the wild-type genotype of this IGF-I gene polymorphism was present, while 27% had the variant type. At baseline, there were no differences in IGF-I levels and HbA(1c) values between subjects with the wild type and subjects with variant type. By Kaplan-Meier analysis, subjects with the variant type of this polymorphism had during follow-up a higher risk of development of MA compared subjects with the wild type (P = 0.03). CONCLUSIONS Subjects with the variant type of an IGF-I gene polymorphism had a significantly increased risk of developing MA. This risk was not mediated through changes in circulating IGF-I levels. Our study suggests that in type 1 diabetes, this IGF-I gene polymorphism is a risk factor of MA.
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Kim WY, Astrup AS, Stuber M, Tarnow L, Falk E, Botnar RM, Simonsen C, Pietraszek L, Hansen PR, Manning WJ, Andersen NT, Parving HH. Subclinical coronary and aortic atherosclerosis detected by magnetic resonance imaging in type 1 diabetes with and without diabetic nephropathy. Circulation 2006; 115:228-35. [PMID: 17190865 DOI: 10.1161/circulationaha.106.633339] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with type 1 diabetes and nephropathy maintain an excess cardiovascular mortality compared with diabetic patients with normoalbuminuria. We sought to evaluate coronary and aortic atherosclerosis in a cohort of asymptomatic type 1 diabetic patients with and without diabetic nephropathy using cardiovascular magnetic resonance imaging. METHODS AND RESULTS In a cross-sectional study, 136 subjects with long-standing type 1 diabetes without symptoms or history of cardiovascular disease, including 63 patients (46%) with nephropathy and 73 patients with normoalbuminuria, underwent cardiovascular magnetic resonance imaging. All subjects underwent cardiac exercise testing and noninvasive tests for peripheral artery disease and autonomic neuropathy. Coronary artery stenoses were identified in 10% of subjects with nephropathy (versus 0% with normoalbuminuria; P=0.007). Coronary plaque burden, expressed as right coronary artery mean wall thickness (1.7+/-0.3 versus 1.3+/-0.2 mm; P<0.001) and maximum right coronary artery wall thickness (2.2+/-0.5 versus 1.6+/-0.3 mm; P<0.001), was greater in subjects with nephropathy. The prevalence of thoracic (3% versus 0%; P=0.28) and abdominal aortic plaque (22% versus 16%; P=0.7) was similar in both groups. Subjects with and without abdominal aortic plaques had similar coronary plaque burden. CONCLUSIONS In asymptomatic type 1 diabetes, cardiovascular magnetic resonance imaging reveals greater coronary plaque burden in subjects with nephropathy compared with those with normoalbuminuria.
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Affiliation(s)
- Won Yong Kim
- Department of Cardiology, Skejby Hospital, Brendstrupgaardsvej, 8200 Aarhus N, Denmark.
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Klausen KP, Scharling H, Jensen JS. Very low level of microalbuminuria is associated with increased risk of death in subjects with cardiovascular or cerebrovascular diseases. J Intern Med 2006; 260:231-7. [PMID: 16918820 DOI: 10.1111/j.1365-2796.2006.01679.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The original definition of microalbuminuria (20-200 microg min-1 or 15-150 microg min-1 overnight) is based on studies of patients with diabetes, in whom microalbuminuria was associated with increased risk of chronic renal failure. In a recent report an overnight urinary albumin excretion (UAE) above only 5 microg min-1 was strongly predictive of coronary heart disease and death in the general population. The aim of the present study was to investigate if this cut-off level also has prognostic value in a population with cardiovascular or cerebrovascular disease. METHODS AND RESULTS In The Third Copenhagen City Heart Study in 1992-1994, 491 men and women aged 30-80 years with a history of coronary heart disease or stroke delivered a timed overnight urine sample. They were followed by registers with respect to vital status until 2004. During follow-up, 141 of the 491 participants died. The relative risk of death in subjects with UAE above 5 microg min-1 compared with subjects with lower UAE was 2.0 (1.4-2.8; P<0.001). It was unaffected [RR 1.9 (1.3-2.7); P<0.005] by adjustment for age, sex, blood pressure, diabetes, lipoproteins, renal creatinine clearance, smoking and body mass index. CONCLUSIONS Subjects with cardiovascular or cerebrovascular disease have about 100% higher risk of death if microalbuminuria defined as UAE above 5 microg min-1 is present. Measurements of UAE should be included in the risk assessment in subjects with cardiovascular or cerebrovascular disease. This study supports the definition of microalbuminuria as UAE above 5 microg min-1.
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Affiliation(s)
- K P Klausen
- Copenhagen City Heart Study, Epidemiological Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark.
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Abstract
Several health organizations recommend that people be regularly checked for proteinuria to detect and treat kidney disease before it progresses. Proteinuria detected by a simple dipstick test should be confirmed by a quantitative measurement to assess persistent proteinuria. Most proteins are too big to pass through the kidneys' filters into the urine unless the kidneys are damaged. Markers of kidney damage in addition to proteinuria include abnormalities in the urine sediment, ultrasound of the kidneys and estimation of kidney function (creatinemia to calculate glomerular filtration rate). These assessments provide clues to the type (diagnosis) of chronic kidney disease and will the risk for developing progressive kidney failure. Thus, early detection of kidney disease will result in a more timely introduction of therapy that may slow the course of kidney disease. Microalbuminuria (albumin excretion above the normal range) that a marker of microvascular lesions in diabetes and hypertension is associated with a worth cardiovascular prognosis. Level of proteinuria in excess of 3,0 g/d in glomerular disease strongly determines the extent of kidney damage and renal prognosis.
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Affiliation(s)
- Jean-Pierre Fauvel
- Service de Néphrologie et Hypertension Artérielle, Hôpital Edouard-Herriot, Pavillon P, Lyon et EA 645 Université Claude-Bernard-Lyon-I, 69437 Lyon cedex 03, France.
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Justesen TI, Petersen JLA, Ekbom P, Damm P, Mathiesen ER. Albumin-to-creatinine ratio in random urine samples might replace 24-h urine collections in screening for micro- and macroalbuminuria in pregnant woman with type 1 diabetes. Diabetes Care 2006; 29:924-5. [PMID: 16567839 DOI: 10.2337/diacare.29.04.06.dc06-1555] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Thomas I Justesen
- Department of Endocrinology, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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Nielsen LR, Müller C, Damm P, Mathiesen ER. Reduced prevalence of early preterm delivery in women with Type 1 diabetes and microalbuminuria--possible effect of early antihypertensive treatment during pregnancy. Diabet Med 2006; 23:426-31. [PMID: 16620272 DOI: 10.1111/j.1464-5491.2006.01831.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS In normotensive women with Type 1 diabetes and microalbuminuria we previously found preterm delivery (< 34 weeks) in 23% of the pregnancies. Antihypertensive treatment was initiated in late pregnancy when preeclampsia was diagnosed and diastolic blood pressure > 90 mmHg. From April 2000 our routine was changed and early antihypertensive treatment with methyldopa was initiated if antihypertensive treatment was given prior to pregnancy, if urinary albumin excretion (UAE) was > 2 g/24 h, or blood pressure > 140/90 mmHg. The present study describes the impact of this more aggressive antiypertensive treatment in the prevalence of preterm delivery. METHODS The old cohort (1995-1999) consisted of 26 and the new cohort (2000-2003) of 20 pregnant women with Type 1 diabetes and microalbuminuria. All were referred before gestational week 17. RESULTS The cohorts were comparable with regard to age, diabetes duration, prepregnancy body mass index, HbA1c, blood pressure 121 (13)/71 (8) vs. 121 (14)/73 (8) mmHg [mean (sd)] and early UAE 69 (16-278) vs. 74 (30-287) mg/24 h (geometric mean and range). Antihypertensive treatment was initiated in the old cohort at 29 (20-33) weeks, n = 9, and in the new at 13 (0-34) weeks, n = 10. The prevalence of preterm delivery before 34 weeks was reduced from 23% to zero (P = 0.02), preterm delivery before 37 weeks from 62% to 40% (P = 0.15) and preeclampsia from 42% to 20% (P = 0.11). Perinatal mortality occurred in 4% vs. 0%. Birth weight was 3124 (767) g vs. 3279 (663) g. CONCLUSION Introduction of early antihypertensive treatment with methyldopa in normotensive pregnant women with Type 1 diabetes and microalbuminuria resulted in a significant reduction in preterm delivery before gestational week 34.
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Affiliation(s)
- L R Nielsen
- Clinic of Endocrinology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark.
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Fuiano G, Mancuso D, Indolfi C, Mongiardo A, Sabbatini M, Conte G, De Nicola L, Minutolo R, Mazza G, Cianfrone P, Andreucci M. Early detection of progressive renal dysfunction in patients with coronary artery disease. Kidney Int 2006; 68:2773-80. [PMID: 16316352 DOI: 10.1111/j.1523-1755.2005.00748.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND An association between renal hemodynamic dysfunction and coronary artery disease (CAD) has been documented in chronic renal failure; however, no information is available in CAD patients with normal glomerular filtration rate (GFR). This study was aimed at evaluating early abnormalities and outcome of renal function in CAD patients. METHODS In 15 nondiabetic patients with normal renal function and no significant stenoses in renal arteries, and having undergone coronary arteriography, we studied systemic and renal hemodynamics before and after a vasodilating stimulus induced by aminoacid (AA) infusion. A control group (C) consisted of 15 sex- and age-matched kidney donors. The statistical adequacy of the sample size was preliminarily verified. Renal clearances were repeated after two years. RESULTS At baseline, GFR (mL/min/1.73 m2) averaged 81.4 +/- 3.8 in CAD and 83.7 +/- 1.4 in C (P= NS); RPF (mL/min/1.73 m2) was 297 +/- 22 in CAD and 456 +/- 15 in C (P < 0.0001); filtration fraction was higher in CAD (P < 0.001). Plasma renin activity was higher in CAD (P < 0.005). The number of coronary stenoses was inversely correlated with RPF but not with GFR. In CAD, at variance with C, AA did not induce any increment of GFR, while RPF increased without achieving the unstimulated value of C. Blood pressure was comparable in CAD and C at baseline and not modified by AA. After two years, a significant decrease in GFR (-14%, P < 0.001) and RPF (-15%, P < 0.001) occurred only in CAD, and in either group, the response to AA did not differ from that detected at baseline. CONCLUSION In CAD patients with normal GFR, reduction in renal perfusion and absence of renal functional reserve likely represent early markers of progressive renal dysfunction.
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Affiliation(s)
- Giorgio Fuiano
- Departments of Nephrology, and Cardiology, University Magna Graecia of Catanzaro, Italy.
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Astrup AS, Tarnow L, Rossing P, Hansen BV, Hilsted J, Parving HH. Cardiac autonomic neuropathy predicts cardiovascular morbidity and mortality in type 1 diabetic patients with diabetic nephropathy. Diabetes Care 2006; 29:334-9. [PMID: 16443883 DOI: 10.2337/diacare.29.02.06.dc05-1242] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Cardiac autonomic neuropathy (CAN) has been associated with a poor prognosis in patients with diabetes. Because CAN is common in patients with diabetic nephropathy, we evaluated the predictive value of CAN in type 1 diabetic patients with and without diabetic nephropathy. RESEARCH DESIGN AND METHODS In a prospective observational follow-up study, 197 type 1 diabetic patients with diabetic nephropathy and a matched group of 191 patients with long-standing type 1 diabetes and normoalbuminuria were followed for 10.1 years (range 0.0-10.3 years). At baseline, CAN was assessed by heart rate variation (HRV) during deep breathing. HRV was evaluated as a predictor of the primary end point: cardiovascular morbidity and mortality. As secondary end points, all-cause mortality and the influence of HRV on progression of diabetic nephropathy (decline in glomerular filtration rate [GFR]) was evaluated. RESULTS During the follow-up, 79 patients (40%) with nephropathy reached the combined primary end point vs. 19 patients (10%) with normoalbuminuria (log-rank test, P < 0.0001). The unadjusted hazard ratio (HR) for reaching the primary end point when having an abnormal HRV (< or =10 bpm) measured at baseline compared with a normal HRV was 7.7 (range 1.9-31.5; P = 0.004) in patients with nephropathy. Similarly in the normoalbuminuric patients, the unadjusted HR was 4.4 (1.4-13.6; P = 0.009). In patients with nephropathy, abnormal HRV was significantly associated with fatal and nonfatal cardiovascular disease after adjustment for cardiovascular risk factors. The adjusted HR for reaching the primary end point in a patient with nephropathy and an abnormal HRV was 6.4 (1.5-26.3, P = 0.010), as compared with a normal HRV. The unadjusted HR for dying when having an abnormal HRV compared with a normal HRV was 3.3 (95% CI 1.0-10.7; P = 0.043) in patients with diabetic nephropathy. After adjustment for confounding factors, the impact of HRV on all-cause mortality in patients with nephropathy was no longer significant (P = 0.293). There was no relationship between abnormal HRV and rate of decline in GFR. CONCLUSIONS HRV is an independent risk factor for cardiovascular morbidity and mortality in type 1 diabetic patients with nephropathy.
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Affiliation(s)
- Anne Sofie Astrup
- Steno Diabetes Center, Niels Steensensvej 2, 2820 Gentofte, Denmark.
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Astrup AS, Tarnow L, Rossing P, Pietraszek L, Riis Hansen P, Parving HH. Improved prognosis in type 1 diabetic patients with nephropathy: a prospective follow-up study. Kidney Int 2006; 68:1250-7. [PMID: 16105058 DOI: 10.1111/j.1523-1755.2005.00521.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND In early studies, a median survival time of 5 to 7 years from onset of diabetic nephropathy was observed. Furthermore, end-stage renal disease (ESRD) was the main cause of death. We prospectively assessed the impact of reno- and cardiovascular protective treatment on prognosis in type 1 diabetic patients with diabetic nephropathy. METHODS We prospectively followed 199 type 1 diabetic patients with diabetic nephropathy and 192 patients with normoalbuminuria for 10 years. Aggressive antihypertensive treatment was initiated in patients with diabetic nephropathy in mid 1980s, whereas statins and aspirin were not prescribed routinely until April 2002. The primary end point was cardiovascular mortality and morbidity. Secondary end points were all-cause mortality and ESRD. RESULTS During follow-up, 79 patients (40%) with nephropathy reached the primary end point versus 19 (10%) of normoalbuminuric patients, log rank test P < 0.0001. Predictors of the primary end point were: nephropathy (hazard ratio 3.26; 95% confidence interval 1.89 to 5.62), previous event (3.19; 2.04 to 4.97), age (1.27; 1.04 to 1.55), and systolic blood pressure (1.13; 1.03 to 1.24). In the nephropathy group, 60 patients (30%) died; hereof, 25 deaths (42%) were ascribed to cardiovascular causes while 30 patients (50%) with nephropathy died with ESRD. The estimate of median survival time from onset of diabetic nephropathy was 21.7 years, SE 3.3 years. CONCLUSION The survival of patients with diabetic nephropathy has improved most likely due to aggressive antihypertensive treatment and improved glycaemic control.
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Rasmussen LM, Tarnow L, Hansen TK, Parving HH, Flyvbjerg A. Plasma osteoprotegerin levels are associated with glycaemic status, systolic blood pressure, kidney function and cardiovascular morbidity in type 1 diabetic patients. Eur J Endocrinol 2006; 154:75-81. [PMID: 16381994 DOI: 10.1530/eje.1.02049] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The bone-related peptide osteoprotegerin (OPG) has recently been found in increased amounts in the vasculature in diabetes. It is produced by vascular smooth muscle and endothelial cells, and may be implicated in the development of vascular calcifications. OPG is present in the circulation, where increased amounts have been observed in patients with diabetes. In this study, we examined whether plasma OPG is associated with the glycaemic and vascular status of patients with type 1 diabetes. METHODS Two gender-, age- and duration-comparable groups of type 1 diabetic patients either with (n = 199) or without (n = 192) signs of diabetic nephropathy were studied. Plasma OPG was determined by an ELISA. RESULTS The plasma OPG concentration was significantly higher in patients with nephropathy than those without (3.11 (2.49-3.99) vs 2.57 (2.19-3.21) (median (interquartiles), ng/ml), P < 0.001). Plasma OPG correlated with haemoglobin A1c (HbA1c), systolic blood pressure and age in both groups and, in addition, with kidney function in the nephropathic group. These correlations remained significant in multivariate models. In addition, we found that plasma OPG concentrations were increased among patients with cardiovascular diseases (CVD), both in the normoalbuminuric and the nephropathic groups. The differences between nephropathic and normoalbuminuric, as well as subgroups with and without CVD, could largely be ascribed to changes in HbA1c, age, systolic blood pressure and creatinine. CONCLUSION OPG is associated with glycaemic control and CVD in patients with type 1 diabetes, compatible with the hypothesis that OPG is associated with the development of diabetic vascular complications.
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Affiliation(s)
- Lars Melholt Rasmussen
- Department of Clinical Biochemistry, University Hospital of Aarhus, Aarhus Amtssygehus, T. Hansengade 2, DK-8000 Aarhus C, Denmark.
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41
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Lekatsas I, Koulouris S, Triantafyllou K, Chrisanthopoulou G, Moutsatsou-Ladikou P, Ioannidis G, Thalassinos N, Kalofoutis A, Anthopoulos L. Prognostic significance of microalbuminuria in non-diabetic patients with acute myocardial infarction. Int J Cardiol 2006; 106:218-23. [PMID: 16321695 DOI: 10.1016/j.ijcard.2005.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2004] [Revised: 02/05/2005] [Accepted: 02/06/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study was to examine whether the presence of microalbuminuria (20-200 microg/min) can predict in-hospital morbidity and mortality in non-diabetic patients with acute myocardial infarction. METHODS Two hundred twenty-three (172 men and 51 women) non-diabetic patients with acute myocardial infarction were studied prospectively. The main outcome measures of the study were based on a comparison of in-hospital mortality and major non-fatal in-hospital events (pulmonary edema, post-infarction angina, infarct extension, mechanical complications, conduction disturbances and ventricular arrhythmias) between microalbuminuric and normoalbuminuric patients. RESULTS A significant proportion of patients (33.6%) had microalbuminuria. Seventy-six patients (34%) developed an in-hospital event (fatal or non-fatal). Six patients (2.7%) with acute myocardial infarction died in the hospital. Patients with microalbuminuria had a higher mortality rate in comparison with normoalbuminuric patients (6.6% vs. 0.68%, p = 0.01). For non-fatal events, the incidence of pulmonary edema and ventricular arrhythmias was significantly higher in patients with microalbuminuria (14.6% vs. 3.4%, p < 0.001 and 12% vs. 3.4%, p = 0.01, respectively). The combined end-point of the total number of fatal and non-fatal events was significantly higher in patients with microalbuminuria (57.3% vs. 22.3%, p < 0.001). In multiple logistic regression analysis, microalbuminuria (p < 0.001) and ejection fraction (p = 0.01) were independently related to the occurrence of major in-hospital events. CONCLUSIONS Microalbuminuria is a significant predictor of in-hospital morbidity and mortality in non-diabetic patients with acute myocardial infarction.
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Affiliation(s)
- Ioannis Lekatsas
- 1st Department of Cardiology, Evagelismos Hospital, Athens, Greece
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42
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Sato A, Tarnow L, Nielsen FS, Knudsen E, Parving HH. Left ventricular hypertrophy in normoalbuminuric type 2 diabetic patients not taking antihypertensive treatment. QJM 2005; 98:879-84. [PMID: 16272208 DOI: 10.1093/qjmed/hci137] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) is an independent risk factor for myocardial ischaemia, cardiac arrhythmia, sudden death, and heart failure, all common findings in patients with type 2 diabetes. AIM To determine the prevalence of, and risk factors for, LVH in normoalbuminuric type 2 diabetic patients not taking antihypertensive treatment. DESIGN Cross-sectional study. METHODS From 1994 to 1998, M-mode echocardiography was performed by one experienced examiner in 262 consecutive, normoalbuminuric Caucasian type 2 diabetic patients, all with blood pressure <160/95 mmHg and not taking antihypertensive medication. Mean +/- SD age was 54 +/- 10 years, 109 were women, and median known duration of diabetes was 4 (range 1-28) years. Body mass index (BMI) was 28 +/- 5 kg/m(2), and blood pressure 134 +/- 13/79 +/- 8 mmHg, all means +/- SD. Median urinary albumin excretion rate was 9 (range 2-30) mg/24 h. RESULTS The prevalence of LVH indexed to height(2.7) was 43% (95%CI 38-50%), and was similar in men and women. BMI, HbA(1c) and log urinary albumin excretion were significantly associated with left ventricular hypertrophy in a logistic regression model, whereas sex, age, known duration of diabetes and blood pressure were not. Similar results were obtained for left ventricular mass index. DISCUSSION LVH was frequent in our normoalbuminuric type 2 diabetic patients not taking antihypertensive treatment. Several potentially modifiable risk factors, such as raised BMI, poor glycaemic control and elevated urinary albumin excretion rate, were associated with LVH.
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Affiliation(s)
- A Sato
- Steno Diabetes Center, Gentofte, Denmark
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43
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Rossing K, Christensen PK, Hovind P, Parving HH. Remission of nephrotic-range albuminuria reduces risk of end-stage renal disease and improves survival in type 2 diabetic patients. Diabetologia 2005; 48:2241-7. [PMID: 16170513 DOI: 10.1007/s00125-005-1937-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2005] [Accepted: 06/16/2005] [Indexed: 10/25/2022]
Abstract
AIMS/HYPOTHESIS We evaluated the impact of remission of nephrotic-range albuminuria (>2500 mg/24 h) (NRA) on end-stage renal disease (ESRD) and mortality in type 2 diabetic patients with nephropathy. METHODS This was a follow-up observational study involving all 79 patients (35%; 62 men, 17 women) with NRA from a cohort of type 2 diabetic patients with nephropathy that was followed for at least 3 years at the Steno Diabetes Center (n=227). Patients were followed from the onset of NRA until death or January 2005. The mean age (+/-SD) was 60+/-8 years and known diabetes duration was 14+/-7 years. Remission of NRA was defined as sustained albuminuria <600 mg/24 h for at least 1 year. RESULTS The duration of follow-up after onset of NRA was 6.5 years (range 2-20 years). Remission was induced in 20 (25%) of the patients, all treated with ACE inhibitors or angiotensin-II receptor blockers. Remission lasted 4.1 years (range 1-10 years) and only three patients relapsed. At the end of follow-up, only 30% (two ESRD and four deaths) of the 20 patients with remission had reached the composite endpoint of ESRD or death, in contrast to 66% (16 ESRD and 23 deaths) of the 59 patients without remission (p<0.01). Cox regression analysis revealed that remission was associated with a risk reduction of 67% (95% CI 10-87) for reaching the composite endpoint of ESRD or death and of 69% (95% CI 21-88%) for death alone. Male sex, greater age and systolic blood pressure at onset of NRA were also independently associated with an increased risk of ESRD and death. CONCLUSIONS/INTERPRETATION Aggressive antihypertensive treatment can lead to long-term remission of NRA in a sizeable proportion of patients with type 2 diabetes. Such remission is associated with a slower progression of nephropathy and substantially improved survival.
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Affiliation(s)
- K Rossing
- Steno Diabetes Center, Gentofte, Denmark.
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44
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Inukai T, Yamamoto R, Suetsugu M, Matsumoto S, Wakabayashi S, Inukai Y, Matsutomo R, Takebayashi K, Aso Y. Small low-density lipoprotein and small low-density lipoprotein/total low-density lipoprotein are closely associated with intima-media thickness of the carotid artery in Type 2 diabetic patients. J Diabetes Complications 2005; 19:269-75. [PMID: 16112502 DOI: 10.1016/j.jdiacomp.2005.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Revised: 02/23/2005] [Accepted: 03/08/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND The intima-media thickness (IMT) of the carotid artery, as determined by ultrasonography, is useful for reflecting the extent of subclinical atherosclerosis. We investigated the relationship between IMT and the serum concentrations of small low-density lipoprotein (LDL) in diabetic patients. METHODS The study was conducted with 27 Type 2 diabetic patients (14 males and 13 females; mean age=62.6+/-8.3 years) and 12 age-matched healthy controls. The LDL subfraction was measured using a polyacrylamide gel electrophoresis method. Vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) concentrations were measured by an enzyme immunoassay. The IMT was expressed as the maximum IMT (Max-IMT) and average IMT (Ave-IMT) of the carotid artery, measured by ultrasonography. RESULTS Both the IMT and the small LDL concentrations were significantly increased in the diabetic patients compared with the healthy participants. The IMTs were significantly correlated with small LDL concentration and small LDL/total LDL more than LDL concentrations by multivariate analysis. The IMTs were not significantly correlated with the serum VEGF or PDGF concentrations. The patients with a larger IMT had a significantly higher prevalence of hypertension or ischemic heart disease than did the patients with a normal IMT. CONCLUSIONS The increased small LDL concentrations and small LDL/total LDL, in addition to total LDL concentrations, in Type 2 diabetic patients are closely associated with increased IMT of the carotid artery.
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Affiliation(s)
- Toshihiko Inukai
- Department of Internal Medicine, Koshigaya Hospital, Dokkyo University School of Medicine, 2-1-50, Minami-Koshigaya, Koshigaya 343-8555, Japan.
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45
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Ahmed SB, Hovind P, Parving HH, Rossing P, Price DA, Laffel LM, Lansang MC, Stevanovic R, Fisher NDL, Hollenberg NK. Oral contraceptives, angiotensin-dependent renal vasoconstriction, and risk of diabetic nephropathy. Diabetes Care 2005; 28:1988-94. [PMID: 16043743 DOI: 10.2337/diacare.28.8.1988] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes, the leading cause of end-stage renal disease in the U.S., is believed to involve activation of the renin angiotensin system (RAS) as a risk factor for nephropathy. RAS activation occurs in healthy women using oral contraceptives (OCs), but the effects of OC use on the diabetic kidney are unclear. RESEARCH DESIGN AND METHODS Renal plasma flow (RPF) response to captopril, as an index of RAS activity, was investigated in 92 women (41 nondiabetic OC nonusers, 10 nondiabetic OC users, 29 diabetic OC nonusers, and 12 diabetic OC users). Based on the hemodynamic findings, we examined the impact of OC use on the development of nephropathy as a post hoc analysis in an inception cohort of 114 female patients with newly diagnosed type 1 diabetes followed for a median of 20.7 years (range 1-24). RESULTS Nondiabetic OC nonusers showed minimal RPF vasodilator response to captopril (9 +/- 10 ml x min(-1) x 1.73 m(-2), P = 0.6). In comparison, nondiabetic OC users showed a significant increase (69 +/- 35 ml x min(-1) x 1.73 m(-2), P = 0.02) (P = 0.04 vs. nondiabetic OC nonusers). Diabetic OC nonusers demonstrated the anticipated vasodilator response (58 +/- 12 ml x min(-1) x 1.73 m(-2), P < 0.0001). Diabetic OC users showed the largest responses (84 +/- 12 ml x min(-1) x 1.73 m(-2), P = 0.002) (P = 0.04 vs. diabetic OC nonusers). Plasma renin activity did not vary with OC use (P = 0.3). The RPF responses to captopril and angiotensin receptor blocker were highly correlated (r = 0.72, P < 0.001), suggesting clear involvement of the RAS. In the observational study, 18% (6/33 [95% CI 4.3-32.1]) of OC users developed macroalbuminuria compared with 2% (2/81 [0-5.9]) of OC nonusers (P = 0.003, univariate analysis). After adjustment for known risk factors with a Cox regression model, OC use remained a predictor for the development of macroalbuminuria (relative risk 8.90 [95%CI 1.79-44.36], P = 0.008). CONCLUSIONS The strong association of OC use with angiotensin-dependent control of the renal circulation and the development of macroalbuminuria suggest that OC use may be a risk factor for diabetic nephropathy. Large prospective studies are required to further investigate this relationship.
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Affiliation(s)
- Sofia B Ahmed
- Department of Medicine, Brigham and Women's Hospital, PBB-3, 75 Francis St., Boston, MA 02115, USA.
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Jensen JS, Feldt-Rasmussen B, Borch-Johnsen K, Jensen KS, Nordestgaard BG. Increased transvascular lipoprotein transport in diabetes: association with albuminuria and systolic hypertension. J Clin Endocrinol Metab 2005; 90:4441-5. [PMID: 15899947 DOI: 10.1210/jc.2004-2420] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Diabetes is associated with a highly increased risk of atherosclerosis, especially if hypertension or albuminuria is present. OBJECTIVE We hypothesized that the increased transvascular lipoprotein transport in diabetes may be further accelerated if hypertension or albuminuria is present, possibly explaining increased intimal lipoprotein accumulation and thus atherosclerosis. DESIGN The study was cross-sectional and was performed in 1999-2002. SETTING The study took place in the referral center. PATIENTS The patients included 60 with diabetes mellitus (27 with type 1 diabetes and 33 with type 2 diabetes) and 42 healthy controls. All were randomly recruited. MAIN OUTCOME MEASURE We used an in vivo method for measurement of transvascular transport of low-density lipoprotein (LDL). Autologous 131I-LDL was reinjected iv, and the 1-h fractional escape rate was taken as an index of transvascular transport. RESULTS Transvascular LDL transport was 1.8 (1.6-2.0), 2.3 (2.0-2.6), and 2.6 (1.3-4.0)%/[h x (liter/m2)] in healthy controls, diabetic controls, and diabetes patients with systolic hypertension or albuminuria, respectively (P = 0.013; F = 4.5; df =2; ANOVA). These differences most likely were not caused by altered hepatic LDL receptor expression, glycosylation of LDL, small LDL size, or medicine use. CONCLUSIONS Transvascular LDL transport is increased in patients with diabetes mellitus, especially if systolic hypertension or albuminuria is present. Accordingly, lipoprotein flux into the arterial wall could be increased in these patients, possibly explaining accelerated development of atherosclerosis.
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Affiliation(s)
- Jan Skov Jensen
- Department of Nephrology and Endocrinology P, The National University Hospital, Copenhagen, Denmark.
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Abstract
Microalbuminuria has so far been defined as urinary albumin excretion between 20 and 200 μg/min (or 15 to 150 μg/min overnight). In a recent report, an overnight urinary albumin excretion >5 μg/min was strongly predictive of coronary heart disease and death in the general population. The aim of the present study was to confirm this observation in a population of hypertensive individuals. In The Third Copenhagen City Heart Study in 1992 to 1994, 1734 men and women aged 30 to 70 years with hypertension, but no history of coronary heat disease, delivered a timed overnight urine sample. They were followed-up prospectively by registers until 2000 with respect to coronary heart disease, and until 2004 with respect to death. During follow-up, 123 incident cases of coronary heart disease and 308 deaths were traced. Incident coronary heart disease occurred in 11% of subjects with urinary albumin excretion ≥5 μg/min compared with 5% in subjects with urinary albumin excretion <5 μg/min (
P
<0.001). Similarly, the cumulative mortality was 28% versus 13% (
P
<0.001). The relative risks of coronary heart disease and death associated with urinary albumin excretion ≥5 μg/min were 2.0 (1.4 to 2.9;
P
<0.001) and 1.9 (1.5 to 2.3;
P
<0.001), respectively, after adjustment for age, sex, blood pressure level, antihypertensive drugs, diabetes, creatinine clearance, smoking, lipoproteins, and body mass index. In conclusion, our study supports the new definition of microalbuminuria as urinary albumin excretion >5 μg/min. In future risk assessment in hypertensive individuals, measurement of microalbuminuria has to be included.
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Affiliation(s)
- Klaus Peder Klausen
- Epidemiological Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark
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Hovind P, Hansen TK, Tarnow L, Thiel S, Steffensen R, Flyvbjerg A, Parving HH. Mannose-binding lectin as a predictor of microalbuminuria in type 1 diabetes: an inception cohort study. Diabetes 2005; 54:1523-7. [PMID: 15855341 DOI: 10.2337/diabetes.54.5.1523] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Inflammation and complement activation via the mannose-binding lectin (MBL) pathway have been suggested to play a role in the pathogenesis of diabetic microvascular complications. The association between the complement-activating protein MBL and the development of persistent microalbuminuria was evaluated in an inception cohort of 286 newly diagnosed type 1 diabetic patients consecutively admitted to the Steno Diabetes Center between 1 September 1979 and 31 August 1984. Serum MBL was measured with an immunofluorometric assay in 270 of the patients (159 men) after 3 years of diabetes duration. During the median (range) follow-up period of 18.0 (1.0-21.8) years, 75 patients subsequently progressed to persistent micro- or macroalbuminuria (urinary albumin excretion rate >30 mg/24 h). In patients with MBL levels above the median (1,597 microg/l), the cumulative incidence of persistent micro- or macroalbuminuria was 41% (CI 31-50) as compared with 26% (CI 17-34) in patients with MBL levels below the median (log-rank test, P = 0.003). In a Cox proportional hazard model with sex and age as fixed covariates, MBL was independently associated with later development of persistent micro- or macroalbuminuria (hazard ratio 1.21 [CI 1.02-1.42] per 1,000 microg/l increase in MBL; P = 0.03) after adjusting for possible confounders. In our study, high levels of MBL early in the course of type 1 diabetes was significantly associated with later development of persistent micro- or macroalbuminuria, suggesting that complement activation initiated by MBL may be involved in the pathogenesis of diabetic microvascular complications.
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Affiliation(s)
- Peter Hovind
- Steno Diabetes Center, Niels Steensens Vej 2, DK-2820 Gentofte, Denmark.
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Koulouris S, Lekatsas I, Karabinos I, Ioannidis G, Katostaras T, Kranidis A, Triantafillou K, Thalassinos N, Anthopoulos L. Microalbuminuria: a strong predictor of 3-year adverse prognosis in nondiabetic patients with acute myocardial infarction. Am Heart J 2005; 149:840-5. [PMID: 15894965 DOI: 10.1016/j.ahj.2004.07.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aim of this study is to evaluate the significance of microalbuminuria (MA) as a 3-year prognostic index in nondiabetic patients with acute myocardial infarction (AMI). METHODS One hundred seventy-five patients with AMI were followed prospectively for 3 years. The study end point was cardiac death or rehospitalization for an acute coronary event. RESULTS Forty-two patients (24%) developed a new cardiac event during the follow-up. Microalbuminuria (P < .001), pulmonary edema during initial hospitalization (P < .001) and postinfarction angina (P = .0364), advanced age (P = .001), severe atherosclerosis (high Gensini score) (P = .036), ejection fraction <50% (P = .0013), history of bypass surgery (P = .0265), and early conservative management (P = .0214) were all associated with adverse prognosis. Cox proportional hazards regression analysis showed that MA was an independent predictor of 3-year adverse prognosis in all the models tested, with an adjusted relative risk for the development of a cardiac event ranging from 2.1 to 4.3. CONCLUSIONS In nondiabetic patients with AMI, MA is a strong and independent predictor of an adverse cardiac event within the next 3 years.
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Rossing K, Christensen PK, Hovind P, Tarnow L, Rossing P, Parving HH. Progression of nephropathy in type 2 diabetic patients. Kidney Int 2005; 66:1596-605. [PMID: 15458456 DOI: 10.1111/j.1523-1755.2004.00925.x] [Citation(s) in RCA: 236] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Kasper Rossing
- Department of Physiology, Steno Diabetes Center, Gentofte, Denmark.
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