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Inker LA, Tighiouart H, Adingwupu OM, Ng DK, Estrella MM, Maahs D, Yang W, Froissart M, Mauer M, Kalil R, Torres V, de Borst M, Klintmalm G, Poggio ED, Seegmiller JC, Rossing P, Furth SL, Warady BA, Schwartz GJ, Velez R, Coresh J, Levey AS. Performance of GFR Estimating Equations in Young Adults. Am J Kidney Dis 2024; 83:272-276. [PMID: 37717845 PMCID: PMC11080956 DOI: 10.1053/j.ajkd.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Lesley A Inker
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Ogechi M Adingwupu
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Derek K Ng
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Michelle M Estrella
- Department of Medicine, Division of Nephrology, San Francisco VA Health Care System and University of California, San Francisco, California
| | - David Maahs
- Division of Endocrinology, Department of Pediatrics, and Stanford Diabetes Research Center, Stanford School of Medicine, Palo Alto, California
| | - Wei Yang
- Departments of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marc Froissart
- Clinical Trial Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Michael Mauer
- Divisions of Pediatric and Adult Nephrology, University of Minnesota, Minneapolis, Minnesota
| | - Roberto Kalil
- Department of Medicine, Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vicente Torres
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Martin de Borst
- Faculty of Medical Sciences, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jesse C Seegmiller
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Peter Rossing
- Steno Diabetes Center Copenhagen and the Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susan L Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, and Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - George J Schwartz
- Department of Pediatrics, Pediatric Nephrology, University of Rochester Medical Center, Rochester, New York
| | | | - Josef Coresh
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andrew S Levey
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Limonte CP, Prince DK, Hoofnagle AN, Galecki A, Hirsch IB, Tian F, Waikar SS, Looker HC, Nelson RG, Doria A, Mauer M, Kestenbaum BR, de Boer IH. Associations of Biomarkers of Tubular Injury and Inflammation with Biopsy Features in Type 1 Diabetes. Clin J Am Soc Nephrol 2024; 19:44-55. [PMID: 37871959 PMCID: PMC10843226 DOI: 10.2215/cjn.0000000000000333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Whether biomarkers of tubular injury and inflammation indicate subclinical structural kidney pathology early in type 1 diabetes remains unknown. METHODS We investigated associations of biomarkers of tubular injury and inflammation with kidney structural features in 244 adults with type 1 diabetes from the Renin-Angiotensin System Study, a randomized, placebo-controlled trial testing effects of enalapril or losartan on changes in glomerular, tubulointerstitial, and vascular parameters from baseline to 5-year kidney biopsies. Biosamples at biopsy were assessed for kidney injury molecule 1 (KIM-1), soluble TNF receptor 1 (sTNFR1), arginine-to-citrulline ratio in plasma, and uromodulin and epidermal growth factor (EGF) in urine. We examined cross-sectional correlations between biomarkers and biopsy features and baseline biomarker associations with 5-year changes in biopsy features. RESULTS Participants' mean age was 30 years (SD 10) and diabetes duration 11 years (SD 5); 53% were women. The mean GFR measured by iohexol disappearance was 128 ml/min per 1.73 m 2 (SD 19) and median urinary albumin excretion was 5 μ g/min (interquartile range, 3-8). KIM-1 was associated with most biopsy features: higher mesangial fractional volume (0.5% [95% confidence interval (CI), 0.1 to 0.9] greater per SD KIM-1), glomerular basement membrane (GBM) width (14.2 nm [95% CI, 6.5 to 22.0] thicker), cortical interstitial fractional volume (1.1% [95% CI, 0.6 to 1.6] greater), fractional volume of cortical atrophic tubules (0.6% [95% CI, 0.2 to 0.9] greater), and arteriolar hyalinosis index (0.03 [95% CI, 0.1 to 0.05] higher). sTNFR1 was associated with higher mesangial fractional volume (0.9% [95% CI, 0.5 to 1.3] greater) and GBM width (12.5 nm [95% CI, 4.5 to 20.5] thicker) and lower GBM surface density (0.003 μ m 2 / μ m 3 [95% CI, 0.005 to 0.001] lesser). EGF and arginine-to-citrulline ratio correlated with severity of glomerular and tubulointerstitial features. Baseline sTNFR1, uromodulin, and EGF concentrations were associated with 5-year glomerular and tubulointerstitial feature progression. CONCLUSIONS Biomarkers of tubular injury and inflammation were associated with kidney structural parameters in early type 1 diabetes and may be indicators of kidney disease risk. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Renin Angiotensin System Study (RASS/B-RASS), NCT00143949. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_11_17_CJN0000000000000333.mp3.
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Affiliation(s)
- Christine P. Limonte
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - David K. Prince
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Andrew N. Hoofnagle
- Kidney Research Institute, University of Washington, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Andrzej Galecki
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Irl B. Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, Washington
| | - Frances Tian
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Sushrut S. Waikar
- Section of Nephrology, Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Helen C. Looker
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona
| | - Robert G. Nelson
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona
| | - Alessandro Doria
- Section on Genetics and Epidemiology, Research Division, Joslin Diabetes Center, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Michael Mauer
- Department of Pediatrics and Medicine, University of Minnesota, Minneapolis, Massachusetts
| | - Bryan R. Kestenbaum
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Ian H. de Boer
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
- Kidney Research Institute, University of Washington, Seattle, Washington
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Wang Y, Adingwupu OM, Shlipak MG, Doria A, Estrella MM, Froissart M, Gudnason V, Grubb A, Kalil R, Mauer M, Rossing P, Seegmiller J, Coresh J, Levey AS, Inker LA. Discordance Between Creatinine-Based and Cystatin C-Based Estimated GFR: Interpretation According to Performance Compared to Measured GFR. Kidney Med 2023; 5:100710. [PMID: 37753251 PMCID: PMC10518599 DOI: 10.1016/j.xkme.2023.100710] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Rationale & Objective Use of cystatin C in addition to creatinine to estimate glomerular filtration rate (estimated glomerular filtration rate based on cystatin C [eGFRcys] and estimated glomerular filtration rate based on creatinine [eGFRcr], respectively) is increasing. When eGFRcr and eGFRcys are discordant, it is not known which is more accurate, leading to uncertainty in clinical decision making. Study Design Cross-sectional analysis. Setting & Participants Four thousand fifty participants with measured glomerular filtration rate (mGFR) from 12 studies in North America and Europe. Exposures Serum creatinine and serum cystatin C. Outcomes Performance of creatinine-based and cystatin C-based glomerular filtration rate estimating equations compared to mGFR. Analytical Approach We evaluated the accuracy of eGFRcr, eGFRcys, and the combination (eGFRcr-cys) compared to mGFR according to the magnitude of the difference between eGFRcr and eGFRcys (eGFRdiff). We used CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equations to estimate glomerular filtration rate. eGFRdiff was defined as eGFRcys minus eGFRcr and categorized as less than -15, -15 to <15, and ≥15 mL/min/1.73 m2 (negative, concordant, and positive groups, respectively). We compared bias (median of mGFR minus eGFR) and the percentage of eGFR within 30% of mGFR. Results Thirty percent of participants had discordant eGFRdiff (21.0% and 9.6% negative and positive eGFRdiffs, respectively). In the concordant eGFRdiff group, all equations displayed similar accuracy. In the negative eGFRdiff groups, eGFRcr had a large overestimation of mGFR (-13.4 [-14.5 to -12.2] mL/min/1.73 m2) and eGFRcys had a large underestimation (9.9 [9.1-11.2] mL/min/1.73m2), with opposite results in the positive eGFRdiff group. In both negative and positive eGFRdiff groups, eGFRcr-cys was more accurate than either eGFRcr or eGFRcys. These results were largely consistent across age, sex, race, and body mass index. Limitations Few participants with major comorbid conditions. Conclusions Discordant eGFRcr and eGFRcys are common. eGFR using the combination of creatinine and cystatin C provides the most accurate estimates among persons with discordant eGFRcr or eGFRcys.
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Affiliation(s)
- Yeli Wang
- Department of Nutrition, Harvard University T.H. Chan School of Public Health, Boston, MA
| | | | - Michael G. Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affair Medical Center and University of California, San Francisco, CA
| | - Alessandro Doria
- Section on Genetics & Epidemiology, Joslin Diabetes Center, and the Department of Medicine, Harvard Medical School, Boston, MA
| | - Michelle M. Estrella
- Division of Nephrology, Department of Medicine, San Francisco VA Health Care System and University of California, San Francisco, CA
| | - Marc Froissart
- Clinical Trial Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Vilmundur Gudnason
- Faculty of Medicine, University of Iceland, Reykjavik, and the Icelandic Heart Association, Kopavogur, Iceland
| | - Anders Grubb
- Department of Clinical Chemistry and Pharmacology, Institute of Laboratory Medicine, Lund University, Sweden
| | - Roberto Kalil
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore MD
| | - Michael Mauer
- Divisions of Pediatric and Adult Nephrology, University of Minnesota, Minneapolis, MN
| | - Peter Rossing
- Steno Diabetes Center Copenhagen and the Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesse Seegmiller
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Josef Coresh
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, MD
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Do DV, Han G, Abariga SA, Sleilati G, Vedula SS, Hawkins BS. Blood pressure control for diabetic retinopathy. Cochrane Database Syst Rev 2023; 3:CD006127. [PMID: 36975019 PMCID: PMC10049880 DOI: 10.1002/14651858.cd006127.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Diabetic retinopathy is a common complication of diabetes and a leading cause of visual impairment and blindness. Research has established the importance of blood glucose control to prevent development and progression of the ocular complications of diabetes. Concurrent blood pressure control has been advocated for this purpose, but individual studies have reported varying conclusions regarding the effects of this intervention. OBJECTIVES To summarize the existing evidence regarding the effect of interventions to control blood pressure levels among diabetics on incidence and progression of diabetic retinopathy, preservation of visual acuity, adverse events, quality of life, and costs. SEARCH METHODS We searched several electronic databases, including CENTRAL, and trial registries. We last searched the electronic databases on 3 September 2021. We also reviewed the reference lists of review articles and trial reports selected for inclusion. SELECTION CRITERIA We included randomized controlled trials (RCTs) in which either type 1 or type 2 diabetic participants, with or without hypertension, were assigned randomly to more intense versus less intense blood pressure control; to blood pressure control versus usual care or no intervention on blood pressure (placebo); or to one class of antihypertensive medication versus another or placebo. DATA COLLECTION AND ANALYSIS Pairs of review authors independently reviewed the titles and abstracts of records identified by the electronic and manual searches and the full-text reports of any records identified as potentially relevant. The included trials were independently assessed for risk of bias with respect to outcomes reported in this review. MAIN RESULTS We included 29 RCTs conducted in North America, Europe, Australia, Asia, Africa, and the Middle East that had enrolled a total of 4620 type 1 and 22,565 type 2 diabetic participants (sample sizes from 16 to 4477 participants). In all 7 RCTs for normotensive type 1 diabetic participants, 8 of 12 RCTs with normotensive type 2 diabetic participants, and 5 of 10 RCTs with hypertensive type 2 diabetic participants, one group was assigned to one or more antihypertensive agents and the control group to placebo. In the remaining 4 RCTs for normotensive participants with type 2 diabetes and 5 RCTs for hypertensive type 2 diabetic participants, methods of intense blood pressure control were compared to usual care. Eight trials were sponsored entirely and 10 trials partially by pharmaceutical companies; nine studies received support from other sources; and two studies did not report funding source. Study designs, populations, interventions, lengths of follow-up (range less than one year to nine years), and blood pressure targets varied among the included trials. For primary review outcomes after five years of treatment and follow-up, one of the seven trials for type 1 diabetics reported incidence of retinopathy and one trial reported progression of retinopathy; one trial reported a combined outcome of incidence and progression (as defined by study authors). Among normotensive type 2 diabetics, four of 12 trials reported incidence of diabetic retinopathy and two trials reported progression of retinopathy; two trials reported combined incidence and progression. Among hypertensive type 2 diabetics, six of the 10 trials reported incidence of diabetic retinopathy and two trials reported progression of retinopathy; five of the 10 trials reported combined incidence and progression. The evidence supports an overall benefit of more intensive blood pressure intervention for five-year incidence of diabetic retinopathy (11 studies; 4940 participants; risk ratio (RR) 0.82, 95% confidence interval (CI) 0.73 to 0.92; I2 = 15%; moderate certainty evidence) and the combined outcome of incidence and progression (8 studies; 6212 participants; RR 0.78, 95% CI 0.68 to 0.89; I2 = 42%; low certainty evidence). The available evidence did not support a benefit regarding five-year progression of diabetic retinopathy (5 studies; 5144 participants; RR 0.94, 95% CI 0.78 to 1.12; I2 = 57%; moderate certainty evidence), incidence of proliferative diabetic retinopathy, clinically significant macular edema, or vitreous hemorrhage (9 studies; 8237 participants; RR 0.92, 95% CI 0.82 to 1.04; I2 = 31%; low certainty evidence), or loss of 3 or more lines on a visual acuity chart with a logMAR scale (2 studies; 2326 participants; RR 1.15, 95% CI 0.63 to 2.08; I2 = 90%; very low certainty evidence). Hypertensive type 2 diabetic participants realized more benefit from intense blood pressure control for three of the four outcomes concerning incidence and progression of diabetic retinopathy. The adverse event reported most often (13 of 29 trials) was death, yielding an estimated RR 0.87 (95% CI 0.76 to 1.00; 13 studies; 13,979 participants; I2 = 0%; moderate certainty evidence). Hypotension was reported in two trials, with an RR of 2.04 (95% CI 1.63 to 2.55; 2 studies; 3323 participants; I2 = 37%; low certainty evidence), indicating an excess of hypotensive events among participants assigned to more intervention on blood pressure. AUTHORS' CONCLUSIONS Hypertension is a well-known risk factor for several chronic conditions for which lowering blood pressure has proven to be beneficial. The available evidence supports a modest beneficial effect of intervention to reduce blood pressure with respect to preventing diabetic retinopathy for up to five years, particularly for hypertensive type 2 diabetics. However, there was a paucity of evidence to support such intervention to slow progression of diabetic retinopathy or to affect other outcomes considered in this review among normotensive diabetics. This weakens any conclusion regarding an overall benefit of intervening on blood pressure in diabetic patients without hypertension for the sole purpose of preventing diabetic retinopathy or avoiding the need for treatment for advanced stages of diabetic retinopathy.
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Affiliation(s)
- Diana V Do
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Genie Han
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Samuel A Abariga
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Barbara S Hawkins
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Xie Y, E J, Cai H, Zhong F, Xiao W, Gordon RE, Wang L, Zheng YL, Zhang A, Lee K, He JC. Reticulon-1A mediates diabetic kidney disease progression through endoplasmic reticulum-mitochondrial contacts in tubular epithelial cells. Kidney Int 2022; 102:293-306. [PMID: 35469894 PMCID: PMC9329239 DOI: 10.1016/j.kint.2022.02.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022]
Abstract
Recent epidemiological studies suggest that some patients with diabetes progress to kidney failure without significant albuminuria and glomerular injury, suggesting a critical role of kidney tubular epithelial cell (TEC) injury in diabetic kidney disease (DKD) progression. However, the major risk factors contributing to TEC injury and progression in DKD remain unclear. We previously showed that expression of endoplasmic reticulum-resident protein Reticulon-1A (RTN1A) increased in human DKD, and the increased RTN1A expression promoted TEC injury through endoplasmic reticulum (ER) stress response. Here, we show that TEC-specific RTN1A overexpression worsened DKD in mice, evidenced by enhanced tubular injury, tubulointerstitial fibrosis, and kidney function decline. But RTN1A overexpression did not exacerbate diabetes-induced glomerular injury or albuminuria. Notably, RTN1A overexpression worsened both ER stress and mitochondrial dysfunction in TECs under diabetic conditions by regulation of ER-mitochondria contacts. Mechanistically, ER-bound RTN1A interacted with mitochondrial hexokinase-1 and the voltage-dependent anion channel-1 (VDAC1), interfering with their association. This disengagement of VDAC1 from hexokinase-1 resulted in activation of apoptotic and inflammasome pathways, leading to TEC injury and loss. Thus, our observations highlight the importance of ER-mitochondrial crosstalk in TEC injury and the salient role of RTN1A-mediated ER-mitochondrial contact regulation in DKD progression.
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Affiliation(s)
- Yifan Xie
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing E
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Nephrology, Ningxia People's Hospital, Ningxia, China
| | - Hong Cai
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fang Zhong
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Wenzhen Xiao
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ronald E Gordon
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lois Wang
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ya-Li Zheng
- Department of Nephrology, Ningxia People's Hospital, Ningxia, China
| | - Aihua Zhang
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Kyung Lee
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - John Cijiang He
- Department of Medicine, Nephrology Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Renal Section, James J. Peters Veterans Affair Medical Center, Bronx, New York, USA.
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6
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Inker LA, Couture SJ, Tighiouart H, Abraham AG, Beck GJ, Feldman HI, Greene T, Gudnason V, Karger AB, Eckfeldt JH, Kasiske BL, Mauer M, Navis G, Poggio ED, Rossing P, Shlipak MG, Levey AS. A New Panel-Estimated GFR, Including β 2-Microglobulin and β-Trace Protein and Not Including Race, Developed in a Diverse Population. Am J Kidney Dis 2021; 77:673-683.e1. [PMID: 33301877 PMCID: PMC8102017 DOI: 10.1053/j.ajkd.2020.11.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
Abstract
RATIONALE AND OBJECTIVE Glomerular filtration rate (GFR) estimation based on creatinine and cystatin C (eGFRcr-cys) is more accurate than estimated GFR (eGFR) based on creatinine or cystatin C alone (eGFRcr or eGFRcys, respectively), but the inclusion of creatinine in eGFRcr-cys requires specification of a person's race. β2-Microglobulin (B2M) and β-trace protein (BTP) are alternative filtration markers that appear to be less influenced by race than creatinine is. STUDY DESIGN Study of diagnostic test accuracy. SETTING AND PARTICIPANTS Development in a pooled population of 7 studies with 5,017 participants with and without chronic kidney disease. External validation in a pooled population of 7 other studies with 2,245 participants. TESTS COMPARED Panel eGFR using B2M and BTP in addition to cystatin C (3-marker panel) or creatinine and cystatin C (4-marker panel) with and without age and sex or race. OUTCOMES GFR measured as the urinary clearance of iothalamate, plasma clearance of iohexol, or plasma clearance of [51Cr]EDTA. RESULTS Mean measured GFRs were 58.1 and 83.2 mL/min/1.73 m2, and the proportions of Black participants were 38.6% and 24.0%, in the development and validation populations, respectively. In development, addition of age and sex improved the performance of all equations compared with equations without age and sex, but addition of race did not further improve the performance. In validation, the 4-marker panels were more accurate than the 3-marker panels (P < 0.001). The 3-marker panel without race was more accurate than eGFRcys (percentage of estimates greater than 30% different from measured GFR [1 - P30] of 15.6% vs 17.4%; P = 0.01), and the 4-marker panel without race was as accurate as eGFRcr-cys (1 - P30 of 8.6% vs 9.4%; P = 0.2). Results were generally consistent across subgroups. LIMITATIONS No representation of participants with severe comorbid illness and from geographic areas outside of North America and Europe. CONCLUSIONS The 4-marker panel eGFR is as accurate as eGFRcr-cys without requiring specification of race. A more accurate race-free eGFR could be an important advance.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA.
| | - Sara J Couture
- Division of Nephrology, Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA; Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Alison G Abraham
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Harold I Feldman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Tom Greene
- Department of Internal Medicine, University of Utah Health, Salt Lake City, UT
| | - Vilmundur Gudnason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Icelandic Heart Association, Kopavogur, Iceland
| | - Amy B Karger
- Departments of Laboratory Medicine and Pathology, University of Minnesota; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - John H Eckfeldt
- Departments of Laboratory Medicine and Pathology, University of Minnesota; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Bertram L Kasiske
- University of Minnesota; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Michael Mauer
- Medicine, University of Minnesota; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Gerjan Navis
- Faculty of Medical Sciences, University Medical Center Groningen, Groningen, The Netherlands
| | - Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Peter Rossing
- Steno Diabetes Center Copenhagen and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, CA
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
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7
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Looker HC, Mauer M, Saulnier PJ, Harder JL, Nair V, Boustany-Kari CM, Guarnieri P, Hill J, Esplin CA, Kretzler M, Nelson RG, Najafian B. Changes in Albuminuria But Not GFR are Associated with Early Changes in Kidney Structure in Type 2 Diabetes. J Am Soc Nephrol 2020; 30:1049-1059. [PMID: 31152118 DOI: 10.1681/asn.2018111166] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/27/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND In type 1 diabetes, changes in the GFR and urine albumin-to-creatinine ratio (ACR) are related to changes in kidney structure that reflect disease progression. However, such changes have not been studied in type 2 diabetes. METHODS Participants were American Indians with type 2 diabetes enrolled in a clinical trial of losartan versus placebo. We followed a subset who underwent kidney biopsy at the end of the 6-year trial, with annual measurements of GFR (by urinary clearance of iothalamate) and ACR. Participants had a second kidney biopsy after a mean follow-up of 9.3 years. We used quantitative morphometric analyses to evaluate both biopsy specimens. RESULTS Baseline measures for 48 participants (12 men and 36 women, mean age 45.6 years) who completed the study included diabetes duration (14.6 years), GFR (156 ml/min), and ACR (15 mg/g). During follow-up, glomerular basement membrane (GBM) width, mesangial fractional volume, and ACR increased, and surface density of peripheral GBM and GFR decreased. After adjustment for sex, age, ACR, and each morphometric variable at baseline, an increase in ACR during follow-up was significantly associated with increases in GBM width, mesangial fractional volume, and mean glomerular volume, and a decrease in surface density of peripheral GBM. Decline in GFR was not associated with changes in these morphometric variables after additionally adjusting for baseline GFR. CONCLUSIONS In American Indians with type 2 diabetes and preserved GFR at baseline, increasing ACR reflects the progression of earlier structural glomerular lesions, whereas early GFR decline may not accurately reflect such lesions.
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Affiliation(s)
- Helen C Looker
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona;
| | - Michael Mauer
- Department of Pediatrics and Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Pierre-Jean Saulnier
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona.,Centre Hospitalier Universitaire of Poitiers, Clinical Investigation Center, Institut National de la Santé et de la Recherche Médicale Poitiers, Poitiers, France
| | - Jennifer L Harder
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Viji Nair
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Carine M Boustany-Kari
- Cardiometabolic Diseases Research, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut
| | - Paolo Guarnieri
- Cardiometabolic Diseases Research, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut
| | - Jon Hill
- Cardiometabolic Diseases Research, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut
| | - Cordell A Esplin
- Department of Radiology, St Luke's Medical Center, Phoenix, Arizona; and
| | - Matthias Kretzler
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Robert G Nelson
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona
| | - Behzad Najafian
- Department of Pathology, University of Washington, Seattle, Washington
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8
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Looker HC, Merchant ML, Rane MJ, Nelson RG, Kimmel PL, Rovin BH, Klein JB, Mauer M. Urine inositol pentakisphosphate 2-kinase and changes in kidney structure in early diabetic kidney disease in type 1 diabetes. Am J Physiol Renal Physiol 2018; 315:F1484-F1492. [PMID: 30132343 DOI: 10.1152/ajprenal.00183.2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We examined the association of urine inositol 1,3,4,5,6-pentakisphosphate 2-kinase (IPP2K) with the presence and progression of diabetic kidney disease (DKD) lesions. Urine IPP2K was measured at baseline by quantitative liquid chromatography-mass spectrometry in 215 participants from the Renin-Angiotensin System Study who had type 1 diabetes and were normoalbuminuric and normotensive with normal or increased glomerular filtration rate (GFR). Urine IPP2K was detectable in 166 participants. Participants with IPP2K below the limit of quantification (LOQ) were assigned concentrations of LOQ/√2. All concentrations were then standardized to urine creatinine (Cr) concentration. Kidney morphometric data were available from biopsies at baseline and after 5 yr. Relationships of IPP2K/Cr with morphometric variables were assessed by linear regression after adjustment for age, sex, diabetes duration, hemoglobin A1c, mean arterial pressure, treatment assignment, and, for longitudinal analyses, baseline structure. Baseline mean age was 29.7 yr, mean diabetes duration 11.2 yr, median albumin excretion rate 5.0 μg/min, and mean iohexol GFR 129 ml·min-1·1.73m-2. Higher IPP2K/Cr was associated with higher baseline peripheral glomerular total filtration surface density [Sv(PGBM/glom), tertile 3 vs. tertile 1 β = 0.527, P = 0.011] and with greater preservation of Sv(PGBM/glom) after 5 yr ( tertile 3 vs. tertile 1 β = 0.317, P = 0.013). Smaller increases in mesangial fractional volume ( tertile 3 vs. tertile 1 β = -0.578, P = 0.018) were observed after 5 yr in men with higher urine IPP2K/Cr concentrations. Higher urine IPP2K/Cr is associated with less severe kidney lesions at baseline and with preservation of kidney structure over 5 yr in individuals with type 1 diabetes and no clinical evidence of DKD at baseline.
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Affiliation(s)
- Helen C Looker
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases , Phoenix, Arizona
| | - Michael L Merchant
- Division of Nephrology and Hypertension, University of Louisville , Louisville, Kentucky
| | - Madhavi J Rane
- Department of Biochemistry and Molecular Genetics, University of Louisville , Louisville, Kentucky
| | - Robert G Nelson
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases , Phoenix, Arizona
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases , Bethesda, Maryland
| | - Brad H Rovin
- Division of Nephrology, Ohio State University , Columbus, Ohio
| | - Jon B Klein
- Department of Medicine, University of Louisville , Louisville, Kentucky
| | - Michael Mauer
- Division of Renal Diseases and Hypertension, University of Minnesota , Minneapolis, Minnesota
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9
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Xu JL, Gan XX, Ni J, Shao DC, Shen Y, Miao NJ, Xu D, Zhou L, Zhang W, Lu LM. SND p102 promotes extracellular matrix accumulation and cell proliferation in rat glomerular mesangial cells via the AT1R/ERK/Smad3 pathway. Acta Pharmacol Sin 2018; 39:1513-1521. [PMID: 30150789 DOI: 10.1038/aps.2017.184] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 12/14/2017] [Indexed: 02/06/2023] Open
Abstract
SND p102 was first described as a transcriptional co-activator, and subsequently determined to be a co-regulator of Pim-1, STAT6 and STAT5. We previously reported that SND p102 expression was increased in high glucose-treated mesangial cells (MCs) and plays a role in the extracellular matrix (ECM) accumulation of MCs by regulating the activation of RAS. In this study, we further examined the roles of SND p102 in diabetic nephropathy (DN)-induced glomerulosclerosis. Rats were injected with STZ (50 mg/kg, ip) to induce diabetes. MCs or isolated glomeruli were cultured in normal glucose (NG, 5.5 mmol/L)- or high glucose (HG, 25 mmol/L)-containing DMEM. We found that SND p102 expression was significantly increased in the diabetic kidneys, as well as in HG-treated isolated glomeruli and MCs. In addition, HG treatment induced significant fibrotic changes in MCs evidenced by enhanced protein expression of TGF-β, fbronectin and collagen IV, and significantly increased the proliferation of MCs. We further revealed that overexpression of SND p102 significantly increased the protein expression of angiotensin II (Ang II) type 1 receptor (AT1R) in MCs by increasing its mRNA levels via directly targeting the AT1R 3'-UTR, which resulted in activation of the ERK/Smad3 signaling and subsequently promoted the up-regulation of fbronectin, collagen IV, and TGF-β in MCs, as well as the cell proliferation. These results demonstrate that SND p102 is a key regulator of AT1R-mediating ECM synthesis and cell proliferation in MCs. Thus, small molecule inhibitors of SND p102 may be a novel therapeutic strategy for DN.
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10
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Hu ZB, Ma KL, Zhang Y, Wang GH, Liu L, Lu J, Chen PP, Lu CC, Liu BC. Inflammation-activated CXCL16 pathway contributes to tubulointerstitial injury in mouse diabetic nephropathy. Acta Pharmacol Sin 2018; 39:1022-1033. [PMID: 29620052 DOI: 10.1038/aps.2017.177] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/19/2017] [Indexed: 02/06/2023] Open
Abstract
Inflammation and lipid disorders play crucial roles in synergistically accelerating the progression of diabetic nephropathy (DN). In this study we investigated how inflammation and lipid disorders caused tubulointerstitial injury in DN in vivo and in vitro. Diabetic db/db mice were injected with 10% casein (0.5 mL, sc) every other day for 8 weeks to cause chronic inflammation. Compared with db/db mice, casein-injected db/db mice showed exacerbated tubulointerstitial injury, evidenced by increased secretion of extracellular matrix (ECM) and cholesterol accumulation in tubulointerstitium, which was accompanied by activation of the CXC chemokine ligand 16 (CXCL16) pathway. In the in vitro study, we treated HK-2 cells with IL-1β (5 ng/mL) and high glucose (30 mmol/L). IL-1β treatment increased cholesterol accumulation in HK-2 cells, leading to greatly increased ROS production, ECM protein expression levels, which was accompanied by the upregulated expression levels of proteins in the CXCL16 pathway. In contrast, after CXCL16 in HK-2 cells was knocked down by siRNA, the IL-1β-deteriorated changes were attenuated. In conclusion, inflammation accelerates renal tubulointerstitial lesions in mouse DN via increasing the activity of CXCL16 pathway.
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11
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Fiorentino M, Bolignano D, Tesar V, Pisano A, Biesen WV, Tripepi G, D'Arrigo G, Gesualdo L. Renal biopsy in patients with diabetes: a pooled meta-analysis of 48 studies. Nephrol Dial Transplant 2017; 32:97-110. [PMID: 27190327 DOI: 10.1093/ndt/gfw070] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 03/01/2016] [Indexed: 01/19/2023] Open
Abstract
Background The utility of renal biopsy in patients with diabetes is highly debated. Diabetics with rapidly worsening renal disease are often 'clinically' labelled as having diabetic nephropathy (DN), whereas, in many cases, they are rather developing a non-diabetic renal disease (NDRD) or mixed forms (DN + NDRD). Methods We performed a systematic search for studies on patients with diabetes with data on the frequency of DN, NDRD and mixed forms, and assessed the positive predictive values (PPVs) and odds ratios (ORs) for such diagnoses by meta-analysing single-study prevalence. Possible factors explaining heterogeneity among the different diagnoses were explored by meta-regression. Results In the 48 included studies ( n = 4876), the prevalence of DN, NDRD and mixed forms ranged from 6.5 to 94%, 3 to 82.9% and 4 to 45.5% of the overall diagnoses, respectively. IgA nephropathy was the most common NDRD (3-59%). PPVs for DN, NDRD and mixed forms were 50.1% [95% confidence interval (CI): 44.7-55.2], 36.9% (95% CI: 32.3-41.8) and 19.7% (95% CI: 16.3-23.6), respectively. The PPV when combining NDRD and mixed forms was 49.2% (95% CI: 43.8-54.5). Meta-regression identified systolic pressure, HbA1c, diabetes duration and retinopathy as factors explaining heterogeneity for NDRD, creatinine and glomerular filtration rate for mixed forms and only serum creatinine for DN. ORs of DN versus NDRD and mixed forms were 1.71 (95% CI: 1.54-1.91) and 4.1 (95% CI: 3.43-4.80), respectively. Conclusions NDRD are highly prevalent in patients with diabetes. Clinical judgment alone can lead to wrong diagnoses and delay the establishment of adequate therapies. Risk stratification according to individual factors is needed for selecting patients who might benefit from biopsy.
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Affiliation(s)
- Marco Fiorentino
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari, Bari, Italy
| | - Davide Bolignano
- CNR-Institute of Clinical Physiology, Reggio Calabria, Italy.,European Renal Best Practice (ERBP), University Hospital, Ghent, Belgium
| | - Vladimir Tesar
- Department of Nephrology, 1st School of Medicine, Charles University, Prague, Czech Republic
| | - Anna Pisano
- CNR-Institute of Clinical Physiology, Reggio Calabria, Italy
| | - Wim Van Biesen
- European Renal Best Practice (ERBP), University Hospital, Ghent, Belgium
| | | | | | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari, Bari, Italy
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12
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Wheelock KM, Cai J, Looker HC, Merchant ML, Nelson RG, Fufaa GD, Weil EJ, Feldman HI, Vasan RS, Kimmel PL, Rovin BH, Mauer M, Klein JB. Plasma bradykinin and early diabetic nephropathy lesions in type 1 diabetes mellitus. PLoS One 2017; 12:e0180964. [PMID: 28700653 PMCID: PMC5507314 DOI: 10.1371/journal.pone.0180964] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 06/23/2017] [Indexed: 12/18/2022] Open
Abstract
Objective To examine the association of bradykinin and related peptides with the development of diabetic nephropathy lesions in 243 participants with type 1 diabetes (T1D) from the Renin-Angiotensin System Study who, at baseline, were normoalbuminuric, normotensive and had normal or increased glomerular filtration rate (GFR). Design Plasma concentrations of bradykinin and related peptides were measured at baseline by quantitative mass spectrometry. All participants were randomly assigned at baseline to receive placebo, enalapril or losartan during the 5 years between kidney biopsies. Kidney morphometric data were available from kidney biopsies at baseline and after 5 years. Relationships of peptides with changes in morphometric variables were assessed using multiple linear regression after adjustment for age, sex, diabetes duration, HbA1c, mean arterial pressure, treatment assignment and, for longitudinal analyses, baseline structure. Results Baseline median albumin excretion rate of study participants was 5.0 μg/min, and mean GFR was 128 mL/min/1.73 m2. After multivariable adjustment, higher plasma concentration of bradykinin (1–8) was associated with greater glomerular volume (partial r = 0.191, P = 0.019) and total filtration surface area (partial r = 0.211, P = 0.010), and higher bradykinin (1–7) and hyp3-bradykinin (1–7) were associated with lower cortical interstitial fractional volume (partial r = -0.189, P = 0.011; partial r = -0.164, P = 0.027 respectively). In longitudinal analyses, higher bradykinin was associated with preservation of surface density of the peripheral glomerular basement membrane (partial r = 0.162, P = 0.013), and for participants randomized to losartan, higher hyp3-bradykinin (1–8) was associated with more limited increase in cortical interstitial fractional volume (partial r = -0.291, P = 0.033). Conclusions Higher plasma bradykinin and related peptide concentrations measured before clinical onset of diabetic nephropathy in persons with T1D were associated with preservation of glomerular structures, suggesting that elevations of these kinin concentrations may reflect adaptive responses to early renal structural changes in diabetic nephropathy.
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Affiliation(s)
- Kevin M. Wheelock
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona, United States of America
| | - Jian Cai
- University of Louisville, Louisville, Kentucky, United States of America
| | - Helen C. Looker
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona, United States of America
| | | | - Robert G. Nelson
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona, United States of America
- * E-mail:
| | - Gudeta D. Fufaa
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona, United States of America
| | - E. Jennifer Weil
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona, United States of America
| | - Harold I. Feldman
- University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | | | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, United States of America
| | - Brad H. Rovin
- Ohio State University, Columbus, Ohio, United States of America
| | - Michael Mauer
- University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Jon B. Klein
- University of Louisville, Louisville, Kentucky, United States of America
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13
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Ting DSW, Cheung GCM, Wong TY. Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review. Clin Exp Ophthalmol 2016; 44:260-77. [DOI: 10.1111/ceo.12696] [Citation(s) in RCA: 444] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 12/07/2015] [Accepted: 12/21/2015] [Indexed: 12/12/2022]
Affiliation(s)
- Daniel Shu Wei Ting
- Singapore National Eye Center, Singapore Health Service (SingHealth); Singapore Singapore
- Singapore Eye Research Institute; Singapore Singapore
| | - Gemmy Chui Ming Cheung
- Singapore National Eye Center, Singapore Health Service (SingHealth); Singapore Singapore
- Singapore Eye Research Institute; Singapore Singapore
- Duke-NUS Graduate Medical School; Singapore Singapore
| | - Tien Yin Wong
- Singapore National Eye Center, Singapore Health Service (SingHealth); Singapore Singapore
- Singapore Eye Research Institute; Singapore Singapore
- Duke-NUS Graduate Medical School; Singapore Singapore
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14
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Fufaa GD, Weil EJ, Nelson RG, Hanson RL, Knowler WC, Rovin BH, Wu H, Klein JB, Mifflin TE, Feldman HI, Vasan RS, Kimmel PL, Kusek JW, Mauer M. Urinary monocyte chemoattractant protein-1 and hepcidin and early diabetic nephropathy lesions in type 1 diabetes mellitus. Nephrol Dial Transplant 2015; 30:599-606. [PMID: 25648911 DOI: 10.1093/ndt/gfv012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Urinary monocyte chemoattractant protein-1 (MCP-1) and hepcidin are potential biomarkers of renal inflammation. We examined their association with development of diabetic nephropathy (DN) lesions in normotensive normoalbuminuric subjects with type 1 diabetes (T1D) from the Renin-Angiotensin System Study. METHODS Biomarker concentrations were measured in baseline urine samples from 224 subjects who underwent kidney biopsies at baseline and after 5 years. Fifty-eight urine samples below the limit of quantitation (LOQ, 28.8 pg/mL) of the MCP-1 assay were assigned concentrations of LOQ/√2 for analysis. Relationships between ln(MCP-1/Cr) or ln(hepcidin/Cr) and morphometric variables were assessed by sex using multiple linear regression after adjustment for age, T1D duration, HbA1c, mean arterial pressure, albumin excretion rate (AER) and glomerular filtration rate (GFR). In models that examined changes in morphometric variables, the baseline morphometric value was also included. RESULTS Baseline mean age was 24.6 years, mean duration of T1D 11.2 years, median AER 6.4 µg/min and mean iohexol GFR 129 mL/min/1.73 m(2). No associations were found between hepcidin/Cr and morphometric variables. Higher MCP-1/Cr was associated with higher interstitial fractional volume at baseline and after 5 years in women (baseline partial r = 0.244, P = 0.024; 5-year partial r = 0.299, P = 0.005), but not in men (baseline partial r = -0.049, P = 0.678; 5-year partial r = 0.026, P = 0.830). MCP-1 was not associated with glomerular lesions in either sex. CONCLUSIONS Elevated urinary MCP-1 concentration measured before clinical findings of DN in women with T1D was associated with changes in kidney interstitial volume, suggesting that inflammatory processes may be involved in the pathogenesis of early interstitial changes in DN.
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Affiliation(s)
- Gudeta D Fufaa
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ, USA
| | - E Jennifer Weil
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ, USA
| | - Robert G Nelson
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ, USA
| | - Robert L Hanson
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ, USA
| | - William C Knowler
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ, USA
| | | | - Haifeng Wu
- Ohio State University, Columbus, OH, USA
| | - Jon B Klein
- University of Louisville, Louisville, KY, USA
| | | | | | | | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Michael Mauer
- Department of Pediatrics and Medicine, University of Minnesota, Minneapolis, MN 55454, USA
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15
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Do DV, Wang X, Vedula SS, Marrone M, Sleilati G, Hawkins BS, Frank RN. Blood pressure control for diabetic retinopathy. Cochrane Database Syst Rev 2015; 1:CD006127. [PMID: 25637717 PMCID: PMC4439213 DOI: 10.1002/14651858.cd006127.pub2] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Diabetic retinopathy is a common complication of diabetes and a leading cause of visual impairment and blindness. Research has established the importance of blood glucose control to prevent development and progression of the ocular complications of diabetes. Simultaneous blood pressure control has been advocated for the same purpose, but findings reported from individual studies have supported varying conclusions regarding the ocular benefit of interventions on blood pressure. OBJECTIVES The primary aim of this review was to summarize the existing evidence regarding the effect of interventions to control or reduce blood pressure levels among diabetics on incidence and progression of diabetic retinopathy, preservation of visual acuity, adverse events, quality of life, and costs. A secondary aim was to compare classes of anti-hypertensive medications with respect to the same outcomes. SEARCH METHODS We searched a number of electronic databases including CENTRAL as well as ongoing trial registries. We last searched the electronic databases on 25 April 2014. We also reviewed reference lists of review articles and trial reports selected for inclusion. In addition, we contacted investigators of trials with potentially pertinent data. SELECTION CRITERIA We included in this review randomized controlled trials (RCTs) in which either type 1 or type 2 diabetic participants, with or without hypertension, were assigned randomly to intense versus less intense blood pressure control, to blood pressure control versus usual care or no intervention on blood pressure, or to different classes of anti-hypertensive agents versus placebo. DATA COLLECTION AND ANALYSIS Pairs of review authors independently reviewed titles and abstracts from electronic and manual searches and the full text of any document that appeared to be relevant. We assessed included trials independently for risk of bias with respect to outcomes reported in this review. We extracted data regarding trial characteristics, incidence and progression of retinopathy, visual acuity, quality of life, and cost-effectiveness at annual intervals after study entry whenever provided in published reports and other documents available from included trials. MAIN RESULTS We included 15 RCTs, conducted primarily in North America and Europe, that had enrolled 4157 type 1 and 9512 type 2 diabetic participants, ranging from 16 to 2130 participants in individual trials. In 10 of the 15 RCTs, one group of participants was assigned to one or more anti-hypertensive agents and the control group received placebo. In three trials, intense blood pressure control was compared to less intense blood pressure control. In the remaining two trials, blood pressure control was compared with usual care. Five of the 15 trials enrolled type 1 diabetics, and 10 trials enrolled type 2 diabetics. Six trials were sponsored entirely by pharmaceutical companies, seven trials received partial support from pharmaceutical companies, and two studies received support from government-sponsored grants and institutional support.Study designs, populations, interventions, and lengths of follow-up (range one to nine years) varied among the included trials. Overall, the quality of the evidence for individual outcomes was low to moderate. For the primary outcomes, incidence and progression of retinopathy, the quality of evidence was downgraded due to inconsistency and imprecision of estimates from individual studies and differing characteristics of participants.For primary outcomes among type 1 diabetics, one of the five trials reported incidence of retinopathy and one trial reported progression of retinopathy after 4 to 5 years of treatment and follow-up; four of the five trials reported a combined outcome of incidence and progression over the same time interval. Among type 2 diabetics, 5 of the 10 trials reported incidence of diabetic retinopathy and 3 trials reported progression of retinopathy; one of the 10 trials reported a combined outcome of incidence and progression during a 4- to 5-year follow-up period. One trial in which type 2 diabetics participated had reported no primary (or secondary) outcome targeted for this review.The evidence from these trials supported a benefit of more intensive blood pressure control intervention with respect to 4- to 5-year incidence of diabetic retinopathy (estimated risk ratio (RR) 0.80; 95% confidence interval (CI) 0.71 to 0.92) and the combined outcome of incidence and progression (estimated RR 0.78; 95% CI 0.63 to 0.97). The available evidence provided less support for a benefit with respect to 4- to 5-year progression of diabetic retinopathy (point estimate was closer to 1 than point estimates for incidence and combined incidence and progression, and the CI overlapped 1; estimated RR 0.88; 95% CI 0.73 to 1.05). The available evidence regarding progression to proliferative diabetic retinopathy or clinically significant macular edema or moderate to severe loss of best-corrected visual acuity did not support a benefit of intervention on blood pressure: estimated RRs and 95% CIs 0.95 (0.83 to 1.09) and 1.06 (0.85 to 1.33), respectively, after 4 to 5 years of follow-up. Findings within subgroups of trial participants (type 1 and type 2 diabetics; participants with normal blood pressure levels at baseline and those with elevated levels) were similar to overall findings.The adverse event reported most often (7 of 15 trials) was death, yielding an estimated RR 0.86 (95% CI 0.64 to 1.14). Hypotension was reported from three trials; the estimated RR was 2.08 (95% CI 1.68 to 2.57). Other adverse ocular events were reported from single trials. AUTHORS' CONCLUSIONS Hypertension is a well-known risk factor for several chronic conditions in which lowering blood pressure has proven to be beneficial. The available evidence supports a beneficial effect of intervention to reduce blood pressure with respect to preventing diabetic retinopathy for up to 4 to 5 years. However, the lack of evidence to support such intervention to slow progression of diabetic retinopathy or to prevent other outcomes considered in this review, along with the relatively modest support for the beneficial effect on incidence, weakens the conclusion regarding an overall benefit of intervening on blood pressure solely to prevent diabetic retinopathy.
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Affiliation(s)
- Diana V Do
- Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Xue Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Michael Marrone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Barbara S Hawkins
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert N Frank
- Department of Ophthalmology, Kresge Eye Institute, Detroit, Michigan, USA
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16
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Robiner WN, Strand TD, Mauer M. Adherence and renal biopsy feasibility in the Renin Angiotensin-System Study (RASS) primary prevention diabetes trial. Diabetes Res Clin Pract 2013; 102:25-34. [PMID: 24050942 PMCID: PMC4452734 DOI: 10.1016/j.diabres.2013.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 05/22/2013] [Accepted: 06/06/2013] [Indexed: 11/28/2022]
Abstract
AIMS Enhancing adherence in research trials is fundamental to the proper testing of treatment hypotheses. METHODS Regimen and follow-up adherence as well as factors associated with adherence in the Renin Angiotensin-System Study (RASS) diabetic nephropathy primary prevention trial were evaluated. Adherence to medication (i.e., pill count), follow-up visits, and follow-up renal biopsies was evaluated. RESULTS 89.8% of subjects completed the second renal biopsy. 96% of follow-up visits were attended within prescribed time windows. Mean medication adherence was 85.6%. Subgroup analyses revealed greater declines in the least adherent participants over time. Factors associated with greater adherence levels included older age, type 1 diabetes (TIDM) duration, lower HbA1c and blood pressure, GFR, ethnicity, and participants', principal investigators' (PI), and trial coordinators' (TC) baseline predictions of adherence. CONCLUSIONS T1DM patients without nephropathy were willing to take experimental medications and undergo repeat renal biopsies. Although overall adherence was excellent, patterns of adherence varied among participants, suggesting the need to better track adherence and to develop customized and targeted approaches for promoting adherence to clinical research regimens. Staff subjective predictions of adherence were imprecise, supporting need for further development of adherence predictors.
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Affiliation(s)
- William N. Robiner
- Health Psychology, Department of Medicine, University of Minnesota Medical School, USA
- Corresponding author at: Health Psychology, Department of Medicine, University of Minnesota Medical School, MMC 741, 420 Delaware Street S.E., Minneapolis, MN 55455, USA. Tel.: +1 612 624 1479; fax: +1 612 624 3189. (W.N. Robiner)
| | - Trudy D. Strand
- Health Psychology, Department of Medicine, University of Minnesota Medical School, USA
- Division of Pediatric Nephrology, Department of Pediatrics, University of Minnesota Medical School, 2450 Riverside Avenue, 6th Floor East Building, MB681, Minneapolis, MN 55454, USA
| | - Michael Mauer
- Health Psychology, Department of Medicine, University of Minnesota Medical School, USA
- Division of Pediatric Nephrology, Department of Pediatrics, University of Minnesota Medical School, 2450 Riverside Avenue, 6th Floor East Building, MB681, Minneapolis, MN 55454, USA
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17
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Abstract
Progressive renal dysfunction is a major complication of type 1 diabetes. Studying relationships between evolution of diabetic nephropathy lesions and renal functional alterations (structural-functional relationships) helps to better understand the natural history of diabetic nephropathy. The focus of this review is our current understanding of the interplay between morphologic changes of diabetic nephropathy and glomerular filtration rate (GFR) loss. These morphologic changes often may not progress in parallel to each other or to the decline in GFR or increase in albumin excretion rate (AER). Quantitative measures of renal (mainly glomerular) structural changes can predict a substantially larger fraction of AER variability compared with that of GFR, especially using linear correlation analyses. However, nonlinear models better fit the structural-functional relationships across a wide range of GFRs and AERs. Currently, there are insufficient longitudinal data to show which structural changes predict the slope of GFR decline in type 1 diabetic patients. Based on cross-sectional studies, however, such a predictor would be about 10% more robust in patients whose GFR was 45 mL/min/1.73 m(2) or greater if comprised of a composite of glomerular, tubular, and interstitial parameters versus glomerular changes alone. For a slowly progressive disease, such as diabetic nephropathy, in which, especially in the earlier stages, it takes a long time for GFR to decline substantially, such predictors are much needed and, if sufficiently precise, could potentially serve as a surrogate of renal functional decline in clinical trials.
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Affiliation(s)
- Behzad Najafian
- Department of Pathology, University of Washington, Seattle, WA, USA
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Lv J, Perkovic V, Foote CV, Craig ME, Craig JC, Strippoli GFM. Antihypertensive agents for preventing diabetic kidney disease. Cochrane Database Syst Rev 2012; 12:CD004136. [PMID: 23235603 PMCID: PMC11357690 DOI: 10.1002/14651858.cd004136.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Various blood pressure-lowering agents, and particularly inhibitors of the renin-angiotensin system (RAS), are widely used for people with diabetes to prevent the onset of diabetic kidney disease (DKD) and adverse cardiovascular outcomes. This is an update of a Cochrane review first published in 2003 and updated in 2005. OBJECTIVES This systematic review aimed to assess the benefits and harms of blood pressure lowering agents in people with diabetes mellitus and a normal amount of albumin in the urine (normoalbuminuria). SEARCH METHODS In January 2011 we searched the Cochrane Renal Group's Specialised Register through contact with the Trials Search Co-ordinator. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing any antihypertensive agent with placebo or another agent in hypertensive or normotensive patients with diabetes and no kidney disease (albumin excretion rate < 30 mg/d) were included. DATA COLLECTION AND ANALYSIS Two investigators independently extracted data on kidney and other patient-relevant outcomes (all-cause mortality and serious cardiovascular events), and assessed study quality. Analysis was by a random effects model was applied to analyse results which were expressed as risk ratio (RR) and 95% confidence intervals (CI). MAIN RESULTS We identified 26 studies that enrolling 61,264 participants. Angiotensin-converting enzyme inhibitors (ACEi) reduced the risk of new onset of microalbuminuria, macroalbuminuria or both when compared to placebo (8 studies, 11,906 patients: RR 0.71, 95% CI 0.56 to 0.89), with similar benefits in people with and without hypertension (P = 0.74), and when compared to calcium channel blockers (5 studies, 1253 participants: RR 0.60, 95% CI 0.42 to 0.85). ACEi reduced the risk of death when compared to placebo (6 studies, 11,350 participants: RR 0.84, 95% CI 0.73 to 0.97). No effect was observed for angiotensin receptor blockers (ARB) when compared to placebo for new microalbuminuria, macroalbuminuria or both (5 studies, 7653 participants: RR 0.90, 95% CI 0.68 to 1.19) or death (5 studies, 7653 participants: RR 1.12, 95% CI 0.88 to 1.41); however, meta-regression suggested possible benefits from ARB for preventing kidney disease in high risk patients. There was a trend towards benefit from use of combined ACEi and ARB for prevention of DKD compared with ACEi alone (2 studies, 4171 participants: RR 0.88, 95% CI 0.78 to 1.00).The risk of cough was significantly increased with ACEi when compared to placebo (6 studies, 11,791 patients: RR 1.84, 95% CI 1.24 to 2.72), however there was no significant difference in the risk of headache or hyperkalaemia. There was no significant difference in the risk of cough, headache or hyperkalaemia when ARB was to placebo. On average risk of bias was judged to be either low (27% to 69%) or unclear (i.e. no information available) (8% to 73%). Blinding of participants, incomplete outcome data and selective reporting were judged to be high in 23%, 31% and 31% of studies, respectively. AUTHORS' CONCLUSIONS ACEi were found to prevent new onset DKD and death in normoalbuminuric people with diabetes, and could therefore be used in this population. More data are needed to clarify the role of ARB and other drug classes in preventing DKD.
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Affiliation(s)
- Jicheng Lv
- The George Institute for Global HealthRenal and Metabolic DivisionLevel 10, KGV Building, RPAHMissenden RdCamperdownNSWAustralia2050
| | - Vlado Perkovic
- The George Institute for Global HealthRenal and Metabolic DivisionLevel 10, KGV Building, RPAHMissenden RdCamperdownNSWAustralia2050
| | - Celine V Foote
- The George Institute for Global HealthRenal and Metabolic DivisionLevel 10, KGV Building, RPAHMissenden RdCamperdownNSWAustralia2050
| | - Maria E Craig
- University of New South WalesDivison of Women's and Children's HealthSt George HospitalGray StreetKogarahNSWAustralia2025
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly70100
- Mario Negri Sud ConsortiumDepartment of Clinical Pharmacology and EpidemiologySanta Maria ImbaroItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
- DiaverumMedical‐Scientific OfficeLundSweden
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19
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Wright JW, Harding JW. The brain renin–angiotensin system: a diversity of functions and implications for CNS diseases. Pflugers Arch 2012; 465:133-51. [DOI: 10.1007/s00424-012-1102-2] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 03/20/2012] [Accepted: 03/30/2012] [Indexed: 12/14/2022]
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Signaling mechanisms in the regulation of renal matrix metabolism in diabetes. EXPERIMENTAL DIABETES RESEARCH 2012; 2012:749812. [PMID: 22454628 PMCID: PMC3290898 DOI: 10.1155/2012/749812] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 11/02/2011] [Indexed: 02/06/2023]
Abstract
Renal hypertrophy and accumulation of extracellular matrix proteins are among cardinal manifestations of diabetic nephropathy. TGF beta system has been implicated in the pathogenesis of these manifestations. Among signaling pathways activated in the kidney in diabetes, mTOR- (mammalian target of rapamycin-)regulated pathways are pivotal in orchestrating high glucose-induced production of ECM proteins leading to functional and structural changes in the kidney culminating in adverse outcomes. Understanding signaling pathways that influence individual matrix protein expression could lead to the development of new interventional strategies. This paper will highlight some of the diverse components of the signaling network stimulated by hyperglycemia with an emphasis on extracellular matrix protein metabolism in the kidney in diabetes.
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21
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Wright JW, Harding JW. Brain renin-angiotensin—A new look at an old system. Prog Neurobiol 2011; 95:49-67. [DOI: 10.1016/j.pneurobio.2011.07.001] [Citation(s) in RCA: 147] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 06/27/2011] [Accepted: 07/03/2011] [Indexed: 12/15/2022]
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Harindhanavudhi T, Mauer M, Klein R, Zinman B, Sinaiko A, Caramori ML. Benefits of Renin-Angiotensin blockade on retinopathy in type 1 diabetes vary with glycemic control. Diabetes Care 2011; 34:1838-42. [PMID: 21715517 PMCID: PMC3142059 DOI: 10.2337/dc11-0476] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Optimal glycemic control slows diabetic retinopathy (DR) development and progression and is the standard of care for type 1 diabetes. However, these glycemic goals are difficult to achieve and sustain in clinical practice. The Renin Angiotensin System Study (RASS) showed that renin-angiotensin system (RAS) blockade can slow DR progression. In the current study, we evaluate whether glycemic control influenced the benefit of RAS blockade on DR progression in type 1 diabetic patients. RESEARCH DESIGN AND METHODS We used RASS data to analyze the relationships between two-steps or more DR progression and baseline glycemic levels in 223 normotensive, normoalbuminuric type 1 diabetic patients randomized to receive 5 years of enalapril or losartan compared with placebo. RESULTS A total of 147 of 223 patients (65.9%) had DR at baseline (47 of 74 patients [63.5%] in placebo and 100 of 149 patients [67.1%] in the combined treatment groups [P = 0.67]). Patients with two-steps or more DR progression had higher baseline A1C than those without progression (9.4 vs. 8.2%, P < 0.001). There was no beneficial effect of RAS blockade (P = 0.92) in patients with baseline A1C ≤7.5%. In contrast, 30 of 112 (27%) patients on the active treatment arms with A1C >7.5% had two-steps or more DR progression compared with 26 of 56 patients (46%) in the placebo group (P = 0.03). CONCLUSIONS RAS blockade reduces DR progression in normotensive, normoalbuminuric type 1 diabetic patients with A1C >7.5%. Whether this therapy could benefit patients with A1C ≤7.5% will require long-term studies of much larger cohorts.
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Korn EL, Freidlin B. Inefficacy interim monitoring procedures in randomized clinical trials: the need to report. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2011; 11:2-10. [PMID: 21400374 DOI: 10.1080/15265161.2010.546471] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
If definitive evidence concerning treatment effectiveness becomes available from an ongoing randomized clinical trial, then the trial could be stopped early, with the public release of results benefiting current and future patients. However, stopping an ongoing trial based on accruing outcome data requires methodological rigor to preserve validity of the trial conclusions. This has led to the use of formal interim monitoring procedures, which include inefficacy monitoring that will stop a trial early when the experimental treatment appears not to be working. For participants, inefficacy monitoring is especially important as it ensures that they are not being treated worse than if they had not enrolled on the trial. We discuss the importance of reporting with trial results the formal interim inefficacy monitoring guidelines that were utilized, and, if none were used, the reasons for their absence. A survey of two leading medical journals suggests that this is not current practice.
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Affiliation(s)
- Edward L Korn
- Biometric Research Branch, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD 20892, USA.
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Stevens LA, Claybon MA, Schmid CH, Chen J, Horio M, Imai E, Nelson RG, Van Deventer M, Wang HY, Zuo L, Zhang YL, Levey AS. Evaluation of the Chronic Kidney Disease Epidemiology Collaboration equation for estimating the glomerular filtration rate in multiple ethnicities. Kidney Int 2010; 79:555-62. [PMID: 21107446 DOI: 10.1038/ki.2010.462] [Citation(s) in RCA: 384] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
An equation from the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) provides more accurate estimates of the glomerular filtration rate (eGFR) than that from the modification of diet in renal disease (MDRD) Study, although both include a two-level variable for race (Black and White and other). Since creatinine generation differs among ethnic groups, it is possible that a multilevel ethnic variable would allow more accurate estimates across all groups. To evaluate this, we developed an equation to calculate eGFR that includes a four-level race variable (Black, Asian, Native American and Hispanic, and White and other) using a database of 8254 patients pooled from 10 studies. This equation was then validated in 4014 patients using 17 additional studies from the United States and Europe (validation database), and in 1022 patients from China (675), Japan (248), and South Africa (99). Coefficients for the Black, Asian, and Native American and Hispanic groups resulted in 15, 5, and 1% higher levels of eGFR, respectively, compared with the White and other group. In the validation database, the two-level race equation had minimal bias in Black, Native American and Hispanic, and White and other cohorts. The four-level ethnicity equation significantly improved bias in Asians of the validation data set and in Chinese. Both equations had a large bias in Japanese and South African patients. Thus, heterogeneity in performance among the ethnic and geographic groups precludes use of the four-level race equation. The CKD-EPI two-level race equation can be used in the United States and Europe across a wide range of ethnicity.
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Affiliation(s)
- Lesley A Stevens
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts 02111, USA.
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Glycation and biomarkers of vascular complications of diabetes. Amino Acids 2010; 42:1171-83. [PMID: 21042818 DOI: 10.1007/s00726-010-0784-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 09/04/2010] [Indexed: 01/02/2023]
Abstract
Propensity to diabetic nephropathy (DN), retinopathy (DR), and cardiovascular disease (CVD) varies between individuals. Current biomarkers such as indicators of glycemia (HbA1c), retinal examinations, and albuminuria, cannot detect early tissue damage. HbAIc also doesn't reflect most glycative and oxidative chemical pathways that cause complications, and studies of new biomarkers to measure their end-products are needed. This review proposes the study of advanced glycation end products (AGEs) and oxidation end-products (OPs) in long-term diabetes outcome studies. AGEs integrate the activity of glycation pathways that form dicarbonyls, while OPs reflect superoxides, hydroxyl radicals, and peroxides. We discuss using these biomarkers to predict risk of development and progression of DN, DR, and CVD, and to determine if they confer risk independently of the level of HbA1c. We also discuss methods and guidelines to document sample quality in such studies. These studies have the potential to validate unique biomarkers during the early stages of diabetes in those who are at high risk of diabetic complications. Information on basic mechanisms responsible for complications could also stimulate development of therapeutic approaches to delay or arrest them. The ultimate goal is to predict those requiring aggressive therapies during the earliest stages, when prevention or reversal of complications is still possible.
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26
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Klein R, Knudtson MD, Klein BEK, Zinman B, Gardiner R, Suissa S, Sinaiko AR, Donnelly SM, Goodyer P, Strand T, Mauer M. The relationship of retinal vessel diameter to changes in diabetic nephropathy structural variables in patients with type 1 diabetes. Diabetologia 2010; 53:1638-46. [PMID: 20437026 PMCID: PMC2892559 DOI: 10.1007/s00125-010-1763-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 03/22/2010] [Indexed: 12/22/2022]
Abstract
AIMS/HYPOTHESIS We examined whether retinal vessel diameter in persons with type 1 diabetes mellitus is associated with changes in subclinical anatomical and functional indicators of diabetic nephropathy. METHODS Persons with type 1 diabetes mellitus had gradable fundus photographs and renal biopsy data at baseline and 5-year follow-up (n = 234). Retinal arteriolar and venular diameters were measured at baseline and follow-up. Central retinal arteriole equivalent (CRAE) and central retinal venule equivalent (CRVE) were computed. Baseline and 5-year follow-up renal structural variables were assessed by masked electron microscopic morphometric analyses from percutaneous renal biopsy specimens. Variables assessed included: mesangial fractional volume, glomerular basement membrane width, mesangial matrix fractional volume and glomerular basement membrane width composite glomerulopathy index. RESULTS While controlling for other covariates, baseline CRAE was positively associated with change in the glomerulopathy index over the 5-year period. Change in CRAE was inversely related to a change in mesangial matrix fractional volume and abnormal mesangial matrix fractional volume, while change in CRVE was directly related to change in the volume fraction of cortex that was interstitium [Vv((Int/cortex))] over the 5-year period. Baseline CRAE or CRVE or changes in these diameters were not related to changes in other anatomical or functional renal endpoints. CONCLUSIONS/INTERPRETATION Independently of other factors, baseline CRAE correlated with changes in glomerulopathy index, a composite measure of extracellular matrix accumulation in the mesangium and glomerular basement membrane. A narrowing of the CRAE was related to mesangial matrix accumulation. Changes in CRVE were related to changes in Vv((Int/cortex),) a measure of interstitial expansion in persons with type 1 diabetes mellitus.
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Affiliation(s)
- R Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, 610 North Walnut Street, Fourth Floor WARF, Madison, WI 53726-2397, USA.
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Lin S, Li D, Jia J, Zheng Z, Jia Z, Shang W. Spironolactone ameliorates podocytic adhesive capacity via restoring integrin alpha 3 expression in streptozotocin-induced diabetic rats. J Renin Angiotensin Aldosterone Syst 2010; 11:149-57. [PMID: 20525748 DOI: 10.1177/1470320310369603] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Podocyte responses to various injuries include detachment from the glomerular basement membrane (GBM) with impaired adhesion ability. Growing evidence suggests inappropriately enhanced aldosterone levels in glomeruli may contribute to podocytic injury and subsequently glomerulosclerosis in diabetic nephropathy (DN). In the present study, we aimed to investigate podocytic integrin alpha 3 expression and urinary podocyte excretion in streptozotocin (STZ)-induced diabetic rats, and to evaluate their responses to spironolactone (SPL). STZ-induced male diabetic Wistar rats were treated with vehicle (the STZ group, n=7), or spironolactone (the STZ+SPL group, n=6) for 12 weeks, six additional rats of similar body weight serving as control. Urine specimens were obtained for measurement of urine albumin concentration and urinary podocyte quantitation upon completion of the 12 weeks. Urinary podocyte excretion was quantified by immunofluorescence and expression of integrin alpha 3 was detected by immunohistochemistry and Western blotting. At 12 weeks, rats given STZ alone revealed an increase in blood glucose and were unaffected by spironolactone, whereas the STZ+SPL group showed considerable improvement in urine albumin and podocyte excretion, as well as up-regulation of integrin alpha 3. Our results suggest that spironolactone ameliorates impaired podocytic adhesion capacity and prevents STZ-induced DN progression.
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Affiliation(s)
- Shan Lin
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China.
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28
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Maple-Brown LJ, Lawton PD, Hughes JT, Sharma SK, Jones GRD, Ellis AG, Hoy W, Cass A, MacIsaac RJ, Sinha AK, Thomas MAB, Piers LS, Ward LC, Drabsch K, Panagiotopoulos S, McDermott R, Warr K, Cherian S, Brown A, Jerums G, O'Dea K. Study Protocol--accurate assessment of kidney function in Indigenous Australians: aims and methods of the eGFR study. BMC Public Health 2010; 10:80. [PMID: 20167129 PMCID: PMC2836987 DOI: 10.1186/1471-2458-10-80] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 02/19/2010] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is an overwhelming burden of cardiovascular disease, type 2 diabetes and chronic kidney disease among Indigenous Australians. In this high risk population, it is vital that we are able to measure accurately kidney function. Glomerular filtration rate is the best overall marker of kidney function. However, differences in body build and body composition between Indigenous and non-Indigenous Australians suggest that creatinine-based estimates of glomerular filtration rate derived for European populations may not be appropriate for Indigenous Australians. The burden of kidney disease is borne disproportionately by Indigenous Australians in central and northern Australia, and there is significant heterogeneity in body build and composition within and amongst these groups. This heterogeneity might differentially affect the accuracy of estimation of glomerular filtration rate between different Indigenous groups. By assessing kidney function in Indigenous Australians from Northern Queensland, Northern Territory and Western Australia, we aim to determine a validated and practical measure of glomerular filtration rate suitable for use in all Indigenous Australians. METHODS/DESIGN A cross-sectional study of Indigenous Australian adults (target n = 600, 50% male) across 4 sites: Top End, Northern Territory; Central Australia; Far North Queensland and Western Australia. The reference measure of glomerular filtration rate was the plasma disappearance rate of iohexol over 4 hours. We will compare the accuracy of the following glomerular filtration rate measures with the reference measure: Modification of Diet in Renal Disease 4-variable formula, Chronic Kidney Disease Epidemiology Collaboration equation, Cockcroft-Gault formula and cystatin C- derived estimates. Detailed assessment of body build and composition was performed using anthropometric measurements, skinfold thicknesses, bioelectrical impedance and a sub-study used dual-energy X-ray absorptiometry. A questionnaire was performed for socio-economic status and medical history. DISCUSSION We have successfully managed several operational challenges within this multi-centre complex clinical research project performed across remote North, Western and Central Australia. It seems unlikely that a single correction factor (similar to that for African-Americans) to the equation for estimated glomerular filtration rate will prove appropriate or practical for Indigenous Australians. However, it may be that a modification of the equation in Indigenous Australians would be to include a measure of fat-free mass.
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Affiliation(s)
- Louise J Maple-Brown
- Menzies School of Health Research, Institute of Advanced Studies, Charles Darwin University, Darwin, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Paul D Lawton
- Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Jaquelyne T Hughes
- Menzies School of Health Research, Institute of Advanced Studies, Charles Darwin University, Darwin, Australia
| | - Suresh K Sharma
- Menzies School of Health Research, Institute of Advanced Studies, Charles Darwin University, Darwin, Australia
| | - Graham RD Jones
- Chemical Pathology, St Vincent's Hospital, Sydney, Australia
| | - Andrew G Ellis
- University of Melbourne, Department of Medicine, Austin and Northern Health, Heidelberg, Victoria, Australia
| | - Wendy Hoy
- Centre for Chronic Disease, The University of Queensland, Australia
| | - Alan Cass
- The George Institute for International Health, University of Sydney, Sydney, Australia
| | - Richard J MacIsaac
- Department of Endocrinology, Endocrine Centre Austin Health & University of Melbourne, Heidelberg Repatriation Hospital, Heidelberg West, Victoria, Australia
| | - Ashim K Sinha
- Endocrine and Diabetes Unit, Cairns Base Hospital, Queensland, Australia
| | - Mark AB Thomas
- Department of Nephrology, Royal Perth Hospital, Perth, Australia
| | - Leonard S Piers
- Centre for Health and Society, School of Population Health, University of Melbourne, Melbourne, Australia
| | - Leigh C Ward
- School of Chemistry and Molecular Biosciences, The University of Queensland, Australia
| | - Katrina Drabsch
- Menzies School of Health Research, Institute of Advanced Studies, Charles Darwin University, Darwin, Australia
| | - Sianna Panagiotopoulos
- Department of Endocrinology, Endocrine Centre Austin Health & University of Melbourne, Heidelberg Repatriation Hospital, Heidelberg West, Victoria, Australia
| | - Robyn McDermott
- Sansom Institute for Health Research, UniSA, Adelaide, Australia
| | - Kevin Warr
- Department of Nephrology, Royal Perth Hospital, Perth, Australia
| | - Sajiv Cherian
- Department of Renal Medicine, Alice Springs Hospital, Alice Springs, Australia
| | - Alex Brown
- Baker IDI Heart and Diabetes Institute, Alice Springs, Australia
| | - George Jerums
- Department of Endocrinology, Endocrine Centre Austin Health & University of Melbourne, Heidelberg Repatriation Hospital, Heidelberg West, Victoria, Australia
| | - Kerin O'Dea
- Sansom Institute for Health Research, UniSA, Adelaide, Australia
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Klein R, Myers CE, Klein BEK, Zinman B, Gardiner R, Suissa S, Sinaiko AR, Donnelly SM, Goodyer P, Strand T, Mauer M. Relationship of blood pressure to retinal vessel diameter in type 1 diabetes mellitus. ARCHIVES OF OPHTHALMOLOGY (CHICAGO, ILL. : 1960) 2010; 128:198-205. [PMID: 20142543 PMCID: PMC2945902 DOI: 10.1001/archophthalmol.2009.391] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine the relationship of blood pressure (BP) and use of angiotensin-receptor blocker or angiotensin-converting enzyme inhibitor to retinal vessel diameter in normotensive, normoalbuminuric persons with type 1 diabetes mellitus. METHODS In a randomized, controlled clinical trial, clinic and 24-hour ambulatory BPs were measured in persons with type 1 diabetes mellitus and gradable fundus photographs both at baseline (n = 147) and at 5-year follow-up (n = 124). Retinal arteriole and venule diameters were measured by a computer-assisted technique. Individual arteriole and venule measurements were combined into summary indexes that reflect the average retinal arteriole (central retinal arteriole equivalent [CRAE]) and venule (central retinal venule equivalent [CRVE]) diameter of an eye, respectively. RESULTS While controlling for age, study site, glycosylated hemoglobin level, and ambulatory pulse rate, the daytime ambulatory systolic (-0.29-microm effect per 1 mm Hg; P = .02), daytime ambulatory diastolic (-0.44-microm effect per 1 mm Hg; P = .04), nighttime ambulatory systolic (-0.27-microm effect per 1 mm Hg; P = .03), and 24-hour ambulatory systolic (-0.31-microm effect per 1 mm Hg; P = .03) BPs were cross-sectionally associated with a smaller CRAE. While controlling for age, study site, glycosylated hemoglobin level, ambulatory pulse rate, and baseline CRAE, no BP measure was associated with a change in CRAE or CRVE during 5 years of follow-up. Treatment with losartan potassium or enalapril maleate was not associated with a statistically significant change in CRAE or CRVE. CONCLUSION Angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy does not affect retinal arteriole or venule diameter in normotensive persons with type 1 diabetes mellitus. Trial Registration clinicaltrials.gov Identifier: NCT00143949.
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Affiliation(s)
- Ronald Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, 610 N Walnut St, 417 WARF, Madison, WI 53726-2336, USA.
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Steckelings UM, Rompe F, Kaschina E, Unger T. The evolving story of the RAAS in hypertension, diabetes and CV disease - moving from macrovascular to microvascular targets. Fundam Clin Pharmacol 2009; 23:693-703. [DOI: 10.1111/j.1472-8206.2009.00780.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Marcovecchio ML, Tossavainen PH, Dunger DB. Status and rationale of renoprotection studies in adolescents with type 1 diabetes. Pediatr Diabetes 2009; 10:347-55. [PMID: 19496962 DOI: 10.1111/j.1399-5448.2009.00510.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Mauer M, Zinman B, Gardiner R, Suissa S, Sinaiko A, Strand T, Drummond K, Donnelly S, Goodyer P, Gubler MC, Klein R. Renal and retinal effects of enalapril and losartan in type 1 diabetes. N Engl J Med 2009; 361:40-51. [PMID: 19571282 PMCID: PMC2978030 DOI: 10.1056/nejmoa0808400] [Citation(s) in RCA: 504] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Nephropathy and retinopathy remain important complications of type 1 diabetes. It is unclear whether their progression is slowed by early administration of drugs that block the renin-angiotensin system. METHODS We conducted a multicenter, controlled trial involving 285 normotensive patients with type 1 diabetes and normoalbuminuria and who were randomly assigned to receive losartan (100 mg daily), enalapril (20 mg daily), or placebo and followed for 5 years. The primary end point was a change in the fraction of glomerular volume occupied by mesangium in kidney-biopsy specimens. The retinopathy end point was a progression on a retinopathy severity scale of two steps or more. Intention-to-treat analysis was performed with the use of linear regression and logistic-regression models. RESULTS A total of 90% and 82% of patients had complete renal-biopsy and retinopathy data, respectively. Change in mesangial fractional volume per glomerulus over the 5-year period did not differ significantly between the placebo group (0.016 units) and the enalapril group (0.005, P=0.38) or the losartan group (0.026, P=0.26), nor were there significant treatment benefits for other biopsy-assessed renal structural variables. The 5-year cumulative incidence of microalbuminuria was 6% in the placebo group; the incidence was higher with losartan (17%, P=0.01 by the log-rank test) but not with enalapril (4%, P=0.96 by the log-rank test). As compared with placebo, the odds of retinopathy progression by two steps or more was reduced by 65% with enalapril (odds ratio, 0.35; 95% confidence interval [CI], 0.14 to 0.85) and by 70% with losartan (odds ratio, 0.30; 95% CI, 0.12 to 0.73), independently of changes in blood pressure. There were three biopsy-related serious adverse events that completely resolved. Chronic cough occurred in 12 patients receiving enalapril, 6 receiving losartan, and 4 receiving placebo. CONCLUSIONS Early blockade of the renin-angiotensin system in patients with type 1 diabetes did not slow nephropathy progression but slowed the progression of retinopathy. (ClinicalTrials.gov number, NCT00143949.)
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Affiliation(s)
- Michael Mauer
- Department of Pediatrics, University of Minnesota, Minneapolis 55455, USA.
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Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, Feldman HI, Kusek JW, Eggers P, Van Lente F, Greene T, Coresh J. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009. [PMID: 19414839 DOI: 10.7326/0003-4819-150-9-200905050-0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Equations to estimate glomerular filtration rate (GFR) are routinely used to assess kidney function. Current equations have limited precision and systematically underestimate measured GFR at higher values. OBJECTIVE To develop a new estimating equation for GFR: the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. DESIGN Cross-sectional analysis with separate pooled data sets for equation development and validation and a representative sample of the U.S. population for prevalence estimates. SETTING Research studies and clinical populations ("studies") with measured GFR and NHANES (National Health and Nutrition Examination Survey), 1999 to 2006. PARTICIPANTS 8254 participants in 10 studies (equation development data set) and 3896 participants in 16 studies (validation data set). Prevalence estimates were based on 16,032 participants in NHANES. MEASUREMENTS GFR, measured as the clearance of exogenous filtration markers (iothalamate in the development data set; iothalamate and other markers in the validation data set), and linear regression to estimate the logarithm of measured GFR from standardized creatinine levels, sex, race, and age. RESULTS In the validation data set, the CKD-EPI equation performed better than the Modification of Diet in Renal Disease Study equation, especially at higher GFR (P < 0.001 for all subsequent comparisons), with less bias (median difference between measured and estimated GFR, 2.5 vs. 5.5 mL/min per 1.73 m(2)), improved precision (interquartile range [IQR] of the differences, 16.6 vs. 18.3 mL/min per 1.73 m(2)), and greater accuracy (percentage of estimated GFR within 30% of measured GFR, 84.1% vs. 80.6%). In NHANES, the median estimated GFR was 94.5 mL/min per 1.73 m(2) (IQR, 79.7 to 108.1) vs. 85.0 (IQR, 72.9 to 98.5) mL/min per 1.73 m(2), and the prevalence of chronic kidney disease was 11.5% (95% CI, 10.6% to 12.4%) versus 13.1% (CI, 12.1% to 14.0%). LIMITATION The sample contained a limited number of elderly people and racial and ethnic minorities with measured GFR. CONCLUSION The CKD-EPI creatinine equation is more accurate than the Modification of Diet in Renal Disease Study equation and could replace it for routine clinical use. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.
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Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, Feldman HI, Kusek JW, Eggers P, Van Lente F, Greene T, Coresh J. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150:604-12. [PMID: 19414839 PMCID: PMC2763564 DOI: 10.7326/0003-4819-150-9-200905050-00006] [Citation(s) in RCA: 18544] [Impact Index Per Article: 1236.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Equations to estimate glomerular filtration rate (GFR) are routinely used to assess kidney function. Current equations have limited precision and systematically underestimate measured GFR at higher values. OBJECTIVE To develop a new estimating equation for GFR: the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. DESIGN Cross-sectional analysis with separate pooled data sets for equation development and validation and a representative sample of the U.S. population for prevalence estimates. SETTING Research studies and clinical populations ("studies") with measured GFR and NHANES (National Health and Nutrition Examination Survey), 1999 to 2006. PARTICIPANTS 8254 participants in 10 studies (equation development data set) and 3896 participants in 16 studies (validation data set). Prevalence estimates were based on 16,032 participants in NHANES. MEASUREMENTS GFR, measured as the clearance of exogenous filtration markers (iothalamate in the development data set; iothalamate and other markers in the validation data set), and linear regression to estimate the logarithm of measured GFR from standardized creatinine levels, sex, race, and age. RESULTS In the validation data set, the CKD-EPI equation performed better than the Modification of Diet in Renal Disease Study equation, especially at higher GFR (P < 0.001 for all subsequent comparisons), with less bias (median difference between measured and estimated GFR, 2.5 vs. 5.5 mL/min per 1.73 m(2)), improved precision (interquartile range [IQR] of the differences, 16.6 vs. 18.3 mL/min per 1.73 m(2)), and greater accuracy (percentage of estimated GFR within 30% of measured GFR, 84.1% vs. 80.6%). In NHANES, the median estimated GFR was 94.5 mL/min per 1.73 m(2) (IQR, 79.7 to 108.1) vs. 85.0 (IQR, 72.9 to 98.5) mL/min per 1.73 m(2), and the prevalence of chronic kidney disease was 11.5% (95% CI, 10.6% to 12.4%) versus 13.1% (CI, 12.1% to 14.0%). LIMITATION The sample contained a limited number of elderly people and racial and ethnic minorities with measured GFR. CONCLUSION The CKD-EPI creatinine equation is more accurate than the Modification of Diet in Renal Disease Study equation and could replace it for routine clinical use. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.
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Robiner WN, Yozwiak JA, Bearman DL, Strand TD, Strasburg KR. Barriers to clinical research participation in a diabetes randomized clinical trial. Soc Sci Med 2009; 68:1069-74. [PMID: 19167143 PMCID: PMC2702260 DOI: 10.1016/j.socscimed.2008.12.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Indexed: 10/21/2022]
Abstract
Little is known about how barriers to research participation are perceived, affected by or interact with patient characteristics, or how they vary over the course of a clinical trial. Participants (285) in the Renin-Angiotensin System Study (RASS), a randomized clinical primary prevention study of diabetic nephropathy and retinopathy at 2 Canadian and 1 US university, rated potential barriers to research participation yearly for 5 years. Baseline barriers rated as most adversely affecting participation were: missing work; frequency of appointments and procedures; study length; number of appointments and procedures; access to study location; and physical discomfort associated with procedures. Inadequate social support, unstable job, and the use of alcohol and drugs were cited relatively infrequently, suggesting that although they may be important, candidates for whom these might be issues likely self-selected out of the study. Gender and gender by age interactions were found for specific perceived barriers, such as work and child care, and baseline barriers correlated with adherence. Elucidating the natural history of barriers to research participation is a step toward identifying strategies for helping participants overcome them, and ultimately may enhance the conduct of research.
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Abstract
Inhibitors of the renin-angiotensin-aldosterone system (RAS) exert beneficial effects in diabetic nephropathy, but the possibility of regression of existing renal lesions remains to be investigated. Teles et al. tested the effects of the RAS inhibitor losartan in rats starting 10 months after induction of diabetes, when glomerular lesions were already present. They linked the reductions of proteinuria with regression of mesangial expansion. More advanced lesions were not affected. There were no dose-response renal effects of losartan.
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Affiliation(s)
- Sharon Anderson
- Division of Nephrology and Hypertension, Oregon Health and Science University, Portland, Oregon, USA.
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Datz N, Rachmiel M. Highlights of the 34th annual ISPAD meeting, 13-16 August 2008, Durban, South Africa. Pediatr Diabetes 2009; 10:82-7. [PMID: 19140900 DOI: 10.1111/j.1399-5448.2008.00493.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Nicolin Datz
- Centre of Pediatric Endocrinology and Diabetes, Kinderkrankenhaus auf der Bult, Hannover, Germany.
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Affiliation(s)
- Stephen S Rich
- Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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Trojachanec J, Zafirov D, Slaninka-Miceska M, Labachevski N, Kostova E, Georgievska K, Miloschevski P, Petrov S. Role of endoethelin-1 in development of neprhopathy induced with streptozocin. MAKEDONSKO FARMACEVTSKI BILTEN 2006. [DOI: 10.33320/maced.pharm.bull.2006.52.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The main aim of our study was to detect changes in plasma level of endoethelin-1 after experimentally induced diabetes and diabetic nephropathy with streptozocin in rats. The effects of ACE inhibitors are well known and thus, we wanted to analyze the influence of enalapril (ACE inhibitor) on plasma concentrations of endoethelin-1 as well as its effects in the treatment of diabetic nephropathy. Single i.p. administration of streptozocin (STZ) caused a significant increase of endoethelin-1 plasma concentrations associated with distinct signs and symptoms of diabetic nephropathy (microalbuminuria, increased urine N-acetyl-D-glucosamidase, increased serum concentrations of urea and creatinine, polyuria). Four-week treatment with endoethelin-1 resulted in significant reduction of endoethelin-1 plasma concentrations and improved sings and symptoms of diabetic nephropathy. The results obtained have confirmed that endoethelin-1 may play an important role in development and progression of diabetic nephropathy and ACE inhibitors, that is enalapril, may alleviate and delay the progression of diabetic nephropathy
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Klein R, Zinman B, Gardiner R, Suissa S, Donnelly SM, Sinaiko AR, Kramer MS, Goodyer P, Moss SE, Strand T, Mauer M. The relationship of diabetic retinopathy to preclinical diabetic glomerulopathy lesions in type 1 diabetic patients: the Renin-Angiotensin System Study. Diabetes 2005; 54:527-33. [PMID: 15677511 DOI: 10.2337/diabetes.54.2.527] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Few epidemiological data exist regarding the correlation of anatomic measures of diabetic retinopathy and nephropathy, especially early in the disease processes. The aim of this study was to examine the association of severity of diabetic retinopathy with histological measures of diabetic nephropathy in normoalbuminuric patients with type 1 diabetes. The study included participants (n = 285) in the Renin-Angiotensin System Study (RASS; a multicenter diabetic nephropathy primary prevention trial) who were aged >/=16 years and had 2-20 years of type 1 diabetes with normal baseline renal function measures. Albumin excretion rate (AER), blood pressure, serum creatinine, and glomerular filtration rate (GFR) were measured using standardized protocols. Diabetic retinopathy was determined by masked grading of 30 degrees color stereoscopic fundus photographs of seven standard fields using the Early Treatment Diabetic Retinopathy Study (ETDRS) severity scale. Baseline renal structural parameters, e.g., fraction of the glomerulus occupied by the mesangium or mesangial fractional volume [Vv(Mes/glom)] and glomerular basement membrane width, were assessed by masked electron microscopic morphometric analyses of research percutaneous renal biopsies. No retinopathy was present in 36%, mild nonproliferative diabetic retinopathy in 53%, moderate to severe nonproliferative diabetic retinopathy in 9%, and proliferative diabetic retinopathy in 2% of the cohort. Retinopathy was not related to AER, blood pressure, serum creatinine, or GFR. All renal anatomical end points were associated with increasing severity of diabetic retinopathy, while controlling for other risk factors. These data demonstrate a significant association between diabetic retinopathy and preclinical morphologic changes of diabetic nephropathy in type 1 diabetic patients.
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Affiliation(s)
- Ronald Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin Medical School, Madison, WI, USA.
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Abstract
UNLABELLED Microalbuminuria and hypertension with Over the past decade, there has been considerable focus on the concept of microalbuminuria, not only because it predicts renal disease in type 1 and type 2 diabetes, but also because it relates to premature mortality in the diabetic and in the general population. More importantly, intervention at this stage is now possible with the perspective of preserving glomerular filtration rate (GFR) and ameliorating cardiovascular disease and ensuing strong end-points. INITIAL STUDIES: The concept of microalbuminuria was introduced about 20 years ago and since then there has been a multitude of studies and papers on this subject using the original definition, but not always, in the US. Before that time it was suggested, mainly from the US, that diabetic renal disease was an untreatable relentlessly progressive condition. GENETIC STUDIES There is an overwhelming number of studies on genetics and diabetes and also covering the genetics of diabetic complications including nephropathy. However, so far the results are extremely disappointing. Patients at risk cannot be identified and genetic analyses are of no value as a guide to treatment. The notion that the development of complications is controlled mainly by a special genetic pattern is increasingly doubtful. In genetic studies, it is rather phenotypic well-accepted risk factors that dominate. STRUCTURAL BASIS OF MICROALBUMINURIA: Patients with microalbuminuria have significant abnormalities in the kidney, including glomeruli. This is quite clear in patients with type 1 diabetes, but is also seen in type 2 diabetes, where on the other hand, other risk factors such as hypertension and dyslipidaemia also seem to be of importance, including loss of autoregulation. Renal biopsies are generally not indicated in the management of diabetic patients. MICROALBUMINURIA AND EARLY MORTALITY: It is quite clear that microalbuminuria predicts early mortality both in type 1 and type 2 diabetes. The association to other risk factors may partly explain this--but this does not account for the whole picture. Endothelial dysfunction as well as inflammatory and arteriosclerotic abnormalities in blood vessels may be a relevant hypothesis that needs to be further explored along with other possibilities. CLINICAL COURSE AND ASSOCIATED ABNORMALITIES: The risk factor for progression in normoalbuminuric patients to microalbuminuria is higher than normal albumin excretion (strongest factor), poor glycaemic control, elevated blood pressure, and to some extent smoking. The clinical course of microalbuminuria is usually progressive, but with the more effective intervention now available we encounter that the so-called natural history (without intervention) is increasingly difficult to study. Microalbuminuria is clearly associated with a number of abnormalities, almost in all organs, but GFR is generally well preserved in spite of more advanced structural lesions. Therefore, microalbuminuria is an important marker for more pronounced diabetic vascular disease in general as well as for nephropathy. Regression to normoalbuminuria only rarely occurs during standard unchanged nonintensive treatment. TREATMENT STRATEGIES: The best possible glycaemic control is important in preventing and ameliorating the course of normo- and micro-albuminuria. Another major treatment strategy, especially in microalbuminuric patients, is antihypertensive treatment including inhibition of the renal angiotensin aldosterone system. Numerous new studies are available, both in type 1 and type 2 diabetes, documenting that not only microalbuminuria but also renal and cardiovascular complications in these patient are also far better controlled by early detection and treatment. Therefore, screening for microalbuminuria should be a strategy in all diabetes management followed by effective intervention as outlined in this paper.
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Affiliation(s)
- C E Mogensen
- Medical Department M, Aarhus Kommunehospital, Aarhus University Hospital, DK-8000 Aarhus C, Denmark.
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Affiliation(s)
- John D Baxter
- The Diabetes Center, University of California, San Francisco, California 94122, USA.
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