Current Challenges in Diabetic Nephropathy: Early Diagnosis and Ways to Improve Outcomes

The Role of Angiotensin-Converting Enzyme (ACE) Polymorphisms in the Risk of Development and Treatment of Diabetic Nephropathy

BACKGROUND

Angiotensin-converting enzyme (ACE) is responsible for the production of angiotensin II, and increased production of angiotensin II is observed in diabetes. What is more, ACE polymorphisms may play a role in the development of diabetic nephropathy. The aim of this study was to assess the role of selected ACE polymorphisms (rs4343 and rs4646994) in the risk of development of diabetic nephropathy and in the likelihood of renal replacement therapy.

METHODS

ACE polymorphisms were analyzed in a group of 225 patients who were divided into three subgroups. The rs4343 polymorphism was determined using the PCR-RFLP, and the rs4646994 polymorphism was determined using the PCR. Molecular docking between domains of ACE and its ligands was performed by using AutoDock Vina.

RESULTS

The G/G genotype of rs4343 polymorphism is associated with increased odds of developing diabetic nephropathy. The G allele is also associated with a higher risk of this disease. Similar results were obtained in patients who had already had a kidney transplant as a result of diabetic nephropathy.

CONCLUSIONS

The presence of G/G and G/A genotypes, and the G allele increases the likelihood of developing diabetic nephropathy. This may also be a risk factor for renal replacement therapy.

The Role of Tubulointerstitial Markers in Differential Diagnosis and Prognosis in Patients with Type 2 Diabetes and Biopsy Proven Diabetic Kidney Disease

OBJECTIVE

To evaluate the potential application of tubularinterstitial biomarkers in the differential diagnosis of diabetic kidney disease (DKD) from non-diabetic kidney disease (NDKD), as well as investigate key clinical and pathological parameters to help improve the stratification of patients according to end-stage renal disease risk.

METHODS

132 type 2 diabetic patients with chronic kidney disease were enrolled. Patients were categorized into 2 groups according to the renal biopsy results: DKD (n=61) and NDKD (n=71).The independent factors of the occurrence of DKD and the diagnostic implications of tubular biomarkers were explored by logistic regression and receiver-operating characteristic curve analysis. Furthermore, predictors were analyzed by least absolute shrinkage and selection operator regression, and constructed a new model for predicting the unfavorable renal outcomes through Cox proportional hazard regression analysis.

RESULTS

Serum neutrophil gelatinase-associated lipocalin (sNGAL) (OR= 1.007; 95%CI = [1.003, 1.012], p = 0.001) was identified as an independent risk factor for the occurrence of DKD in diabetic patients with CKD. Tubular biomarkers including sNGAL, N-acetyl-β-D-glucosaminidase and β2 microglobulin (β2-MG) could complement albuminuria for DKD detection (AUC = 0.926, specificity = 90.14%, sensitivity = 80.33%).Moreover, among of the 47 variables, 4 predictors such as sNGAL, interstitial fibrosis and tubular atrophy (IFTA)score, β2-MG and estimated glomerular filtration rate were selected to construct a new model for predicting the unfavorable renal outcomes through regression analysis. sNGAL (HR = 1.004; 95%CI = [1.001, 1.007], p = 0.013), IFTA score of 2 (HR = 4.283; 95%CI = [1.086, 16.881], p = 0.038), and IFTA score of 3 (HR = 6.855; 95%CI = [1.766, 26.610], p = 0.005) were considered to be independent risk factors for unfavorable renal outcomes.

CONCLUSIONS

Tubulointerstitial injury in DKD is independently associated with renal function decline and routinely detected tubular biomarkers are able to enhance the level of non-invasive diagnosis of DKD beyond traditional factors.

Role of neutrophil-lymphocyte ratio as a prognostic marker for type 2 diabetic nephropathy among Indians

Diabetic nephropathy/diabetic kidney disease (DKD) is one of the leading causes of renal failure. Early identification of the development or progression of diabetic nephropathy using appropriate screening and diagnostic tools is very important in order to provide timely and proper management. Inflammation plays a crucial role in development and progression of diabetic nephropathy. The aim of this study was to evaluate the relationship of inflammatory markers (neutrophil-to-lymphocyte ratio-NLR) as an early indicator to prevent the progression of diabetic kidney disease. A total of 158 patients with type 2 diabetes mellitus were distributed into three groups according urinary albumin-to-creatinine ratio. Levels of inflammatory markers neutrophil-to-lymphocyte ratio was recorded and compared among the three groups. Significant differences were detected between the groups in terms of neutrophil-to-lymphocyte ratio (p = 0.000).Characteristic curve analysis of inflammatory markers and microalbuminuria prediction demonstrated an area under curve (AUC) of 0.869 for neutrophil-to-lymphocyte ratio (p = 0.000). A NLR cut-off point of 2.2 has 72.3 % sensitivity and 78.1 % specificity, which suggested sufficient accuracy. Increased neutrophil-to-lymphocyte ratio was significantly correlated with diabetic nephropathy progression and increased neutrophil-to-lymphocyte ratio can be considered as an early indicator and a prognostic risk marker of diabetic nephropathy.

Renal Protection of Mineralocorticoid Receptor Antagonist, Finerenone, in Diabetic Kidney Disease

Chronic kidney disease (CKD) is the most common cause of end-stage renal disease in patients with type 2 diabetes mellitus (T2DM). CKD increases the risk of cardiovascular diseases; therefore, its prevention and treatment are important. The prevention of diabetic kidney disease (DKD) can be achieved through intensive glycemic control and blood pressure management. Additionally, DKD treatment aims to reduce albuminuria and improve kidney function. In patients with T2DM, renin-angiotensin-aldosterone system inhibitors, sodium glucose cotransporter 2 inhibitors, and glucagon-like peptide-1 receptor agonists can delay the progression of DKD. Hence, there is a need for novel treatments that can effectively suppress DKD progression. Finerenone is a first-in-class nonsteroidal mineralocorticoid receptor antagonist with clinically proven efficacy in improving albuminuria, estimated glomerular filtration rate, and risk of cardiovascular events in early and advanced DKD. Therefore, finerenone is a promising treatment option to delay DKD progression. This article reviews the mechanism of renal effects and major clinical outcomes of finerenone in DKD.

Pyruvate Kinase M2: A New Biomarker for the Early Detection of Diabetes-Induced Nephropathy

Diabetic nephropathy (DN) is a common complication of diabetes. DN progresses to end-stage renal disease, which has a high mortality rate. Current research is focused on identifying non-invasive potential biomarkers in the early stage of DN. We previously indicated that pyruvate kinase M2 (PKM2) is excreted in the urine of rats after cisplatin-induced acute kidney injury (AKI). However, it has not been reported whether PKM2 can be used as a biomarker to diagnose DN. Therefore, we try to compare whether the protein PKM2 can be detected in the urine samples from diabetic patients as shown in the results of DN models. In this study, high-fat diet (HFD)-induced Zucker diabetic fatty (ZDF) rats were used for DN phenotyping. After 19 weeks of receiving a HFD, the DN model's blood glucose, blood urea nitrogen, and serum creatinine levels were significantly increased; severe tubular and glomerular damages were also noted. The following protein-based biomarkers were increased in the urine of these models: kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), and PKM2. PKM2 had the earliest detection rate. In the urine samples of patients, PKM2 protein was highly detected in the urine of diabetic patients but was not excreted in the urine of normal subjects. Therefore, PKM2 was selected as the new biomarker for the early diagnosis of DN. Our results reflect current knowledge on the role of PKM2 in DN.

Acrolein plays a culprit role in the pathogenesis of diabetic nephropathy in vitro and in vivo

OBJECTIVE

Diabetic nephropathy (DN), also known as diabetic kidney disease (DKD), is a major chronic complication of diabetes and is the most frequent cause of kidney failure globally. A better understanding of the pathophysiology of DN would lead to the development of novel therapeutic options. Acrolein, an α,β-unsaturated aldehyde, is a common dietary and environmental pollutant.

DESIGN

The role of acrolein and the potential protective action of acrolein scavengers in DN were investigated using high-fat diet/ streptozotocin-induced DN mice and in vitro DN cellular models.

METHODS

Acrolein-protein conjugates (Acr-PCs) in kidney tissues were examined using immunohistochemistry. Renin-angiotensin system (RAS) and downstream signaling pathways were analyzed using quantitative RT-PCR and Western blot analyses. Acr-PCs in DN patients were analyzed using an established Acr-PC ELISA system.

RESULTS

We found an increase in Acr-PCs in kidney cells using in vivo and in vitro DN models. Hyperglycemia activated the RAS and downstream MAPK pathways, increasing inflammatory cytokines and cellular apoptosis in two human kidney cell lines (HK2 and HEK293). A similar effect was induced by acrolein. Furthermore, acrolein scavengers such as N-acetylcysteine, hydralazine, and carnosine could ameliorate diabetes-induced kidney injury. Clinically, we also found increased Acr-PCs in serum samples or kidney tissues of DKD patients compared to normal volunteers, and the Acr-PCs were negatively correlated with kidney function.

CONCLUSIONS

These results together suggest that acrolein plays a role in the pathogenesis of DN and could be a diagnostic marker and effective therapeutic target to ameliorate the development of DN.

Network pharmacology and molecular docking technology-based predictive study of the active ingredients and potential targets of rhubarb for the treatment of diabetic nephropathy

Diabetic nephropathy (DN) is one of the most serious complications of diabetes and the main cause of end-stage renal failure. Rhubarb is a widely used traditional Chinese herb, and it has exhibited efficacy in reducing proteinuria, lowering blood sugar levels and improving kidney function in patients with DN. However, the exact pharmacological mechanism by rhubarb improves DN remain unclear due to the complexity of its ingredients. Hence, we systematically explored the underlying mechanisms of rhubarb in the treatment of DN. We adopted a network pharmacology approach, focusing on the identification of active ingredients, drug target prediction, gene collection, Gene Ontology enrichment and Kyoto Encyclopedia of Genes and Genomes enrichment. Molecular docking technology was used to verify the binding ability between the main active compounds and central therapeutic targets, and screen out the core active ingredients in rhubarb for the treatment of DN. Finally, molecular dynamics simulation was performed for the optimal core protein-ligand obtained by molecular docking using GROMACS software. The network analysis identified 16 active compounds in rhubarb that were linked to 37 possible therapeutic targets related to DN. Through protein–protein interaction analysis, TP53, CASP8, CASP3, MYC, JUN and PTGS2 were identified as the key therapeutic targets. By validation of molecular docking, finding that the central therapeutic targets have good affinities with the main active compounds of rhubarb, and rhein, beta-sitosterol and aloe-emodin were identified as the core active ingredients in rhubarb for the treatment of DN. Results from molecular dynamics simulations showed that TP53 and aloe-emodin bound very stably with a binding free energy of − 26.98 kcal/mol between the two. The results of the gene enrichment analysis revealed that the PI3K-Akt signalling pathway, p53 signalling pathway, AGE-RAGE signalling pathway and MAPK signalling pathway might be the key pathways for the treatment of DN, and these pathways were involved in podocyte apoptosis, glomerular mesangial cell proliferation, inflammation and renal fibrosis. Based on the network pharmacology approach and molecular docking technology, we successfully predicted the active compounds and their respective targets. In addition, we illustrated the molecular mechanisms that mediate the therapeutic effects of rhubarb against DN. These findings provided an important scientific basis for further research of the mechanism of rhubarb in the treatment of DN.

Proteinuria as a significant predictive factor for the progression of carotid artery atherosclerosis in non-albuminuric type 2 diabetes

AIMS

This study aimed to evaluate the clinical significance of urine protein to creatinine ratio (uPCR) in relation to the cardiovascular risk associated with carotid artery intima-media thickness (cIMT) progression in subjects with type 2 diabetes (T2D) and normoalbuminuria.

METHODS

In this retrospective longitudinal study on T2D, we recruited 927 participants with normoalbuminuria (urine albumin to creatinine ratio [uACR] < 30 mg/g) whose cIMT was measured at baseline and after at least 1 year, and whose initial uPCR and uACR data were available.

RESULTS

Higher initial uPCR was positively correlated with a greater increment in maximal cIMT (β = 0.074, p = 0.028), and this correlation was significant even after adjusting for multiple confounding factors (β = 0.074, p = 0.046). High baseline uPCR was an independent predictive factor for the increased risk of maximal cIMT progression in a simple logistic regression model (OR, 1.41; 95% CI, [1.08-1.86]; p = 0.013). Even after adjusting for several confounding variables, higher uPCR was significantly associated with a higher risk of cIMT progression (OR, 1.48; 95% CI, [1.08-2.03]; p = 0.014).

CONCLUSIONS

These results suggest that high uPCR may be a useful predictive marker for the progression of carotid artery atherosclerosis, even in subjects with T2D and without albuminuria.

Sodium-glucose cotransporter 2 inhibitors benefit to kidney and cardiovascular outcomes for patients with type 2 diabetes mellitus and chronic kidney disease 3b-4: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

A systematic review and meta-analysis was performed to assess the kidney and cardiovascular (CV) outcomes of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) stage 3b-4.

METHOD

We conducted a systematic review and meta-analysis of randomized, placebo-controlled trials (RCTs). Medline, Embase, and the Cochrane Central were searched for available trials up to Jan 18, 2021.

RESULTS

From identifying 1892 citations, we included nine studies into quantitative analyses with a total of 6521 participants. In the patients with T2DM and CKD stage 3b-4, SGLT2 inhibitors significantly decreased the risk of the primary kidney outcome (HR 0.65, 95% CI 0.55-0.76) and slowed the decline in eGFR slope with a difference between treatment and control of 0.46 ml/min/1.73 m2 per year (95% CI 0.37-0.55). SGLT2 inhibitors also reduced the risk of the major adverse cardiovascular events (MACE) (HR 0.75, 95% CI 0.60-0.93).

CONCLUSIONS

SGLT2 inhibitors can reduce the risk of kidney disease and MACE outcomes for patients with T2DM and CKD stage 3b-4, which may be the most beneficial effects observed in the included trials.

Amelioration of STZ-induced nephropathy in diabetic rats by saffron hydro alcoholic extract

OBJECTIVES

Type 1 diabetes is one of the most important causes of microvascular complications such as nephropathy. On other hand, the use of herbal medicines is more affordable and has fewer side effects. Therefore, this study was conducted to assessment the therapeutic effect of saffron in diabetic nephropathy by regulating the expression of CTGF and RAGE genes as well as oxidative stress in rats with type 1 diabetes.

METHODS

In this study, we used 24 Wistar rats in four groups. To induce diabetes, we used a 55 mg/kg.bw dose of streptozotocin intraperitoneally. Type 1 diabetic rats were administered saffron (20 and 40 mg/kg/day) by gavage once daily for 42 days. Finally, serum urea, creatinine, albumin and SOD, MDA levels in kidney tissue were measured using spectrophotometric methods and CTGF and RAGE gene expression in kidney tissue was measured using real-time PCR method.

RESULTS

Diabetes significantly increases serum FBG, urea, creatinine and decreases albumin (p<0.001). AS well as increased the CTGF and RAGE genes expression, MDA level and decreased the SOD activity in the kidney tissue (p<0.001). Serum urea, creatinine, albumin was significantly ameliorated by saffron (p<0.001). It was shown the saffron significantly decrease the kidney expression CTGF and RAGE genes and MDA level and increased the SOD activity (p<0.001). Also, it was found that the beneficial effects of the saffron were dose-dependent (p<0.05).

CONCLUSIONS

The results of this study suggest that saffron as an adjunct therapy may prevent development and treatment of diabetic nephropathy by regulating the expression of the CTGF and RAGE genes and oxidative stress.

Blood Oxygen Level-Dependent (BOLD) MRI in Glomerular Disease

Renal hypoxia has recently been implicated as a key contributor and indicator of various glomerular diseases. As such, monitoring changes in renal oxygenation in these disorders may provide an early diagnostic advantage that could prevent potential adverse outcomes. Blood oxygen level-dependent magnetic resonance imaging (BOLD MRI) is an emerging noninvasive technique for assessing renal oxygenation in glomerular disease. Although BOLD MRI has produced promising initial results for the use in certain renal pathologies, the use of BOLD imaging in glomerular diseases, including primary and secondary nephrotic and nephritic syndromes, is relatively unexplored. Early BOLD studies on primary nephrotic syndrome, nephrotic syndrome secondary to diabetes mellitus, and nephritic syndrome secondary to systemic lupus erythematosus have shown promising results to support its future clinical utility. In this review, we outline the advancements made in understanding the use of BOLD MRI for the assessment, diagnosis, and screening of these pathologies.

Probiotics ameliorates glycemic control of patients with diabetic nephropathy: A randomized clinical study

OBJECTIVE

This research aimed to explore the effects of probiotic administration on glycemic control and renal function in patients with diabetic nephropathy (DN).

METHODS

The 101 participants were randomly divided into two treatment groups and 76 patients were included in the final analysis. In 76 patients with diabetic nephropathy of type 2 diabetes, a randomized double-blind and placebo-controlled clinical trial was conducted to evaluate the administration of 3.2 × 109  CFU probiotic supplements per day (Bifidobacterium bifidum, 1.2 × 109  CFU, Lactobacillus acidophilus 4.2 × 109  CFU, Streptococcus thermophilus 4.3 × 109  CFU) for 12 weeks on glycemic control of patients, including fasting blood glucose, 2 h postprandial blood glucose, glycosylated hemoglobin (HbA1c), microalbuminuria/creatinine (mAlb/Cr) and estimated glomerular filtration rate (eGFR) levels. The placebo group daily received empty capsules filled with starch.

RESULTS

After 12 weeks, the administration of probiotics demonstrated a significant reduction in fasting blood glucose (10.68 ± 3.24 mmol/L before vs. 7.81 ± 2.77 mmol/L after, p < 0.05), HbA1c (8.19 ± 1.60% before vs. 7.32 ± 1.20% after, p < 0.05) and mAlb/Cr (101.60 ± 22.17 mg/g before vs. 67.53 ± 20.11 mg/g after, p < 0.05), while only mAlb/Cr level was significantly lower in the probiotic group than in the placebo group after intervention (67.53 ± 20.11 mg/g vs. 87.71 ± 23.01, p < 0.05). Meanwhile, there was no significant reduction of 2 h postprandial blood glucose level (18.95 ± 5.23 mmol/L vs. 17.35 ± 6.28 mmol/L, p = 0.24) and eGFR (84.34 ± 6.97 ml/min vs. 82.8 ± 8.72 ml/min, p = 0.45) in patients before and after probiotic intake. In addition, the placebo group failed to show any significant change of these parameters.

CONCLUSION

This clinical study revealed probiotic administration could ameliorate glycemic control of patients with diabetic nephropathy, potentiating its therapeutic potential in clinical application.

Exosomes: Biomarkers and Therapeutic Targets of Diabetic Vascular Complications

Diabetic vascular complications (DVC) including macrovascular and microvascular lesions, have a significant impact on public health, and lead to increased patient mortality. Disordered intercellular cascades play a vital role in diabetic systemic vasculopathy. Exosomes participate in the abnormal signal transduction of local vascular cells and mediate the transmission of metabolic disorder signal molecules in distant organs and cells through the blood circulation. They can store different signaling molecules in the membrane structure and release them into the blood, urine, and tears. In recent years, the carrier value and therapeutic effect of exosomes derived from stem cells have garnered attention. Exosomes are not only a promising biomarker but also a potential target and tool for the treatment of DVC. This review explored changes in the production process of exosomes in the diabetic microenvironment and exosomes' early warning role in DVC from different systems and their pathological processes. On the basis of these findings, we discussed the future direction of exosomes in the treatment of DVC, and the current limitations of exosomes in DVC research.

The Role of Mesenchymal Stromal Cells-Derived Small Extracellular Vesicles in Diabetes and Its Chronic Complications

Mesenchymal stromal cells (MSCs) are applied in regenerative medicine of several tissues and organs nowadays by virtue of their self-renewal capabilities, multiple differentiation capacity, potent immunomodulatory properties, and their ability to be favourably cultured and manipulated. With the continuous development of "cell-free therapy" research, MSC-derived small extracellular vesicles (MSC-sEVs) have increasingly become a research hotspot in the treatment of various diseases. Small extracellular vesicles (SEVs) are membrane vesicles with diameters of 30 to 150 nm that mediate signal transduction between adjacent or distal cells or organs by delivering non-coding RNA, protein, and DNA. The contents and effects of sEVs vary depending on the properties of the originating cell. In recent years, MSC-sEVs have been found to play an important role in the occurrence and development of diabetes mellitus as a new way of communication between cells. Diabetes mellitus is a common metabolic disease in clinic. Its complications of the heart, brain, kidney, eyes, and peripheral nerves are a serious threat to human health and has been a hot issue for clinicians. MSC-sEVs could be applied to repair or prevent damage from the complications of diabetes mellitus through anti-inflammatory effects, reduction of endoplasmic reticulum-related protein stress, polarization of M2 macrophages, and increasing autophagy. Therefore, we highly recommend that MSC-sEVs-based therapies to treat diabetes mellitus and its chronic complication be further explored. The analysis of the role and molecular mechanisms of MSC-sEVs in diabetes and its related complications will provide new idea and insights for the prevention and treatment of diabetes.

Efficacy and safety of Shenkang injection as adjuvant therapy in patients with diabetic nephropathy: A protocol for systematic review and meta-analysis

BACKGROUND

Diabetic nephropathy is a frequent microvascular complication of diabetes mellitus that causes end-stage renal disease most of the time. In China, Shenkang injection is one of widely used traditional Chinese medicine for treating chronic kidney disease, but its efficacy and safety have not yet been clarified. We will systematically review the current randomized controlled trial (RCT) evidence to summarize the efficacy and safety of Shenkang injection in treating diabetic nephropathy.

METHODS

We will search 7 literature databases including PubMed, EMBASE, Cochrane Library, Sinomed, Chinese National Knowledge Infrastructure, Wanfang, and VIP. Two trial registry platforms will also be searched. The time frame of the search will be from the inceptions of the databases to December 31, 2020. RCTs assessing Shenkang injection combined with basic treatments versus basic treatments alone for treating diabetic nephropathy will be included. The risk of bias within the individual RCTs will be evaluated using criteria proposed by the Cochrane Handbook 5.1.0. The primary outcomes to be investigated are glomerular filtration rate and serum creatinine; the secondary outcome will include 24-hour urine albumin excretion rate, blood urea nitrogen, fasting blood glucose, postprandial blood glucose, hemoglobin A1c, total cholesterol, triglyceride, response to treatment, and incidence of adverse events. The effect data of individual RCTs by performing random-effects model meta-analysis. Statistical heterogeneity will be measured by the Cochran Q test and I-squared statistics. Three subgroup analyses, set based on clinical experience, will be performed to explore the sources of heterogeneity. Sensitivity analyses excluding RCTs with high risk of bias and using fixed effect model will be done to test the robustness of the meta-analytic results. Publication bias across included RCTs will be evaluated by funnel plots and Egger test.

RESULTS

This study will provide systematic review on the efficacy and safety of Shenkang Injection as adjuvant therapy in patients with diabetic nephropathy by rigorous quality assessment and reasonable data synthesis. The results will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This systematic review will provide the best evidence currently on Shenkang Injection as adjuvant therapy in patients with diabetic nephropathy.

INPLASY REGISTRATION NUMBER

INPLASY2020110014.

Urinary proteins detected using modern proteomics intervene in early type 2 diabetic kidney disease – a pilot study

Aim: An advanced proteomics platform for protein biomarker discovery in diabetic chronic kidney disease (DKD) was developed, validated and implemented. Materials & methods: Three Type 2 diabetes mellitus patients and three control subjects were enrolled. Urinary peptides were extracted, samples were analyzed on a hybrid LTQ-Orbitrap Velos Pro instrument. Raw data were searched using the SEQUEST algorithm and integrated into Proteome Discoverer platform. Results & discussion: Unique peptide sequences, resulted sequence coverage, scoring of peptide spectrum matches were reported to albuminuria and databases. Five proteins that can be associated with early DKD were found: apolipoprotein AI, neutrophil gelatinase-associated lipocalin, cytidine deaminase, S100-A8 and hemoglobin subunit delta. Conclusion: Urinary proteome analysis could be used to evaluate mechanisms of pathogenesis of DKD.

Assessment of urinary NGAL for differential diagnosis and progression of diabetic kidney disease

OBJECTIVE

Chronic kidney disease (CKD) related to diabetes has become more common than glomerulonephritis in recent years. Given the inefficient and difficult identification of diabetic kidney disease (DKD) from non-diabetic kidney disease (NDKD) as well as a result of emerging evidence supporting a role for tubular involvement in DKD, we aimed to investigate the utility of urinary neutrophil gelatinase-associated lipocalin (uNGAL) in the differential diagnosis and predictive value of DKD from NDKD.

METHODS

Data for 100 type 2 diabetic patients with CKD at our center from June 2016 to August 2019 were reviewed. All the patients were categorized into 2 groups by the renal biopsy results: DKD and NDKD. Urinary NGAL levels were normalized by urinary creatinine and calculated as uNGAL/creatinine ratios (uNCR). The independent factors of the occurrence of DKD and the diagnostic implications of uNCR were explored by logistic regression and receiver-operating characteristic (ROC) curve analysis. In addition, we analyzed the relationship between uNCR and proteinuria in patients with DKD by Pearson test and linear regression. Kaplan-Meier survival analysis was performed to assess the prospective association of uNCR with the renal outcome.

RESULTS

Significantly higher levels of uNCR were observed in patients with DKD when compared to those with NDKD (28.65 ng/mg vs 27.47 ng/mg, p< .001). uNCR was identified as an independent risk factor for the occurrence of DKD in diabetic patients with CKD (odds ratio [OR] = 1.020; 95%CI = [1.001-1.399], p = .042). The optimal cutoff value of uNCR for predicting DKD was 60.685 ng/mg with high specificity (90.5%) but relatively low sensitivity (55.7%). In Pearson test, uNCR was positively correlated with proteinuria, serum creatine, blood urea nitrogen, duration of diabetes, interstitial inflammation score and global sclerosis, whereas it was inversely correlated with eGFR, hemoglobin, serum albumin and 25-hydroxy vitamin D. Furthermore, in a fully adjusted model including eGFR, serum albumin and total cholesterol, the group with uNCR>60.685 ng/mg was associated with 7.595 times higher likelihood of nephrotic-range proteinuria compared to the group with uNCR≤60.685 ng/mg. In the Kaplan-Meier survival analysis, the event-free survival probability in patients with uNCR>60.685 ng/mg was significantly lower than those with uNCR≤60.685 ng/mg (p = .048).

CONCLUSIONS

uNCR might serve as a potential tool for identifying cases in which there was a high clinical suspicion of DKD and that in whom confirmatory biopsy could be considered, and the best predictive cutoff value of normalized uNCR for DKD diagnosis was 60.685 ng/mg. Type 2 diabetic patients with increased level of uNCR had higher risk to nephrotic-range proteinuria and worse renal outcome.

Coffee Consumption is Associated with a Decreased Risk of Incident Chronic Kidney Disease: A Systematic Review and Meta-analysis of Cohort Studies

BACKGROUND

Recent studies have suggested a renal protective effect of coffee consumption against development of chronic kidney disease (CKD) although the results remain inconclusive. This systematic review and meta-analysis aimed to comprehensively investigate this association by summarizing all available data.

METHODS

A systematic review was performed using MEDLINE and EMBASE database from inception to November 2019 to identify all cohort studies that compared the risk of developing CKD after index date among coffee-drinkers versus non-drinkers. Pooled risk ratio and 95% confidence interval (CI) were calculated using random-effect, generic inverse-variance method of DerSimonian and Laird.

RESULTS

A total of 4 cohort studies comprising of 25,849 participants met the inclusion criteria and were analyzed in the meta-analysis. The meta-analysis found a significantly decreased risk of incident CKD among coffee-drinkers compared with non-drinkers with the pooled risk ratio of 0.87 (95% CI, 0.81-0.95; I² of 57%). The funnel plot of this study was relatively symmetric and was not indicative of publication bias CONCLUSIONS: A significant association between coffee consumption and a lower risk of incident CKD was demonstrated in this study.

Link between ACE I/D Gene Polymorphism and Dyslipidemia in Diabetic Nephropathy: A Case-control Study from Hyderabad, India

Introduction:

Diabetic nephropathy (DN) is the commonest single cause of end-stage renal failure, and dyslipidemia is a critical risk factor in the occurrence of DN. In the light of recent reports emphasizing the importance of angiotensin I-converting enzyme (ACE) in the modulation of plasma lipids, we sought to evaluate the influence of ACE I/D gene polymorphism with dyslipidemia status among type 2 diabetic (T2D) patients with and without nephropathy in the genetic predisposition and the progression to DN.

Method:

This study comprised of 600 subjects, which include patients with DN, T2D, and healthy controls (HC). Polymerase chain reaction based genotyping of ACE I/D polymorphism was performed and appropriate statistical analysis was done.

Results:

Out of the 600 subjects, 20 (10%) of the HC, 73 (36.5%) of the T2D group, and 125 (62.5%) of the DN subjects had dyslipidemia. The D allele (0.62) and DD (42.5) genotype frequencies were higher in the DN group in comparison with T2D and HC (P < 0.05). The genotypes also varied among patients with dyslipidemia (χ² 5.04; P < 0.05) but not in the non-dyslipidemia group. Under the co-dominant model, DD genotype conferred a risk of 1.26 (P < 0.001) toward DN, whereas the ID genotype offered protection from DN among the dyslipidemic subjects (OR = 0.05; P < 0.01). In addition, genotype-dependent difference was seen in the plasma lipid levels among study groups. A multiple logistic regression analysis revealed male gender, BMI, HbA1c, TG, HDL, and ACE DD genotype as independent risk factors for the development of DN.

Conclusion:

The study showed a significant predisposing association of ACE DD genotype with DN and protective effect of ID genotype on DN in the dyslipidemia subgroup.

A meta-analysis of serum Hcy in diagnosis of diabetic nephropathy

Objective This meta-analysis aims to investigate the diagnostic performance of serum homocysteine (Hcy) as a biomarker for diabetic nephropathy (DN).

Methods Clinical publications relevant to serum Hcy level and DN were systematic searched in the electronic databases of; Pubmed, Cochrane Library, Embase, Web of science, CNKI and CBM. The diagnostic data from each included original study was extracted and pooled by the effect size of diagnostic sensitivity, specificity, positive likely hood ratio (+LR), negative likely hood ratio (-LR), diagnostic odds ratio (DOR) and area under the symmetric ROC curve (AUC).

Results 18 publications relevant to serum Hcy and DN were included in the meta-analysis. The I2 test demonstrated significant statistical heterogeneity across the 18 studies for the effect size of diagnostic. The pooled diagnostic sensitivity, specificity, +LR, -L, DOR, AUC were 0.76 (95%CI: 0.74-0.78), 0.84 (95%CI:0.82-0.86), 5.05 (95%CI:3.52-7.24), 0.27 (95%CI:0.19-0.39), 21.68 (95% CI:11.15to 42.14) and 0.90 respectively in the random effect model.

Conclusion Based on the present publications, serum Hcy is a promising serological marker for DN diagnosis.

Understanding molecular upsets in diabetic nephropathy to identify novel targets and treatment opportunities

Diabetes and related complications are becoming a global encumbrance. Diabetic nephropathy (DN) is a major cause of end-stage renal disease (ESRD). The available therapeutic modalities related to DN do not treat DN at the molecular level, proposing further amendments in the management of DN based on the pathogenesis of DN. This manuscript discusses the concept and applications of nanomedicine for the treatment of DN that can improve renal targeting, retention and localization. This review also highlights the current issues related to targeting DN, challenges and allied opportunities toward the development of next-generation drugs and treatments for the management of DN.

Preparation of Ergosterol-Loaded Nanostructured Lipid Carriers for Enhancing Oral Bioavailability and Antidiabetic Nephropathy Effects

In our previously studies, we confirmed that ergosterol could ameliorate diabetic nephropathy by suppressing the proliferation of mesangial cells and the accumulation of extracellular matrix (ECM). However, the therapeutic application of ergosterol may be confined due to poor aqueous solubility and low oral bioavailability. We aim to prepare ergosterol-loaded nanostructured lipid carriers (ERG-NLCs) to enhance the solubility and oral bioavailability of ergosterol. ERG-NLCs were prepared using glyceryl monostearate and decanoyl/octanoyl-glycerides by hot emulsification-ultrasonication method and characterized by dynamic light scattering (DLS), transmission electron microscopy (TEM), differential scanning calorimetry (DSC), powder X-ray diffraction (PXRD) analysis, entrapment efficiency (EE), and drug loading (DL) capacity studies. The prepared ERG-NLCs were spherical, with particle size of 81.39 nm and negative zeta potential of 30.77 mV. Ergosterol was successfully encapsulated in NLCs with a high EE of 92.95% and a DL capacity of 6.51%. In pharmacokinetic study, C_max and AUC_0-∞ of ergosterol in ERG-NLCs were obviously enhanced, and the relative oral bioavailability of ERG-NLCs was 277.56% higher than that of raw ergosterol. Moreover, the in vitro pharmacodynamic study indicated that ERG-NLCs inhibited high-glucose-stimulated mesangial cells over proliferation and ECM accumulation more effectively compared to raw ergosterol. In conclusion, the validated ERG-NLCs showed that NLCs mediated delivery could be used as potential vehicle to enhance solubility, oral bioavailability and therapeutic efficacy of ergosterol.

Serum Homocysteine, cystatin C as Biomarkers for Progression of Diabetic Nephropathy

Objective To investigate the clinical efficacy of serological level homocysteine (Hcy) and cystatin C (Cys-C) as biomarkers for progression of diabetic nephropathy (DN).

Methods Seventy-five patients with type 2 diabetes mellitus (DM) hospitalized in Lishui People’s Hospital from January 2015 to May 2018 were included in the present study. Of the 75 cases, 28 were simple DM, 25 were early stage DN (DNe) and other 22 subjects were clinical stage DN (DNc). The serum level of Hcy and Cys-C were detected and compared among the DM, DNe and DNc groups. The efficacy of serological levels of Hcy, and Cys-C as biomarkers for diagnosis of early stage diabetic nephropathy was calculated.

Results The serological levels of Hcy were 11.53±3.05 μmol/L, 15.39±4.58 μmol/L and 18.14±7.03 μmol/L for DM, DNe and DNc groups respectively (P<0.001). Serum level of Cys-C, were 0.89±0.23 mg/L, 1.51±0.60 mg/L and 2.63±0.90 mg/L respectively for DM, DNe and DNc groups respectively (P<0.001). Significant positive correlation between serum Cys-C and Hcy was detected in DNe (rpearson=0.55, P=0.004) and DNc (rpearson=0.44, P=0.04) groups. However, there was no significant correlation of serological Cys-C and Hcy in DM group (rpearson=0.08, P=0.70). The sensitivity and specificity in diagnosis of early stage DN were 76.0 (95%CI:54.87-90.64)%, 64.29 (544.07-81.36)% for serological Hcy and 80.0 (559.30-93.17)%, 89.29 (571.77-97.73)% for serum Cys-C respectively. The diagnostic area under the ROC curve (AUC) was 0.76 (0.63 to 0.90) and 0.84 (0.72-0.96) respectively for serum Hcy and Cys-C in detection early stage DN.

Conclusion: Serum levels of Hcy and Cys-C in diabetic nephropathy patients were elevated compared to that of simple DM cases, making them potential biomarkers for diagnosis of early DN from DM patients.

Carbon dots as fluorescent nanoprobe for the determination of N-acetyl-β-d-glucosaminidase activity

Carbon dots (CDs) were synthesized from p-aminophenol and ethylenediamine via one-step under mild condition and used as a sensitive fluorescent nanoprobe for the activity determination of N-acetyl-β-d-glucosaminidase (NAG). In this assay, p-nitrophenol was in situ produced from p-nitrophenyl-β-D-N-acetyl-glucosaminide, which was exclusively hydrolyzed by NAG. The UV absorption peak of p-nitrophenol (maximum at 400 nm) overlapped the excitation peak of CDs with maximum wavelength at 415 nm, which caused the fluorescence decline of CDs based on inner filter effect. The activity of NAG was determined by the fluorescence changes. The assay is highly sensitive to NAG with a low detection limit of 0.75 U L^-1 (K = 3) and showed a good linear relationship in the range from 1 to 45 U L^-1. This CDs nanoprobe was successfully applied for the determination of NAG activity in human serum and urine samples.

A Nucleoside/Nucleobase-Rich Extract from Cordyceps Sinensis Inhibits the Epithelial-Mesenchymal Transition and Protects against Renal Fibrosis in Diabetic Nephropathy

Cordyceps Sinensis, a traditional Chinese medicine and a healthy food, has been used for the treatment of kidney disease for a long time. The aim of present study was to isolate a nucleoside/nucleobase-rich extract from Cordyceps Sinensis (CS-N), determine the contents of nucleosides and nucleobases, and explore its anti-diabetic nephropathy activity. CS-N was isolated and purified by using microporous resin and glucan columns and the unknown compounds were identified by using HPLC-DAD and LC-MS. The effects of CS-N on the epithelial-mesenchymal transition (EMT), extracellular matrix (ECM) depositions, and the MAPK signaling pathway were evaluated in streptozotocin (STZ)-induced diabetic mice and high glucose (HG)-exposed HK-2 cells. CS-N significantly attenuated the abnormity of renal functional parameters, ameliorated histopathological changes, and inhibited EMT and ECM accumulation by regulating p38/ERK signaling pathways. Our findings indicate that CS-N exerts a therapeutic effect on experimental diabetic renal fibrosis by mitigating the EMT and the subsequent ECM deposition with inhibition of p38 and ERK signaling pathways.

Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Renal Outcomes in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This study was conducted to investigate the effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors on individual renal outcomes in patients with type 2 diabetes. We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to September 2017 to identify randomized controlled trials comparing SGLT2 inhibitors with placebo or antidiabetic drugs and reporting any renal outcomes in patients with type 2 diabetes. Additionally, we identified 4 articles which were published after the predefined period to include relevant data. A meta-analysis was performed to calculate weighted mean differences (WMDs) and relative risks (RRs) with 95% confidence intervals (CIs) for each renal outcome. We included 48 studies involving 58,165 patients in the analysis. SGLT2 inhibitors significantly lowered urine albumin-to-creatinine ratio (UACR) (WMD, −14.64 mg/g; 95% CI, −25.15 to −4.12; P = 0.006) compared with controls. The UACR-lowering effects of SGLT2 inhibitors were greater with a higher baseline UACR. Overall changes in estimated glomerular filtration rate (eGFR) were comparable between two groups (WMD, 0.19 mL/min/1.73 m²; 95% CI, −0.44 to 0.82; P = 0.552). However, SGLT2 inhibitors significantly slowed eGFR decline in patients with a higher baseline eGFR and a longer duration of treatment. Compared with controls, SGLT2 inhibitors significantly reduced the risk of microalbuminuria (RR, 0.69; 95% CI, 0.49 to 0.97; P = 0.032), macroalbuminuria (RR, 0.49; 95% CI, 0.33 to 0.73; P < 0.001), and worsening nephropathy (RR, 0.73; 95% CI, 0.58 to 0.93; P = 0.012). In addition, the risk of end-stage renal disease was significantly lower in SGLT2 inhibitors than in controls (RR, 0.70; 95% CI, 0.57 to 0.87; P = 0.001). In conclusion, SGLT2 inhibitors had beneficial renal effects by lowering the risk of albuminuria development or progression and reducing the risk of end-stage renal disease compared with placebo or other antidiabetic drugs.

Lack of Association between Past Helicobacter pylori Infection and Diabetes: A Two-Cohort Study

Helicobacter pylori (H. pylori) may be involved in diabetes and other insulin-related processes. This study aimed to investigate the associations between H. pylori infection and the risks of type 2 diabetes, impaired glucose tolerance (IGT), diabetic nephropathy, and poor glycemic control. We retrospectively evaluated 16,091 subjects without diabetes at baseline who underwent repeated health examinations. Subjects were categorized according to whether they were seropositive and seronegative for H. pylori infection. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazard models. The serological results were validated using an independent cohort (n = 42,351) based on a histological diagnosis of H. pylori infection. During 108,614 person-years of follow-up, 1338 subjects (8.3%) developed newly diagnosed diabetes, although the cumulative incidence of diabetes was not significantly related to serological H. pylori status. The multivariate Cox proportional-hazards regression models revealed that H. pylori seropositivity was not significantly associated with diabetes (HR: 1.01, 95% CI: 0.88–1.16; p = 0.854), IGT (HR: 0.98, 95% CI: 0.93–1.04; p = 0.566), diabetic nephropathy (HR: 0.99, 95% CI: 0.82–1.21; p = 0.952), or poor glycemic control (HR: 1.05, 95% CI: 0.90–1.22; p = 0.535). Similarly, histopathological findings of H. pylori infection were not significantly associated with diabetes (p = 0.311), diabetic nephropathy (p = 0.888), or poor glycemic control (p = 0.989). The findings from these large Korean cohorts indicate that there does not appear to be a role for past H. pylori infection in the development of diabetes, IGT, diabetic nephropathy, or poor glycemic control.

Association between nonalbumin proteinuria and renal tubular damage of N-acetyl-β-d-glucosaminidase and its clinical relevance in patients with type 2 diabetes without albuminuria

AIM

Although albuminuria and urinary N-acetyl-β-d-glucosaminidase (uNAG) are known as progression markers of diabetic kidney disease, there is limited information regarding the association between urinary nonalbumin proteinuria (NAP) and uNAG and the clinical relevance thereof in patients without albuminuria.

METHODS

This cross-sectional study included samples from 244 consecutive patients with type 2 diabetes mellitus (T2D) without albuminuria. Proteinuria and albuminuria were defined according to protein-to-creatinine ratio (uPCR) and albumin-to-creatinine ratio (uACR), respectively. NAP was indirectly calculated by the difference between uPCR and uACR.

RESULTS

NAP and uNAG excretion were significantly correlated (r = 0.525, P < 0.001). Individuals whose NAP levels were in the highest tertile had a longer duration of diabetes, uncontrolled hyperglycemia, and impaired insulin stimulation (all P < 0.05), although more patients in the highest NAP tertile were prescribed insulin and sulfonylurea. Multiple linear regression analyses revealed associations among uNAG, diabetes duration, and waist circumference.

CONCLUSIONS

T2D patients without albuminuria excrete proteinuria and that presence of the protein in urine is associated with uNAG. NAP was positively correlated with T2D duration and waist circumference, but negatively correlated with body mass index. Lean, but centrally obese, T2D patients in late diabetes experience more tubular damage, regardless of the presence of albuminuria.

Serum leptin in diabetic nephropathy male patients from Gaza Strip

OBJECTIVE

To assess serum leptin in diabetic nephropathy male patients from Gaza Strip.

MATERIALS AND METHODS

This case-control study comprised 132 type 2 diabetic patients and 44 non-diabetic controls. The diabetic patients were classified into three groups; 44 normoalbuminurics, 44 microalbuminurics and 44 macroalbuminurics. Data were obtained from questionnaire interview, and biochemical analysis of blood and urine samples. Patients and controls were matched for age and body mass index (BMI).

RESULTS

Serum leptin was significantly higher in micro- and macro-albuminuric patients (14.6 ± 11.7 and 15.6 ± 13.5 ng/ml) than controls and normoalbuminurics (5.9 ± 4.0 and 8.1 ± 7.6 ng/ml) with P < 0.05. In general, serum glucose, urea, createnine, cholesterol, triglycerides, low density lipoprotein cholesterol (LDL-C), urinary albumin and albumin creatinine ratio (ACR) were increased in diabetic groups compared to non-diabetics, and reaching their maximum increase in macroalbuminurics whereas high density lipoprotein cholesterol (HDL-C), urinary creatinine and glomerular filtration rate (GFR) were decreased reaching its maximum decrease in macroalbuminurics. Serum leptin showed significant positive correlations with diabetes duration (r = 0.188, P = 0.020), glucose (r = 0.298, P < 0.001), cholesterol (r = 0.323, P < 0.001), triglycerides (r = 0.361, P < 0.001), LDL-C (r = 0.248, P = 0.001) and urinary albumin (r = 0.256, P = 0.001) whereas negative significant correlations were found with HDL-C (r = -0.313, P < 0.001) and urinary creatinine (r = -0.202, P = 0.007).

CONCLUSION

The comitant raise of serum leptin with urinary albumin combined with decrease in GFR makes leptin eligible candidate as a biomarker for progression towards diabetic nephropathy in type 2 diabetes.

MicroRNA-326-3p ameliorates high glucose and ox-LDL-IC- induced fibrotic injury in renal mesangial cells by targeting FcγRIII

AIM

The aim of the present study was to identify the regulatory relationship between miR-326-3p and FcγRIII, and to explore the involvement of miR-326-3p/FcγRIII/TGF-β/Smad signalling pathway in fibrotic injury, which was induced by the high glucose (HG) and oxidized low density lipoprotein immune complex (ox-LDL-IC) in mouse glomerular mesangial cells (GMCs).

METHODS

Dual-luciferase reporter system and real time PCR (RT-PCR) were used to identify FcγRIII as a target gene of miR-326-3p. Lentiviral transduction was used to construct different expression of miR-326-3p in GMCs, which were divided into three groups: miR-326-3p mimics group (miR-326-3p group), miR-326-3p inhibitor group (miR-326-3p-inhibit group) and scramble control group (control group). Then, each group was stimulated by normal glucose (NG), HG, ox-LDL-IC and HG + ox-LDL-IC, respectively. RT-PCR and western blot were used to measure the expressions of Col-I, CTGF, α-SMA, TGF-β, Smad2/3 and pSmad2/3.

RESULTS

FcγRIII was regulated negatively by miR-326-3p in GMCs under the condition of HG and ox-LDL-IC, which implied FcγRIII as a target gene of miR-326-3p. Furthermore, compared with normal glucose group, the expressions of Col-I, CTGF, α-SMA, TGF-β and pSmad2/3 were higher under the condition of HG, ox-LDL-IC and HG + ox-LDL-IC (P < 0.05). In particular, miR-326-3p-inhibit groups exhibited the most significant increase (P < 0.05), while miR-326-3p could attenuate the increase (P < 0.05).

CONCLUSION

FcγRIII was identified as a target gene of miR-326-3p. MiR-326-3p/FcγRIII/TGF-β/Smad signaling pathway was investigated to be involved in the pathophysiology of renal fibrosis of DKD.

Supplementation of Abelmoschus manihot Ameliorates Diabetic Nephropathy and Hepatic Steatosis by Activating Autophagy in Mice

Diabetic nephropathy (DN) is a diabetic complication marked by albuminuria and a decline of the glomerular filtration rate. Diabetic kidneys are defective in the autophagy process and mitochondrial function and their enhancement of activity alleviates the pathology. In this paper, we developed a mouse model of DN by a combined treatment of a high-fat diet and streptozotocin after unilateral nephrectomy and supplementation with flower or leaf extracts of Abelmoschus manihot (AM) were tested. The preventive effects of the extracts on DN pathology and changes on autophagy and mitochondrial proteins were investigated. DN mice showed a significant increase in fasting blood glucose, plasma creatinine, blood urea nitrogen, and urinary albumin levels. Periodic acid–Schiff and Sirius red staining of the diabetic kidney presented a significant change in glomerular and tubular structures that was associated with podocyte loss and fibrotic protein accumulation. These changes were attenuated by AM extract treatment in DN mice. In addition, hepatic injury, proinflammatory cytokines, and lipid accumulation were decreased by AM extracts in DN mice. As a protective mechanism, AM extracts significantly increased the expression of proteins by regulating autophagy and mitochondrial dynamics, which potentially prevented the kidney and liver from accumulating pathogenic proteins and dysfunctional mitochondria, which alleviated the progression of DN.

Urinary Extracellular Vesicle: A Potential Source of Early Diagnostic and Therapeutic Biomarker in Diabetic Kidney Disease

OBJECTIVE

Diabetic kidney disease (DKD) has become one of the major causes of end-stage renal disease. Urinary extracellular vesicles (uEVs) contain rich biological information which could be the ideal source for noninvasive biomarkers of DKD. This review discussed the potential early diagnostic and therapeutic values of proteins and microRNAs in uEVs in DKD.

DATA SOURCES

This review was based articles published in PubMed, Embase, Cochrane, and Google Scholar databases up to November 20, 2017, with the following keywords: "Diabetic kidney disease", "Extracellular vesicle", and "Urine".

STUDY SELECTION

Relevant articles were carefully reviewed, with no exclusions applied to the study design and publication type.

RESULTS

There is no "gold standard" technology to separate and/or purify uEVs. The uEVs contain a variety of proteins and RNAs and participate in the physiological and pathological processes of the kidney. UEVs, especially urinary exosomes, may be useful biomarkers for early diagnosis and treatment to DKD. Furthermore, the uEVs has been used as a therapeutic target for DKD.

CONCLUSION

Proteins and nucleic acids in uEVs represent promising biomarker for the diagnosis and treatment of DKD.

Perioperative management of adult diabetic patients. Preoperative period

In diabetic patients undergoing surgery, we recommend assessing glycaemic control preoperatively by assessing glycated haemoglobin (HbA1c) levels and recent capillary blood sugar (glucose) levels, and to adjust any treatments accordingly before surgery, paying particular attention to specific complications of diabetes. Gastroparesis creates a risk of stasis and aspiration of gastric content at induction of anaesthesia requiring the use of a rapid sequence induction technique. Cardiac involvement can be divided into several types. Coronary disease is characterised by silent myocardial ischaemia, present in 30-50% of T2D patients. Diabetic cardiomyopathy is a real cause of heart failure. Finally, cardiac autonomic neuropathy (CAN), although rarely symptomatic, should be investigated because it causes an increased risk of cardiovascular events and a risk of sudden death. Several signs are suggestive of CAN, and confirmation calls for close perioperative surveillance. Chronic diabetic kidney disease (diabetic nephropathy) aggravates the risk of perioperative acute renal failure, and we recommend measurement of the glomerular filtration rate preoperatively. The final step of the consultation concerns the management of antidiabetic therapy. Preoperative glucose infusion is not necessary if the patient is not receiving insulin. Non-insulin drugs are not administered on the morning of the intervention except for metformin, which is not administered from the evening before. The insulins are injected at the usual dose the evening before. The insulin pump is maintained until the patient arrives in the surgical unit. It should be remembered that insulin deficiency in a T1D patient leads to ketoacidosis within a few hours.

SiRNA-Cyp4a14 and diabetic nephropathy: silencing of Cyp4a14 by siRNA inhibits proliferation and fibrosis of mesangial cells

Diabetic nephropathy (DN) is one of the most common complications of diabetes, which increases mortality of diabetic patients. In recent years, many studies have confirmed that patients with diabetes are often accompanied by lipid metabolism disorders. Peroxisome proliferator-activated receptor (PPARs) is known to play pivotal roles in the regulation of insulin signaling, glucose and lipid metabolism. Cyp4a14 was confirmed to be the PPARα-target marker genes. We attempt to explore the biological role of Cyp4a14 in diabetic nephropathy. In our previous study, lncRNA microarray analysis showed us Cyp4a29-ps, Cyp4a14, Cyp4a12a and Cyp4a12b were the nearby mRNAs of lncRNA CYP4B1-PS1-001, we chose Cyp4a14 as our candidate. Renal cortical tissues were collected from db/db and db/m mice, and the mRNA expression of Cyp4a14 in diabetic tissue was significantly higher than that in normal tissue. And the expression of Cyp4a14 in mesangial cells cultured in high glucose was higher than that in low glucose by qualitative reverse transcription polymerase chain reaction (qRT-PCR) and Western blot analysis. By Cell Counting Kit-8 (CCK8) and colony- forming ability, it is found that siRNA-Cyp4a14 treatment effectively suppressed the proliferation of mesangial cells. From our results, the protein expression of proliferating cell nuclear antigen (PCNA), Cyclin D1, Collagen I, and Fibronectin were all regulated dramatically in siRNA-Cyp4a14 group compared with the negative control group. Our data indicated that siRNA-Cyp4a14 inhibits proliferation and fibrosis of mesangial cells, which can be considered as a therapeutic target for diabetic nephropathy.

Salvia miltiorrhiza Lipophilic Fraction Attenuates Oxidative Stress in Diabetic Nephropathy through Activation of Nuclear Factor Erythroid 2-Related Factor 2

Diabetic nephropathy (DN) is a common cause of chronic kidney disease and end-stage renal disease, which can be triggered by oxidative stress. In this study, we investigated the renoprotective effect of the ethyl acetate extract of Salvia miltiorrhiza (EASM) on DN and examined the underlying molecular mechanism. We observed that EASM treatment attenuated metabolic abnormalities associated with hyperglycemic conditions in the experimental DN model. In streptozotocin (STZ)-induced mice, EASM treatment reduced albuminuria, improved renal function and alleviated the pathological alterations within the glomerulus. To mimic the hyperglycemic conditions in DN patients, we used high glucose (25[Formula: see text]mmol/L) media to stimulate mouse mesangial cells (MMCs), and EASM inhibited high glucose-induced reactive oxygen species. We also observed that EASM enhanced the expression of nuclear factor erythroid-2-related factor 2 (Nrf2), which mediated the anti-oxidant response, and its downstream gene heme oxygenase-1 (HO-1) and NAD(P)H quinone dehydrogenase 1 (NQO1) with concomitant decrease of expression of kelch-like ECH-associated protein 1 (keap1) both in vitro and in vivo. Taken together, these results suggest that EASM alleviates the progression of DN and this might be associated with activation of Nrf2.

Exercise-induced albuminuria and circadian blood pressure abnormalities in type 2 diabetes

AIM

To investigate the relationship between circadian variations in blood pressure (BP) and albuminuria at rest, and during exercise in non-hypertensive type 2 diabetes (T2D) patients.

METHODS

We conducted a cross-sectional study in well controlled T2D patients, non-hypertensive, without clinical proteinuria and normal creatinine clearance. In each participant, we recorded the BP using ambulatory blood pressure monitoring (ABPM) for 24-h, and albuminuria at rest and after a standardized treadmill exercise.

RESULTS

We enrolled 27 type 2 patients with a median age of 52; and a mean duration of diabetes and HbA1c of 3.6 ± 0.8 years and 6.3% ± 0.5% respectively. Using a 24-h ABPM, we recorded a mean diurnal systolic blood pressure (SBP) of 128 ± 17 mmHg vs nocturnal of 123 ± 19 mmHg (P = 0.004), and mean diurnal diastolic blood pressure (DBP) of 83 ± 11 mmHg vs nocturnal 78 ± 14 mmHg (P = 0.002). There was a significant difference between albuminuria at rest [median = 23 mg, interquartile range (IQR) = 10-51] and after exercise (median = 35 mg, IQR = 23-80, P < 0.001). Patients with exercise induced albuminuria had an increase in nocturnal BP values on all three components (128 mmHg vs 110 mmHg, P = 0.03 for SBP; 83 mmHg vs 66 mmHg, P = 0.04; 106 vs 83, P = 0.02 for mean arterial pressure), as well as albuminuric patients at rest. Moreover, exercise induced albuminuria detect a less increase in nocturnal DBP (83 vs 86, P = 0.03) than resting albuminuria.

CONCLUSION

Exercise induced albuminuria is associated with an increase in nocturnal BP values in T2D patients.

Comparison between Atorvastatin and Rosuvastatin in Renal Function Decline among Patients with Diabetes

BACKGROUND

Although the beneficial effects of statin treatment in dyslipidemia and atherosclerosis have been well studied, there is limited information regarding the renal effects of statins in diabetic nephropathy. We aimed to investigate whether, and which, statins affected renal function in Asian patients with diabetes.

METHODS

We enrolled 484 patients with diabetes who received statin treatment for more than 12 months. We included patients treated with moderate-intensity dose statin treatment (atorvastatin 10 to 20 mg/day or rosuvastatin 5 to 10 mg/day). The primary outcome was a change in estimated glomerular filtration rate (eGFR) during the 12-month statin treatment, and rapid renal decline was defined as a >3% reduction in eGFR in a 1-year period.

RESULTS

In both statin treatment groups, patients showed improved serum lipid levels and significantly reduced eGFRs (from 80.3 to 78.8 mL/min/1.73 m² for atorvastatin [P=0.012], from 79.1 to 76.1 mL/min/1.73 m² for rosuvastatin [P=0.001]). A more rapid eGFR decline was observed in the rosuvastatin group than in the atorvastatin group (48.7% vs. 38.6%, P=0.029). Multiple logistic regression analyses demonstrated more rapid renal function loss in the rosuvastatin group than in the atorvastatin group after adjustment for other confounding factors (odds ratio, 1.60; 95% confidence interval, 1.06 to 2.42).

CONCLUSION

These results suggest that a moderate-intensity dose of atorvastatin has fewer detrimental effects on renal function than that of rosuvastatin.

Diffusion tensor imaging of the renal cortex in diabetic patients: correlation with urinary and serum biomarkers

PURPOSE

To demonstrate role of diffusion tensor imaging of the kidney in diabetic patients and to correlate renal fractional anisotropy (FA) and apparent diffusion coefficient (ADC) of the renal cortex with urinary and serum biomarkers of diabetes.

MATERIAL AND METHODS

Prospective study was conducted upon 42 diabetic patients (28 males, 14 females; mean age = 33 years) and 17 age- and sex-matched volunteers. Diabetic patients were micro-normoalbuminuric (n = 27) and macroalbuminuric (n = 15). Patients and volunteers underwent diffusion tensor imaging of the kidney. The FA and ADC of the renal cortex were calculated from 3 regions of interests of both kidneys.

RESULTS

The mean FA and ADC of the renal cortex in diabetic patients (0.36 ± 0.10 and 1.74 ± 0.16 × 10^-3 mm²/s) was significantly different (p = 0.001) from that of volunteers (0.26 ± 0.02 and 1.88 ± 0.03 × 10^-3 mm²/s). The cut-off renal FA and ADC used to differentiate diabetic patients from volunteers were 0.28 and 1.89 × 10^-3 mm²/s with AUC of 0.791 and 0.773 and accuracy of 71% and 76%. The FA and ADC calculated in the renal cortex in patients with macroalbuminuria (0.43 ± 0.10 and 1.63 ± 0.19 × 10^-3 mm²/s) was significantly different (p = 0.001) from that of patients with micro-normoalbuminuria (0.35 ± 0.12 and 1.80 ± 0.18 × 10^-3 mm²/s). The FA and ADC of the renal cortex in diabetic patients correlated with urinary albumin (r = 0.530; p = 0.001, r = -0.421; p = 0.006), urinary NAG (r = 0.376; p = 0.014, r = -0.245; p = 0.01), urinary TGF-β1 (r = 0.287; p = 0.065, r = -0.214; p = 0.175), and serum creatinine (r = 0.381; p = 0.013, r = -0.349; p = 0.023).

CONCLUSION

The FA and ADC of the renal cortex may help in differentiation of diabetic kidney from volunteers and prediction of the presence of macroalbuminuria in diabetic patients and correlated with some of the urinary and serum biomarkers of diabetes.

WITHDRAWN: Salvianolate attenuates renal fibrosis in rat models of diabetic nephropathy by inhibiting inflammation and oxidative stress mechanisms

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Global Cardiovascular and Renal Outcomes of Reduced GFR

The burden of premature death and health loss from ESRD is well described. Less is known regarding the burden of cardiovascular disease attributable to reduced GFR. We estimated the prevalence of reduced GFR categories 3, 4, and 5 (not on RRT) for 188 countries at six time points from 1990 to 2013. Relative risks of cardiovascular outcomes by three categories of reduced GFR were calculated by pooled random effects meta-analysis. Results are presented as deaths for outcomes of cardiovascular disease and ESRD and as disability-adjusted life years for outcomes of cardiovascular disease, GFR categories 3, 4, and 5, and ESRD. In 2013, reduced GFR was associated with 4% of deaths worldwide, or 2.2 million deaths (95% uncertainty interval [95% UI], 2.0 to 2.4 million). More than half of these attributable deaths were cardiovascular deaths (1.2 million; 95% UI, 1.1 to 1.4 million), whereas 0.96 million (95% UI, 0.81 to 1.0 million) were ESRD-related deaths. Compared with metabolic risk factors, reduced GFR ranked below high systolic BP, high body mass index, and high fasting plasma glucose, and similarly with high total cholesterol as a risk factor for disability-adjusted life years in both developed and developing world regions. In conclusion, by 2013, cardiovascular deaths attributed to reduced GFR outnumbered ESRD deaths throughout the world. Studies are needed to evaluate the benefit of early detection of CKD and treatment to decrease these deaths.

Addition of nonalbumin proteinuria to albuminuria improves prediction of type 2 diabetic nephropathy progression

BACKGROUND

Albuminuria is generally accepted as a sensitive marker of diabetic nephropathy but has limitations in predicting its progression. The aim of this study was to evaluate the use of nonalbumin proteinuria in addition to albuminuria for predicting the progression of type 2 diabetic nephropathy.

METHODS

In this retrospective observational study, the urine albumin-to-creatinine ratio (ACR) and the nonalbumin protein-to-creatinine ratio (NAPCR) were measured in 325 patients with type 2 diabetes and estimated glomerular filtration rates (eGFR) ≥30 mL/min/1.73 m². The patients were divided into four groups based on the cutoff points for the urinary ACR (30 mg/g) and NAPCR (120 mg/g). The renal outcomes were chronic kidney disease (CKD) progression and accelerated eGFR decline.

RESULTS

During the 4.3-year follow-up period, 25 (7.7%) patients showed CKD progression and 69 (21.2%) patients showed accelerated eGFR decline. After adjusting for nine clinical parameters, the group with a NAPCR greater than 120 mg/g exhibited higher cumulative incidences of CKD progression (hazard ratio 6.84; P = 0.001) and accelerated eGFR decline (hazard ratio 1.95; P = 0.011) than the group with a NAPCR < 120 mg/g. In patients with normoalbuminuria, the group with NAPCR levels greater than 120 mg/g also exhibited a higher cumulative incidence than that with NAPCR levels <120 mg/g of CKD progression (hazard ratio 21.82; P = 0.005). The addition of NAPCR to ACR improved the model fit for CKD progression and accelerated eGFR decline.

CONCLUSION

Nonalbumin proteinuria showed additional value over and above that of albuminuria for predicting the progression of CKD in patients with type 2 diabetes.

Reversal of Early Diabetic Nephropathy by Islet Transplantation under the Kidney Capsule in a Rat Model

Objective. Diabetic nephropathy (DN) is a common microvascular complication of diabetes mellitus, and insulin therapy has many side effects in the treatment of DN. Islet transplantation has emerged as a promising therapy for diabetic patients. This study was established to investigate its advantageous effects in a rat model of early DN. Methods. Streptozotocin was administered to the rats to induce diabetes. Twelve weeks later, the diabetic rats were divided into 3 groups: the islet-transplanted group (IT group), the insulin-treated group (IN group), and the untreated group (DN group). Renal injury and kidney structure were assessed by urinalysis and transmission electron microscopy (TEM) detection. Immunohistochemical staining and western blotting were performed to assess renal fibrosis levels. Results. The early DN features were reversed and the glomerular filtration barrier and basement membrane structures were improved at 4 weeks after islet transplantation. The urine microalbumin-to-creatinine ratio (ACR), protein-to-creatinine ratio, and mean thickness of the glomerular basement membrane (GBM) were significantly decreased in the IT group. The expression of renal fibrotic factors was also significantly decreased. Conclusions. These data suggest that early DN can be reversed after islet transplantation, and they may facilitate the development of a clinical therapeutic strategy for human diabetes mellitus.