cGAS-STING activation contributes to podocyte injury in diabetic kidney disease

Diabetic kidney disease (DKD) is the leading cause of end-stage renal diseases. DKD does not have efficacious treatment. The cGAS-STING pathway is activated in podocytes at the early stage of kidney dysfunction, which is associated with the activation of STING downstream effectors TBK1 and NF-κB but not IRF3. Lipotoxicity induces mitochondrial damage and mtDNA leakage to the cytosol through Bcl-2 associated X protein (BAX) in podocytes. BAX-mediated mtDNA cytosolic leakage can activate the cGAS-STING pathway in the absence of lipotoxicity and is sufficient to cause podocyte injury. Depletion of cytosolic mtDNA, genetic STING knockdown, or pharmacological inhibition of STING or TBK1 alleviates podocyte injury and improves renal functions in cultured podocytes or mouse models of diabetes and obesity. These results suggest that the mtDNA-cGAS-STING pathway promotes podocyte injury and is a potential therapeutic target for DKD or other obesity-related kidney diseases.

Heat therapy shows benefit in patients with type 2 diabetes mellitus: a systematic review and meta-analysis

AIMS

Type-2 diabetes mellitus (T2DM) is a common health condition which prevalence increases with age. Besides lifestyle modifications, passive heating could be a promising intervention to improve glycemic control. This study aimed to assess the efficacy of passive heat therapy on glycemic and cardiovascular parameters, and body weight among patients with T2DM.

METHODS

A systematic review and meta-analysis were reported according to PRISMA Statement. We conducted a systematic search in three databases (MEDLINE, Embase, CENTRAL) from inception to 19 August 2021. We included interventional studies reporting on T2DM patients treated with heat therapy. The main outcomes were the changes in pre-and post-treatment cardiometabolic parameters (fasting plasma glucose, glycated plasma hemoglobin, and triglyceride). For these continuous variables, weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated. Study protocol number: CRD42020221500.

RESULTS

Five studies were included in the qualitative and quantitative synthesis, respectively. The results showed a not significant difference in the hemoglobin A1c [WMD -0.549%, 95% CI (-1.262, 0.164), p = 0.131], fasting glucose [WMD -0.290 mmol/l, 95% CI (-0.903, 0.324), p = 0.355]. Triglyceride [WMD 0.035 mmol/l, 95% CI (-0.130, 0.200), p = 0.677] levels were comparable regarding the pre-, and post intervention values.

CONCLUSION

Passive heating can be beneficial for patients with T2DM since the slight improvement in certain cardiometabolic parameters support that. However, further randomized controlled trials with longer intervention and follow-up periods are needed to confirm the beneficial effect of passive heat therapy.

Proteomic pathways to metabolic disease and type 2 diabetes in the pancreatic islet

Pancreatic islets are essential for maintaining physiological blood glucose levels, and declining islet function is a hallmark of type 2 diabetes. We employ mass spectrometry-based proteomics to systematically analyze islets from 9 genetic or diet-induced mouse models representing a broad cross-section of metabolic health. Quantifying the islet proteome to a depth of >11,500 proteins, this study represents the most detailed analysis of mouse islet proteins to date. Our data highlight that the majority of islet proteins are expressed in all strains and diets, but more than half of the proteins vary in expression levels, principally due to genetics. Associating these varied protein expression levels on an individual animal basis with individual phenotypic measures reveals islet mitochondrial function as a major positive indicator of metabolic health regardless of strain. This compendium of strain-specific and dietary changes to mouse islet proteomes represents a comprehensive resource for basic and translational islet cell biology.

Analysis and Comparison of Two Artificial Intelligence Diabetic Retinopathy Screening Algorithms in a Pilot Study: IDx-DR and Retinalyze

BACKGROUND

The prevalence of diabetic retinopathy (DR) is expected to increase. This will put an increasing strain on health care resources. Recently, artificial intelligence-based, autonomous DR screening systems have been developed. A direct comparison between different systems is often difficult and only two such comparisons have been published so far. As different screening solutions are now available commercially, with more in the pipeline, choosing a system is not a simple matter. Based on the images gathered in a local DR screening program we performed a retrospective comparison of IDx-DR and Retinalyze.

METHODS

We chose a non-representative sample of all referable DR positive screening subjects (n = 60) and a random selection of DR negative patient images (n = 110). Only subjects with four good quality, 45-degree field of view images, a macula-centered and disc-centered image from both eyes were chosen for comparison. The images were captured by a Topcon NW-400 fundus camera, without mydriasis. The images were previously graded by a single ophthalmologist. For the purpose of this comparison, we assumed two screening strategies for Retinalyze-where either one or two out of the four images needed to be marked positive by the system for an overall positive result at the patient level.

RESULTS

Percentage agreement with a single reader in DR positive and DR negative cases respectively was: 93.3%, 95.5% for IDx-DR; 89.7% and 71.8% for Retinalyze strategy 1; 74.1% and 93.6% for Retinalyze under strategy 2.

CONCLUSIONS

Both systems were able to analyse the vast majority of images. Both systems were easy to set up and use. There were several limitations to the current pilot study, concerning sample choice and the reference grading that need to be addressed before attempting a more robust future study.

Sodium-glucose co-transporter 2 inhibitors and diabetic retinopathy: insights into preservation of sight and looking beyond

Sodium-glucose co-transporter 2 Inhibitors (SGLT2i) were initially developed as therapeutic options for patients with type 2 diabetes mellitus (T2DM). Recently, randomized clinical trials have investigated their effects in cardiorenal protection through major adverse cardiovascular event reduction and reductions in diabetic nephropathy. While multiple mechanisms are proposed for this protection, microvascular protection is the primary component of their efficacy. While not primarily emphasized in clinical trials, evidence in other studies suggests that SGLT2i may confer retinoprotective effects via some of the same mechanisms in the aforementioned cardiorenal trials. Diabetic patients are susceptible to vision loss with chronic hyperglycemia promoting inflammation, edema, and retinal pathological changes. Targeting these pathways via SGLT2i may represent opportunities for providers to decrease retinopathy in high-risk T2DM patients, reduce disease progression, and lower drug burden in diabetic retinopathy patients. Further comprehensive clinical trials investigating these associations are needed to establish the potential retinoprotective effects of SGLT2i.

Metabolic and endocrine diseases - is our approach always rational?

Choosing wisely in metabolic and endocrine diseases shows the inutility of some, in clinical practice often used, ways of management. In diabetology, the routine recommendation for selfmonitoring of type 2 diabetic patients not treated with insulin represents a contraversial issue. On the contrary, there is a consensus on rational targets of glycemic control in elderly frailty patients with limited life expectancy. In endocrinology (thyroid diseases), the iniciative fights against the overuse of some laboratory examinations and ultrasonography. The recommendations on the rational indications of densitometry are discussed. In conclusion, these recommendations within Choosing wisely initiative of different professional associations usualy arise from expert views, supported by relevant clinical studies. They represent a challange to think over rational management of care.

The systemic implication of novel non-statin therapies in cardiovascular diabetology: PCSK9 as a case model

PCSK9, like other novel non-statin drugs were primarily developed to help patients achieve low-density lipoprotein cholesterol targets, especially in patients with dyslipidemia not achieving lipid goals with statins due to poor tolerance or inadequate response. PCSK9 inhibitors, in addition to modulating lipid metabolism, improve mortality outcomes in cardiovascular disease. These benefits are markedly pronounced in patients with type 2 diabetes mellitus. However, these benefits do not come without associated risk. Multiple trials, studies, and case reports have attempted to explain observed outcomes with PCSK9 expression and administration of PCSK9 inhibitors from multiple perspectives, such as their effects on insulin sensitivity and glucose tolerance, changes in renal physiology, thyroid physiology, vascular tone, intestinal regulation of lipids, and improved cardiovascular function. These agents represent an opportunity for physicians to exercise prudence by using appropriate clinical judgement when managing comorbidities in the hyperglycemic patient, a concept that extends to other novel non-statin drugs.

Determinants of Vitamin D Supplementation among Individuals with Type 1 Diabetes

Half of the individuals with type 1 diabetes (T1DM) may present Vitamin D (VD) deficiency. There is little known about factors determining a decision on VD supplementation. The study aimed to determine the factors affecting vitamin D supplementation in people with T1DM. A cross-sectional survey study using the authors’ questionnaire paper and its digital version was performed. The questions involved data on the basic characteristics of the respondent, medical history, VD supplementation status, influence of the social environment, self-education, and the most important personal motivator for VD supplement use. Multivariate logistic regression analysis was performed. We collected a total of n = 184 papers and n = 550 digital complete surveys. From 734 total respondents, 62.0% declared VD supplementation. The main personal rationale for VD supplementation were recommendation of medical specialist 172 (37.8%) and self-education 135 (29.7%). The main reasons for non-supplementation of VD were lack of knowledge about VD 159 (57.0%) and lack of motivation 77 (27.6%). VD supplementation was independently associated with a family doctor (odds ratio (OR), 95% confidence interval (CI): 4.67, 2.32–9.40) or medical specialist recommendation (16.20, 9.57–27.43), and self-education (5.97, 3.90–9.13). Most Polish individuals with T1DM use VD supplements, and the decision is related to physicians’ recommendations and self-education.

Management of diabetic patients with lower extremity peripheral arterial disease

Extremitovascular arterial ischemic disease (lower extremity peripheral arterial disease - PAD) is an important manifestation of systemic atherosclerosis and other arterial diseases of vascular system. The lower the ankle-brachial pressure index, the greater the risk of serious acute instable organovascular events (e. g. acute myocardial infarction, stroke). Complex prevention and treatment of extremitovascular arterial disease is discussed in this article. Angiology/vascular medicine is the fastest growing field of internal medicine.

Kidney Diseases and Pregnancy: A Multidisciplinary Approach for Improving Care by Involving Nephrology, Obstetrics, Neonatology, Urology, Diabetology, Bioethics, and Internal Medicine

This multidisciplinary series is aimed at offering readers many opportunities to appreciate how a clinical and ethical approach to pregnancy has changed in patients with kidney diseases and with related conditions, including diabetes, hypertension, and immunologic diseases. Furthermore, this series aims to focus on the fact that many issues remain unreslved, that there are enormous gaps in knowledge, and that the bioethical approach needs to integrated in the clinical practice, which would allow for a deeper appreciation of different cultural and religious backgrounds. Much still needs to be done to allow women suffering from all stages of chronic kidney disease (CKD) and those with predisposed conditions, so that they may experience safe pregnancies, starting from an increased awareness of the importance of CKD, even in its early stages, to the detection of risk factors. Women who have experienced preeclampsia or acute kidney injury in pregnancy need to have follow-up checks. The role of urinary infections, kidney stones, and urinary malformations is not fully acknowledged, nor have univocal control schedules and treatment schemas yet been defined for the different kidney diseases. In this regard, the fight for equitable treatment for all women with acute or chronic kidney disease in pregnancy and for the widespread prevention of adverse pregnancy-related and long-term outcomes is ultimately a battle for equitable healthcare.

Novel combined management approaches to patients with diabetes, chronic kidney disease and cardiovascular disease

Most patients we care for today suffer from more than one chronic disease, and multimorbidity is a rapidly growing challenge. Concomitant cardiovascular disease, renal dysfunction and diabetes represent a large proportion of all patients in cardiology, nephrology and diabetology. These entities commonly overlap due to their negative effects on vascular function and an accelerated atherosclerosis progression. At the same time, a progressive subspecialisation has caused the cardiologist to treat 'only' the heart, nephrologists 'only' the kidneys and endocrinologists' 'only' diabetes. Studies and guidelines follow the same pattern. This often requires patients to visit specialists for each field, with a risk of both under-diagnosis and under-treatment. From the patient's perspective, there is a great need for coordination and facilitation of the care, not only to reduce disease progression but also to improve quality of life. Person-centred integrated clinics for patients with cardiovascular disease, renal dysfunction and diabetes are a promising approach for complex chronic disease management.

Successful Application of Closed-Loop Artificial Pancreas Therapy After Islet Autotransplantation

Total pancreatectomy with islet autotransplantation (TPIAT) may relieve the pain of chronic pancreatitis while avoiding postsurgical diabetes. Minimizing hyperglycemia after TPIAT limits beta cell apoptosis during islet engraftment. Closed-loop (CL) therapy combining an insulin pump with a continuous glucose monitor (CGM) has not been investigated previously in islet transplant recipients. Our objective was to determine the feasibility and efficacy of CL therapy to maintain glucose profiles close to normoglycemia following TPIAT. Fourteen adult subjects (36% male; aged 35.9 ± 11.4 years) were randomized to subcutaneous insulin via CL pump (n = 7) or multiple daily injections with blinded CGM (n = 7) for 72 h at transition from intravenous to subcutaneous insulin. Mean serum glucose values were significantly lower in the CL pump group than in the control group (111 ± 4 vs. 130 ± 13 mg/dL; p = 0.003) without increased risk of hypoglycemia (percentage of time <70 mg/dL: CL pump 1.9%, control 4.8%; p = 0.46). Results from this pilot study suggest that CL therapy is superior to conventional therapy in maintaining euglycemia without increased hypoglycemia. This technology shows significant promise to safely maintain euglycemic targets during the period of islet engraftment following islet transplantation.

Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions

A consensus meeting was held in Vienna on September 8-9, 2013, to discuss diagnostic and therapeutic challenges surrounding development of diabetes mellitus after transplantation. The International Expert Panel comprised 24 transplant nephrologists, surgeons, diabetologists and clinical scientists, which met with the aim to review previous guidelines in light of emerging clinical data and research. Recommendations from the consensus discussions are provided in this article. Although the meeting was kidney-centric, reflecting the expertise present, these recommendations are likely to be relevant to other solid organ transplant recipients. Our recommendations include: terminology revision from new-onset diabetes after transplantation to posttransplantation diabetes mellitus (PTDM), exclusion of transient posttransplant hyperglycemia from PTDM diagnosis, expansion of screening strategies (incorporating postprandial glucose and HbA1c) and opinion-based guidance regarding pharmacological therapy in light of recent clinical evidence. Future research in the field was discussed with the aim of establishing collaborative working groups to address unresolved questions. These recommendations are opinion-based and intended to serve as a template for planned guidelines update, based on systematic and graded literature review, on the diagnosis and management of PTDM.

Patient centred care in diabetology: an Islamic perspective from Iran

Patient-centred system of care is essential in managing many disorders such as diabetes mellitus. The cultural and religious context can influence the involvement of patients and their families in such a care. We intend to discuss patient-centred care in diabetology in view of Islam. For more clarification, we will take into consideration a few illustrative lines of argument in detail about situation in Iran. In conclusion, dynamic spirit of Islamic jurisprudence is reflected in its adaptability to change in medical practice. In recent decades, Iranian religious scholars have provided scientists in new fields of science and research with appropriate directions and guidelines. Decree issued by Iranian religious leaders permitting research on stem cells for therapeutic purposes in many disorders including diabetes mellitus is one example. Understanding of the nature of Islam is importance for communication with patients in Islamic countries.