Effects of acute insulin-induced hypoglycaemia on endothelial microparticles in adults with and without type 2 diabetes

AIMS

To assess whether endothelial microparticles (EMPs), novel surrogate markers of endothelial injury and dysfunction, are differentially produced in response to acute insulin-induced hypoglycaemia in adults with and without type 2 diabetes.

MATERIALS AND METHODS

A prospective, parallel study was conducted in individuals with type 2 diabetes (n = 23) and controls (n = 22). Hypoglycaemia (<2.2 mmoL/L: <40 mg/dL) was achieved by intravenous infusion of soluble insulin. Blood samples were collected at baseline and at 0, 30, 60, 120, 240 minutes and 24 hours after hypoglycaemia and analysed for CD31⁺ (platelet endothelial cell adhesion molecule-1), CD54⁺ (intercellular adhesion molecule 1), CD62-E⁺ (E-selectin), CD105⁺ (endoglin), CD106⁺ (vascular cell adhesion molecule 1) and CD142⁺ (tissue factor) EMPs by flow cytometry. The peak elevations (% rise from 0 minutes after hypoglycaemia) in EMP within 240 minutes after insulin-induced hypoglycaemia were modelled using a regression model, with adjustment for relevant covariates. All EMPs were expressed as percentage from 0 minutes hypoglycaemia for each time point and total areas under the curve (AUC_0min-24h ) were calculated.

RESULTS

Following insulin-induced hypoglycaemia, levels of circulating EMPs were maximal at 240 minutes (P < 0.001) and returned to baseline values within 24 hours for both groups. The peak elevations (% rise from 0 minutes following hypoglycaemia) seen in CD31⁺ , CD54⁺ , CD62-E⁺ , CD105⁺ and CD142⁺ EMPs within 240 minutes were associated with diabetes status after adjustments for all relevant covariates. Individuals with type 2 diabetes showed increased CD31⁺ EMPs AUC_0min-24h (P = 0.014) and CD105⁺ EMPs AUC_0min-24h (P = 0.006) compared with controls, but there were no differences for CD54⁺ (P = 0.91), CD62-E⁺ (P = 0.14), CD106⁺ (P = 0.36) or CD142⁺ (P = 0.77) EMPs AUC_0min-24h .

CONCLUSIONS

The associations between peak elevations within 240 minutes after insulin-induced hypoglycaemia for CD31⁺ , CD54⁺ , CD62-E⁺ , CD105⁺ and CD142⁺ and diabetes status indicate that the assessment of a panel of EMPs within this timeframe would identify a hypoglycaemic event in this population. The greater overall responses over time (AUCs) for apoptosis-induced CD31⁺ and CD105⁺ EMPs suggest that hypoglycaemia exerts greater endothelial stress in type 2 diabetes.

Association of hyperglycemia episodes on long-term mortality in type 2 diabetes mellitus with vascular dementia: A population-based cohort study

AIM

This study investigated the effect of severe hyperglycemia episodes on survival and associated factors related to risk of mortality in type 2 diabetes mellitus (DM) patients with dementia.

METHODS

We enrolled all type 2 DM patients newly diagnosed as having dementia in Taiwan from 1998 to 2005. These patients were categorized into those who had hyperglycemia episodes and those who did not based on whether or not they had been hospitalized for hyperglycemia after dementia diagnosis. Factors independently associated with mortality were evaluated.

RESULTS

Of 5314 patients identified, 303 (5.7%) had at least one hyperglycemia hospitalization. Patients with at least one hyperglycemia hospitalization had a 30% greater risk of mortality than those who had no such admissions (adjusted hazard ratio: 1.30, 95% confidence interval: 1.09-1.55). Other variables, including age, sex, geographical region, insurance amount, patient with congestive heart failure, cerebrovascular disease, renal disease, use of anti-hypertensive drugs, use of anti-lipid drugs, and use of insulin were independently associated with risk of mortality.

CONCLUSION

Severe hyperglycemia is common in type 2 DM patients with dementia and it substantially shortens their life. The findings of this study suggest a great need to improve care in DM patients with dementia.

Metformin is the key factor in elevated plasma growth differentiation factor-15 levels in type 2 diabetes: A nested, case-control study

Produced as a tissue defence response to hypoxia and inflammation, growth differentiation factor-15 (GDF-15) is elevated in people receiving metformin treatment. To gain insight into the relationship of GDF-15 with metformin and major cardiovascular risk factors, we analysed the data from the SUMMIT cohort (n = 1438), a four-centre, nested, case-control study aimed at verifying whether biomarkers of atherosclerosis differ according to the presence of type 2 diabetes and cardiovascular disease. While in univariate analysis, major cardiovascular risk factors, with the exception of gender and cholesterol, increased similarly and linearly across GDF-15 quartiles, the independent variables associated with GDF-15, both in participants with and without diabetes, were age, plasma creatinine, N-terminal pro-brain natriuretic peptide, diuretic use, smoking exposure and glycated haemoglobin. In participants with diabetes, metformin treatment was associated with a 40% rise in GDF-15 level, which was independent of the other major factors, and largely explained their elevated GDF-15 levels. The relatively high GDF-15 bioavailability might partly explain the protective cardiovascular effects of metformin.

Dendritic cell activation is blunted in patients with coronary artery disease and diabetes mellitus

BACKGROUND

It has been shown that functional status of dendritic cells (DCs) in diabetic patients with unstable angina pectoris (UAP) are more mature and activated than diabetic patients without coronary artery disease (CAD) and none diabetic patients with UAP. Accordingly we aimed to assess the activation of DCs in patients with CAD with/and without Diabetes Mellitus (DM) and compare to those in subjects with normal coronary arteries (NCA).

MATERIALS AND METHODS

Twenty three patients with severe CAD who were scheduled to coronary artery by-pass grafting surgery and 6 patients with angiographycally NCAs were included in the study. Activation of peripheral blood DCs have been analyzed by flow cytometric measures of CD86 activation.

RESULTS

In patients with CAD and without DM, DC activation significantly increased after stimulation of oxidesized LDL (135 ± 121 vs 248 ± 197 p = 0.024). However this activation didn't significantly increased in patients with CAD and DM (100 ± 20 vs 120 ± 97, p = 0,54). Patients with NCAs and without DM showed marked activation of CD86 after stimulation with ox-LDL.

CONCLUSION

We have documented that DC activation, upon stimulation of ox-LDL has blunted in patients with CAD compared to patients with NCAs. Moreover this defective activation is more pronounced in those with diabetic patients with CAD.

The association of diabetic microvascular and macrovascular disease with cutaneous circulation in patients with type 2 diabetes mellitus

AIMS

To study the impact of diabetic neuropathy, both peripheral sensorimotor (DPN) and cardiac autonomic neuropathy (CAN), on transcutaneous oxygen tension (TcPO₂) in patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 163 participants were recruited; 100 with T2DM and 63 healthy individuals. Peripheral arterial disease (PAD) was defined as ankle-brachial index (ABI) values ≤0.90. Diagnosis of DPN was based on neuropathy symptom score and neuropathy disability score (NDS), while diagnosis of CAN on the battery of the cardiovascular autonomic function tests. TcPO₂ was measured using a TCM30 system.

RESULTS

Patients with T2DM had lower TcPO₂ levels when compared with healthy individuals. Among the diabetic cohort, those who had either PAD, DPN or CAN had significantly lower TcPO₂ values than participants without these complications. Multivariate linear regression analysis, after controlling for diabetes duration, diastolic blood pressure, HbA1c, albumin to creatinine ratio and CAN score, demonstrated that TcPO₂ levels were significantly and independently associated with current smoking (p = 0.013), ABI (p = 0.003), and NDS (p = 0.013).

CONCLUSION

Presence of DPN is independently associated with impaired cutaneous perfusion. Low TcPO₂ in subjects with DPN may contribute to delay in healing of diabetic foot ulcers, irrespectively of PAD.

Plasma omentin levels are associated with vascular endothelial function in patients with type 2 diabetes at elevated cardiovascular risk

AIMS

Omentin is an adipokine that has protective effects against cardiovascular damage. Previous studies showed an inverse relationship between omentin and obesity, diabetes, and cardiovascular disease. This study aimed to investigate the association between omentin and vascular endothelial function in patients with type 2 diabetes (T2D).

METHODS

The subjects were 425 patients with T2D and 223 non-diabetic controls. Fasting plasma omentin levels were measured by enzyme-linked immunosorbent assay, and the endothelium-dependent, flow-mediated dilatation (FMD) was measured by ultrasonography.

RESULTS

Plasma omentin levels were higher, while FMD was lower in participants with T2D than in non-diabetic controls. No significant correlation was found between plasma omentin levels and FMD in either non-diabetic controls or participants with T2D on multivariate analysis. However, stratified analysis in T2D patients revealed that plasma omentin levels were independently and positively associated with FMD in high cardiovascular risk subgroups according to age (≥65 years), estimated glomerular filtration rate (<60 mL/min/1.73 m²), or preexisting cardiovascular diseases but not in low-risk subgroups.

CONCLUSIONS

Plasma omentin levels are independently associated with endothelial function in subgroups of patients with T2D at elevated cardiovascular risk. This study suggests a protective role of omentin against endothelial dysfunction, particularly in high-risk patients.

Association of the genetic variant rs2000999 with haptoglobin and diabetic macrovascular diseases in Chinese patients with type 2 diabetes

AIMS

The common copy number variant (CNV) in the haptoglobin (Hp) gene may influence the susceptibility to diabetic macrovascular diseases. We aimed to investigate the relationship of the genetic variant rs2000999, located in the haptoglobin-related protein (HPR) gene, with serum Hp levels and diabetic macrovascular diseases in Chinese type 2 diabetes patients.

METHODS

The Hp CNV and rs2000999 were genotyped in a group of 5457 Chinese patients with type 2 diabetes. Associations of rs2000999 with the common Hp CNV, susceptibility to diabetic macrovascular diseases and related metabolic traits were analysed. Furthermore, 886 patients were selected to detect serum Hp levels and to evaluate the correlation between rs2000999 and serum Hp levels.

RESULTS

The genetic variant rs2000999 was not associated with diabetic macrovascular diseases (P = 0.6109), while subjects carrying the A allele had higher levels of low-density lipoprotein cholesterol (P = 0.0578) and a smaller inter-adventitial diameter of the common carotid artery (P = 0.0266). Additionally, rs2000999 exhibited strong association with serum Hp levels (P = 2.03 × 10^-21).

CONCLUSIONS

The genetic variant rs2000999 was not associated with diabetic macrovascular diseases but showed an association with metabolic traits and serum Hp levels in Chinese patients with type 2 diabetes.

Are blood lipids associated with microvascular complications among type 2 diabetes mellitus patients? A cross-sectional study in Shanghai, China

BACKGROUND

Although there are several studies to investigate the association between blood lipids and microvascular complications, these studies reported conflicting results. The aim of the current study was to explore the association between blood lipid parameters and the risk of microvascular complications, especially the dose-response association between them, among community patients with type 2 diabetes mellitus (T2DM) in Shanghai, China.

METHODS

The cross-sectional study was conducted in 6 community health service centers in Shanghai between December 2014 and December 2016.The associations between blood lipids and diabetic kidney disease (DKD) or diabetic retinopathy (DR) were assessed using multiple logistic regression. Restricted cubic spline (RCS) was employed to estimate the dose-response relation of blood lipids and the risk of microvascular complications.

RESULTS

A total of 3698 participants were included in the final analysis to study the association between blood lipids and DKD, wherein 33.2% of participants had DKD and 1374 were included for the analysis of the association between blood lipids and DR, wherein 23.2% of participants had DR. DKD odds ratio was increased by 1.16(95%CI,1.08-1.25), 1.21(95%CI,1.13-1.30), 1.18(95%CI,1.10-1.26) for comparing fourth to first quartiles of triglycerides (TG), TG/high-density lipoprotein cholesterol (HDL-C), non-HDL-C/HDL-C, respectively, and decreased by 0.83(95%CI,0.78-0.89) for comparing fourth to first quartiles of HDL-C. Furthermore, the dose-response association between TG, HDL-C, TG/HDL-C, non-HDL-C/HDL-C and the risk of DKD demonstrated turning points in TG of 1.90 mmol/L, HDL-C of 1.62 mmol/L, TG/HDL-C of 2.00, non-HDL-C/HDL-C of 3.09, respectively. However, no significant association was found between blood lipid parameters and DR.

CONCLUSIONS

This community-based study indicated that TG, HDL-C, TG/HDL-C, non-HDL-C/HDL-C were independently associated with DKD but not DR.

Enhancement of postprandial endogenous insulin secretion rather than exogenous insulin injection ameliorated insulin antibody-induced unstable diabetes: a case report

BACKGROUND

Insulin injection, especially with insulin analogs, occasionally induces the production of insulin antibodies with high binding capacity and low affinity, similar to the insulin autoantibodies characteristic of insulin autoimmune syndrome (IAS). Production of these "IAS-like" insulin antibodies causes marked glycemic fluctuations with postprandial hyperglycemia and fasting hypoglycemia.

CASE PRESENTATION

A 66-year-old man with a 27-year history of diabetes was admitted because of marked glycemic fluctuations. Human insulin treatment had been initiated at age 56, followed by multiple daily injections of insulin analogs 5 years later. After the initial year of insulin analog treatment, the patient began to experience frequent morning hypoglycemic attacks and day-time hyperglycemia. Marked hyperinsulinemia (4500 μU/mL) and high titers of insulin antibodies (80.4%) with high binding capacity and low affinity indicated that IAS-like insulin antibodies were causing severe glucose fluctuations. Altering insulin formulations (insulin aspart → regular human insulin→ insulin lispro) proved to be ineffective. After several therapeutic trials, cessation of exogenous insulin and addition of mitiglinide to liraglutide with voglibose finally attenuated glycemic fluctuations with increased postprandial insulin secretion. Continuous glucose monitoring revealed improvement of morning hypoglycemia and postprandial hyperglycemia with smaller mean amplitude of glycemic excursion. Therefore, compared to exogenously injected insulin, endogenously secreted insulin directly and rapidly acts on hepatocytes and suppresses postprandial glucose output.

CONCLUSIONS

Proper enhancement of postprandial endogenous insulin aimed at suppressing postprandial glucose output without stimulating excessive glucose uptake in the periphery is potentially useful for treating diabetes with insulin antibody-induced glycemic instability.

Serum adipocytokines are associated with microalbuminuria in patients with type 1 diabetes and incipient chronic complications

AIMS

Recent studies have implicated possible contribution of adipocytokines in development and progression of microvascular complications in patients with type 1 diabetes (T1DM). The aim of our study was to investigate relationship between adipocytokines, namely leptin, resistin, adiponectin and dipeptidyl peptidase-4 (DPP-4) activity, with albuminuria in T1DM.

METHODS

This study included 202 T1DM without or with incipient microvascular complications. Urinary albumin excretion rate (UAE) was measured from at least two 24-h urine samples. Serum DPP-4 activity was measured by a colorimetric assay, and the level of adiponectin, leptin, and resistin was determined by the ELISA method.

RESULTS

Serum DPP-4 activity and adiponectin were significantly higher in patients with normoalbuminuria compared to patients with microalbuminuria (47 vs 36 U/L, and 10.9 vs 7.3 μg/mL, respectively, p ≤ 0.02). In multivariate logistic regression analysis adiponectin and serum DPP-4 activity were significantly associated with risk of microalbuminuria in our subjects (p ≤ 0.04), with odds ratios of 0.72-0.99. However, after adjustment for age, sex, HbA1c, duration of diabetes and BMI, only serum DPP-4 activity was significantly associated with risk of microalbuminuria (p = 0.008).

CONCLUSION

The results of our study suggest that serum DPP-4 activity is lower in T1DM with microalbuminuria. Prospective studies are warranted to evaluate the relationship between serum DPP-4 activity and progression and development of albuminuria and nephropathy in T1DM.

Regional Variation in Comorbid Prediabetes and Diabetes and Associated Factors among Hypertensive Individuals in Rural Bangladesh, Pakistan, and Sri Lanka

We aimed to explore the cross-country variation in the prevalence of comorbid prediabetes or diabetes and determine the sociodemographic, lifestyle, and clinical factors, especially body mass index (BMI) and waist circumference, associated with comorbid diabetes in individuals with hypertension in rural South Asia. We analyzed cross-sectional data of 2426 hypertensive individuals of ≥40 years from 30 randomly selected rural communities in Bangladesh, Pakistan, and Sri Lanka. Prediabetes was defined as fasting plasma glucose (FPG) between 100 and 125 mg/dL without use of antidiabetic treatment and diabetes as FPG ≥126 mg/dL or use of antidiabetic medication. The prevalence (95% CI) of prediabetes or diabetes (53.5% (51.5%, 55.5%)) and diabetes (27.7% (25.9%, 29.5%)) was high in the overall hypertensive study population in rural communities in 3 countries. Rural communities in Sri Lanka had the highest crude prevalence of prediabetes or diabetes and diabetes (73.1% and 39.3%) with hypertension, followed by those in Bangladesh (47.4% and 23.1%) and Pakistan (39.2% and 20.5%). The factors independently associated with comorbid diabetes and hypertension were residing in rural communities in Sri Lanka, higher education, international wealth index, waist circumference, pulse pressure, triglyceride, and lower high-density lipoprotein. The association of diabetes with waist circumference was stronger than with BMI in hypertensive individuals. Prediabetes or diabetes are alarmingly common among adults with hypertension and vary among countries in rural South Asia. The high prevalence of comorbid diabetes in Sri Lanka among hypertensives is not fully explained by conventional risk factors and needs further etiological research. Urgent public health efforts are needed to integrate diabetes control within hypertension management programs in rural South Asia, including screening waist circumference.

Hyperglycaemia correlates with skeletal muscle capillary regression and is associated with alterations in the murine double minute-2/forkhead box O1/thrombospondin-1 pathway in type 1 diabetic BioBreeding rats

Type 1 diabetes can have deleterious effects on skeletal muscle and its microvasculature. Our laboratory has recently identified murine double minute-2 as a master regulator of muscle microvasculature by controlling expression levels of two key molecular actors of the angio-adaptive process: the pro-angiogenic vascular endothelial growth factor-A and the anti-angiogenic thrombospondin-1. Here, we show for the first time that in the soleus and plantaris muscles of the diabetes-prone BioBreeding rats, a rodent model of autoimmune type 1 diabetes, murine double minute-2 protein levels are significantly decreased, coinciding with elevated protein levels of thrombospondin-1 and its transcription factor forkhead box O1. Significant capillary regression was observed to similar extent in soleus and plantaris muscles of type 1 diabetic rats. Elevated blood glucose levels were correlated with the loss of capillaries, the reduction in murine double minute-2 expression and with the elevations in thrombospondin-1. Vascular endothelial growth factor-A protein levels were unaltered or even increased in diabetic animals, yet type 1 diabetic animals had less vascular endothelial growth factor receptor-2 abundance. The vascular endothelial growth factor-A/thrombospondin-1 ratio, a good indicator of skeletal muscle angio-adaptive environment, was decreased in type 1 diabetic muscle. Our results suggest that the murine double minute-2-forkhead box O1-thrombospondin-1 pathway plays an important role in angio-regulation of the skeletal muscle in the pathophysiological context of type 1 diabetes.

Circulating adipocyte fatty acid-binding protein levels predict the development of subclinical atherosclerosis in type 2 diabetes

OBJECTIVE

The aim of this study was to investigate the prospective association of circulating adipocyte fatty acid-binding protein (A-FABP) levels with the development of subclinical atherosclerosis in patients with type 2 diabetes in an 8-year prospective study.

METHODS

A total of 170 patients with newly diagnosed type 2 diabetes were recruited in the study and 133 patients completed the follow-up of 8 years. Baseline plasma A-FABP levels were measured with enzyme-linked immunosorbent assays. The role of A-FABP in predicting the development of subclinical atherosclerosis over 8 years was analyzed using multiple logistic regression.

RESULTS

Of the 133 patients without subclinical atherosclerosis at baseline, a total of 100 had progressed to subclinical atherosclerosis over 8 years. Baseline A-FABP level was significantly higher in patients who had progressed to subclinical atherosclerosis at year 8 compared with ones who had not developed subclinical atherosclerosis after adjustment for sex (15.3 [12.1-23.2] versus 13.3 [10.0-18.9] ng/ml, P = 0.021). High baseline A-FABP level was an independent predictor for the development of subclinical atherosclerosis in patients with type 2 diabetes (odds ratio: 16.24, P = 0.022).

CONCLUSIONS

Circulating A-FABP levels predict the development of subclinical atherosclerosis in type 2 diabetes patients.

Vascular complications in patients with type 2 diabetes: prevalence and associated factors in 38 countries (the DISCOVER study program)

BACKGROUND

The global prevalence of type 2 diabetes-related complications is not well described. We assessed prevalence of vascular complications at baseline in DISCOVER (NCT02322762; NCT02226822), a global, prospective, observational study program of 15,992 patients with type 2 diabetes initiating second-line therapy, conducted across 38 countries.

METHODS

Patients were recruited from primary and specialist healthcare settings. Data were collected using a standardized case report form. Prevalence estimates of microvascular and macrovascular complications at baseline were assessed overall and by country and region, and were standardized for age and sex. Modified Poisson regression was used to assess factors associated with the prevalence of complications.

RESULTS

The median duration of type 2 diabetes was 4.1 years (interquartile range [IQR]: 1.9-7.9 years), and the median glycated hemoglobin (HbA1c) level was 8.0% (IQR: 7.2-9.1%). The crude prevalences of microvascular and macrovascular complications were 18.8% and 12.7%, respectively. Common microvascular complications were peripheral neuropathy (7.7%), chronic kidney disease (5.0%), and albuminuria (4.3%). Common macrovascular complications were coronary artery disease (8.2%), heart failure (3.3%) and stroke (2.2%). The age- and sex-standardized prevalence of microvascular complications was 17.9% (95% confidence interval [CI] 17.3-18.6%), ranging from 14.2% in the Americas to 20.4% in Europe. The age- and sex-standardized prevalence of macrovascular complications was 9.2% (95% CI 8.7-9.7%), ranging from 4.1% in South-East Asia to 18.8% in Europe. Factors positively associated with vascular complications included age (per 10-year increment), male sex, diabetes duration (per 1-year increment), and history of hypoglycemia, with rate ratios (95% CIs) for microvascular complications of 1.14 (1.09-1.19), 1.30 (1.20-1.42), 1.03 (1.02-1.04) and 1.45 (1.25-1.69), respectively, and for macrovascular complications of 1.41 (1.34-1.48), 1.29 (1.16-1.45), 1.02 (1.01-1.02) and 1.24 (1.04-1.48), respectively. HbA1c levels (per 1.0% increment) were positively associated with microvascular (1.05 [1.02-1.08]) but not macrovascular (1.00 [0.97-1.04]) complications.

CONCLUSIONS

The global burden of microvascular and macrovascular complications is substantial in these patients with type 2 diabetes who are relatively early in the disease process. These findings highlight an opportunity for aggressive early risk factor modification, particularly in regions with a high prevalence of complications. Trial registration ClinicalTrials.gov; NCT02322762. Registered 23 December 2014. https://clinicaltrials.gov/ct2/show/NCT02322762 . ClinicalTrials.gov; NCT02226822. Registered 27 August 2014. https://clinicaltrials.gov/ct2/show/NCT02226822.

Prescription of lipid-lowering medications for patients with type 2 diabetes mellitus and risk-associated LDL cholesterol: a nationwide study of guideline adherence from the Swedish National Diabetes Register

BACKGROUND

Management of type 2 diabetes mellitus (T2DM) encompasses intensive glycaemic control, along with treatment of comorbidities and complications to handle the increased risk of cardiovascular disease (CVD). Improved control of LDL-cholesterol (LDL-C) with lipid-lowering medications is associated with reduced CVD risk in T2DM patients. Thus, treatment guidelines recommend lipid-lowering medications for T2DM patients with LDL-C above risk-associated thresholds. This study aimed to assess healthcare provider adherence to guidelines regarding lipid-lowering medication prescription among T2DM patients and to analyse factors associated with lipid-lowering medication prescription.

METHODS

Observations in 2007 - 2014 for T2DM patients age ≥ 18 were collected from the Swedish National Diabetes Register. Observations were excluded if they lacked information about LDL-C, lipid-lowering medication prescription or CVD. Observations with established CVD were attributed to secondary prevention; remaining observations were attributed to primary prevention. The analyses included primary and secondary prevention observations with LDL-C above risk-associated thresholds (LDL-C ≥ 2.5 mmol/l and LDL-C ≥ 1.8 mmol/l respectively). Guideline adherence was analysed as the probability of prescribing lipid-lowering medications using mixed-effect model regression adjusted for potential confounders. Factors associated with prescribing lipid-lowering medications were analysed for patient and healthcare provider characteristics using mixed-effect model regression and odds ratio.

RESULTS

A total of 1,204,376 observations from 322,046 patients reported by 1352 healthcare providers were included. Primary prevention accounted for 63%; 52% were men, mean age was 64 and mean LDL-C was 3.4 mmol/l. For secondary prevention, 60% were men, mean age was 72 and mean LDL-C was 2.7 mmol/l. During 2007-2014, guideline adherence ranged from 36 to 47% for primary prevention and 59 to 69% for secondary prevention. In general, concomitant prescription of diabetes medications, antiplatelets and antihypertensives along with smoking and specialised care were associated with higher prescription of lipid-lowering medications. Patients age ≥ 80 were associated with lower prescription of lipid-lowering medications. Higher prescription was associated with longer diabetes duration in primary prevention and men in secondary prevention.

CONCLUSIONS

Adherence to treatment guidelines levelled off after an initial increase in both prevention groups. Lipid-lowering medication prescription was based on individualised CVD risk.

Association between serum magnesium and common complications of diabetes mellitus

BACKGROUND:

Magnesium ion, as important cation in the human body, involved in various enzymatic reactions, glucose transport and insulin release. Now diabetes mellitus and diabetic complications have become important public health problems around the world.

OBJECTIVE:

This paper explores the association between concentration levels of serum magnesium and common complications and comorbidities of diabetes mellitus and other biochemical indexes.

METHODS:

There are 1217 eligible patients selected from 14,317 cases of diabetic hospitalization patients from January 2010 to December 2011. Random forest algorithm was applied to assess the importance of various biochemical indexes and to perform diabetic complications prediction.

RESULTS:

The research results showed that low concentration of serum magnesium and four common diabetic complications – diabetic retinopathy, diabetic nephropathy, diabetic neuropathy and diabetic macroangiopathy – exists association, but no obvious correlation with other comorbidities like hypertension.

CONCLUSIONS:

The specific factors of four common diabetic complications were selected from the biochemical indexes to provide a reference direction for further research.

Interactive effect of serum uric acid and total bilirubin for micro-vascular disease of type 2 diabetes in China

AIMS

Serum uric acid (SUA) and bilirubin at high levels had both pro-oxidant and anti-oxidant properties. The present study aimed to examine additive interactions between SUA and total bilirubin (TBIL) for the risk of micro-vascular disease (MVD) in type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional survey of 6713 inpatients with T2DM was conducted in 81 tertiary care hospitals in China. MVD was defined as having either prior diabetic retinopathy (DR) or diabetic nephropathy (DN). Binary logistic regression was used to estimate odds ratios of SUA and TBIL for MVD. Additive interaction was measured by three indices, i.e., relative excess risk due to interaction, attributable proportion due to interaction and synergy index.

RESULTS

Among 6713 inpatients, 408 (6.08%) suffered from MVD. SUA ≥ 283 μmol/l (i.e., its media) was defined as high SUA, and TBIL <11.5 μmol/l (n = 2290 or 34.11%) was defined as low TBIL. Overall, 621 patients were exposed to co-presence of high SUA and low TBIL. The co-presence of both factors greatly increased the effect sizes from 1.03(95%CI: 0.72-1.46) (high SUA alone) or 0.70(95%CI: 0.48-1.05) (low TBIL alone) to 1.90 (95%CI: 1.26-2.87) for MVD in multivariable analysis. The additive interaction of both factors was significant for MVD in both univariable analysis and multivariable analysis.

CONCLUSIONS

Co-presence of both high SUA and low TBIL indentified a group of patients at a markedly increased risk of MVD in high-risk Chinese patients with T2DM.

Urinary tubular biomarkers as predictors of kidney function decline, cardiovascular events and mortality in microalbuminuric type 2 diabetic patients

AIMS

Urinary levels of kidney injury molecule 1 (u-KIM-1) and neutrophil gelatinase-associated lipocalin (u-NGAL) reflect proximal tubular pathophysiology and have been proposed as risk markers for development of complications in patients with type 2 diabetes (T2D). We clarify the predictive value of u-KIM-1 and u-NGAL for decline in eGFR, cardiovascular events (CVE) and all-cause mortality in patients with T2D and persistent microalbuminuria without clinical cardiovascular disease.

METHODS

This is a prospective study that included 200 patients. u-KIM-1 and u-NGAL were measured at baseline and were available in 192 patients. Endpoints comprised: decline in eGFR > 30%, a composite of fatal and nonfatal CVE consisting of: cardiovascular mortality, myocardial infarction, stroke, ischemic heart disease and heart failure based on national hospital discharge registries, and all-cause mortality. Adjusted Cox models included traditional risk factors, including eGFR. Hazard ratios (HR) are provided per 1 standard deviation (SD) increment of log2-transformed values. Relative integrated discrimination improvement (rIDI) was calculated.

RESULTS

During the 6.1 years' follow-up, higher u-KIM-1 was a predictor of eGFR decline (n = 29), CVE (n = 34) and all-cause mortality (n = 29) in adjusted models: HR (95% CI) 1.68 (1.04-2.71), p = 0.034; 2.26 (1.24-4.15), p = 0.008; and 1.52 (1.00-2.31), p = 0.049. u-KIM-1 contributed significantly to risk prediction for all-cause mortality evaluated by rIDI (63.1%, p = 0.001). u-NGAL was not a predictor of any of the outcomes after adjustment.

CONCLUSIONS

In patients with T2D and persistent microalbuminuria, u-KIM-1, but not u-NGAL, was an independent risk factor for decline in eGFR, CVE and all-cause mortality, and contributed significant discrimination for all-cause mortality, beyond traditional risk factors.

Glycemic variability in the development of cardiovascular complications in diabetes

Diabetes mellitus represents a major risk factor for the development of coronary artery disease and other vascular complications. Glycated haemoglobin, fructosamine, and fasting blood glucose levels are partial parameters to exhaustively describe patient dysglycemic status. Thus, recently the new concept of glycemic variability has emerged, including information about two major aspects: the magnitude of blood glucose excursions (from nadir to peak, thus lower and higher spikes) and the time intervals in which these fluctuations occur. Despite the lack of consensus regarding the most appropriate definition and tools for its assessment, glycemic variability seems to have more deleterious effects than sustained hyperglycemia in the pathogenesis of diabetic cardiovascular complications. This manuscript aimed to review the most recent evidence on glycemic variability and its potential use in everyday clinical practice to identify diabetic patients at higher risk of cardiovascular complications and thus needing stricter monitoring and treatment.

Neutrophil-lymphocyte ratio correlates with limited joint mobility of hand in patients with type 2 diabetes

Limited joint mobility (LJM) of hand, which is one of the complications of diabetic hand, is associated with diabetic micro- and macroangiopathy although the precise pathogenesis is not completely understood. Neutrophil-lymphocyte ratio (NLR), a simple and novel inflammatory marker, has been reported to have a predictive effect to some diabetic complications in recent years. However, it is not elucidated about the relationship between LJM of hand and NLR in patients with type 2 diabetes. We evaluated the relationships between LJM of hand and NLR in 335 consecutive patients with type 2 diabetes in this cross-sectional study. LJM of hand was diagnosed by a 'prayer sign' or 'table test'. LJM of hand was present in 80 patients. The patients with LJM of hand had significantly older age, longer duration of diabetes, worse renal function, and higher proportion of diabetic neuropathy, retinopathy and nephropathy. NLR in patients with LJM of hand was higher than that in patients without LJM of hand (2.54 ± 1.46 vs. 2.11 ± 1.04, p = 0.004). Multivariate logistic regression analysis revealed that LJM of hand was positively correlated with NLR (odds ratio, 1.31; 95% confidence interval 1.03-1.69, p = 0.027) after adjustment for age, sex, duration of diabetes, body mass index, hemoglobin A1c, hypertension and dyslipidemia. Our results demonstrate a positive relation between LJM of hand and NLR in patients with type 2 diabetes.

Anti-Angiogenic miR-222, miR-195, and miR-21a Plasma Levels in T1DM Are Improved by Metformin Therapy, Thus Elucidating Its Cardioprotective Effect: The MERIT Study

Type 1 diabetes (T1DM) is associated with increased cardiovascular disease (CVD) and reduced life expectancy. We thus hypothesized that anti-angiogenic miRs are increased in T1DM, and the cardioprotective effect of metformin is mediated via reducing those miRs. In an open label, case-controlled study, 23 T1DM patients without CVD were treated with metformin for eight weeks (TG), matched with nine T1DM patients on standard treatment (SG) and 23 controls (CG). Plasma miR-222, miR-195, miR-21a and miR-126 were assayed by real-time RT-qPCR. The results were correlated with: endothelial function (RHI), circulating endothelial progenitor cells (cEPCs) (vascular repair marker, CD45^dimCD34⁺VEGFR2⁺ cells) and circulating endothelial cells (cECs) (vascular injury marker, CD45^dimCD34⁺CD133^-CD144⁺ cells). miR-222, miR-195 and miR-21a were higher in T1DM than CG; p = 0.009, p < 0.0001, p = 0.0001, respectively. There was an inverse correlation between logmiR-222 and logRHI (p < 0.05) and a direct correlation between logmiR-222 and logCD34⁺ (p < 0.05) in TG. Metformin reduced miR-222, miR-195 and miR-21a levels in TG; p = 0.007, p = 0.002 p = 0.0012, respectively. miRs remained unchanged in SG. miR-126 was similar in all groups. There was a positive association between changes in logmiR-222 and logcECs after metformin in TG (p < 0.05). Anti-angiogenic miRs are increased in T1DM. Metformin has cardioprotective effects through downregulating miR-222, miR-195 and miR-21a, beyond improving glycemic control.

The associated risk factors for coronary artery calcium in asymptomatic individuals with and without diabetes in rural Central Appalachia

AIM

To examine the risk factor of coronary artery calcium (CAC) in individuals with diabetes and those without diabetes in Central Appalachia.

METHODS

Study population included 2479 asymptomatic participants who underwent CAC screening between August 2012 and November 2016. CAC score was classified into four categories [0 (no plaque), 1-99 (mild plaque), 100-399 (moderate plaque), and ≥400 (severe plaque)]. Multinomial logistic regression analyses were conducted to test the association between CAC and cardiovascular disease (CVD) risk factors among participants with diabetes, age and gender matched controls, and randomly selected controls.

RESULTS

13.6% of total participants had diabetes. Around 69%, 59.8%, and 57.7% of the participants with diabetes, matched controls, and randomly selected controls had CAC score ≥1, respectively. Participants with diabetes had higher prevalence of all CVD risk factors than controls. Among participants with diabetes, hypertension and physical inactivity increased the odds of CAC = 100-399, while among those without diabetes, hypertension and hypercholesteremia increased the odds of having CAC = 1-99 and CAC ≥ 400.

CONCLUSION

Half of study participants had subclinical atherosclerosis (i.e., CAC), and individuals with diabetes had higher CAC scores. This study suggests that individuals with diabetes in Central Appalachia might benefit from screening for CAC.

CONNECTION BETWEEN SERUM VASCULAR ENDOTHELIAL GROWTH FACTOR LEVELS AND SEVERITY OF MICROANGIOPATHY IN PATIENTS WITH TYPE 2 DIABETES AND OBSTRUCTIVE SLEEP APNEA

Our aim was to evaluate the serum vascular endothelial growth factor (VEGF) level in type 2 diabetes patients with comorbid obstructive sleep apnea (OSA) and to compare it in connection with diabetic retinopathy and chronic kidney disease severity. In the prospective cohort study following data were collected: medical anamnesis; demographic and anthropometric data; laboratory (serum VEGF, complete blood count, biochemistry, immunology, complete urine test, including microalbuminuria) and instrumental investigation data (fundoscophy, laboratory polysomnography). From 232 analyzed patients 54 (23.27%) were placed in OSA+ group, 178-OSA- group Mean VEGF value in OSA+ group was significantly higher, than in OSA- group. Serum VEGF level in patients with diabetic retinopathy was signifcantly higher with OSA comorbidity. Pearson correlation coefficient between VEGF and diabetic retinopathy stages, VEGF and CKD stages was significant in both groups. Our study suggests, that the blood VEGF play an important role in microangiopathy severity in patients with T2DM, especially with OSA comorbily.

Is there an association between non-dipping blood pressure and measures of glucose variability in type 1 diabetes?

AIM

To assess the relationship between glucose variability (GV) and non-dipping of blood pressure (BP) as a marker of cardiovascular autonomic neuropathy (CAN) among patients with type 1 diabetes (T1D).

METHODS

Forty-one subjects with T1D (age 34 ± 13 years, duration 13 ± 6 years, HbA1c 8 ± 1.2%) without cardiovascular disease, dyslipidemia, or hypertension at baseline were enrolled in a 3-year observational cohort study. Subjects were phenotyped for CAN with heart rate variability, cardiovascular autonomic reflex tests, and 24-h BP profiles at baseline and during follow-up. Non-dipping was defined as nocturnal systolic and diastolic BP fall of ≤10%. Reverse dipping BP was defined as a <0% change in the day to night for systolic and diastolic BP. Indices of GV were derived from 5-day continuous glucose monitoring obtained at 3-month intervals, and serum inflammatory biomarkers in all subjects.

RESULTS

At baseline 10% of the T1D subjects were non-dippers. The dippers and non-dippers were similar in age, diabetes duration, glucose control, traditional cardiovascular risk factors, GV and inflammatory markers. No significant correlations were found at baseline between non-dipping nocturnal blood pressure and measures of GV. At 3 years there were no differences in risk factor profile of subjects who were non-dippers over time (progressors) and those who were dippers (non-progressors).

CONCLUSION

In a cohort of contemporary patients with T1D following the current standard of care in diabetes, the prevalence of non-dipping is relatively low. There were no clear phenotypes that explained the difference in the risk for non-dipping, including GV. Ambulatory blood pressure monitoring could be used as a tool for improved CVD risk stratification and development of therapeutic interventions in these patients.

Hemoglobin glycation index predicts cardiovascular disease in people with type 2 diabetes mellitus: A 10-year longitudinal cohort study

BACKGROUND AND AIMS

Previous studies have suggested that the hemoglobin glycation index (HGI) can be used as a predictor of diabetes-related complications. We examined the prognostic significance of a high HGI for cardiovascular disease (CVD) in an ongoing hospital-based cohort.

METHODS

From March 2003 to December 2004, 1302 consecutive patients with type 2 diabetes and without a prior history of CVD were enrolled. CVD was defined as the occurrence of coronary artery disease or ischemic stroke. The HGI was calculated as the measured glycated hemoglobin (HbA1c) minus predicted HbA1c. Predicted HbA1c were calculated for 1302 participants by inserting fasting blood glucose (FBG) into the equation, Predicted HbA1c level = 0.02106 × FBG [mg/dL] + 4.973. Cox proportional hazards models were used to identify the associations between the HGI and CVD after adjusting for confounding variables.

RESULTS

During 11.1 years of follow-up, 225 participants (17.2%) were newly diagnosed with CVD. The baseline HGI was significantly higher in subjects with incident CVD than in those without CVD, although the baseline FBG levels did not differ according to the occurrence of CVD. Compared with patients without CVD, those with CVD were older, had a longer duration of diabetes and hypertension, and used more insulin at baseline. A Cox hazard regression analysis revealed that the development of CVD was significantly associated with baseline HGI (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.31-2.87; p < 0.001, comparing the highest and lowest quartiles of HGI). This relationship was unchanged after additional adjustment for baseline HbA1c level (HR, 1.74; 95% CI, 1.08-2.81). The HRs of HbA1c in relation to outcomes were similar to or lower than those seen for HGI. After adjustment for HGI, the effect of the highest HbA1c on incident CVD disappeared.

CONCLUSIONS

High HGI was independently associated with incident CVD in patients with type 2 diabetes. Patients with high HGI at baseline had a higher inherent risk for CVD.