Cardiovascular disease biomarkers are associated with declining renal function in type 2 diabetes

Association between high-sensitivity troponin T levels below the ninety-ninth percentile and diabetic kidney disease: A cross-sectional study

BACKGROUND

Identification of myocardial injury has traditionally relied on high-sensitivity troponin T (hs-TnT) levels exceeding the 99th percentile threshold. However, patients with detectable hs-TnT levels below this threshold represent a heterogeneous group with an inadequately characterized risk profile.

AIM

To investigate the association between hs-TnT levels below the 99th percentile and the presence of diabetic kidney disease (DKD) in patients with diabetes mellitus.

METHODS

This study analyzed data from the National Health and Nutrition Examination Survey obtained between 1999 and 2004, focusing on adults with type 2 diabetes mellitus. Serum hs-TnT concentrations were evaluated. DKD was defined as impaired glomerular filtration rate (< 60 mL/minute/1.73 m²), proteinuria (urinary albumin-to-creatinine ratio of ≥ 30 mg/g), or both conditions in patients with diabetes mellitus. Weighted multivariable logistic regression analysis and restricted cubic spline analyses were employed to examine the independent association between hs-TnT and DKD, with the likelihood ratio test being used to evaluate nonlinearity.

RESULTS

The study included 2505 patients with a mean age of 55.02 (standard error: 0.72) years, of whom 44.87% were females. Among the participants, 909 (32.34%) were diagnosed with DKD. Multivariable logistic regression analysis indicated that, compared to the lowest tertile of hs-TnT (< 5.93 ng/L), tertile 2 (5.94-9.79 ng/L) had an odds ratio of 1.25 (95% confidence interval: 0.77-2.02, P = 0.350), while tertile 3 (9.80-21.88 ng/L) had an odds ratio of 2.07 (95% confidence interval: 1.13-3.80, P = 0.022), with a significant trend (P for trend = 0.022). Smoothed curve fitting demonstrated a linear association between hs-TnT levels and DKD in the overall population (P = 0.061 for nonlinearity) and in male (P = 0.136 for nonlinearity) and female (P = 0.067 for nonlinearity) subgroups. Further stratification and sensitivity analyses yielded consistent conclusions.

CONCLUSION

Our study findings suggest that in individuals with type 2 diabetes, detectable hs-TnT levels below the 99th percentile are associated with DKD.

N-terminal pro-B-type natriuretic peptide, eGFR, and progression of kidney disease in chronic kidney disease patients without heart failure

Background

Cardiorenal syndrome highlights the bidirectional relationship between kidney and heart dysfunction. N-terminal pro-B-type natriuretic peptide (NT-proBNP), which is the gold standard biomarker in heart failure (HF), may be an important biomarker for chronic kidney disease (CKD) progression. However, NT-proBNP is negatively related with estimated glomerular filtration rate (eGFR). In this study, we investigated the association of NT-proBNP, eGFR, and progression of kidney disease in CKD patients without HF.

Methods

This multicentric retrospective cohort study recruited 23 860 CKD patients without HF, who had at least one NT-proBNP record from China Renal Data System database. Linear regression model evaluated the relationship between eGFR and NT-proBNP. Cox regression analysis assessed the association between NT-proBNP and CKD progression. Sensitivity analysis examined the robustness of the main findings.

Results

This study involved 23 860 CKD patients without HF, distributed across different CKD stages: 10 526 in stages G1-2, 4665 in G3a, 3702 in G3b, 2704 in G4, and 2263 in G5. NT-proBNP was negatively correlated with eGFR, particularly in stages 4-5 CKD. A 15-unit decrease in eGFR was associated with increases in log (NT-proBNP) levels by 1.04-fold, 1.27-fold, 1.29-fold, 1.80-fold, and 3.50-fold for stages 1-2, 3a, 3b, 4, and 5, respectively. After excluding patients who developed CKD progression within 1 year, the Cox regression analysis revealed that the relationship between NT-proBNP and CKD progression was not significant in stages 4 and 5. However, for stages 1-3, each standard deviation increase in log (NT-proBNP) was associated with a 26%, 36%, and 28% higher risk of CKD progression, with P interaction ≤.001. The hazard ratios were 1.26 (95% confidence intervals (CI), 1.18 to 1.35), 1.36 (95% CI, 1.22 to 1.51), and 1.28 (95% CI, 1.14 to 1.43) for stages 1-2, stage 3a, and stage 3b, respectively.

Conclusions

Despite its strong inverse association with eGFR, NT-proBNP was positively associated with the risk of progression of kidney disease in CKD patients with stages 1-3 without HF. Future studies should investigate the effectiveness of NT-proBNP as a predictive biomarker for the progression of kidney disease across diverse racial groups and healthcare settings.

Association of Arterial Stiffness with Chronic Kidney Disease: A Systematic Review

INTRODUCTION

Significant kidney function may be lost before CKD is diagnosed. Arterial stiffness may be a risk factor for CKD and the relationship may be bi-directional. A systematic review of cohort studies was undertaken to ascertain the temporal relationship of arterial stiffness and CKD.

METHODS

MEDLINE and Embase were searched to 4 October 2023 to identify studies that investigated whether arterial stiffness, as estimated by pulse wave velocity, was predictive of the development or progression of CKD, rapid decline in kidney function, and vice versa. The characteristics and outcomes of the included studies were set out in a qualitative summary. The review protocol is registered with PROSPERO (CRD42019129563).

RESULTS

Forty-two studies were included, all of which were high quality with respect to bias. Thirteen of seventeen studies that investigated arterial stiffness as a predictor of incident CKD found a positive association (p < 0.05). Of the 10 studies that controlled for CKD risk factors, 6 found a positive association. Eight of seventeen studies that investigated arterial stiffness as a predictor of progression of CKD, and five out of eight studies, which investigated rapid kidney decline, found a positive association. One study of six found kidney function was able to predict future elevated arterial stiffness.

CONCLUSION

Arterial stiffness may predict incident CKD and a rapid decline in CKD. It is uncertain if arterial stiffness is associated with CKD progression or whether reduced kidney function is predictive of increased arterial stiffness. Further longitudinal research is required.

Common carotid artery intima media thickness (CIMT) in patients with prediabetes and newly diagnosed type 2 diabetes mellitus

AIM

To evaluate the relationship between common carotid artery intima media thickness (CIMT) in patients with prediabetes and new-onset diabetes mellitus without proven cardiovascular disease and some classic cardio-metabolic risk factors.

PATIENTS AND METHODS

The study included 461 obese patients with an average age of 53.2 ± 10.7 years, divided into three groups - group 1 without carbohydrate disturbances (n = 182), group 2 with prediabetes (n = 193) and group 3 with newly diagnosed diabetes mellitus (n = 86).

RESULTS

The patients with new-onset diabetes had significantly higher mean CIMT values compared to those with prediabetes or without carbohydrate disturbances and a higher frequency of abnormal IMT values. CIMT correlated significantly with age, systolic BP, diastolic BP and fasting blood glucose and showed a high predictive value for the presence of diabetic neuropathy and sudomotor dysfunction. Patients with abnormal CIMT values had a higher incidence of arterial hypertension, dyslipidemia, metabolic syndrome, peripheral neuropathy, and sudomotor dysfunction. Patients who developed type 2 diabetes during follow-up had a significantly higher initial mean CIMT, which showed the highest predictive value for the risk of new-onset diabetes, with CIMT≥0.7 mm having 53 % sensitivity and 83 % specificity for the risk of progression to diabetes mellitus.

CONCLUSION

Patients with new-onset diabetes mellitus had significantly greater intima media thickness of the common carotid artery and a greater frequency of abnormal CIMT values compared to those with normoglycemia and prediabetes. CIMT has a high predictive value for the presence of diabetic neuropathy, sudomotor dysfunction and the risk of new onset diabetes.

Changes in Natriuretic Peptide Levels and Subsequent Kidney Function Decline in SPRINT

RATIONALE & OBJECTIVE

Novel approaches to the assessment of kidney disease risk during hypertension treatment are needed because of the uncertainty of how intensive blood pressure (BP) lowering impacts kidney outcomes. We determined whether longitudinal N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements during hypertension treatment are associated with kidney function decline.

STUDY DESIGN

Prospective observational study.

SETTING & PARTICIPANTS

8,005 SPRINT (Systolic Blood Pressure Intervention Trial) participants with NT-proBNP measurements at baseline and 1 year.

EXPOSURE

1-year change in NT-proBNP categorized as a ≥25% decrease, ≥25% increase, or <25% change (stable).

OUTCOME

Annualized change in estimated glomerular filtration rate (eGFR) and ≥30% decrease in eGFR.

ANALYTICAL APPROACH

Linear mixed-effect and logistic regression models were used to evaluate the association of changes in NT-proBNP with subsequent annualized change in eGFR and ≥30% decrease in eGFR, respectively. Analyses were stratified by baseline chronic kidney disease (CKD) status.

RESULTS

Compared with stable 1-year NT-proBNP levels, a ≥25% decrease in NT-proBNP was associated with a slower decrease in eGFR in participants with CKD (adjusted difference, 1.09%/y; 95% CI, 0.35-1.83) and without CKD (adjusted difference, 0.51%/y; 95% CI, 0.21-0.81; P = 0.4 for interaction). Meanwhile, a ≥25% increase in NT-proBNP in participants with CKD was associated with a faster decrease in eGFR (adjusted difference, -1.04%/y; 95% CI, -1.72 to -0.36) and risk of a ≥30% decrease in eGFR (adjusted odds ratio, 1.44; 95% CI, 1.06-1.96); associations were stronger in participants with CKD than in participants without CKD (P = 0.01 and P < 0.001 for interaction, respectively). Relationships were similar irrespective of the randomized BP arm in SPRINT (P > 0.2 for interactions).

LIMITATIONS

Persons with diabetes and proteinuria >1 g/d were excluded.

CONCLUSIONS

Changes in NT-proBNP during BP treatment are independently associated with subsequent kidney function decline, particularly in people with CKD. Future studies should assess whether routine NT-proBNP measurements may be useful in monitoring kidney risk during hypertension treatment.

PLAIN-LANGUAGE SUMMARY

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a biomarker in the blood that reflects mechanical stress on the heart. Measuring NT-proBNP may be helpful in assessing the risk of long-term losses of kidney function. In this study, we investigated the association of changes in NT-proBNP with subsequent kidney function among individuals with and without chronic kidney disease. We found that increases in NT-proBNP are associated with a faster rate of decline of kidney function, independent of baseline kidney measures. The associations were more pronounced in individuals with chronic kidney disease. Our results advance the notion of considering NT-proBNP as a dynamic tool for assessing kidney disease risk.

Machine Learning Models for Prediction of Diabetic Microvascular Complications

IMPORTANCE AND AIMS

Diabetic microvascular complications significantly impact morbidity and mortality. This review focuses on machine learning/artificial intelligence (ML/AI) in predicting diabetic retinopathy (DR), diabetic kidney disease (DKD), and diabetic neuropathy (DN).

METHODS

A comprehensive PubMed search from 1990 to 2023 identified studies on ML/AI models for diabetic microvascular complications. The review analyzed study design, cohorts, predictors, ML techniques, prediction horizon, and performance metrics.

RESULTS

Among the 74 identified studies, 256 featured internally validated ML models and 124 had externally validated models, with about half being retrospective. Since 2010, there has been a rise in the use of ML for predicting microvascular complications, mainly driven by DKD research across 27 countries. A more modest increase in ML research on DR and DN was observed, with publications from fewer countries. For all microvascular complications, predictive models achieved a mean (standard deviation) c-statistic of 0.79 (0.09) on internal validation and 0.72 (0.12) on external validation. Diabetic kidney disease models had the highest discrimination, with c-statistics of 0.81 (0.09) on internal validation and 0.74 (0.13) on external validation, respectively. Few studies externally validated prediction of DN. The prediction horizon, outcome definitions, number and type of predictors, and ML technique significantly influenced model performance.

CONCLUSIONS AND RELEVANCE

There is growing global interest in using ML for predicting diabetic microvascular complications. Research on DKD is the most advanced in terms of publication volume and overall prediction performance. Both DR and DN require more research. External validation and adherence to recommended guidelines are crucial.

Carotid intima-media thickness and atherosclerotic plaques are associated with renal function decline: a 14-year longitudinal population-based study

BACKGROUND

Chronic kidney disease (CKD) leads to increased morbidity and mortality. The underlying causes of CKD are often similar to those of atherosclerosis. We investigated whether carotid atherosclerotic parameters are associated with renal function decline.

METHODS

Within the population-based Study of Health in Pomerania (SHIP), Germany, 2904 subjects were observed over 14 years. The carotid intima-media thickness (cIMT) as well as carotid plaques were measured by standardized B-mode ultrasound protocol. CKD is defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 and albuminuria as urinary albumin-creatinine ratio (ACR) ≥30 mg/g. eGFR was calculated by the full age spectrum (FAS) equation and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Mixed models were applied to associate carotid parameters with change in renal function longitudinally and adjusted for confounding.

RESULTS

The age range of the study sample was 25-86 years with a median of 54 years at baseline. In longitudinal analyses, subjects with high cIMT and the presence of plaques at baseline showed a greater decrease in eGFR (cIMT: FAS-eGFR: P < .001, CKD-EPI-eGFR: P < .001; plaques: FAS-eGFR: P < .001, CKD-EPI-eGFR: n.s.) as well as an increased risk of developing CKD during the follow-up (cIMT: FAS-eGFR: P = .001, CKD-EPI-eGFR: P = .04; plaques: FAS-eGFR: P = .008, CKD-EPI-eGFR: P = .001). There was no association between atherosclerotic parameters and the risk of developing albuminuria.

CONCLUSIONS

cIMT and carotid plaques are associated with renal function decline as well as CKD in a population-based sample. Furthermore, the FAS equation adapts best to this study population.

Associations of blood biomarkers with arterial stiffness in patients with diabetes mellitus: A population-based study

BACKGROUND

Arterial stiffness contributes to additional cardiovascular risks in diabetic patients by triggering the loss of vascular and myocardial compliance and promoting endothelial dysfunction. Thus, prevention of arterial stiffness is a public health priority, and the identification of potential biomarkers may provide benefits for early prevention. This study investigates the relationships between serum laboratory tests and pulse wave velocity (PWV) tests. We also investigated the associations between PWV and all-cause mortality.

METHODS

We examined a panel of 33 blood biomarkers among diabetic populations in the Atherosclerosis Risk in Communities Study. The carotid-femoral (cfPWV) and femoral-ankle PWV (faPWV) were measured using an automated cardiovascular screening device. The aortic-femoral arterial stiffness gradient (afSG) was calculated as faPWV divided by cfPWV. Biomarker levels were log-transformed and correlated with PWV. Cox proportional hazard models were employed for survival analysis.

RESULTS

Among 1079 diabetic patients, biomarkers including high-density lipoprotein cholesterol, glycated hemoglobin, high-sensitivity troponin T, cystatin C, creatinine, and albuminuria were significantly correlated with afSG (R = 0.078, -0.193, -0.155, -0.153, -0.116, and -0.137, respectively) and cfPWV (R = -0.068, 0.175, 0.128, 0.066, 0.202, and 0.062, respectively). Compared with the lowest tertile of afSG, the risk of all-cause mortality was lower in the highest tertile (hazard ratio 0.543; 95% confidence interval 0.328-0.900).

CONCLUSION

Certain biomarkers related to blood glucose monitoring, myocardial injury, and renal function significantly correlated with PWV, suggesting that these putative risk factors are likely to be important atherosclerosis mechanisms in diabetic patients. AfSG may be an independent predictor of mortality among diabetic populations.

The potential of cardiac biomarkers, NT-ProBNP and troponin T, in predicting the progression of nephropathy in diabetic patients: A meta-analysis of prospective cohort studies

AIMS

A meta-analysis was done to investigate the association of two cardiac biomarkers of N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) and circulating troponin T (TnT) with the progression of diabetic nephropathy (DN).

METHODS

A thorough search of the PubMed, Scopus, and Web of Science databases was done until June 2022. The outcome (progression of DN) was described as either of the followings: a) eGFR decline, b) albuminuria, c) end-stage renal disease, or d) mortality. A pooled analysis of eligible studies was performed using random-effect models to compensate for the differences in measurement standards between the studies. We further carried out subgroup analyses to examine our results' robustness and find the source of heterogeneity. A sensitivity analysis was performed to assess the influence of individual studies on the pooled result and the funnel plot and Egger's test were used to assess publication bias.

RESULTS

For NT-proBNP, 8741 participants from 14 prospective cohorts, and for TnT, 7292 participants from 9 prospective cohorts were included in the meta-analysis. Higher NT-proBNP levels in diabetic patients were associated with a higher probability of DN progression (relative risk [RR]: 1.67, 95% confidence interval [CI]: 1.44 to 1.92). Likewise, elevated levels of TnT were associated with an increased likelihood of DN (RR: 1.57, 95% CI: 1.34 to 1.83). The predictive power of both biomarkers for DN remained significant when the subgroup analyses were performed. The risk estimates were sensitive to none of the studies. The funnel plot and Egger's tests indicated publication bias for both biomarkers. Hence, trim and fill analysis was performed to compensate for this putative bias and the results remained significant both for NT-proBNP (RR: 1.50, 95% CI: 1.31 to 1.79) and TnT (RR: 1.35, 95% CI 1.15 to 1.60).

CONCLUSIONS

The increased blood levels of TnT and NT-proBNP can be considered as predictors of DN progression in diabetic individuals. PROSPERO registration code: CRD42022350491.

Prediction of the risk of developing end-stage renal diseases in newly diagnosed type 2 diabetes mellitus using artificial intelligence algorithms

OBJECTIVES

Type 2 diabetes mellitus (T2DM) imposes a great burden on healthcare systems, and these patients experience higher long-term risks for developing end-stage renal disease (ESRD). Managing diabetic nephropathy becomes more challenging when kidney function starts declining. Therefore, developing predictive models for the risk of developing ESRD in newly diagnosed T2DM patients may be helpful in clinical settings.

METHODS

We established machine learning models constructed from a subset of clinical features collected from 53,477 newly diagnosed T2DM patients from January 2008 to December 2018 and then selected the best model. The cohort was divided, with 70% and 30% of patients randomly assigned to the training and testing sets, respectively.

RESULTS

The discriminative ability of our machine learning models, including logistic regression, extra tree classifier, random forest, gradient boosting decision tree (GBDT), extreme gradient boosting (XGBoost), and light gradient boosting machine were evaluated across the cohort. XGBoost yielded the highest area under the receiver operating characteristic curve (AUC) of 0.953, followed by extra tree and GBDT, with AUC values of 0.952 and 0.938 on the testing dataset. The SHapley Additive explanation summary plot in the XGBoost model illustrated that the top five important features included baseline serum creatinine, mean serum creatine within 1 year before the diagnosis of T2DM, high-sensitivity C-reactive protein, spot urine protein-to-creatinine ratio and female gender.

CONCLUSIONS

Because our machine learning prediction models were based on routinely collected clinical features, they can be used as risk assessment tools for developing ESRD. By identifying high-risk patients, intervention strategies may be provided at an early stage.

Prognostic models of diabetic microvascular complications: a systematic review and meta-analysis

BACKGROUND

Many prognostic models of diabetic microvascular complications have been developed, but their performances still varies. Therefore, we conducted a systematic review and meta-analysis to summarise the performances of the existing models.

METHODS

Prognostic models of diabetic microvascular complications were retrieved from PubMed and Scopus up to 31 December 2020. Studies were selected, if they developed or internally/externally validated models of any microvascular complication in type 2 diabetes (T2D).

RESULTS

In total, 71 studies were eligible, of which 32, 30 and 18 studies initially developed prognostic model for diabetic retinopathy (DR), chronic kidney disease (CKD) and end stage renal disease (ESRD) with the number of derived equations of 84, 96 and 51, respectively. Most models were derived-phases, some were internal and external validations. Common predictors were age, sex, HbA1c, diabetic duration, SBP and BMI. Traditional statistical models (i.e. Cox and logit regression) were mostly applied, otherwise machine learning. In cohorts, the discriminative performance in derived-logit was pooled with C statistics of 0.82 (0.73‑0.92) for DR and 0.78 (0.74‑0.83) for CKD. Pooled Cox regression yielded 0.75 (0.74‑0.77), 0.78 (0.74‑0.82) and 0.87 (0.84‑0.89) for DR, CKD and ESRD, respectively. External validation performances were sufficiently pooled with 0.81 (0.78‑0.83), 0.75 (0.67‑0.84) and 0.87 (0.85‑0.88) for DR, CKD and ESRD, respectively.

CONCLUSIONS

Several prognostic models were developed, but less were externally validated. A few studies derived the models by using appropriate methods and were satisfactory reported. More external validations and impact analyses are required before applying these models in clinical practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018105287.

Importance of Identifying Novel Biomarkers of Microvascular Damage in Type 1 Diabetes

Microvascular complications of type 1 diabetes, which primarily include diabetic kidney disease, retinopathy, and neuropathy, are characterized by damage to the microvasculature of the kidney, retina, and neurons. The pathogenesis of these complications is multifactorial, and several pathways are implicated. These complications are often silent during their early stages, and once symptoms develop, there might be little to be done to cure them. Thus, there is a strong need for novel biomarkers to identify individuals at risk of microvascular complications at an early stage and guide the implementation of new therapeutic options for preventing their development and progression. Recent advancements in proteomics, metabolomics, and other 'omics' have led to the identification of several potential biomarkers of microvascular complications. However, biomarker discovery has met several challenges and, up to now, there are no new biomarkers that have been implemented into clinical practice. This highlights the need for further work in this area to move towards better diagnostic and prognostic approaches.

N-Terminal Pro-B-Type Natriuretic Peptide and Incident CKD

Introduction

Serum N-terminal pro–B-type natriuretic peptide (NT-proBNP) levels have been associated with the progression of kidney impairment among patients with chronic kidney disease (CKD), but only a few studies have investigated the association between serum NT-proBNP levels and incident CKD in general populations.

Methods

A total of 2486 Japanese community-dwelling residents ≥40 years of age without CKD at baseline were followed up by repeated annual health examinations for 10 years. Participants were divided into 4 groups according to serum NT-proBNP levels. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m² or the presence of proteinuria. Cox proportional hazards models were used to estimate hazard ratios (HRs) for risk of CKD. Linear mixed models were used to compare changes in eGFR.

Results

During the follow-up period, 800 participants developed CKD. The multivariable-adjusted HRs (95% confidence intervals [CIs]) for developing CKD were 1.00 (reference), 1.32 (1.11–1.57), 1.40 (1.10–1.78), and 1.94 (1.38–2.73) for serum NT-proBNP levels of <55, 55–124, 125–299, and ≥300 pg/ml, respectively (P for trend <0.001). The decline of eGFR during the follow-up was significantly more rapid among participants with higher serum NT-proBNP levels (P for trend <0.001). Adding serum NT-proBNP to the model composed of known risk factors for CKD improved the predictive ability for developing CKD.

Conclusions

Higher serum NT-proBNP levels were associated with greater risks of developing CKD and greater decline in eGFR. Serum NT-proBNP could be a useful biomarker for assessing the future risk of CKD in a general Japanese population.

Diabetic kidney disease: new clinical and therapeutic issues. Joint position statement of the Italian Diabetes Society and the Italian Society of Nephrology on "The natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function"

AIMS

This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents.

DATA SYNTHESIS

Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., "nonalbuminuric renal impairment" and "progressive renal decline", suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered.

CONCLUSIONS

The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.

Peripheral Artery Disease in Type 2 Diabetes Mellitus: Survival Analysis of an Ecuadorian Population in Primary Care

Background

Peripheral artery disease (PAD) is associated with cardiovascular risk in type 2 diabetes mellitus (DM). The ankle-brachial index (ABI) is used for diagnosis of PAD.

Objectives

Establish the prevalence and incidence rate for PAD and determine the associated factors and survival time for the development of PAD.

Methods

Retrospective cross-sectional cohort study (follow up: 10 years) in 578 DM patients with at least 1 ABI measurement in a primary level of care diabetes clinic. Data was collected from clinical records. Sociodemographic and laboratory variables were analyzed determining its association (mean difference and bivariate logistic regression). Survival was calculated through life tables and Kaplan-Meier analysis.

Results

The prevalence of PAD was 13.98%. The incidence rate through the time of follow up was 23.38 per 1000 person-year (95% CI: 19.91-27.26). The group that developed PAD showed higher glycated hemoglobin levels ( P = .025), more years of DM ( P < .001) and lower glomerular filtration rate (GFR, P = .003). The median time for developing PAD was 26.97 years (95% CI: 26.89-27.05). The risk for PAD was higher in females (95% CI: 1.51-4.38), GFR <60 mL/min/m2 (95% CI: 1.05-2.22) and use of metformin plus insulin (95% CI: 1.10-2.35).

Conclusion

Half of a DM patient’s population in primary level of care will develop PAD in the third decade of disease. There are identifiable risk factors for PAD development in DM in the primary level of care such as low GFR, female sex, and use of metformin plus insulin.

Diabetic kidney disease: New clinical and therapeutic issues. Joint position statement of the Italian Diabetes Society and the Italian Society of Nephrology on "The natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function"

AIMS

This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents.

DATA SYNTHESIS

Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., "nonalbuminuric renal impairment" and "progressive renal decline", suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered.

CONCLUSIONS

The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.

Prognostic impact of carotid intima-media thickness and carotid plaques on the development of micro- and macrovascular complications in individuals with type 2 diabetes: the Rio de Janeiro type 2 diabetes cohort study

BACKGROUND

The prognostic importance of carotid atherosclerosis in individuals with diabetes is unsettled. We aimed to evaluate the relationships between parameters of carotid atherosclerosis and the future occurrence of micro- and cardiovascular complications in individuals with type 2 diabetes.

METHODS

Ultrasonographic parameters of carotid atherosclerosis, intima-media thickness (CIMT) and plaques, were measured at baseline in 478 participants who were followed-up for a median of 10.8 years. Multivariate Cox analysis was used to examine the associations between carotid parameters and the occurrence of microvascular (retinopathy, renal, and peripheral neuropathy) and cardiovascular complications (total cardiovascular events [CVEs] and cardiovascular mortality), and all-cause mortality. The improvement in risk stratification was assessed by using the C-statistic and the integrated discrimination improvement (IDI) index.

RESULTS

During follow-up, 116 individuals had a CVE and 115 individuals died (56 from cardiovascular diseases); 131 newly-developed or worsened diabetic retinopathy, 156 achieved the renal composite outcome (94 newly developed microalbuminuria and 78 deteriorated renal function), and 83 newly-developed or worsened peripheral neuropathy. CIMT, either analysed as a continuous or as a categorical variable, and presence of plaques predicted CVEs occurrence and renal outcomes, but not mortality or other microvascular complications. Individuals with an increased CIMT and plaques had a 1.5- to 1.8-fold increased risk of CVEs and a 1.6-fold higher risk of renal outcome. CIMT and plaques modestly improved cardiovascular risk discrimination over classic risk factors, with IDIs ranging from 7.8 to 8.4%; but more markedly improved renal risk discrimination, with IDIs from 14.8 to 18.5%.

CONCLUSIONS

Carotid atherosclerosis parameters predicted cardiovascular and renal outcomes, and improved renal risk stratification. Ultrasonographic carotid imaging may be useful in type 2 diabetes management.

Assessment of the Relationship between Carotid Intima-Media Thickening and Early-Stage Diabetic Kidney Disease Coupled with Helicobacter pylori Infection

OBJECTIVE

This study aimed to explore the associations between carotid intima-media thickness (CIMT) and early-stage diabetic kidney disease (DKD) coupled with Helicobacter pylori (H. pylori) infection in type 2 diabetic patients.

METHODS

A cross-sectional study including 180 type 2 diabetic participants was conducted to explore the associations between CIMT and early-stage DKD coupled with H. pylori infection, and a stepwise multivariate regression analysis evaluated the correlations of CIMT with clinical and serologic parameters.

RESULTS

The type 2 diabetic patients with early-stage DKD coupled with H. pylori infections had the highest CIMT values. Apolipoprotein B (ApoB), urine albumin/creatinine ratio (UACR), and interleukin-6 (IL-6) were independent predictors of CIMT.

CONCLUSIONS

Early-stage DKD coupled with H. pylori infection may synergistically lead to significant CIMT thickening in type 2 diabetic patients. Additionally, ApoB, UACR, and IL-6 levels were important independent risk factors for increased CIMT.