Prevention of nephropathy in patients with type 2 diabetes mellitus

Cardiovascular health metrics and diabetic nephropathy: a nationally representative cross-sectional study

BACKGROUND

The pathogenesis of diabetic nephropathy is well-documented to be multifactorial. However, research available on the association between cardiovascular health and diabetic nephropathy is limited. Thus, this study aimed to investigate these potential associations and provide guidance for disease prevention.

METHODS

We applied Life's Essential 8 (LE8) identified by the American Heart Association, which integrates multiple health behaviors and health factors to measure cardiovascular health. This study covered 4207 adults with diabetes from the National Health and Nutrition Examination Survey spanning 2007-2018. Weighted regression models assessed the estimated effect of LE8 score on the prevalence of diabetic nephropathy as well as their corresponding clinical indicators. Weighted restricted cubic spline models discussed the possible nonlinear dose-response relationships further. Subgroup analyses clarified the effects of other covariates on correlations.

RESULTS

After adjusting for all covariates, participants with moderate or high cardiovascular health showed a decreased prevalence of diabetic nephropathy (odds ratio [OR]:0.52; 95% confidence interval [CI]:0.42-0.63), and also a decrease in the urinary albumin-to-creatinine ratio [UACR] (β: - 0.83; 95% CI:- 1.00 to - 0.65). The prevalence of diabetic nephropathy and the level of UACR tended to decrease linearly as the total LE8 score increased (P for nonlinear > 0.05). Subgroup analyses showed that the effects of increased overall LE8 score and the specific cardiovascular health construct varied across age and obesity strata.

CONCLUSION

Elevated overall LE8 score was significantly associated with a lower prevalence of diabetic nephropathy in U.S. adults, and the effects of the specific cardiovascular health construct on diabetic nephropathy and their corresponding clinical indicators varied. In all, maintaining good cardiovascular health by refining LE8 metrics may help reduce the adverse effects.

Development and assessment of diabetic nephropathy prediction model using hub genes identified by weighted correlation network analysis

Diabetic nephropathy (DN) is one microvascular complication of diabetes. About 30% of diabetic patients can develop DN, which is closely related to the high incidence and mortality of heart diseases, and then develop end-stage renal diseases. Therefore, early detection and screening of high-risk patients with DN is important. Herein, we explored the differences of serum transcriptomics between DN and non-DN in type II diabetes mellitus (T2DM) patients. We obtained 110 target genes using weighted correlation network analysis. Gene Ontology enrichment analysis indicates these target genes are mainly related to membrane adhesion, alpha-amino acid biosynthesis, metabolism, and binding, terminus, inhibitory synapse, clathrinid-sculpted vesicle, kinase activity, hormone binding, receptor activity, and transporter activity. Kyoto Encyclopedia of Genes and Genomes analysis indicates the process of DN in diabetic patients can involve synaptic vesicle cycle, cysteine and methionine metabolism, N-Glycan biosynthesis, osteoclast differentiation, and cAMP signaling pathway. Next, we detected the expression levels of hub genes in a retrospective cohort. Then, we developed a risk score tool included in the prediction model for early DN in T2DM patients. The prediction model was well applied into clinical practice, as confirmed by internal validation and several other methods. A novel DN risk model with relatively high prediction accuracy was established based on clinical characteristics and hub genes of serum detection. The estimated risk score can help clinicians develop individualized intervention programs for DN in T2DM. External validation data are required before individualized intervention measures.

An Overview of the Posttranslational Modifications and Related Molecular Mechanisms in Diabetic Nephropathy

Diabetic nephropathy (DN), a common diabetic microvascular complication, is characterized by its complex pathogenesis, higher risk of mortality, and the lack of effective diagnosis and treatment methods. Many studies focus on the diagnosis and treatment of diabetes mellitus (DM) and have reported that the pathophysiology of DN is very complex, involving many molecules and abnormal cellular activities. Given the respective pivotal roles of NF-κB, Nrf2, and TGF-β in inflammation, oxidative stress, and fibrosis during DN, we first review the effect of posttranslational modifications on these vital molecules in DN. Then, we describe the relationship between these molecules and related abnormal cellular activities in DN. Finally, we discuss some potential directions for DN treatment and diagnosis. The information reviewed here may be significant in the design of further studies to identify valuable therapeutic targets for DN.

p22phox C242T gene polymorphism and overt diabetic nephropathy: a meta-analysis of 1,452 participants

BACKGROUND/AIMS

The p22phox C242T gene polymorphism (rs4673) may be linked to an increased susceptibility for overt diabetic nephropathy (ODN), but the study results are still inconclusive.

METHODS

To explore the relationship between p22phox C242T gene polymorphism and ODN, the current meta-analysis of 707 ODN patients and 745 controls from five individual studies was conducted. The pooled odds ratio (OR) and its corresponding 95% confidence interval (CI) were evaluated by either a random or fixed effect model.

RESULTS

In our meta-analysis, a significant relationship between the p22phox C242T gene polymorphism and ODN was found under allelic (OR, 2.760; 95% CI, 1.400 to 5.450; p = 0.004), recessive (OR, 5.080; 95% CI, 1.020 to 25.430; p = 0.05), dominant (OR, 1.700; 95% CI, 1.167 to 2.477; p = 0.006), homozygous (OR, 3.900; 95% CI, 1.022 to 14.889; p = 0.046), heterozygous (OR, 1.523; 95% CI, 1.167 to 1.986; p = 0.002), and additive genetic models (OR, 2.019; 95% CI, 1.232 to 3.309; p = 0.005).

CONCLUSIONS

A positive correlation between p22phox C242T gene polymorphism and ODN risk was found. The T allele carriers of p22phox C242T gene polymorphism might be predisposed to ODN.

Type 2 diabetes mellitus and renal impairment in a large outpatient electronic medical records database: rates of diagnosis and antihyperglycemic medication dose adjustment

OBJECTIVE

To assess rates of diagnosis and antihyperglycemic dose adjustment in patients with moderate to end-stage renal impairment (RI) and type 2 diabetes mellitus (T2DM).

METHODS

Retrospective database analysis using GE Centricity Outpatient Electronic Medical Records. Patients aged ≥ 18 years with evidence of T2DM (International Classification of Diseases, Ninth Edition, Clinical Modification codes 250.x0 and 250.x2) between January 1, 2000 and June 30, 2009, and ≥ 12 months of data after identification were selected. Moderate to end-stage RI was evaluated using a formula-derived estimated glomerular filtration rate (eGFR) based on serum creatinine (SCr). Patients were classified as moderate (eGFR, 30-59 mL/min/1.73 m(2)), severe (eGFR, 15-29 mL/min/1.73 m(2)), or end-stage (eGFR, < 15 mL/min/1.73 m(2)), per the National Kidney Foundation guidelines, based on the first-observed SCr test. Among patients with a physician diagnosis, the time to diagnosis was reported. Dose adjustment was reported for patients receiving metformin and sitagliptin. Predictors of progression to end-stage RI based on logistic regressions were examined.

RESULTS

35.2% of patients with T2DM had evidence of moderate to end-stage RI. Of these patients, 20% had a chart-documented physician diagnosis (range, 16% [moderate RI] to 66% [end-stage RI]). Patients with moderate or severe RI had a physician diagnosis mean of 253.4 (standard deviation [SD], 584.5) and 86.9 (SD, 417.4) days, respectively, after the eGFR calculation indicating RI. Patients with end-stage RI had a physician diagnosis mean of 83.6 (SD, 399.2) days before the eGFR calculation. After the eGFR calculation, 15.1% and 0.1% of patients with orders for sitagliptin and metformin, respectively, received doses of the drug appropriate for their degree of RI. Among patients with moderate or severe RI, appropriate diagnosis of RI was associated with significantly lower odds of progressing to end-stage RI (odds ratio, 0.200; 95% confidence interval, 0.188-0.213).

CONCLUSIONS

Renal impairment is common but often undetected in patients with T2DM. Patients with a documented RI diagnosis have lower odds of progression to end-stage RI. Metformin and sitagliptin are frequently used at inappropriate doses in patients with RI. Further analyses to understand the clinical and economic consequences of these findings are needed.

Abnormalities of serum potassium concentration in dialysis-associated hyperglycemia and their correction with insulin: review of published reports

The main difference between dialysis-associated hyperglycemia (DH) and diabetic ketoacidosis (DKA) or nonketotic hyperglycemia (NKH) occurring in patients with preserved renal function is the absence of osmotic diuresis in DH, which eliminates the need for large fluid and solute (including potassium) replacement. We analyzed published reports of serum potassium (K(+)) abnormalities and their treatment in DH. Hyperkalemia was often present at presentation of DH with higher frequency and severity than in hyperglycemic syndromes in patients with preserved renal function. The frequency and severity of hyperkalemia were higher in DH episodes with DKA than those with NKH in both hemodialysis and peritoneal dialysis. For DKA, the frequency and severity of hyperkalemia were similar in hemodialysis and peritoneal dialysis. For NKH, hyperkalemia was more severe and frequent in hemodialysis than in peritoneal dialysis. Insulin infusion corrected the hyperkalemia of DH in most cases. Additional measures for the management of hyperkalemia or modest potassium infusions for hypokalemia were needed in a few DH episodes. The predictors of the decrease in serum K(+) during treatment of DH with insulin included the starting serum K(+) level, the decreases in serum values of glucose concentration and tonicity, and the increase in serum total carbon dioxide level. DH represents a risk factor for hyperkalemia. Insulin infusion is the only treatment for hyperkalemia usually required.

Abnormalities of serum potassium concentration in dialysis-associated hyperglycemia and their correction with insulin: review of published reports

The main difference between dialysis-associated hyperglycemia (DH) and diabetic ketoacidosis (DKA) or nonketotic hyperglycemia (NKH) occurring in patients with preserved renal function is the absence of osmotic diuresis in DH, which eliminates the need for large fluid and solute (including potassium) replacement. We analyzed published reports of serum potassium (K(+)) abnormalities and their treatment in DH. Hyperkalemia was often present at presentation of DH with higher frequency and severity than in hyperglycemic syndromes in patients with preserved renal function. The frequency and severity of hyperkalemia were higher in DH episodes with DKA than those with NKH in both hemodialysis and peritoneal dialysis. For DKA, the frequency and severity of hyperkalemia were similar in hemodialysis and peritoneal dialysis. For NKH, hyperkalemia was more severe and frequent in hemodialysis than in peritoneal dialysis. Insulin infusion corrected the hyperkalemia of DH in most cases. Additional measures for the management of hyperkalemia or modest potassium infusions for hypokalemia were needed in a few DH episodes. The predictors of the decrease in serum K(+) during treatment of DH with insulin included the starting serum K(+) level, the decreases in serum values of glucose concentration and tonicity, and the increase in serum total carbon dioxide level. DH represents a risk factor for hyperkalemia. Insulin infusion is the only treatment for hyperkalemia usually required.