Albuminuria and associated medical risk factors: a cross-sectional study in 451 type II (noninsulin-dependent) diabetic patients. Part 2

The prevalence of hypertension in relation with the normal albuminuria range in type 2 diabetes mellitus within the South Korean population: The Korean National Health and Nutrition Examination Survey, 2011-2012

AIMS

The coexistence of hypertension (HTN) and diabetes mellitus (DM) increases the risk of cardiovascular disease. In some studies, normal albuminuria has also been associated with cardiovascular disease and HTN. Therefore, we examined the relationships between albuminuria and the prevalence of HTN and its control rate in type 2 DM patients.

RESULTS

We analyzed data from the 2011-2012 Korea National Health and Nutrition Examination Survey, and 1188 subjects with type 2 DM were included in the study. We divided albuminuria into 3 albuminuria tertiles (T): T1: <4.82mg/g; T2: 4.82-17.56mg/g; and T3: ≥17.56mg/g. The systolic and diastolic blood pressure were positively correlated with the albumin to creatinine ratio (ACR) after adjusting for all covariates (P<0.001). Type 2 DM subjects with hypertension had more ACR T3 (odds ratio=2.018, 95% confidence interval=1.445-2.818) than subjects without HTN. Subjects with controlled HTN had less ACR T3 than subjects without controlled HTN (odds ratio=0.566, 95% confidence interval=0.384-0.836). When, we redivided albuminuria by <10, 10-30 (high normal albuminuria), 30-300mg/g (microalbuminuria), and 300mg/g≤(macroalbuminuria), the odds ratio for high normal albuminuria and microalbuminuria was 1.52 and 2.24, respectively in the presence of HTN, however, high normal albuminuria was not associated with HTN control.

CONCLUSIONS

In conclusion, albuminuria within the high normal range was associated with the prevalence of HTN in South Korean patients with type 2 DM.

The incidence of microalbuminuria and its associated risk factors in type 2 diabetic patients in isfahan, iran

AIM

The study was carried out to determine the five-year incidence of microalbuminuria and to assess its associated risk factors for type 2 diabetic patients in Isfahan, Iran.

METHODS

505 type 2 diabetic patients (22% male, 78% female) with normal urinary albumin levels, being treated at Isfahan Endocrine and Metabolism Research Center, were consecutively selected. After the initial selection in 1999, the patients were followed for five years. Mean and standard deviation (SD) of age and duration of diabetes was 57.4 (9.5) and 10.2 (4.7) years, respectively. BMI, blood pressure, fasting plasma glucose, HbA1c, serum lipids and serum creatinine were measured and re-examined every three months. 24-h urinary albumin excretion was measured and reviewed annually. Microalbuminuria was diagnosed when at least two measurements indicated the excretion of more than 30 mg albumin in 24-h urinary samples.

RESULTS

During 5-year follow up, 176 patients developed microalbuminuria, giving an incidence rate of 82.3/1000 person/year (95% CI: 78.3-86.2). Males had a higher incidence than females (104.4 vs. 66.2/1000 person/year, p < 0.001). Duration of diabetes, abnormal levels of HbA1c, hypertension and high serum creatinine were significantly associated with microalbuminuria. There was no difference in mean of age, BMI, and lipid levels between patients with and without microalbuminuria. Multivariate analysis was used to show that duration of diabetes, HbA1c, hypertension and retinopathy were the independent variables related to microalbuminuria.

CONCLUSIONS

The incidence of microalbuminuria in the study population was higher than in other populations. The higher incidence and the considerable gender difference in this population may be attributed to inferior glycemic control and lack in screening for risk factors, but this needs to be explored in further studies.

Diabetic nephropathy in the elderly

Renal impairment is frequent in aged diabetic patients, notably with type 2 diabetes. It results from a multifactorial pathogeny, particularly the combined actions of hyperglycaemia, arterial hypertension and ageing. Diabetic nephropathy (DN) is associated with an increased cardiovascular mortality. DN often leads to end stage renal failure (ESRF) which causes specific problems of decision and practical organization of extra-renal epuration in diabetic and aged patients. In the absence of renal biopsy, clinical signs are often insufficient to assess the diabetic origin of a nephropathy in an elderly diabetic patient. Prevention of DN is principally based on tight glycaemic and blood pressure control. The progression of renal lesions can be retarded by strict blood pressure control, notably by blocking of the renin-angiotensin system, if well tolerated in aged patients. It is absolutely necessary to avoid the worsening of renal lesions by potentially nephrotoxic products, notably non steroidal anti-inflammatory drugs (NSAIDs) and iodinated contrast media. At the stage of renal failure, it is important to adapt the antidiabetic treatment, and in the majority of the cases, to switch to insulin when glomerular filtration rate (GFR) is below 30 ml/mn/1.73 m2.

Urinary albumin excretion rate is associated with increased ambulatory blood pressure in normoalbuminuric type 2 diabetic patients

OBJECTIVE

To evaluate the 24-h blood pressure profile in normoalbuminuric type 2 diabetic patients.

RESEARCH DESIGN AND METHODS

A cross-sectional study was conducted in 90 type 2 diabetic patients with a urinary albumin excretion rate (UAER) <20 microg/min on two occasions, 6 months apart (immunoturbidimetry). Patients underwent clinical and laboratory evaluations. Ambulatory blood pressure monitoring and echocardiograms were also performed.

RESULTS

UAER was found to correlate positively with systolic doctor's office blood pressure measurements (r = 0.243, P = 0.021) and ambulatory blood pressure (24 h: r = 0.280, P = 0.008) and left ventricular posterior wall thickness (r = 0.359, P = 0.010). Patients were divided into four groups according to UAER (<5, > or =5-10, > or =10-15, and > or =15-20 microg/min). Systolic blood pressure parameters for the 1st, 2nd, 3rd, and 4th groups, respectively, were 123.0 +/- 10.6, 132.5 +/- 15.0, 139.0 +/- 23.4, and 130.7 +/- 8.0 mmHg for 24-h blood pressure (ANOVA P = 0.004) and 48.4 +/- 6.0, 54.5 +/- 11.2, 58.8 +/- 15.6, and 57.6 +/- 8.0 mmHg for 24-h pulse pressure (ANOVA P = 0.003). A progressive increase in the prevalence of diabetic retinopathy was observed from the 1st to the 4th UAER group: 27.3, 43.8, 45.5, and 66.7% (P = 0.029 for trend).

CONCLUSIONS

In type 2 diabetic patients, UAER in the normoalbuminuric range is positively associated with systolic ambulatory blood pressure indexes, left ventricular posterior wall thickness, and diabetic retinopathy, suggesting that intensive blood pressure treatment may prevent diabetes complications in these patients.

Increased plasma glycated low-density lipoprotein concentrations in diabetes: a marker of atherogenic risk

Nonenzymatic glycation of apolipoprotein B in the low-density lipoprotein (LDL) complex has been considered a proatherogenic modification contributory to the increased susceptibility of patients with diabetes to atherosclerosis. We postulated that glycated LDL concentrations might be associated with other markers of cardiovascular disease. To explore this hypothesis, we measured glycated LDL concentrations by a monospecific immunoassay in 50 patients with type 1 and 100 patients with type 2 diabetes and examined relationships with the amount of albumin excretion and the serum cholesterol and triglyercide concentrations. Plasma glycated LDL showed a significant positive correlation (r = 0.325; P < 0.001) with urinary albumin excretion that was higher in type 1 (r = 0.463) than in type 2 (r = 0.245) patients. The mean glycated LDL concentration progressively increased with increasing albumin excretion when patients were subcategorized into groups of normoalbuminuria, low (</=100 microg/mg of creatinine), and high (101-300 microg/mg) microalbuminuria, and proteinuria. Glycated LDL also correlated positively and significantly with cholesterol (r = 0.578) and triglyceride (r = 0.350) concentrations. The significant correlations in this cross-sectional analysis between glycated LDL and urinary albumin excretion, an index of cardiovascular mortality, and cholesterol and triglyceride concentrations, traditional markers of risk for cardiovascular disease, support the hypothesis that an elevated level of glycated LDL represents an atherogenic risk factor in patients with diabetes.

Determinants of albuminuria in people with Type 2 diabetes mellitus

This study sought to identify determinants of albuminuria in people with Type 2 diabetes. In 335 primary care patients, we assessed albumin-creatinine ratio (ACR) in two 24-h urine samples, and its cross-sectional associations with protein and alcohol intake, cigarette smoking, body weight and height, glycosuria, blood pressure, hypoglycaemic and antihypertensive treatment, gender, age, age at diagnosis, diabetes duration, family history of diabetes and cardiovascular diseases, ethnic origin, and education. The prevalence of micro- or macro-albuminuria (ACR> or =2.0 mg/mmol) was 33%. Among these patients, compared to those with normo-albuminuria, there were more men, protein intake (g/kg) estimated from urinary urea as well as systolic blood pressure and glycosuria were higher, there were more smokers, men were shorter, and a family history of diabetes was less prevalent (all P<0.05). In linear and logistic regression (n=270) albuminuria was independently associated (P<0.05 unless indicated otherwise) with systolic blood pressure (OR(10 mmHg)=1.32), smoking (OR(ex/never)=2.36, OR(current/never)=4.89), glycosuria (OR(> or =7/<1 g/l)=2.41), gender (OR(men/women)=2.50), age in men (OR(10 year)=1.60) (P<0.10) and, inversely, in women (OR(10 year)=0.63) (P>0.10). On aggregation, the modifiable determinants systolic blood pressure, smoking and glycosuria explained 12% of the variation in albuminuria. These factors thus are, although to a moderate extent only, potential determinants of albuminuria. We also observed an independent, inverse association with body height (OR(0.10 m)=0.47). This is in line with the hypothesis that development in utero or during early life influences kidney function in later life.

The prognosis for type 2 diabetic patients with heart disease. A 10-year observation study of 385 patients

The objective was to study the development and progression of heart disease in type 2 diabetic patients and to evaluate the influence of revascularisation procedures on its outcome. A 10-year observation study in 385 patients attending a hospital-based outpatient clinic was performed. A total of 156/385 patients developed myocardial infarction (n=68), angina (n=44), heart failure (n=34) or died (n=109). A high mortality was seen in patients with myocardial infarction (73%) and heart failure (71%), in contrast, to patients with angina (25%). Thirty patients had a coronary angiography because of angina, out of which 23 were revascularised. Four (17%) of patients with bypass surgery or angioplasty died compared with 57 (67%) of the patients with no intervention (p<0.001). The occurrence of myocardial infarction was associated with age (p<0.0001), and mean systolic (p<0.05) and diastolic (p<0.05) blood pressure and degree of albuminuria at entry (p<0.05). Heart failure was associated with age (p<0.0001), and mean HbA(1c) levels (p<0.05), while angina was associated with age only (p<0.05). Death was associated with age (p<0.0001), diabetes duration (p<0.05), mean diastolic blood pressure (p<0.05), and degree of albuminuria at entry (p<0.0001). This study shows a high incidence of heart disease in patients with type 2 diabetes. The prognosis was better in patients who had had a revascularisation procedure. Thus, a more active attitude towards revascularisation may potentially improve the prognosis for type 2 diabetic patients with atherosclerotic heart disease.

Risk factors for microalbuminuria in black americans with newly diagnosed type 2 diabetes

We conducted a cross-sectional analysis to describe the prevalence of and risk factors for microalbuminuria among blacks with newly diagnosed type 2 diabetes. Black adults with diagnosed type 2 diabetes mellitus of 2 years' duration or less who presented for care to the Grady Diabetes Clinic (Atlanta, GA) between January 1, 1994, and December 31, 1996, were eligible (n = 1,167). Information obtained at the initial visit included age; sex; body mass index (BMI); serum total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, C-peptide, serum creatinine, and hemoglobin A1c (HbA(1c)) levels; and seated systolic and diastolic blood pressures. Outcome was urine albumin-creatinine (Alb/Cr) ratio at the initial visit. Alb/Cr ratios were categorized as normal (Alb/Cr <25 microgram/mg), microalbuminuric (Alb/Cr, 25 to 250 microgram/mg), and macroalbuminuric (Alb/Cr >250 microgram/mg). Patients with macroalbuminuria or creatinine levels of 2 mg/dL or greater were excluded. We used multiple linear regression to assess the joint association between HbA(1c) level, mean arterial pressure (MAP), and log-transformed Alb/Cr, controlling for other covariates. Of 1,044 patients studied, macroalbuminuria was present in 3.8%, and microalbuminuria, in 23.4%. Alb/Cr was independently associated with increased HbA(1c) level (P = 0.0070), MAP (P = 0.0001), BMI (P = 0.0156), log-transformed triglyceride levels (P = 0.0031), C-peptide level of 6.5 ng/mL or greater (P = 0.0007), serum creatinine level (P: = 0.0068), and male sex (P = 0.0220). The relationship between HbA(1c) level and microalbuminuria was stronger in patients with lower BMIs. Microalbuminuria prevalence was high in this population of urban blacks with newly diagnosed type 2 diabetes. Risk factors associated with increased Alb/Cr included male sex, poor glycemic control, endogenous hyperinsulinemia, high blood pressure, elevated triglyceride levels, and obesity.

Low prevalence of long-term complications in non-insulin-dependent diabetes mellitus in France: a multicenter study. CODIAB-INSERM-ZENECA Pharma Study Group

The aim of this study was to assess the prevalence of long-term complications in a large sample of French NIDDM patients. Therefore, 427 NIDDM patients 35-74 years old were recruited in ten centers. Standardized clinical criteria and central reading for retinal and electrocardiographic changes were used to assess the presence of complications. The prevalence rates of complications were 29.7% and 3.3% for background and proliferative retinopathy; 21.8%, 6.1%, and 2.8% for microalbuminuria, proteinuria, and renal insufficiency; 19.9 and 11.7% for asymptomatic and symptomatic pheripheral neuropathy; 8.2% for orthostatic hypotension; 10.1% and 8.4% for angina pectoris and myocardial infarction; and 13.1% and 6.3% for mild and moderate to severe peripheral vascular disease, respectively. In conclusion, prevalence rates in this study were lower than in most studies from other countries.

Microalbuminuria in type 2 diabetic patients: a prospective follow-up study

We have studied 46 patients, 30 men and 16 women, with type 2 (non-insulin-dependent) diabetes in a follow-up period of 6-52 months (mean 30 months). The patients were consecutively entered in the study from the out-patient diabetic clinic. None had urinary tract infections nor proteinuria at entry. Investigations were done every 3 months during the first year and after that every 6 months. At entry 16 patients (35%) had microalbuminuria and a further 16 patients developed microalbuminuria and 16 proteinuria. The systolic blood pressure was higher in men with microalbuminuria compared to men without microalbuminuria. The glomerular filtration rate decreased with time for patients with microalbuminuria without change in plasma creatinine. The C-peptide concentration was higher in the hypertensive patients compared to non-hypertensive and the same was found for the triglyceride concentration. During the observation period the various complications increased in frequency (retinopathy, cardiomyopathy, neuropathy, angiopathy and hypertension) without significant relation to the presence of microalbuminuria or proteinuria. During the observation period nine patients died mainly due to cardiovascular events.

Day-night blood pressure variation in normotensive and hypertensive NIDDM patients with asymptomatic autonomic neuropathy

In order to assess the characteristics of day-night blood pressure (BP) variation in normotensive and hypertensive non-insulin-dependent diabetic (NIDDM) patients with asymptomatic autonomic neuropathy, 54 NIDDM patients and 13 healthy control subjects were studied by casual BP measurements and 24-h ambulatory blood pressure monitoring. Signs but not symptoms of autonomic neuropathy were documented by results of standard cardiovascular function tests in each patient. Daytime (06:00-22:00) and nighttime (22:00-06:00) BP values were separately analyzed and delta day-night BP values and diurnal index were determined. Patients were classified as being normotensive or having hypertension according to the casual BP values and medical history. In normotensive NIDDM patients (n = 30), nighttime systolic BP was significantly higher, whereas delta day-night systolic and delta day night diastolic BP values as well as diurnal index were considerably lower than those in control subjects (n = 13). In hypertensive NIDDM patients (n = 24), similar alterations were found at higher BP levels. No significant difference was found in BP values if normoalbuminuric and microalbuminuric NIDDM patients were compared. 'Non-dipper' phenomenon could be found in normotensive and hypertensive NIDDM patients with asymptomatic autonomic neuropathy, suggesting that relative sympathetic overdrive due to incipient and predominantly parasympathetic impairment of cardiovascular innervation might play a role in early alterations of circadian BP variation.

The prognostic value of albuminuria for the development of cardiovascular disease and retinopathy: a 5-year follow-up of 451 patients with type 2 diabetes mellitus

The aim of the present study was to evaluate the risk for vascular morbidity or death and retinopathy in relation to urinary albumin concentration. To that end, we performed a 5-year follow-up study of all type 2 diabetic patients attending the outpatient-clinic. A total of 444 (98.4%) out of 451 adult patients initially studied were evaluated for the degree of retinopathy and levels of HbA1c blood pressure, serum creatinine and urinary albumin. Vascular morbidity and causes of death were registered by one and the most severe event only. Forty-seven patients developed atherosclerotic vascular disease, i.e. myocardial infarction (n = 19), cerebrovascular disease (n = 20), or amputation (n = 8), and 42 died. The observed annual mortality rate was 22.1/1000 compared to an expected rate of 13.6/1000 for the general population with corresponding age and sex. Urinary albumin concentration was found to be a prognostic marker for the development of vascular disease and death in patients treated with insulin at baseline (P < 0.01), whereas this was not the case in patients treated with diet and/or oral agents at baseline. However, insulin treatment per se was not associated with an increased mortality or mortality or morbidity. Urinary albumin concentration was not correlated with incidence or progression of retinopathy regardless of type of diabetes treatment. In conclusion, this study showed that albuminuria was a prognostic factor for vascular morbidity and death in type 2 diabetic patients treated with insulin but not in patients treated with diet or oral agents. Furthermore, albuminuria was not a predictor for incidence or progression of retinopathy.

Associations with retinopathy in type 2 diabetes: a population-based study in a Swedish rural area

This population-based study was carried out in a rural area in Sweden. The impact of duration of diabetes, metabolic control, albuminuria, and mode of detection (screening or presence of overt symptoms at the time of diagnosis) on retinopathy in patients with type 2 diabetes aged under 70 years was investigated at a primary health care centre. Ninety-nine percent of all known persons with Type 2 diabetes were under care at the centre. The fundi were examined in all but one of those under 70 years, and a 100% attendance rate was noted with regard to other variables such as albuminuria, glycated haemoglobin, and blood lipids. A team approach (general practitioner, nurse specialist, dietitian, and chiropodist) with patient education as an integral part of the treatment has been practised for the past 15 years. Retinopathy was associated with duration of disease, glycaemic control, systolic blood pressure, detection by overt symptoms, and albuminuria. The risk of retinopathy was not associated with smoking or treatment category. The prevalence of retinopathy was 26.5% in the whole population, and 18.8% among the patients who had been treated for their diabetes at the centre from the time of diagnosis. The importance of an appropriate organization in primary health care for early case finding, near-normal glycaemia, team approach, and structured collaboration with a department of ophthalmology is emphasized in order to realize the aims of the St Vincent declaration to reduce eye complications due to Type 2 diabetes.

Microalbuminuria in type 2 diabetic patients: a cross-sectional study of frequency, sex distribution and relation to hypertension

We studied 112 type 2 diabetic patients. Fourteen patients had frank proteinuria, and 37 of the remaining 98 had microalbuminuria which was more frequent in men than in women (P < 0.02). Hypertension was found in 47 of the patients, equally distributed between sexes. Male diabetics with microalbuminuria had higher systolic blood pressure than diabetics without microalbuminuria (P < 0.02). Body mass index was higher in both sexes with hypertension compared to patients without hypertension. In the hypertensive men plasma C-peptide values were higher compared to patients without hypertension (P < 0.01) irrespective of the presence of microalbuminuria. A positive correlation between blood pressure and C-peptide was found (P < 0.01) in the men. We suggest that gender should be taken into account in the analysis and interpretation of microalbuminuria in type 2 diabetes.

Epidemiology of renal involvement in newly-diagnosed middle-aged and elderly diabetic patients. Cross-sectional data from the population-based study "Diabetes Care in General Practice", Denmark

We report on a study in which 487 Danish general practitioners participated with the purpose of including all newly-diagnosed diabetic patients aged 40 years or more from a well-defined catchment population during a well-defined time period. A total of 1267 diabetic patients with a median age of 65.3 years were included. Renal involvement was assessed from the albumin/creatinine ratio in a morning urine sample. Albumin/creatinine ratio was < 2/2- < 20/ > or = 20 mg/mmol in 59.8/33.6/6.6% of male and 66.6/28.8/4.6% of female patients. The level of albumin/creatinine ratio increased with age and the observed overall male predominance was almost confined to diabetic patients with an albumin/creatinine ratio of 5 mg/mmol or greater. By taking into account the confounding effect of age and sex, a positive association between smoking and albumin/creatinine ratio was disclosed. Moreover, high systolic blood pressure, hypertriglyceridaemia, hypercholesterolaemia (males only) and high HbA1c, but not body mass index or diastolic blood pressure were identified as correlates of elevated albumin/creatinine ratio. Glucosuria was positively correlated with albumin/creatinine ratio even when the influence of HbA1c, sex and age was taken into account. A positive correlation between serum creatinine and albumin/creatinine ratio was seen in males, but not in females. In addition, renal involvement was associated with the presence of peripheral angiopathy and diabetic retinopathy and with high resting heart rate. The cross-sectional data presented highlight the importance of reducing the overall burden of modifiable risk factors in newly-diagnosed Type 2 diabetic patients.

The association of microalbuminuria with diabetic retinopathy. The Wisconsin Epidemiologic Study of Diabetic Retinopathy

PURPOSE

To investigate the relationship between microalbuminuria and the presence and severity of diabetic retinopathy in a large population-based cohort of individuals with diabetes.

METHODS

Microalbuminuria was measured by an agglutination inhibition assay in random urine samples obtained from participants in the Wisconsin Epidemiologic Study of Diabetic Retinopathy (n = 1139) who did not have hematuria, gross proteinuria, or a history of renal disease. Retinopathy was determined from stereoscopic color fundus photographs graded according to a modification of the Airlie House Classification System.

RESULTS

Younger-onset (diagnosed with diabetes before 30 years of age) and older-onset (diagnosed with diabetes when 30 years of age or older) individuals with microalbuminuria were more likely to have retinopathy than those without microalbuminuria. Younger-onset individuals who had microalbuminuria at the time of examination were more likely to have proliferative retinopathy than younger-onset subjects with normoalbuminuria. These relationships remained after controlling for glycemia, hypertension, duration of diabetes, and other potential confounders.

CONCLUSIONS

Microalbuminuria is associated cross-sectionally with the presence of retinopathy in persons with diabetes and with the presence of proliferative disease in younger-onset individuals. These data suggest that microalbuminuria may be a marker for the risk of proliferative retinopathy developing. If longitudinal studies confirm these findings, individuals with insulin-dependent diabetes mellitus (IDDM) who have microalbuminuria may benefit from ophthalmologic follow-up.