Predictors and determinants of albuminuria in people with prediabetes and diabetes based on smoking status: A cross-sectional study using the UK Biobank data

Clinical Features and Implications of Albuminuria Trajectories in Type 2 Diabetes: The Fremantle Diabetes Study Phase 2

Context

The urinary albumin:creatinine ratio (uACR) can exhibit significant temporal changes but few studies have characterized transition patterns between uACR categories in type 2 diabetes.

Objective

The study aim was to use group-based trajectory modeling (GBTM) to identify clusters of people with type 2 diabetes and distinct uACR trajectories.

Methods

Of 1482 participants in the observational Fremantle Diabetes Study Phase 2, a total of 1145 (77.3%; mean age 65.4 years, 53.3% males) with 2 or more biennial uACR measurements over 6 years were included in GBTM. Independent baseline associates of uACR trajectory group membership were assessed using multinomial regression. Associations between group membership and changes in estimated glomerular filtration rate over 4 years were explored.

Results

The optimum GBTM model comprised 6 categories: normoalbuminuria (n = 429, 37.5%), regression (n = 82, 7.2%), progression (n = 71, 6.2%), progression/regression (n = 104, 9.1%), persistent microalbuminuria (n = 401, 35.0%), and persistent macroalbuminuria (n = 58, 5.1%). The latter 5 groups had worse glycemic control than the normoalbuminuria group. The 3 groups starting from/returning to normoalbuminuria had heterogeneous baseline characteristics but a decline in renal function that was similar to the normoalbuminuric group. The persistent microalbuminuria group had adverse baseline cardiometabolic features and longitudinal renal outcomes relative to the normoalbuminuria/other microalbuminuria groups. The persistent macroalbuminuria group had, consistent with its baseline characteristics, the highest mortality (31.0% vs ≤18.5% in the other groups) and most rapid progression of renal dysfunction.

Conclusion

GBTM identified distinct uACR trajectory groups with clinical and prognostic implications, and could be used to stratify participants in clinical trials of new therapies for diabetic kidney disease.

Cardiovascular-kidney-metabolic syndrome modifies smoking-related risk for cardiovascular diseases: findings from an observational cohort study in UK Biobank

BACKGROUND

The present study aims to investigate the association of smoking behaviors and cardiovascular-kidney-metabolic (CKM) syndrome with incident cardiovascular disease (CVD), and to evaluate whether the cardiovascular benefits of smoking cessation vary across different CKM conditions.

METHODS

This study included 242,636 white European participants from the UK Biobank who were classified as CKM syndrome Stages 0 to 3 and free of CVD at baseline. Covariates adjusted Cox proportional hazards models were employed to evaluate the associations of CKM syndrome with the risks of total CVD, stroke, coronary heart disease (CHD), major adverse cardiovascular events (MACE), and 13 CVD subtypes. The impact of smoking behavior across different CKM stages and the joint effect of smoking and CKM syndrome on CVD risk were also evaluated. To investigate the potential effect modification by CKM syndrome, we examined the multiplicative scale by interaction terms in Cox models, and quantified the additive scale using statistics such as the relative excess risk due to interaction (RERI).

RESULTS

The risk of total CVD, stroke, and CHD increased progressively with advancing CKM stages, with Stage 3 associated with hazard ratios (HRs) of 3.38 (95% CI: 3.05-3.74), 3.01 (2.49-3.64), and 3.65 (3.25-4.10), respectively (P for trend < 0.001). The time required to reduce CVD risk to a level not significantly different from that of never smokers tends to be longer for individuals with advancing CKM stage: smokers at Stages 0-1 achieved this after approximately 10 years of cessation, whereas those at Stages 2-3 required more than 25 years. Compared with never smokers at CKM Stage 0, current smokers at CKM Stage 3 had substantially higher risk of total CVD (HR = 4.14, 95% CI: 3.54-4.83) and several subtypes, particularly abdominal aortic aneurysm (HR = 17.68, 95% CI: 6.33-49.43) and peripheral vascular disease (HR = 10.53, 95% CI: 6.79-16.34). CKM syndrome appeared to act as a positive additive effect modifier in smoking-related risk of total CVD (RERI = 0.20, 95% CI: 0.05-0.32), as well as several CVD subtypes, suggesting that the combined effect of smoking and CKM progression exceeds the sum of their individual effects.

CONCLUSIONS

Our finding emphasizes the importance of smoking cessation among individuals with advanced CKM syndrome, as they face heightened CVD risk. However, compared to those at earlier CKM stages, the short-term benefits of smoking cessation may be less pronounced in this population. Interventions that combine smoking cessation promotion with CKM syndrome management may yield greater reductions in the risk of several CVD outcomes.

Analysis of the kidney failure risk equation implementation in routine clinical practice and health inequalities in chronic kidney disease care: a retrospective cohort study

BACKGROUND

NICE guidelines recommend GPs use the kidney failure risk equation (KFRE) to identify people with chronic kidney disease (CKD) at higher risk of kidney failure. Albuminuria results are required to calculate KFRE.

AIM

Analyse the implementation of KFRE into clinical practice and investigate if albuminuria testing varied amongst patients with CKD, particularly for underserved groups.

DESIGN AND SETTING

Retrospective cohort study of 23,063 adults in Glasgow from 2013 to 2022.

METHOD

We evaluated albuminuria testing rates and the predictive performance of KFRE in estimating 5-year kidney failure risk amongst people with CKD. Logistic regression models quantified associations between demographic/clinical variables and albuminuria testing. Amongst people who developed kidney failure, we retrospectively assessed the impact of KFRE on the timing of meeting criteria for referral to renal services.

RESULTS

Albuminuria testing was performed in 44.5% of 10,874 adults with CKD. Females (adjusted odds ratio (aOR) 0.86: 95% CI 0.79-0.93) and those with hypertension (aOR 0.69: 95% CI 0.63-0.77) were less likely to have albuminuria testing. Those aged 40-50 years (aOR 1.83: 95% CI 1.15-2.91), with diabetes (aOR 2.35: 95% CI 2.14-2.58) and living in the least socioeconomically deprived areas (aOR 1.11: 95% CI 1.00-1.23) were more likely to have albuminuria testing. Of 1,352 individuals with incident kidney failure, incorporating KFRE into referral guidelines helped identify high-risk patients early.

CONCLUSION

KFRE could be calculated for less than half of people due to lack of albuminuria testing. Focus should be given to improving albuminuria testing and inequities identified to allow wider implementation of KFRE.

Non-linear relationship between arteriosclerosis index and diabetes risk in non-obese east Asian adults

Previous studies have shown a positive association between the arteriosclerosis index (AI) and future diabetes risk. However, evidence in non-obese populations is limited. This study investigates the relationship between AI and future diabetes risk in non-obese East Asian adults. This retrospective cohort study enrolled 95,402 non-obese adults from China and Japan. Participants had a mean age of 42.92 ± 12.24 years, with 51,295 (53.77%) being male. Median follow-up was 3.01 years. Cox proportional hazards models assessed the association between baseline AI and diabetes risk. Non-linear associations were explored using cubic splines and smoothed curves in Cox models. Sensitivity analyses were performed. After adjusting for covariates, a positive association was found between AI and diabetes risk in non-obese adults (HR 1.09, 95% CI 1.03-1.15, P = 0.0017). A non-linear relationship was identified, with an inflection point at 1.47. Below this point, HR was 5.87 (95% CI 1.20-28.63, P = 0.0287); above, it was 1.07 (95% CI 1.02-1.13, P = 0.0115). Sensitivity analyses affirmed the robustness of these results. This study identifies a positive, non-linear association between the AI and diabetes risk in non-obese adults. Interventions targeting AI reduction could significantly lower the risk of future diabetes in this population.

Impact of diabetes on the association between serum urate levels and incident dementia: a cohort study in the UK biobank

OBJECTIVES

Diabetes was associated with increased serum urate levels and a higher risk of dementia. However, current evidence regarding the association between serum urate and dementia is controversial.The research gap on how to effectively control urate levels in the population with diabetes still remains. We aim to examine the association of diabetes status and serum urate with dementia incidence, and the differences in this association among participants with different diabetes statuses.

METHODS

A total of 321,896 participants was recruited from the UK Biobank and followed up until 2022. Diabetes status was classified into diabetes, prediabetes and normoglycaemia according to the American Diabetes Association 2023 guideline. Serum urate levels were stratified using gender-specific quartiles of concentrations. All-cause dementia, Alzheimer's disease and vascular dementia were ascertained using the International Classification of Diseases-10th revision (ICD-10). Cox proportional hazards regression models were used to examine the association between serum urate, diabetes status, and dementia incidence.

RESULTS

Of the 321,896 participants (mean age, 57 years old; 43.5% males), 7,087 (2.20%) individuals were diagnosed with dementia during the follow-up period. Diabetes was associated with a 70% 58%, and 134% increased risk for all-cause dementia, Alzheimer's disease, and vascular dementia respectively. Elevated serum urate levels were associated with a lower risk of all-cause and cause-specific dementia regardless of the status of diabetes. Each standard deviation increase in urate concentration was related to a 11% reduced risk for all-cause dementia (HR, 0.89; 95% CI, 0.86 to 0.91), 7% for Alzheimer's disease (HR, 0.93; 95% CI, 0.88 to 0.98), and 12% for vascular dementia (HR, 0.88; 95% CI, 0.81 to 0.95).

CONCLUSION

Appropriately higher urate levels within the threshold of hyperuricemia can reduce the adverse health effects of excessively high urate levels and better protect the cognitive health of people with varying diabetes status.

Association of domain-specific physical activity with albuminuria among prediabetes and diabetes: a large cross-sectional study

BACKGROUND

Albuminuria, the presence of excess of protein in urine, is a well-known risk factor for early kidney damage among diabetic/prediabetic patients. There is a complex interaction between physical activity (PA) and albuminuria. However, the relationship of specific-domain PA and albuminuria remained obscure.

METHODS

Albuminuria was defined as urinary albumin/creatinine ratio (ACR) > 30 mg/g. PA was self-reported by participants and classified into transportation-related PA (TPA), occupation-related PA (OPA), and leisure-time PA (LTPA). Weighted logistic regression was conducted to compute the odds ratios (ORs) and 95% confidence intervals (CIs). Restricted cubic spline (RCS) was used to evaluate the dose-response of PA domains with the risk of albuminuria.

RESULTS

A total of 6739 diabetic/prediabetic patients (mean age: 56.52 ± 0.29 years) were enrolled in our study, including 3181 (47.20%) females and 3558 (52.80%) males. Of them, 1578 (23.42%) were identified with albuminuria, and 5161(76.58%) were without albuminuria. Diabetic/prediabetic patients who adhered the PA guidelines for total PA had a 22% decreased risk of albuminuria (OR = 0.78, 95%CI 0.64-0.95), and those met the PA guidelines for LTPA had a 28% decreased of albuminuria (OR = 0.72, 95%CI 0.57-0.92). However, OPA and TPA were both not associated with decreased risk of albuminuria. RCS showed linear relationship between the risk of albuminuria with LTPA.

CONCLUSIONS

Meeting the PA guideline for LTPA, but not OPA and TPA, was inversely related to the risk of albuminuria among diabetic/prediabetic patients. Additionally, achieving more than 300 min/week of LTPA conferred the positive effects in reducing albuminuria among diabetic/prediabetic patients.

Kidney shape statistical analysis: associations with disease and anthropometric factors

BACKGROUND

Organ measurements derived from magnetic resonance imaging (MRI) have the potential to enhance our understanding of the precise phenotypic variations underlying many clinical conditions.

METHODS

We applied morphometric methods to study the kidneys by constructing surface meshes from kidney segmentations from abdominal MRI data in 38,868 participants in the UK Biobank. Using mesh-based analysis techniques based on statistical parametric maps (SPMs), we were able to detect variations in specific regions of the kidney and associate those with anthropometric traits as well as disease states including chronic kidney disease (CKD), type-2 diabetes (T2D), and hypertension. Statistical shape analysis (SSA) based on principal component analysis was also used within the disease population and the principal component scores were used to assess the risk of disease events.

RESULTS

We show that CKD, T2D and hypertension were associated with kidney shape. Age was associated with kidney shape consistently across disease groups. Body mass index (BMI) and waist-to-hip ratio (WHR) were also associated with kidney shape for the participants with T2D. Using SSA, we were able to capture kidney shape variations, relative to size, angle, straightness, width, length, and thickness of the kidneys, within disease populations. We identified significant associations between both left and right kidney length and width and incidence of CKD (hazard ratio (HR): 0.74, 95% CI: 0.61-0.90, p < 0.05, in the left kidney; HR: 0.76, 95% CI: 0.63-0.92, p < 0.05, in the right kidney) and hypertension (HR: 1.16, 95% CI: 1.03-1.29, p < 0.05, in the left kidney; HR: 0.87, 95% CI: 0.79-0.96, p < 0.05, in the right kidney).

CONCLUSIONS

The results suggest that shape-based analysis of the kidneys can augment studies aiming at the better categorisation of pathologies associated with chronic kidney conditions.

Relationship of cardiorenal risk factors with albuminuria based on age, smoking, glycaemic status and BMI: a retrospective cohort study of the UK Biobank data

Introduction

Smoking is harmful, and its cessation is recommended to prevent chronic kidney disease, which often begins with abnormal leakage of albumin in the urine, called albuminuria. Smoking cessation's effect on albuminuria depends on the pack-years smoked, length of abstinence, body mass index (BMI) and glycosylated haemoglobin (HbA1c). Using the UK Biobank data, we examined the relationship between these cardiorenal variables and albuminuria.

Methods

For this study, we selected a UK Biobank cohort with urinary albumin concentration (UAC) in the first and second visits. Participants were divided into progressor and regressor groups, where progressors were defined as those with increased UAC value, and regressors were those with decreased UAC value. Three different logistic regression models were fitted. In model 1, with a cohort design, we explored the impact of a change in age, HbA1c and BMI between the first and second visits and the UAC. In model 2 and 3, in a cross-sectional design, we explored which cardiorenal risk factors were associated with a rise or fall of UAC at the time point of the second visit. Results are expressed in OR and 95% CI.

Results

The prevalence of albuminuria was highest in ex-smokers who started smoking between the ages of 13 and 18. With a mean duration of 51 months, there was no statistically significant relationship between smoking status and BMI with albuminuria. Each year of ageing and each unit of increase in HbA1c (mmol/mol) increased the odds of progression of albuminuria by 20% and 3%, respectively. In ex-smokers, at the time point of the second visit, each year of smoking increased, and each year of abstinence decreased the odds by 4% and 6%, respectively.

Conclusion

Smokers should be supported to stop smoking and remain abstinent despite short-term weight gain. Childhood smoking should be actively discouraged.