The pathologic continuum of diabetic vascular disease

Epinephrine as a Therapeutic Agent for Hyperferritinemia in Diabetes Mellitus and Hypertension

BACKGROUND Diabetes mellitus was the first non-communicable disease to be recognized as a 21st century pandemic. Type 2 diabetes (T2DM) results from increased insulin resistance (IR) or relative insulin deficiency. IR impairs glucose disposal, leading to a compensatory hyper-insulinemic state. Increased iron stores as reflected by high serum ferritin (SF) have been associated with the development T2DM and affect glucose homeostasis by impairing tissue response to insulin. Iron overload (IO) is quite common in essential hypertension (HTN). The first clinical effect of epinephrine on SF was reported in 2024, showing that epinephrine resulted in normalization of SF and recovery from severe COVID-19 infection. CASE REPORT A patient with T2DM, HTN, and dyslipidemia associated with hyperferritinemia received the conventional treatment of T2DM and HTN, with a poor control of hyperglycemia and HTN. Since the patient had elevated SF, we obtained informed written consent for epinephrine's use to lower SF. Epinephrine 0.6 mcg/kg was injected subcutaneously under hemodynamic monitoring, and the results showed normalization of SF and complete recovery of T2DM and HTN. CONCLUSIONS Epinephrine can normalize elevated SF by its iron chelating effect; therefore, it can relieve IO and alleviate IR associated with T2DM and HTN. Epinephrine has an anti-inflammatory and scavenging properties that can inhibit ferroptosis. As a new clinical indication, extensive studies are required for further assessment and possible therapeutic uses in IO disorders such as hereditary hemochromatosis (HH), Alzheimer disease (AD), Parkinsonian disease (PD), and multiple sclerosis (MS).

Can 4 weeks of real-world active breaks improve glycaemic management in sedentary adults with type 1 diabetes? The EXTOD-Active randomised control trial protocol

Sedentary behaviour is associated with an increased risk of cardiovascular disease and all-cause mortality in individuals with type 1 diabetes (T1D). Recent laboratory-based research suggests that breaking up prolonged sedentary periods improves glycaemic markers in people with T1D. However, the effects of breaking up sedentary behaviour for prolonged periods in real-world settings remain unknown. This study aims to assess the effect of 4 weeks of active breaks on time spent within the target glycaemic range (time in range (TIR), 3.9-10.0 mmol/L) in adults with T1D Adults with T1D (n=118) who are sedentary for ≥8 hours per day will first complete a 7-day baseline assessment. Participants will then be randomised into either a control group (maintenance of habitual lifestyle) or an intervention group, where active breaks (3 min of self-paced walking every 30 min between 09:00 and 17:00, Monday through Friday) will be prescribed for 4 weeks. Activity levels (activPAL), TIR (via continuous glucose monitor), insulin dose and carbohydrate intake will be monitored throughout. The effect of active breaks on TIR will be compared between baseline and week 4, with data analysed using analysis of covariance (ANCOVA). The trial has been approved in the UK by the West Midlands-Solihull Ethics Committee (22/WM/0221). The findings from the study will be disseminated through peer-reviewed journals and presentations at national and international scientific conferences. Trial registration number NCT05706298.

Vascular mechanoreceptor magnetic activation, hemodynamic evidence and potential clinical outcomes

There is sufficient proof that static magnetic fields (SMFs) of different parameters have a significant effect on the cardiovascular system. The sometimes contradictory, opposite-directional nature of SMF's hemodynamic effect generates uncertainty; therefore, an explanation of the underlying mechanisms is required. Following SMF selective carotid baroreceptors or microvascular net exposure, both high and low blood pressure (BP)/vascular tone starting conditions showed a return to normal. Beyond the previous descriptions of SMF's simple hemodynamic results, the current study aims to clarify the physiology of the SMF BP/vascular tone normalizing effects. The examination of available literature and hemodynamic tracings provided strong evidence that mechanoreceptor magnetic activation is concealed behind SMF vascular tone adjustment (increasing or decreasing as needed), filling in the knowledge gap regarding SMF opposite directional vascular tone normalizing outcomes. It has been proposed that cytoskeletal actin filament rearrangement, mechanically-gated Ca2+ influx, and nitric oxide (NO) activity may strengthen SMF's vascular mechanoreceptor sensing/regulation ability, modifying BP and vascular tone features in a hemodynamic normalizing pattern. It is suggested that baro/mechanoreceptor magnetic activation physiology is a unique mechanism of the magneto-cardiovascular interaction with substantial potential for cardiovascular protection.

Does 10-Year Atherosclerotic Cardiovascular Disease Risk Predict Incident Diabetic Nephropathy and Retinopathy in Patients with Type 2 Diabetes Mellitus? Results from Two Prospective Cohort Studies in Southern China

BACKGRUOUND

Diabetic macrovascular and microvascular complications often coexist and may share similar risk factors and pathological pathways. We aimed to investigate whether 10-year atherosclerotic cardiovascular disease (ASCVD) risk, which is commonly assessed in diabetes management, can predict incident diabetic nephropathy (DN) and retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM).

METHODS

This prospective cohort study enrolled 2,891 patients with clinically diagnosed T2DM who were free of ASCVD, nephropathy, or retinopathy at baseline in the Guangzhou (2017-2022) and Shaoguan (2019-2021) Diabetic Eye Study in southern China. The 10-year ASCVD risk was calculated by the Prediction for ASCVD Risk in China (China-PAR) equations. Multivariable- adjusted Cox proportional hazard models were developed to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). The area under the receiver operating characteristic curve (AUC) was used to evaluate predictive capability.

RESULTS

During follow-up, a total of 171 cases of DN and 532 cases of DR were documented. Each 1% increment in 10-year ASCVD risk was associated with increased risk of DN (pooled HR, 1.122; 95% CI, 1.094 to 1.150) but not DR (pooled HR, 0.996; 95% CI, 0.979 to 1.013). The model demonstrated acceptable performance in predicting new-onset DN (pooled AUC, 0.670; 95% CI, 0.628 to 0.715). These results were consistent across cohorts and subgroups, with the association appearing to be more pronounced in women.

CONCLUSION

Ten-year ASCVD risk predicts incident DN but not DR in our study population with T2DM. Regular monitoring of ASCVD risk in routine diabetes practice may add to the ability to enhance population-based prevention for both macrovascular and microvascular diseases, particularly among women.

Risk factors associated with the recurrence of diabetic foot ulcers: A meta-analysis

AIMS

Diabetic foot ulcers have caused significant medical, economic and social consequences for patients, families and society. With appropriate treatment, many diabetic foot ulcers can heal, temporarily avoiding possible amputation. Unfortunately, even if foot ulcers subside, recurrence is still common. The recurrence of ulcer has brought another physical and psychological trauma to diabetic foot patients who yearn for a better life. Therefore, it may be more useful to evaluate the factors associated with ulcer recurrence in diabetic foot ulcer patients.

METHODS

The PubMed, Web of Science, Embase and China National Knowledge Infrastructure databases were comprehensively searched for prospective or retrospective studies published up to February 1, 2024. All English or Chinese language studies on diabetic foot ulcer patients who experience recurrence were included, and RevMan 5.3 software was used to analyze the data.

RESULTS

A total of 22 studies meeting the eligibility criteria were ultimately included in this meta-analysis. 1861 of 5252 diabetic foot ulcer patients experienced recurrence during follow-up. The following variables were associated with an increased risk of ulcer recurrence: male (OR = 1.26, 95% CI = 1.10 ~ 1.44, P = 0.0009), smoking history (OR = 1.18, 95% CI = 1.04 ~ 1.35, P = 0.01), living alone (OR = 1.86, 95% CI = 1.21 ~ 2.86, P = 0.004), plantar ulcers (OR = 2.44, 95% CI = 1.41 ~ 4.23, P = 0.001), diabetic retinopathy (OR = 1.59, 95% CI = 1.35 ~ 1.88, P < 0.00001), diabetic nephropathy (OR = 1.37, 95% CI = 1.12 ~ 1.68, P = 0.002), diabetic peripheral neuropathy (OR = 1.78, 95% CI = 1.45 ~ 2.19, P < 0.00001), foot deformity (OR = 2.51, 95% CI = 1.85 ~ 3.40 P < 0.00001) and peripheral arterial disease (OR = 3.10, 95% CI = 2.43 ~ 3.95 P < 0.00001). However, hypertension (OR = 1.16, 95% CI = 0.96 ~ 1.40, P = 0.13) and body mass index (MD = 0.20, 95% CI = -0.12 ~ 0.53, P = 0.22) were not associated with diabetic foot ulcer recurrence.

CONCLUSIONS

Our meta-analysis identified the following important risk factors for diabetic foot ulcer recurrence: male sex, smoking history, living alone, plantar ulcer, diabetic retinopathy, diabetic nephropathy, diabetic peripheral neuropathy, foot deformity, and peripheral arterial disease. Understanding these factors and their impact on ulcer recurrence is crucial for multidisciplinary teams to develop management and treatment plans for diabetic foot ulcer patients.

Impact of Diabetes on Persistent Radiological Abnormalities and Pulmonary Diffusion Dysfunction in COVID-19 Survivors: A 3-Year Prospective Cohort Study

RATIONALE AND OBJECTIVES

Little is known about the long-term impact of diabetes on lung impairment in COVID-19 survivors over a three-year period. This study evaluated the long-term impact of diabetes on persistent radiological pulmonary abnormalities and lung function impairment in COVID-19 survivors over three years.

MATERIALS AND METHODS

In this prospective, multicenter, cohort study, pulmonary sequelae were compared between COVID-19 survivors with and without diabetes. Serial chest CT scans, symptom questionnaires and pulmonary function tests were obtained 6 months, 12 months, 2 years and 3 years post-discharge. The independent predictors for lung dysfunction at the 3-year follow-up were analyzed.

RESULTS

A total of 278 COVID-19 survivors (63 [IQR 57-69] year-old, female: 103 [37.0%]) were included. At the 3-year follow-up, individuals in the diabetes group had higher incidences of respiratory symptoms, radiological pulmonary abnormalities and pulmonary diffusion dysfunction than those in the control group. Diabetes (OR: 2.18, 95% CI: 1.04-4.59, p = 0.034), allergy (OR: 2.26, 95% CI: 1.09-4.74, p = 0.029), female (OR: 2.70, 95% CI: 1.37-5.29, p = 0.004), severe COVID-19 (OR: 4.10, 95% CI: 1.54-10.93, p = 0.005), and fibrotic-like CT changes (OR: 5.64, 95% CI: 2.28-13.98, p < 0.001) were independent predictors of pulmonary diffusion dysfunction in COVID-19 survivors.

CONCLUSION

These results highlight the long-term deleterious effect of diabetes status on radiological pulmonary abnormalities and pulmonary dysfunction in COVID-19 survivors. This study provides important evidence support for long-term monitoring of lung abnormalities in COVID-19 recovery survivors with diabetes.

Unravelling the cardio-renal-metabolic-foot connection in people with diabetes-related foot ulceration: a narrative review

Diabetes-related foot ulceration (DFU), a serious but preventable complication of diabetes, is a leading cause of hospitalisation, lower extremity amputation and disability worldwide. People with DFU have a greater burden of cardiovascular risk factors, heart failure and chronic kidney disease, resulting in over two-fold higher risk of cardiovascular death compared with people with diabetes without DFU. Here, we propose a "cardio-renal-metabolic-foot" connection in people with diabetes based on shared pathophysiological mechanisms linking DFU with cardiovascular and renal disease. Whilst these mechanistic links remain to be fully elucidated, systemic inflammation and infection in the context of DFU are postulated as key mediators in the development, and progression of, cardiovascular and renal disease. However, cardiovascular and renal disease are also implicated in the pathogenesis of DFU, highlighting the multi-directional interplay between conditions. The impact of screening, prevention, and early management of cardiovascular complications associated with DFU requires further research. Multi-modality cardiac imaging could play a role in unravelling disease mechanisms leading to novel therapeutic strategies, as well as facilitating personalised risk assessment and management. Recent clinical trials have transformed the therapeutic landscape for people with type 2 diabetes, by demonstrating that sodium glucose co-transporter 2 inhibitors, glucagon-like peptide-1 agonists and non-steroidal mineralocorticoid receptor antagonists improve cardiovascular and renal outcomes. Although dedicated research in people with DFU is warranted, these therapies could target multiple facets of the "cardio-renal-metabolic-foot" connection. The holistic, person-centred approach to managing DFU should incorporate new multidisciplinary models of care focusing on the prevention and management of cardiovascular and kidney disease.

The impact of donor diabetes on recipient postoperative complications, renal function, and survival rate in deceased donor kidney transplantation: a single-center analysis

As the global incidence of diabetes rises and diagnoses among younger patients increase, transplant centers worldwide are encountering more organ donors with diabetes. This study examined 80 donors and 160 recipients, including 30 donors with diabetes (DD) and their 60 recipients (DDR). The control group comprised 50 non-diabetic donors (ND) and 100 recipients (NDR). We analyzed clinical, biochemical, and pathological data for both diabetic and control groups, using logistic regression to identify risk factors for delayed graft function (DGF) after kidney transplantation. Results showed that pre-procurement blood urea nitrogen levels were significantly higher in DD [18.20 ± 10.63 vs. 10.86 ± 6.92, p = 0.002] compared to ND. Renal pathological damage in DD was notably more severe, likely contributing to the higher DGF incidence in DDR compared to NDR. Although DDR had poorer renal function during the first three months post-transplant, both groups showed similar renal function thereafter. No significant differences were observed in 1-year or 3-year mortality rates or graft failure rates between DDR and NDR. Notably, according to the Renal Pathology Society (RPS) grading system, kidneys from diabetic donors with a grade > IIb are associated with significantly lower postoperative survival rates. Recipient gender [OR: 5.452 (1.330-22.353), p = 0.013] and pre-transplant PRA positivity [OR: 34.879 (7.698-158.030), p < 0.001] were identified as independent predictors of DGF in DDR. In conclusion, transplant centers may consider utilizing kidneys from diabetic donors, provided they are evaluated pathologically, without adversely impacting recipient survival and graft failure rates.

Association of pulse pressure with incident end-stage kidney disease according to histopathological kidney findings in patients with diabetic nephropathy

Diabetic patients as well as the elderly are known to have high pulse pressure (PP), but there are few studies on how microangiopathy and macroangiopathy are involved in its mechanism. In this study, we examined the association between PP and atherosclerotic lesions by vessel size in kidney biopsy tissue and examined how PP is associated with kidney prognosis. This retrospective observational study included 408 patients with biopsy-proven diabetic nephropathy at Nara Medical University Hospital. Exposure of interest was PP measured at kidney biopsy. Outcome variable was kidney failure with replacement therapy (KFRT). Cox proportional hazards and competing risk regression models with all-cause mortality as a competing event were used to examine these associations. A total of 408 patients were divided into tertiles based on PP (mmHg): Tertile 1 (reference), <51; Tertile 2, 51-64; and Tertile 3, >64. Among the 408 patients, 99 developed KFRT during a median follow-up period of 6.7 years. Higher PP was independently associated with higher incidences of KFRT (hazard ratio [95% confidence interval] for Tertile 3 vs. Tertile 1; 2.07 [1.05-4.09]. In histological lesions, PP was strongly associated with glomerular lesions, tubulointerstitial lesions, and arteriolar hyalinosis (all ps for trend <0.001), but not with intimal thickening (p for trend = 0.714). PP was significantly associated with diabetic glomerular/tubulointerstitial lesions and arteriolar hyalinosis but not with intimal thickening at the time of kidney biopsy and was also significantly associated with subsequent KFRT in patients with diabetic nephropathy.

Is Family History for the Management of Cardiovascular Health in Youth Still Relevant in Clinical Practice?

PURPOSE OF REVIEW

Family history of premature cardiovascular disease is a strong predictor of individual cardiovascular risk. However, family history is not always available and not always reliable. Roughly 80% of health outcomes are influenced not by genetic risk but by societal factors, including adverse health behaviors and environment. Furthermore, in the present age of genetic testing, laboratory evaluations, and imaging, a key question remains: What is the contemporary relevance of family history screening in the management of cardiovascular disease in youth?

RECENT FINDINGS

Knowledge of an individual's family history can help clinicians identify not only inherited risk but also familial clustering of unhealthy behaviors and environmental adversity contributing to enhanced cardiovascular disease risk in youth. For those at greatest risk, prevention strategies can be applied sooner and more conservatively. Integrating family history into clinical practice is crucial for cardiovascular risk assessment and for optimizing outcomes, but, in some cases, is more reflective of social factors.

Exploring Platelet Indices as Predictors of Nephropathy Severity in Type 2 Diabetes Mellitus: A Hospital-Based Cross-Sectional Analysis

Background Increased platelet activity in type 2 diabetes mellitus (T2DM) plays a key role in the development of vascular complications. Platelet indices such as mean platelet volume (MPV), platelet distribution width (PDW), platelet large cell ratio (PLCR), and plateletcrit (PCT) reflect both the functional and morphological status of platelets. These indices are markers of inflammation and metabolic dysregulation, which are pivotal in diabetic vasculopathy. If platelet indices correlate with nephropathy severity, they could be used as cost-effective, accessible markers for assessing disease progression in T2DM. Materials and methods This cross-sectional study was conducted at Kalinga Institute of Medical Sciences (KIMS), Bhubaneswar, India, from September 2019 to August 2021. A total of 203 patients with T2DM and nephropathy were included, diagnosed per American Diabetes Association 2017 criteria and staged using Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Nephropathy was assessed using the albumin-to-creatinine ratio, and the glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula. Venous blood samples were collected to measure platelet indices using the SYSMEX XN-1000 automated analyzer (Sysmex Corporation, Kobe, Japan). Statistical analysis was conducted using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 24.0, Armonk, NY), with a comparison of MPV, PDW, PCT, and PLCR across nephropathy stages performed via the Kruskal-Wallis test. Pairwise comparisons were made using the Mann-Whitney test, with a significance level set at p < 0.05. Results The study population had a mean age of 61.7 ± 12.0 years, with 62.1% over 60 years and a male-to-female ratio of 1.5:1. The average diabetes duration was 8.0 ± 5.2 years. The mean platelet count was 236.4 ± 112.6, and the mean values for MPV, PDW, PCT, and PLCR were 11.4 ± 1.7, 15.2 ± 3.8, 0.28 ± 0.11, and 38.9 ± 11.8, respectively. Most patients (63.1%) were in the early stages of nephropathy (stages 1-3). Significant differences in platelet indices were observed across nephropathy stages, with Kruskal-Wallis p-values of 0.027, 0.009, 0.001, and 0.007 for MPV, PDW, PCT, and PLCR, respectively. Pairwise comparisons showed that platelet indices were significantly elevated in advanced nephropathy stages (stages 4 and 5) compared to early stages (stages 1 and 2) with p < 0.05. Conclusion There is a significant correlation between platelet indices and the severity of nephropathy in T2DM patients. MPV, PDW, PCT, and PLCR all increase in advanced stages of nephropathy, suggesting these indices can be used as surrogate markers for assessing disease progression. Their ease of measurement and cost-effectiveness make them valuable tools in monitoring diabetic nephropathy, offering a simpler and more cost-effective alternative for monitoring disease progression.

Unawareness of being prescribed medications for diabetes and incident cardiovascular disease

BACKGROUND

Some patients with diabetes are unaware that they are prescribed medications for diabetes. The purpose of this study is to determine, using a Japanese nationwide epidemiologic database, the association between unawareness of being prescribed medication for diabetes and the risk of developing cardiovascular disease (CVD) in patients with diabetes.

METHODS

This observational cohort study analyzed data from the JMDC Claims Database between 2005 and 2022, including 94,048 patients with diabetes treated with medications. The primary endpoint was a composite endpoint including myocardial infarction (MI), stroke, heart failure (HF), and atrial fibrillation (AF).

RESULTS

We identified 7561 composite CVD endpoints during a mean follow-up of 1199 ± 902 days. Overall, 7779 (8.3 %) patients were unaware of being prescribed medications for diabetes. Those who did not know they were prescribed drugs were younger and had better glycemic control, but these individuals were at higher risk of developing combined CVD [hazard ratio (HR) 1.13, 95 % confidence interval (95 % CI) 1.04-1.22]. HRs of unawareness of being prescribed medications for diabetes were 1.33 (95 % CI 1.06-1.68) for MI, 1.13 (95 % CI 0.97-1.31) for stroke, 1.10 (95 % CI 1.00-1.21) for HF, and 1.19 (95 % CI 0.97-1.47) for AF, respectively.

CONCLUSIONS

In patients with diabetes taking medications for diabetes, even if they are young and have good glycemic control, unawareness of being prescribed medications for diabetes was associated with a greater risk of developing CVD. It is important that they receive adequate education from their healthcare providers to accurately identify their treatment status.

Attitudes and practices related to hypoglycemia unawareness in patients with type 1 and type 2 diabetes

Diabetes is considered one of the most prevalent endocrine metabolic diseases. Monitoring hypoglycemia unawareness is an important component of routine diabetes care and can identify patients at increased risk of a severe hypoglycaemic event. This study aimed to evaluate the frequency of hypoglycemia unawareness and identify the factors contributing to its occurrence. A sample of 390 patients diagnosed with type 1 and type 2 diabetes was interviewed in an endocrine and diabetes center in Al-Ahsa city. Sociodemographic data, risk factors, and Clarke scores were used to evaluate the impairment of hypoglycemia awareness. Reduced awareness of hypoglycemia was found in 93 patients (23.8%). There were no statistically significant differences in the age of the patients, mean age of diagnosis, or cumulative glucose level between patients with awareness and those with reduced awareness (P > 0.05). Patients with type 2 diabetes mellitus (T2DM) showed significantly reduced awareness compared to type 1 diabetes (T1DM) (P = 0.038). Additionally, there were no statistically significant differences in hypoglycemia awareness between patients who underwent nephropathy screening and those who did not (P = 0.523). In conclusion, our study revealed reduced hypoglycemia awareness in 93 patients. However, there was no statistically significant difference related to various factors, including age and cumulative glucose levels. Patients with T2DM showed significantly lower hypoglycaemic awareness compared to patients with T1DM. Further research is needed to evaluate other factors of hypoglycemia unawareness.

Investigation of geographic disparities of diabetes-related hospitalizations in Florida using flexible spatial scan statistics: An ecological study

BACKGROUND

Hospitalizations due to diabetes complications are potentially preventable with effective management of the condition in the outpatient setting. Diabetes-related hospitalization (DRH) rates can provide valuable information about access, utilization, and efficacy of healthcare services. However, little is known about the local geographic distribution of DRH rates in Florida. Therefore, the objectives of this study were to investigate the geographic distribution of DRH rates at the ZIP code tabulation area (ZCTA) level in Florida, identify significant local clusters of high hospitalization rates, and describe characteristics of ZCTAs within the observed spatial clusters.

METHODS

Hospital discharge data from 2016 to 2019 were obtained from the Florida Agency for Health Care Administration through a Data Use Agreement with the Florida Department of Health. Raw and spatial empirical Bayes smoothed DRH rates were computed at the ZCTA level. High-rate DRH clusters were identified using Tango's flexible spatial scan statistic. Choropleth maps were used to display smoothed DRH rates and significant high-rate spatial clusters. Demographic, socioeconomic, and healthcare-related characteristics of cluster and non-cluster ZCTAs were compared using the Wilcoxon rank sum test for continuous variables and Chi-square test for categorical variables.

RESULTS

There was a total of 554,133 diabetes-related hospitalizations during the study period. The statewide DRH rate was 8.5 per 1,000 person-years, but smoothed rates at the ZCTA level ranged from 0 to 101.9. A total of 24 significant high-rate spatial clusters were identified. High-rate clusters had a higher percentage of rural ZCTAs (60.9%) than non-cluster ZCTAs (41.8%). The median percent of non-Hispanic Black residents was significantly (p < 0.0001) higher in cluster ZCTAs than in non-cluster ZCTAs. Populations of cluster ZCTAs also had significantly (p < 0.0001) lower median income and educational attainment, and higher levels of unemployment and poverty compared to the rest of the state. In addition, median percent of the population with health insurance coverage and number of primary care physicians per capita were significantly (p < 0.0001) lower in cluster ZCTAs than in non-cluster ZCTAs.

CONCLUSIONS

This study identified geographic disparities of DRH rates at the ZCTA level in Florida. The identification of high-rate DRH clusters provides useful information to guide resource allocation such that communities with the highest burdens are prioritized to reduce the observed disparities. Future research will investigate determinants of hospitalization rates to inform public health planning, resource allocation and interventions.

Significance of Neutrophil to Lymphocyte Ratio (NLR) and Platelet Lymphocyte Ratio (PLR) in Diabetic Foot Ulcer and Potential New Therapeutic Targets

Diabetic foot ulcer (DFU) is a well-known complication of diabetes and a significant burden on the national health systems. The neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio are inexpensive and easily accessible biomarkers that have proved to be useful in several inflammatory, infectious and cardiovascular diseases. We carried out a comprehensive review examining the association of NLR and PLR with the onset and progression of DFU. PLR and NLR were significantly increased in patients with DFU, compared with a control group of T2DM patients without DFU, and correlate well with DFU severity, evaluated by Wagner and IWGDF grading scales. In patients with diabetic foot infections (DFI), elevated NLR and PLR were correlated with osteomyelitis, increased risk of amputation, and septic complications. The significance of the elevated value of these biomarkers in DFU is related to chronic hyperglycemia and low-grade systemic inflammation, atherosclerotic and vascular complications, and also the associated septic factor. Serial, dynamic follow-up can provide useful information in planning and monitoring DFU treatment, as well as in risk stratification of these vulnerable patients. Further randomized studies are needed to set the cut-off values with clinical significance.

Computed Tomography Angiography Characteristics of Thin-Cap Fibroatheroma in Patients With Diabetes

BACKGROUND

It was recently reported that thin-cap fibroatheroma (TCFA) detected by optical coherence tomography was an independent predictor of future cardiac events in patients with diabetes. However, the clinical usefulness of this finding is limited by the invasive nature of optical coherence tomography. Computed tomography angiography (CTA) characteristics of TCFA have not been systematically studied. The aim of this study was to investigate CTA characteristics of TCFA in patients with diabetes.

METHODS AND RESULTS

Patients with diabetes who underwent preintervention CTA and optical coherence tomography were included. Qualitative and quantitative analyses were performed for plaques on CTA. TCFA was assessed by optical coherence tomography. Among 366 plaques in 145 patients with diabetes, 111 plaques had TCFA. The prevalence of positive remodeling (74.8% versus 50.6%, P<0.001), low attenuation plaque (63.1% versus 33.7%, P<0.001), napkin-ring sign (32.4% versus 11.0%, P<0.001), and spotty calcification (55.0% versus 34.9%, P<0.001) was significantly higher in TCFA than in non-TCFA. Low-density noncalcified plaque volume (25.4 versus 15.7 mm3, P<0.001) and remodeling index (1.30 versus 1.20, P=0.002) were higher in TCFA than in non-TCFA. The presence of napkin-ring sign, spotty calcification, high low-density noncalcified plaque volume, and high remodeling index were independent predictors of TCFA. When all 4 predictors were present, the probability of TCFA increased to 82.4%.

CONCLUSIONS

The combined qualitative and quantitative plaque analysis of CTA may be helpful in identifying TCFA in patients with diabetes.

REGISTRATION INFORMATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04523194.

Vascular endothelial growth factors and risk of cardio-renal events: Results from the CREDENCE trial

BACKGROUND

Circulating concentrations of vascular endothelial growth factor (VEGF) family members may be abnormally elevated in type 2 diabetes (T2D). The roles of placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFLT-1), and VEGF-A in cardio-renal complications of T2D are not established.

METHOD

The 2602 individuals with diabetic kidney disease (DKD) from the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation trial were randomized to receive canagliflozin or placebo and followed for incident cardio-renal outcomes. PlGF, sFLT-1, and VEGF-A were measured at baseline, year 1, and year 3. Primary outcome was a composite of end-stage kidney disease, doubling of the serum creatinine, or renal/cardiovascular death. Cox proportional hazard regression was used to investigate the association between biomarkers with adverse clinical events.

RESULTS

At baseline, individuals with higher PlGF levels had more prevalent cardiovascular disease compared to those with lower values. Treatment with canagliflozin did not meaningfully change PlGF, sFLT-1, and VEGF-A concentrations at years 1 and 3. In a multivariable model, 1 unit increases in baseline log PlGF (hazard ratio [HR]: 1.76, 95% confidence interval [CI]: 1.23, 2.54, P-value = .002), sFLT-1 (HR: 3.34, [95% CI: 1.71, 6.52], P-value < .001), and PlGF/sFLT-1 ratio (HR: 4.83, [95% CI: 0.86, 27.01], P-value = .07) were associated with primary composite outcome, while 1 unit increase in log VEGF-A did not increase the risk of primary outcome (HR: 0.96 [95% CI: 0.81, 1.07]). Change by 1 year of each biomarker was also assessed: HR (95% CI) of primary composite outcome was 2.45 (1.70, 3.54) for 1 unit increase in 1-year concentration of log PlGF, 4.19 (2.18, 8.03) for 1 unit increase in 1-year concentration of log sFLT-1, and 21.08 (3.79, 117.4) for 1 unit increase in 1-year concentration of log PlGF/sFLT-1. Increase in 1-year concentrations of log VEGF-A was not associated with primary composite outcome (HR: 1.08, [95% CI: 0.93, 1.24], P-value = .30).

CONCLUSIONS

People with T2D and DKD with elevated levels of PlGF, sFLT-1, and PlGF/sFLT-1 ratio were at a higher risk for cardiorenal events. Canagliflozin did not meaningfully decrease concentrations of PlGF, sFLT-1, and VEGF-A.

CLINICAL TRIAL

CREDENCE, https://clinicaltrials.gov/ct2/show/NCT02065791.

Dapagliflozin alleviates high glucose-induced injury of endothelial cells via inducing autophagy

Hyperglycaemia is a key factor in the progression of diabetes complications. Dapagliflozin (DAPA), a new type of hypoglycaemic agent, has been shown to play an important role in anti-apoptotic, anti-inflammatory and antioxidant activities. Previous studies have demonstrated an endothelial protective effect of DAPA, but the underlying mechanism was still unclear. Autophagy is a homeostatic cellular mechanism that circulates unfolded proteins and damaged organelles through lysosomal dependent degradation. In this study, we aimed to investigate whether DAPA plays a protective role against high glucose (HG)-induced endothelial injury through regulating autophagy. The results showed that DAPA treatment resulted in increased cell viability. Additionally, DAPA treatment decreased interleukin (IL)-1β, IL-6, and tumour necrosis factor-α levels in endothelial cells subjected to HG conditions. We observed that HG inhibited autophagy, and DAPA increased the autophagy level by inhibiting the protein kinase B (AKT)/mammalian target of rapamycin (mTOR) signalling pathway. Chloroquine reversed all of these beneficial effects as an autophagy inhibitor. In summary, the endothelial protective effect of DAPA in HG can be attributed in part to its role in activating of autophagy via the AKT/mTOR signalling pathway. Therefore, suggesting that the activation of autophagy by DAPA may be a novel target for the treatment of HG-induced endothelial cell injury.

CircGAB1 Facilitates Podocyte Injury Through Sponging miR-346 and Activating MAPK6 in Diabetic Nephropathy

BACKGROUND

Podocyte injury is very important process in diabetic nephropathy (DN) progression. Circular RNA (circRNA) takes part in regulating the advancement of DN. Herein, we explored the role and mechanism of circGAB1 in DN progression.

METHODS

The abundances of circGAB1, microRNA-346 (miR-346) and mitogen-activated protein kinase 6 (MAPK6) were detected by qRT-PCR in DN serum samples and podocyte HGPC. Moreover, cell viability and apoptosis were determined using CCK8 assay and flow cytometry. Also, the protein levels of MAPK6, proliferation-related markers and apoptosis-related markers were analyzed by western blot. ELISA assay was used to measure the levels of inflammatory factors, and corresponding kits were used to detect the levels of oxidative stress-related markers. The relationship between miR-346 and circGAB1 or MAPK6 was distinguished by dual-luciferase reporter assay.

RESULTS

CircGAB1 expression was increased in DN serum samples and HG-treated HGPC cells. CircGAB1 knockdown inhibited HG-induced apoptosis, inflammatory response and oxidative stress in HGPC cells. In terms of mechanism, circGAB1 sponged miR-346, and miR-346 targeted MAPK6. The inhibition effect of circGAB1 knockdown on HG-induced podocyte injury could be reversed by miR-346 inhibitor. Moreover, miR-346 overexpression repressed HG-induced podocyte injury by targeting MAPK6. CircGAB1 served as miR-346 sponge to positively regulate MAPK6.

CONCLUSION

CircGAB1 contributed to podocyte injury through mediating miR-346/MAPK6 axis, suggesting that circGAB1 might promote DN progression.

Effects of Prior Metformin Use on Stroke Outcomes in Diabetes Patients with Acute Ischemic Stroke Receiving Endovascular Treatment

Diabetes mellitus (DM) predisposes individuals to vascular injury, leading to poor outcomes after ischemic stroke and symptomatic hemorrhagic transformation (SHT) after thrombolytic and endovascular treatment (EVT). Metformin (MET), an oral antidiabetic drug, has shown potential neuroprotective effects, but its impact on stroke prognosis in DM patients undergoing EVT remains unclear. In a multicenter study, 231 patients with DM undergoing EVT for acute ischemic stroke were enrolled. Prior MET use was identified, and patients were stratified into MET+ and MET- groups. Demographics, clinical data, and outcomes were compared between groups. Multivariate analysis was used to assess the effect of MET on stroke prognosis. Of the enrolled patients, 59.3% were previously on MET. MET+ patients had lower initial infarct volumes and NIHSS scores compared to MET-taking patients. Multivariate analysis showed that MET+ was associated with a lower risk of stroke progression and SHT (with stroke progression as follows: odd ratio [OR] 0.24, 95% confidence interval [CI] [0.12-0.48], p < 0.001; SHT: OR 0.33, 95% CI [0.14-0.75], p = 0.01) and was also associated with better 3-month functional outcomes (mRS 0-2) after EVT. Prestroke MET use in DM patients undergoing EVT is associated with improved stroke prognosis, including reduced risk of stroke progression and SHT and better functional outcomes. These findings suggest the potential neuroprotective role of MET in this population and highlight its clinical utility as an adjunctive therapy in the management of ischemic stroke. Further research is warranted to elucidate the underlying mechanisms and to optimize MET therapy in this setting.

A Narrative Review of Diabetic Macroangiopathy: From Molecular Mechanism to Therapeutic Approaches

Diabetic macroangiopathy, a prevalent and severe complication of diabetes mellitus, significantly contributes to the increased morbidity and mortality rates among affected individuals. This complex disorder involves multifaceted molecular mechanisms that lead to the dysfunction and damage of large blood vessels, including atherosclerosis (AS) and peripheral arterial disease. Understanding the intricate pathways underlying the development and progression of diabetic macroangiopathy is crucial for the development of effective therapeutic interventions. This review aims to shed light on the molecular mechanism implicated in the pathogenesis of diabetic macroangiopathy. We delve into the intricate interplay of chronic inflammation, oxidative stress, endothelial dysfunction, and dysregulated angiogenesis, all of which contribute to the vascular complications observed in this disorder. By exploring the molecular mechanism involved in the disease we provide insight into potential therapeutic targets and strategies. Moreover, we discuss the current therapeutic approaches used for treating diabetic macroangiopathy, including glycemic control, lipid-lowering agents, and vascular interventions.

Unveiling the pathogenesis and therapeutic approaches for diabetic nephropathy: insights from panvascular diseases

Diabetic nephropathy (DN) represents a significant microvascular complication in diabetes, entailing intricate molecular pathways and mechanisms associated with cardiorenal vascular diseases. Prolonged hyperglycemia induces renal endothelial dysfunction and damage via metabolic abnormalities, inflammation, and oxidative stress, thereby compromising hemodynamics. Concurrently, fibrotic and sclerotic alterations exacerbate glomerular and tubular injuries. At a macro level, reciprocal communication between the renal microvasculature and systemic circulation establishes a pernicious cycle propelling disease progression. The current management approach emphasizes rigorous control of glycemic levels and blood pressure, with renin-angiotensin system blockade conferring renoprotection. Novel antidiabetic agents exhibit renoprotective effects, potentially mediated through endothelial modulation. Nonetheless, emerging therapies present novel avenues for enhancing patient outcomes and alleviating the disease burden. A precision-based approach, coupled with a comprehensive strategy addressing global vascular risk, will be pivotal in mitigating the cardiorenal burden associated with diabetes.

Magnesium promotes vascularization and osseointegration in diabetic states

Diabetes has long been considered a risk factor in implant therapy and impaired wound healing in soft and hard oral tissues. Magnesium has been proved to promote bone healing under normal conditions. Here, we elucidate the mechanism by which Mg2+ promotes angiogenesis and osseointegration in diabetic status. We generated a diabetic mice model and demonstrated the alveolar bone healing was compromised, with significantly decreased angiogenesis. We then developed Mg-coating implants with hydrothermal synthesis. These implants successfully improved the vascularization and osseointegration in diabetic status. Mechanically, Mg2+ promoted the degradation of Kelch-like ECH-associated protein 1 (Keap1) and the nucleation of nuclear factor erythroid 2-related factor 2 (Nrf2) by up-regulating the expression of sestrin 2 (SESN2) in endothelial cells, thus reducing the elevated levels of oxidative stress in mitochondria and relieving endothelial cell dysfunction under hyperglycemia. Altogether, our data suggested that Mg2+ promoted angiogenesis and osseointegration in diabetic mice by regulating endothelial mitochondrial metabolism.

Nrf2 Pathway and Oxidative Stress as a Common Target for Treatment of Diabetes and Its Comorbidities

Diabetes is a chronic disease that induces many comorbidities, including cardiovascular disease, nephropathy, and liver damage. Many mechanisms have been suggested as to how diabetes leads to these comorbidities, of which increased oxidative stress in diabetic patients has been strongly implicated. Limited knowledge of antioxidative antidiabetic drugs and substances that can address diabetic comorbidities through the nuclear factor erythroid 2-related factor 2 (Nrf2) pathway calls for detailed investigation. This review will describe how diabetes increases oxidative stress, the general impact of that oxidative stress, and how oxidative stress primarily contributes to diabetic comorbidities. It will also address how treatments for diabetes, especially focusing on their effects on the Nrf2 antioxidative pathway, have been shown to similarly affect the Nrf2 pathway of the heart, kidney, and liver systems. This review demonstrates that the Nrf2 pathway is a common pathogenic component of diabetes and its associated comorbidities, potentially identifying this pathway as a target to guide future treatments.

Microvascular Function and Exercise Training: Functional Implication of Nitric Oxide Signaling and Ion Channels

Background

Exercise training elicits indubitable positive adaptation in microcirculation in health and disease populations. An inclusive overview of the current knowledge regarding the effects of exercise on microvascular function consolidates an in-depth understanding of microvasculature.

Summary

The main physiological function of microvasculature is to maintain optimal blood flow regulation to supply oxygen and nutrition during elevated physical demands in the cardiovascular system. There are several cellular and molecular alterations in resistance vessels in response to exercise intervention, an increase in nitric oxide-mediated vasodilation through the regulation of oxidative stress, inflammatory response, and ion channels in endothelial cells, thus increasing myogenic tone via voltage-gated Ca2+ channels in smooth muscle cells.

Key Messages

In the review, we postulate that exercise should be considered a medicine for people with diverse diseases through a comprehensive understanding of the cellular and molecular underlying mechanisms in microcirculation through exercise training.

Fufang Zhenzhu Tiaozhi (FTZ) capsule ameliorates diabetes-accelerated atherosclerosis via suppressing YTHDF2-mediated m6A modification of SIRT3 mRNA

ETHNOPHARMACOLOGICAL RELEVANCE

Fufang Zhenzhu TiaoZhi (FTZ), a Chinese medicinal decoction, has continuously been used to treat metabolic syndrome. Atherosclerosis is the main pathological basis of cardiovascular disease. The N6 methyladenosine (m6A) modification is a highly dynamic and reversible process involving a variety of important biological processes.

AIM OF THE STUDY

Here, we investigated the therapeutic effects and mechanism of FTZ in diabetes-accelerated atherosclerosis.

MATERIALS AND METHODS

Doppler ultrasonography was used to examine the carotid intima-media thickness and plaque area in diabetic atherosclerosis patients. HFD mice were injected with streptozotocin to induce diabetes. HE and Oil red O staining were used to assess the effect of FTZ on lipid deposition. HUVECs were induced with HG/ox-LDL as a model of diabetic atherosclerosis. Furthermore, application of m6A methylation level kit, qRT-PCR, Western blot, tunel staining, reactive oxygen species staining and mPTP staining were performed to analyze the detailed mechanism.

RESULTS

Clinical trials of FTZ have shown obvious effect of lowering blood glucose and blood lipids. These effects were reversed after FTZ intervention. Compared with the control, lipid deposition decreased significantly after FTZ administration. FTZ reduced endothelial cell apoptosis. At the same time, we found that FTZ reversed the increase of methylation reader YTHDF2 caused by ox-LDL treatment. Subsequently, we discovered that YTHDF2 degraded SIRT3 mRNA, leading to endothelial cell apoptosis and oxidative stress.

CONCLUSION

FTZ attenuated diabetes-accelerated atherosclerosis by decreasing blood glucose and serum lipids levels, and increased endothelial cell antioxidant capacity, inhibited endothelial cell apoptosis via inhibiting YTHDF2-mediated m6A modification of SIRT3 mRNA, which reduced mRNA degradation.

Investigation of predictors of severity of diabetes complications among hospitalized patients with diabetes in Florida, 2016-2019

BACKGROUND

Severe diabetes complications impact the quality of life of patients and may lead to premature deaths. However, these complications are preventable through proper glycemic control and management of risk factors. Understanding the risk factors of complications is important in guiding efforts to manage diabetes and reduce risks of its complications. Therefore, the objective of this study was to identify risk factors of severe diabetes complications among adult hospitalized patients with diabetes in Florida.

METHODS

Hospital discharge data from 2016 to 2019 were obtained from the Florida Agency for Health Care Administration through a Data Use Agreement with the Florida Department of Health. Adapted Diabetes Complications Severity Index (aDCSI) scores were computed for 1,061,140 unique adult patients with a diagnosis of diabetes. Severe complications were defined as those with an aDCSI ≥ 4. Population average models, estimated using generalized estimating equations, were used to identify individual- and area-level predictors of severe diabetes complications.

RESULTS

Non-Hispanic Black patients had the highest odds of severe diabetes complications compared to non-Hispanic White patients among both males (Odds Ratio [OR] = 1.20, 95% Confidence Interval [CI]: 1.17, 1.23) and females (OR = 1.27, 95% CI: 1.23, 1.31). Comorbidities associated with higher odds of severe complications included hypertension (OR = 2.30, 95% CI: 2.23, 2.37), hyperlipidemia (OR = 1.29, 95% CI: 1.27, 1.31), obesity (OR = 1.24, 95% CI: 1.21, 1.26) and depression (OR = 1.09, 95% CI: 1.07, 1.11), while the odds were lower for patients with a diagnosis of arthritis (OR = 0.81, 95% CI: 0.79, 0.82). Type of health insurance coverage was associated with the severity of diabetes complications, with significantly higher odds of severe complications among Medicare (OR = 1.85, 95% CI: 1.80, 1.90) and Medicaid (OR = 1.83, 95% CI: 1.77, 1.90) patients compared to those with private insurance. Residing within the least socioeconomically deprived ZIP code tabulation areas (ZCTAs) in the state had a protective effect compared to residing outside of these areas.

CONCLUSIONS

Racial, ethnic, and socioeconomic disparities in the severity of diabetes complications exist among hospitalized patients in Florida. The observed disparities likely reflect challenges to maintaining glycemic control and managing cardiovascular risk factors, particularly for patients with multiple chronic conditions. Interventions to improve diabetes management should focus on populations with disproportionately high burdens of severe complications to improve quality of life and decrease premature mortality among adult patients with diabetes in Florida.

Necrosis, netosis, and apoptosis in pulmonary tuberculosis and type-2 diabetes mellitus. Clues from the patient's serum

Pulmonary tuberculosis (PTB) and type 2 diabetes mellitus (T2DM) are two inflammatory diseases whose pathology involves neutrophils (NEU) as key participants. Countless inflammatory elements produced at the lesion sites leak into the blood and are distributed systemically. The study aimed to investigate the effect of the serum of patients with PTB, T2DM, and PTB + T2DM on the cellular and nuclear morphology of healthy NEU. Monolayers of NEU were prepared and incubated with sera from PTB (n꓿ 10), T2DM (n꓿10), PTB + T2DM (n꓿ 10) patients, or sera from healthy people (n = 10). Monolayers were stained for histones, elastase, and myeloperoxidase for NETosis, annexin V for apoptosis, and Iris fuchsia for necrosis. Hoechst stain (DNA) was used to identify the nuclear alterations. Necrosis was the predominant alteration. Sera from PTB + T2DM were the most potent change inducers. Normal sera did not induce cell alterations. The blood of TBP and T2DM patients carries a myriad of abnormal elements that induce necrosis of NEU in normal people, thus reflecting what might occur in the neutrophils of the patients themselves. These findings reinforce the participation of NEU in the pathology of these diseases. Necrosis is expected to be the most frequent neutrophil-induced alteration in tuberculosis and diabetes mellitus.

Dermal features derived from optoacoustic tomograms via machine learning correlate microangiopathy phenotypes with diabetes stage

Skin microangiopathy has been associated with diabetes. Here we show that skin-microangiopathy phenotypes in humans can be correlated with diabetes stage via morphophysiological cutaneous features extracted from raster-scan optoacoustic mesoscopy (RSOM) images of skin on the leg. We obtained 199 RSOM images from 115 participants (40 healthy and 75 with diabetes), and used machine learning to segment skin layers and microvasculature to identify clinically explainable features pertaining to different depths and scales of detail that provided the highest predictive power. Features in the dermal layer at the scale of detail of 0.1-1 mm (such as the number of junction-to-junction branches) were highly sensitive to diabetes stage. A 'microangiopathy score' compiling the 32 most-relevant features predicted the presence of diabetes with an area under the receiver operating characteristic curve of 0.84. The analysis of morphophysiological cutaneous features via RSOM may allow for the discovery of diabetes biomarkers in the skin and for the monitoring of diabetes status.

Non-apoptotic programmed cell deaths in diabetic pulmonary dysfunction: the new side of advanced glycation end products

Diabetes mellitus (DM) is a chronic metabolic disorder that affects multiple organs and systems, including the pulmonary system. Pulmonary dysfunction in DM patients has been observed and studied for years, but the underlying mechanisms have not been fully understood. In addition to traditional mechanisms such as the production and accumulation of advanced glycation end products (AGEs), angiopathy, tissue glycation, oxidative stress, and systemic inflammation, recent studies have focused on programmed cell deaths (PCDs), especially the non-apoptotic ones, in diabetic pulmonary dysfunction. Non-apoptotic PCDs (NAPCDs) including autophagic cell death, necroptosis, pyroptosis, ferroptosis, and copper-induced cell death have been found to have certain correlations with diabetes and relevant complications. The AGE-AGE receptor (RAGE) axis not only plays an important role in the traditional pathogenesis of diabetes lung disease but also plays an important role in non-apoptotic cell death. In this review, we summarize novel studies about the roles of non-apoptotic PCDs in diabetic pulmonary dysfunction and focus on their interactions with the AGE-RAGE axis.

Suberosin Alleviates Thiazolidinedione-Induced Cardiomyopathy in Diabetic Rats by Inhibiting Ferroptosis via Modulation of ACSL4-LPCAT3 and PI3K-AKT Signaling Pathways

Thiazolidinediones are useful antidiabetic medications. However, their use is associated with adverse side effects like edema, heart failure and bone fractures. In this study, we investigated the anti-ferroptosis effects of suberosin (SBR; a prenylated coumarin) in diabetic Sprague Dawley rats. Further, we assessed the effects of co-administration of SBR (30 and 90 mg/kg/day) with thiazolidinedione (TZ at 15 mg/kg) to mitigate TZ-induced cardiomyopathy in diabetic rats. Our results showed that cardiac output, stroke volume, left ventricle systolic and diastolic pressures were aggravated in diabetic rats treated with TZ alone after 4 weeks. TZ treatments induced ferroptosis as well as marked histoarchitecture disarrangements in rat cardiomyocytes. The study found that optimizing volume overload alleviated cardiac hypertrophy and mitigated left ventricular dysfunction in diabetic rats co-treated with SBR. SBR co-administration with TZ reduced MDA levels in heart tissue and serum iron concentration (biomarkers of ferroptosis), downregulated mRNA expressions of LOX, ACSL4, LPCAT3, and promoted GPX4 activity as well as upregulated mRNA levels of AKT/PI3K/GSK3β as compared to the group administered with TZ at 15 mg/kg. SBR co-administration also helped to retain the normal histoarchitecture of cardiomyocytes in diabetic rats. Hence, our results suggested that SBR is an effective supplement and could be prescribed to diabetic patients along with TZ but this requires further clinical trials.

Effects of GLP-1 receptor agonists on mitochondrial function, inflammatory markers and leukocyte-endothelium interactions in type 2 diabetes

OBJECTIVE

Type 2 diabetes (T2D) is linked to metabolic, mitochondrial and inflammatory alterations, atherosclerosis development and cardiovascular diseases (CVDs). The aim was to investigate the potential therapeutic benefits of GLP-1 receptor agonists (GLP-1 RA) on oxidative stress, mitochondrial respiration, leukocyte-endothelial interactions, inflammation and carotid intima-media thickness (CIMT) in T2D patients.

RESEARCH DESIGN AND METHODS

Type 2 diabetic patients (255) and control subjects (175) were recruited, paired by age and sex, and separated into two groups: without GLP-1 RA treatment (196) and treated with GLP-1 RA (59). Peripheral blood polymorphonuclear leukocytes (PMNs) were isolated to measure reactive oxygen species (ROS) production by flow cytometry and oxygen consumption with a Clark electrode. PMNs were also used to assess leukocyte-endothelial interactions. Circulating levels of adhesion molecules and inflammatory markers were quantified by Luminex's technology, and CIMT was measured as surrogate marker of atherosclerosis.

RESULTS

Treatment with GLP-1 RA reduced ROS production and recovered mitochondrial membrane potential, oxygen consumption and MPO levels. The velocity of leukocytes rolling over endothelial cells increased in PMNs from GLP-1 RA-treated patients, whereas rolling and adhesion were diminished. ICAM-1, VCAM-1, IL-6, TNFα and IL-12 protein levels also decreased in the GLP-1 RA-treated group, while IL-10 increased. CIMT was lower in GLP-1 RA-treated T2D patients than in T2D patients without GLP-1 RA treatment.

CONCLUSIONS

GLP-1 RA treatment improves the redox state and mitochondrial respiration, and reduces leukocyte-endothelial interactions, inflammation and CIMT in T2D patients, thereby potentially diminishing the risk of atherosclerosis and CVDs.

Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta-analysis

A meta-analysis study was conducted to measure the consequence of diabetic foot ulcers (DFUs) and other risk factors (RFs) on the prevalence of lower extremity amputation (LEA). A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. Of the 32 chosen studies enclosed, 9934 subjects were in the chosen studies' starting point, and 2906 of them were with LEA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of DFUs and other RFs on the prevalence of LEA by the continuous and dichotomous approaches and a fixed or random effect model. Male gender (OR, 1.30; 95% CI, 1.17-1.44, P < .001), smoking (OR, 1.24; 95% CI, 1.01-1.53, P = .04), previous foot ulcer (OR, 2.69; 95% CI, 1.93-3.74, P < .001), osteomyelitis (OR, 3.87; 95% CI, 2.28-6.57, P < .001), gangrene (OR, 14.45; 95% CI, 7.03-29.72, P < .001), hypertension (OR, 1.17; 95% CI, 1.03-1.33, P = .01), and white blood cells count (WBCC) (MD, 2.05; 95% CI, 1.37-2.74, P < .001) were significantly shown to be an RF in LEA in subjects with DFUs. Age (MD, 0.81; 95% CI, -0.75 to 2.37, P = .31), body mass index (MD, -0.55; 95% CI, -1.15 to 0.05, P = .07), diabetes mellitus type (OR, 0.99; 95% CI, 0.63-1.56, P = .96), and glycated haemoglobin (MD, 0.33; 95% CI, -0.15 to 0.81, P = .17) were not shown to be an RF in LEA in subjects with DFUs. Male gender, smoking, previous foot ulcer, osteomyelitis, gangrene, hypertension, and WBCC were significantly shown to be an RF in LEA in subjects with DFUs. However, age and diabetes mellitus type were not shown to be RF in LEA in subjects with DFUs. However, caused of the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.

The Correlation Between C-Peptide and Severity of Peripheral Atherosclerosis in Type 2 Diabetes Mellitus

Background

One of the major issues affecting global health is Diabetes mellitus (DM), not only in terms of the disease itself but also its complications. Macrovascular complications are both common and serious, affecting many patients. This study aimed to assess fasting C-peptide levels and correlate them with the severity of the peripheral arterial disease complicating type 2 DM (T2DM).

Patients and Methods

This study included 200 participants who were categorized into two groups: Group I (n=100, patients with T2DM complicated by femoropopliteal arterial atherosclerosis) and Group II (n=100, healthy age- and sex-matched individuals serving as controls). Fasting C-peptide levels were estimated using an immunochemiluminometric assay.

Results

Fasting C-peptide levels were significantly higher in Group I than in the control group. Fasting C-peptide levels were positively correlated with the severity of atherosclerosis. In addition, the receiver operating characteristic (ROC) curve analysis revealed that fasting C-peptide levels served as a specific and sensitive marker for detecting the severity of this disease.

Conclusion

Fasting C-peptide levels can be used as a sensitive and specific indicator of the severity of femoropopliteal arteriosclerosis that complicates T2DM.

Prognostic models for short-term annual risk of severe complications and mortality in patients living with type 2 diabetes using a national medical claim database

OBJECTIVE

Prognostic models in patients living with diabetes allow physicians to estimate individual risk based on medical records and biological results. Clinical risk factors are not always all available to evaluate these models so that they may be complemented with models from claims databases. The objective of this study was to develop, validate and compare models predicting the annual risk of severe complications and mortality in patients living with type 2 diabetes (T2D) from a national claims data.

RESEARCH DESIGN AND METHODS

Adult patients with T2D were identified in a national medical claims database through their history of treatments or hospitalizations. Prognostic models were developed using logistic regression (LR), random forest (RF) and neural network (NN) to predict annual risk of outcome: severe cardiovascular (CV) complications, other severe T2D-related complications, and all-cause mortality. Risk factors included demographics, comorbidities, the adjusted Diabetes Severity and Comorbidity Index (aDSCI) and diabetes medications. Model performance was assessed using discrimination (C-statistics), balanced accuracy, sensibility and specificity.

RESULTS

A total of 22,708 patients with T2D were identified, with mean age of 68 years and average duration of T2D of 9.7 years. Age, aDSCI, disease duration, diabetes medications and chronic cardiovascular disease were the most important predictors for all outcomes. Discrimination with C-statistic ranged from 0.715 to 0.786 for severe CV complications, from 0.670 to 0.847 for other severe complications and from 0.814 to 0.860 for all-cause mortality, with RF having consistently the highest discrimination.

CONCLUSION

The proposed models reliably predict severe complications and mortality in patients with T2D, without requiring medical records or biological measures. These predictions could be used by payers to alert primary care providers and high-risk patients living with T2D.

Alteration of Aquaporins 1 and 4 immunohistochemical and gene expression in the cerebellum of diabetic albino rat

Aquaporins (AQPs) are a family of transmembrane channel proteins. AQP1 and AQP4 are expressed in cerebellum amongst others. This study was designed to assess the effect of diabetes on AQP1 and AQP4 expression in cerebellum of rats. Diabetes was induced by a single intraperitoneal injection of Streptozotocin 45 mg/kg in 24 adult male Sprague Dawley rats. Six rats from control and diabetic groups were sacrificed at one, four, and eight weeks post diabetic confirmation. After eight weeks, measurement of malondialdehyde (MDA), reduced glutathione (GSH) concentrations, and cerebellar mRNA expression for AQP1 and AQP4 genes were performed. Immunohistochemical evaluation of AQP1, AQP4, and glial fibrillary acidic protein (GFAP) for cerebellar sections was performed for all groups. Diabetes caused degenerative changes in Purkinje cells with a significant increase in the cerebellar level of MDA and AQP1 immunoreactivity and a significant decrease in GSH level and AQP4 expression levels. However, the alteration in the AQP1 mRNA level was not statistically significant. GFAP immunoreactivity was increased in 8 W diabetic rats following its decrease in 1 W diabetic rats. Diabetes caused some alteration in the AQPs 1 and 4 expression in the cerebellum of diabetic rats which may contribute to diabetes-induced cerebellar complications.

Exploring new insights in coronary lesion assessment and treatment in patients with diabetes mellitus: the impact of optical coherence tomography

In this review, we summarise new insights into diagnostic approaches and treatment strategies for coronary artery disease (CAD) in patients with diabetes mellitus (DM). Despite the improvements in therapy, the clinical management of DM patients remains challenging as they develop more extensive CAD at a younger age and consistently have worse clinical outcomes than non-DM patients. Current diagnostic modalities as well as revascularisation treatments mainly focus on ischemic lesions. However, the impact of plaque morphology and composition are emerging as strong predictors of adverse cardiac events even in the absence of identified ischemia. In particular, the presence of vulnerable plaques such as thin-cap fibroatheroma (TCFA) lesions has been identified as a very strong predictor of future adverse events. This emphasises the need for an approach combining both functional and morphological methods in the assessment of lesions. In particular, optical coherence tomography (OCT) has proven to be a valuable asset by truly identifying TCFAs. New treatment strategies should consist of individualised and advanced medical regimens and may evolve towards plaque sealing through percutaneous treatment.

Synergistic effects of overweight/obesity and high hemoglobin A1c status on elevated high-sensitivity C-reactive protein in Chinese adults: a cross-sectional study

Background

High-sensitivity C-reactive protein (hs-CRP) is an inflammatory marker that has been suggested as a predictor of cardiovascular diseases. High glycated hemoglobin (HbA1c) levels and overweight/obesity are independently associated with elevated hs-CRP; meanwhile, high HbA1c levels are frequently accompanied by overweight or obesity. However, their joint effect on elevated hs-CRP levels has not been well-established. Therefore, we evaluated whether overweight/obesity modified the association between high HbA1c levels and elevated hs-CRP.

Methods

Based on cross-sectional data from the Chinese Urban Adults Diet and Health Study (CUADHS) in 2016, we included 1,630 adults aged 18-75 years (mean age 50.16 years and 33.6% male). Elevated hs-CRP was defined as serum hs-CRP ≥ 3 and <10 mg/L. The interactive effects of BMI and HbA1c levels on the risk of elevated hs-CRP levels were calculated by using multiple logistic regression models, followed by strata-specific analyses.

Results

Individuals with elevated hs-CRP had a higher rate of HbA1c level than those without elevated (25.3 vs. 11.3%, P < 0.001), as well as a higher rate of overweight/obesity (67.1 vs. 43.5%, P < 0.001). Higher HbA1c levels were independently associated with an increased risk of elevated hs-CRP [adjusted odds ratio (aOR) = 2.31, 95% confidence interval (CI): 1.47, 3.65], as well as overweight/obesity with the risk of elevated hs-CRP (aOR = .31, 95% confidenc-3.73). Furthermore, overweight/obesity showed a significant synergistic effect on high HbA1c levels with a higher aOR of 5.25 (2.77, 9.95) (P_interaction < 0.001). This synergistic effect was more prominent when stratified by age (in 18-44 years old, aOR, 95% CI = 30.90, 4.40-236.47 for interaction vs. 6.46, 1.38-30.23 for high HbA1c only) and gender (in women, aOR, 95% CI = 8.33, 3.80-18.23 for interaction vs. 2.46,1.38-4.40 for high HbA1c only).

Conclusion

There are synergistic effects of high HbA1c levels and overweight/obesity on the risk of elevated hs-CRP in Chinese adults, with more significant effects in adults aged 18-44 years or females. Intervention strategies for preventing high blood glucose levels and body weight simultaneously may be important for reducing hs-CRP-related diseases. Further studies are needed to confirm this finding in other populations, and its molecular mechanisms need to be elucidated.

Plasma free amino acid profiles are associated with serum high molecular weight adiponectin levels in Japanese medical check-up population without type 2 diabetes mellitus

To prevent the progression of type 2 diabetes mellitus (T2DM), early detection and intervention are important. Several studies have already shown that the serum adiponectin level could be useful for evaluating the future risk of T2DM. Recently, plasma free amino acid (PFAA) concentrations have also emerged as potential biomarkers that predict the future onset of T2DM. In this study, we aimed to further characterise PFAA profiles by elucidating the association with the serum high molecular weight (HMW) adiponectin level in this cross-sectional study. A total of 1000 Japanese subjects who underwent medical check-ups were enrolled, and their plasma concentrations of 21 amino acids and clinical parameters were measured. The subjects without T2DM were divided into quartiles (Q1-4) by serum HMW adiponectin level, and the association with between PFAA concentrations was analysed. Concentrations of glutamate, alanine, proline, tyrosine, histidine, methionine, lysine, branched-chain amino acids (BCAAs) and tryptophan varied significantly according to the adiponectin quartile. Furthermore, serum adiponectin levels showed significant inverse correlations with these amino acids. The change in the PFAA profile in the group with the lowest adiponectin concentrations (Q1) was similar to that of T2DM patients. Although both adiponectin levels and PFAA concentrations are known to be altered by the accumulation of visceral fat and insulin resistance, the levels of glutamate, BCAA, lysine and tryptophan remain significantly associated with adiponectin level after adjustment for age, body mass index and homeostasis model assessment of insulin resistance, showing the direct association between PFAA concentrations and the serum HMW adiponectin level. Registration number: University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) UMIN000029920, registered on Nov 13th 2017 (prospectively registered).

Retinopathy as an independent predictor of all-cause mortality in individuals with type 2 diabetes

AIMS

To assess whether the presence and grade of diabetic retinopathy (DR) predict all-cause mortality, independent of risk factors for cardiovascular disease (CVD) and other complications, including diabetes-related kidney disease (DKD) and CVD, in individuals with type 2 diabetes mellitus.

METHODS

Prospective cohort study that enroled 15,773 patients in 19 Italian centers in 2006-2008. DR ascertained by fundoscopy, DKD by albuminuria and estimated glomerular filtration rate, and prior CVD by hospital discharge records. All-cause mortality retrieved for 15,656 patients on 31 October 2015.

RESULTS

The adjusted risk of death was increased in patients with any DR (hazard ratio, 1.136 [95% confidence interval, 1.054;1.224] P < 0.0001), advanced DR, including severe non-proliferative and proliferative DR and diabetic macula edema (1.213 [1.097;1.340] P < 0.0001), and especially proliferative DR alone (1.381 [1.207;1.580] P < 0.0001), compared with those without DR. The impact of DR was more evident in patients without than in those with DKD or CVD. Mortality risk was increased in participants with DR alone, though much less than in those with DKD or CVD alone and particularly in those with both DR and DKD or CVD. DR grade was related to mortality in individuals without DKD or CVD, whereas it conferred no additional risk to those with albuminuric or nonalbuminuric DKD or established CVD.

CONCLUSIONS

In patients with type 2 diabetes mellitus, the excess mortality risk conferred by DR is relatively small and higher in those without DKD and CVD, suggesting that it may be mediated by the concurrent presence of these complications, even at a subclinical level.

In situ assessment of Mindin as a biomarker of podocyte lesions in diabetic nephropathy

Diabetic nephropathy (DN) is the leading cause of chronic kidney disease and end-stage renal failure worldwide. Several mechanisms are involved in the pathogenesis of this disease, which culminate in morphological changes such as podocyte injury. Despite the complex diagnosis and pathogenesis, limited attempts have been made to establish new biomarkers for DN. The higher concentration of Mindin protein in the urine of patients with type 2 diabetes mellitus suggests that it plays a role in DN. Therefore, this study investigated whether in situ protein expression of Mindin can be considered a potential DN biomarker. Fifty renal biopsies from patients diagnosed with DN, 57 with nondiabetic glomerular diseases, including 17 with focal segmental glomerulosclerosis (FSGS), 14 with minimal lesion disease (MLD) and 27 with immunoglobulin A nephropathy (IgAN), and 23 adult kidney samples from autopsies (control group) were evaluated for Mindin expression by immunohistochemistry. Podocyte density was inferred by Wilms' tumor 1 (WT1) immunostaining, while foot process effacement was assessed by transmission electron microscopy. Receiver operative characteristic (ROC) analysis was performed to determine the biomarker sensitivity/specificity. Low podocyte density and increased Mindin expression were observed in all cases of DN, regardless of their class. In the DN group, Mindin expression was significantly higher than that in the FSGS, MCD, IgAN and control groups. Higher Mindin expression was significantly positively correlated with foot process effacement only in class III DN cases. Furthermore, Mindin protein presented high specificity in the biopsies of patients with DN (p < 0.0001). Our data suggest that Mindin may play a role in DN pathogenesis and is a promising biomarker of podocyte lesions.

Trimethylamine N-Oxide and Related Metabolites in the Serum and Risk of Type 2 Diabetes in the Chinese Population: A Case-Control Study

BACKGROUND

Trimethylamine N-oxide (TMAO) and its precursors have an association with type 2 diabetes mellitus (T2DM); however, the evidence is unclear. The current study examined the association of serial measures of serum TMAO and related metabolite concentrations with the risk of T2DM.

METHODS

Our study was designed as a community case-control study with 300 participants (150 T2DM and 150 non-T2DM). We examined the association of serum concentrations of TMAO and its related metabolites [trimethylamine, choline, betaine, and L-carnitine] using UPLC-MS/MS. The association between these metabolites and the risk of T2DM was analyzed using a restricted cubic spline and binary logistic regression.

RESULTS

A higher serum choline concentration was significantly associated with an increased risk of T2DM. Serum choline > 22.62 μmol/L was independently associated with an increased risk of T2DM, and the odds ratio was 3.615 [95% CI: (1.453,8.993), P = 0.006]. Similarly, serum betaine and L-carnitine concentrations had a markedly decreased risk of T2DM even after adjusting for the traditional risk factors for T2DM and betaine (0.978 [95% CI:0.964-0.992], P = 0.002) and L-carnitine (0.949 [95% CI: 0.9222-0.978], P = 0.001), respectively.

CONCLUSION

Choline, betaine, and L-carnitine are associated with the risk of T2DM and may be appropriate risk markers to protect high-risk individuals from T2DM.

Debridement of Diabetic Foot Ulcers

Diabetic foot ulcerations have devastating complications, including amputations, poor quality of life, and life-threatening infections. Diabetic wounds can be protracted, take significant time to heal, and can recur after healing. They are costly consuming health care resources. These consequences have serious public health and clinical implications. Debridement is often used as a standard of care. Debridement consists of both nonmechanical (autolytic, enzymatic) and mechanical methods (sharp/surgical, wet to dry debridement, aqueous high-pressure lavage, ultrasound, and biosurgery/maggot debridement therapy). It is used to remove nonviable tissue, to facilitate wound healing, and help prevent these serious outcomes. What are the various forms and rationale behind debridement? This article comprehensively reviews cutting-edge methods and the science behind debridement and diabetic foot ulcers.

Bone Marrow Culture-Derived Conditioned Medium Recovers Endothelial Function of Vascular Grafts following In Vitro Ischemia/Reperfusion Injury in Diabetic Rats

Ischemia/reperfusion injury (IRI) remains a challenge in coronary artery bypass grafting (CABG). Diabetic patients with coronary artery disease are more likely to require CABG and therefore run a high risk for cardiovascular complications. Conditioned medium (CM) from bone marrow-derived mesenchymal stem cells has been shown to have beneficial effects against IRI. We hypothesized that adding CM to physiological saline protects vascular grafts from IRI in diabetic rats. Bone-marrow derived cells were isolated from nondiabetic rat femurs/tibias, and CM was generated. As we previously reported, CM contains 23 factors involved in inflammation, oxidative stress, and apoptosis. DM was induced by streptozotocin administration. Eight weeks later, to measure vascular function, aortic rings were isolated and mounted in organ bath chambers (DM group) or stored in 4°C saline, supplemented either with a vehicle (DM-IR group) or CM (DM-IR+CM group). Although DM was associated with structural changes compared to controls, there were no functional alterations. However, compared to the DM group, in the DM-IR aortas, impaired maximum endothelium-dependent vasorelaxation in response to acetylcholine (DM 86.7 ± 0.1% vs. DM-IR 42.5 ± 2.5% vs. DM-IR+CM 61.9 ± 2.0%, p < 0.05) was improved, caspase-3, caspase-8, caspase-9, and caspase-12 immunoreactivity was decreased, and DNA strand breakage, detected by the TUNEL assay, was reduced by CM. We present the experimental finding that the preservation of vascular grafts with CM prevents endothelial dysfunction after IRI in diabetic rats. Targeting apoptosis by CM may contribute to its protective effect.

Identification of Myocardial Insulin Resistance by Using Liver Tests: A Simple Approach for Clinical Practice

BACKGROUND

We report that myocardial insulin resistance (mIR) occurs in around 60% of patients with type 2 diabetes (T2D) and was associated with higher cardiovascular risk in comparison with patients with insulin-sensitive myocardium (mIS). These two phenotypes (mIR vs. mIS) can only be assessed using time-consuming and expensive methods. The aim of the present study is to search a simple and reliable surrogate to identify both phenotypes.

METHODS

Forty-seven patients with T2D underwent myocardial [18F]FDG PET/CT at baseline and after a hyperinsulinemic-euglycemic clamp (HEC) to determine mIR were prospectively recruited. Biochemical assessments were performed before and after the HEC. Baseline hepatic steatosis index and index of hepatic fibrosis (FIB-4) were calculated. Furthermore, liver stiffness measurement was performed using transient elastography.

RESULTS

The best model to predict the presence of mIR was the combination of transaminases, protein levels, FIB-4 score and HOMA (AUC = 0.95; sensibility: 0.81; specificity: 0.95). We observed significantly higher levels of fibrosis in patients with mIR than in those with mIS (p = 0.034). In addition, we found that patients with mIR presented a reduced glucose uptake by the liver in comparison with patients with mIS.

CONCLUSIONS

The combination of HOMA, protein, transaminases and FIB-4 is a simple and reliable tool for identifying mIR in patients with T2D. This information will be useful to improve the stratification of cardiovascular risk in T2D.

Chemometric exploratory data analysis for patients with diabetes type 2 and diabetic complications

The present study deals with the interpretation and modeling of clinical data for patients with diabetes mellitus type 2 (DMT2) additionally diagnosed with complications of the disease by the use of multivariate statistical methods. The major goal is to determine some specific clinical descriptors characterizing each health problem by applying the options of the exploratory data analysis. The results from the statistical analysis are commented in details by medical reasons for each of the complications. It was found that each of the complications is characterized by specific medical descriptors linked into each one of the five latent factors identified by factor and principal components analysis. Such an approach to interpret concomitant to DMT2 complications is original and allows a better understanding of the role of clinical parameters for diagnostic and prevention goals.

Serum Orotidine: A Novel Biomarker of Increased CVD Risk in Type 2 Diabetes Discovered Through Metabolomics Studies

OBJECTIVE

To identify novel biomarkers of cardiovascular disease (CVD) risk in type 2 diabetes (T2D) via a hypothesis-free global metabolomics study, while taking into account renal function, an important confounder often overlooked in previous metabolomics studies of CVD.

RESEARCH DESIGN AND METHODS

We conducted a global serum metabolomics analysis using the Metabolon platform in a discovery set from the Joslin Kidney Study having a nested case-control design comprising 409 individuals with T2D. Logistic regression was applied to evaluate the association between incident CVD events and each of the 671 metabolites detected by the Metabolon platform, before and after adjustment for renal function and other CVD risk factors. Significant metabolites were followed up with absolute quantification assays in a validation set from the Joslin Heart Study including 599 individuals with T2D with and without clinical evidence of significant coronary heart disease (CHD).

RESULTS

In the discovery set, serum orotidine and 2-piperidinone were significantly associated with increased odds of incident CVD after adjustment for glomerular filtration rate (GFR) (odds ratio [OR] per SD increment 1.94 [95% CI 1.39-2.72], P = 0.0001, and 1.62 [1.26-2.08], P = 0.0001, respectively). Orotidine was also associated with increased odds of CHD in the validation set (OR 1.39 [1.11-1.75]), while 2-piperidinone did not replicate. Furthermore, orotidine, being inversely associated with GFR, mediated 60% of the effects of declining renal function on CVD risk. Addition of orotidine to established clinical predictors improved (P < 0.05) C statistics and discrimination indices for CVD risk (ΔAUC 0.053, rIDI 0.48, NRI 0.42) compared with the clinical predictors alone.

CONCLUSIONS

Through a robust metabolomics approach, with independent validation, we have discovered serum orotidine as a novel biomarker of increased odds of CVD in T2D, independent of renal function. Additionally, orotidine may be a biological mediator of the increased CVD risk associated with poor kidney function and may help improve CVD risk prediction in T2D.

The proteasome activator REGγ promotes diabetic endothelial impairment by inhibiting HMGA2-GLUT1 pathway

Diabetic vascular endothelial impairment is one of the main causes of death in patients with diabetes lacking adequately defined mechanisms or effective treatments. REGγ, the 11S proteasome activator known to promote the degradation of cellular proteins in a ubiquitin- and ATP-independent manner, emerges as a new regulator in the cardiovascular system. Here, we found that REGγ was upregulated in streptozocin (STZ)-induced diabetic mouse aortic endothelium in vivo and high glucose (HG)-treated vascular endothelial cells (ECs) in vitro. REGγ deficiency ameliorated endothelial impairment in STZ-induced diabetic mice by protecting against a decline in cellular glucose uptake and associated vascular ECs dysfunction by suppressing high mobility group AT-hook 2 (HMGA2) decay. Mechanically, REGγ interacted with and degraded the transcription factor HMGA2 directly, leading to decreased HMGA2 transcriptional activity, subsequently lowered expression of glucose transporter type 1 (GLUT1), and reduced cellular glucose uptake, vascular endothelial dysfunction, and impaired diabetic endothelium. Ablation of endogenous GLUT1 or HMGA2 or overexpressing exogenous HMGA2 in vascular ECs significantly blocked or reestablished the REGγ-dependent action on cellular glucose uptake and vascular endothelial functions of HG stimulation in vitro. Furthermore, exogenously introducing HMGA2 improved diabetic mice endothelial impairment features caused by REGγ in vivo, thereby substantiating a REGγ-HMGA2-GLUT1 pathway in diabetic endothelial impairment. Our findings indicate that modulating REGγ-proteasome activity may be a potential therapeutic approach for diabetic disorders with endothelial impairment.