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Meléndez-Flores JD, Cavazos-Benítez AC, Estrada-Bellmann I. Microalbuminuria as a potential biomarker for Parkinson's disease severity: A hypothesis. Med Hypotheses 2021; 149:110510. [PMID: 33609950 DOI: 10.1016/j.mehy.2021.110510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/22/2021] [Indexed: 11/27/2022]
Abstract
Parkinson's disease (PD) is the second most common neurodegenerative condition characterized by motor and non-motor symptoms causing a great burden in patients' quality of life. PD has been associated with various metabolic factors such as diabetes, hypertension, and more recently chronic kidney disease where proteinuria has been associated with an increased risk. The presence of small amounts of albumin in urine, microalbuminuria, is a common biomarker for endothelial damage and a predictive factor for not only cardiovascular but also neurological dysfunction. Multiple studies have assessed potential biomarkers for PD progression with great heterogeneity, we hypothesize the use of microalbuminuria as a potential marker that correlates with PD severity and might represent a feasible and simple method of evaluating PD patients in clinical practice. Evidence supporting the present hypothesis comes from oxidative stress, insulin resistance, and endothelial dysfunction. Oxidative stress is a key element in PD pathogenesis; studies have shown lower antioxidant capacity as PD progresses. On the other side, insulin signaling plays an important role in neuronal growth and survival, with its resistance being associated with PD. Microalbuminuria has been associated with both processes; increased levels of oxidative stress markers and decreased insulin sensitivity, hence its screening in PD might reflect these common pathological mechanisms. Moreover, the low vitamin D levels observed in PD patients, which are correlated with endothelial dysfunction and disease severity, might contribute to microalbuminuria induction. More evidence on this vascular approach comes from white matter lesions (WML), observed in brain imaging, which have been significantly associated with motor and non-motor function in PD patients and are independently associated with microalbuminuria. In this manner, an oxidant and insulin resistant environment, along with low vitamin D levels in PD patients, which are associated with microalbuminuria, might contribute altogether to WML. As the latter are correlated with motor and non-motor function, microalbuminuria might thus give insight on PD status. Prospective cohort studies with an adequate sample size, follow-up, and a thorough battery of clinical tests for PD are needed to confirm this hypothesis.
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Affiliation(s)
- Jesús D Meléndez-Flores
- Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico; Neurology Division, Internal Medicine Department, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - Ingrid Estrada-Bellmann
- Neurology Division, Internal Medicine Department, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Mexico; Movement Disorders Clinic, Neurology Division, Internal Medicine Department, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Mexico.
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Yaribeygi H, Butler AE, Barreto GE, Sahebkar A. Antioxidative potential of antidiabetic agents: A possible protective mechanism against vascular complications in diabetic patients. J Cell Physiol 2019; 234:2436-2446. [DOI: 10.1002/jcp.27278] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/26/2018] [Indexed: 08/30/2023]
Abstract
AbstractMany vascular complications are related to exposure of tissues to elevated levels of glucose, a condition that promotes oxidative stress. The primary goal of antidiabetic medication is for normalization of blood glucose. However, antidiabetic medications may have antioxidant effects that go beyond their hypoglycemic influences. Therefore, antidiabetic drugs may be doubly beneficial in preventing diabetic complications. Vascular dysfunction due to uncontrolled diabetes is a serious complication of the disease and one which has a severe impact on quality of life. Readjustment of the oxidative balance in subjects with diabetes, and the positive effects thereof is a topic of intense interest at present. In the current review, we highlight the antioxidant effects of antidiabetic medications which may prevent or delay the onset of vascular dysfunction.
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Affiliation(s)
- Habib Yaribeygi
- Chronic Kidney Disease Research Center Shahid Beheshti University of Medical Sciences Tehran Iran
| | | | - George E. Barreto
- Departamento de Nutrición y Bioquímica Facultad de Ciencias Pontificia Universidad Javeriana Bogotá D.C. Colombia
- Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile Santiago Chile
| | - Amirhossein Sahebkar
- Neurogenic Inflammation Research Center Mashhad University of Medical Sciences Mashhad Iran
- Biotechnology Research Center Pharmaceutical Technology Institute, Mashhad University of Medical Sciences Mashhad Iran
- School of Pharmacy, Mashhad University of Medical Sciences Mashhad Iran
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Wang W, Zhou X, Kwong JSW, Li L, Li Y, Sun X. Efficacy and safety of thiazolidinediones in diabetes patients with renal impairment: a systematic review and meta-analysis. Sci Rep 2017; 7:1717. [PMID: 28496176 PMCID: PMC5431943 DOI: 10.1038/s41598-017-01965-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 04/06/2017] [Indexed: 02/05/2023] Open
Abstract
We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of TZDs in treatment of diabetes mellitus patients with renal impairment. We searched PubMed, EMBASE and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs), cohort studies, and case-control studies that investigated the effects of TZDs in patients with diabetes and renal impairment were eligible. Outcomes included glycosylated hemoglobin, fasting plasma glucose, serum lipids, and patient-important outcomes (i.e. hypoglycemia, weight, edema, cardiovascular events and mortality). 19 RCTs and 3 cohort studies involving 21,803 patients with diabetes and renal impairment were included. Meta-analysis of RCTs showed that TZDs could significantly reduce HbA1c (MD -0.64, 95%CI -0.93 to -0.35), FPG (MD -26.27, 95%CI -44.90 to -7.64) and increase HDL levels (MD 3.70, 95%CI 1.10, 6.29). TZDs could increase weight (MD 3.23, 95% CI 2.29 to 4.16) and risk of edema (RR 2.96, 95% CI 1.22 to 7.20). Their effects on risk of hypoglycemia (RR 1.46, 95% CI 0.65 to 3.29), heart failure (RR 0.64, 95% CI 0.15 to 2.66), angina (RR 1.45, 95% CI 0.23 to 8.95) and all-cause mortality (RR 0.40, 95% CI 0.08 to 2.01) are uncertain. Results from cohort studies were similar to RCTs.
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Affiliation(s)
- Wen Wang
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xu Zhou
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
- Research Center of Evidence-based Medicine, School of Basic Medicine, Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi, China
| | - Joey S W Kwong
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
- Clinical Research and Evaluation Unit, West China Hospital, Sichuan University, Chengdu, China
| | - Ling Li
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
- Clinical Research and Evaluation Unit, West China Hospital, Sichuan University, Chengdu, China
| | - Youping Li
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
- Clinical Research and Evaluation Unit, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Sun
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China.
- Clinical Research and Evaluation Unit, West China Hospital, Sichuan University, Chengdu, China.
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China.
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Ma C, Sheng J, Liu Z, Guo M. Excretion rates of 1,5-anhydro-D-glucitol, uric acid and microalbuminuria as glycemic control indexes in patients with type 2 diabetes. Sci Rep 2017; 7:44291. [PMID: 28281675 PMCID: PMC5345080 DOI: 10.1038/srep44291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/06/2017] [Indexed: 12/18/2022] Open
Abstract
1,5-anhydroglucitol (1,5-AG), uric acid and urinary proteins are excreted into the urine with increasing glucosuria. In the present retrospective study we analyzed whether these factors could be used as indicators for type 2 diabetes mellitus (T2DM) glucose control in 6,766 (T2DM) patients. There were 3,988 cases (58.9%) with HbA1c ≤ 6.5%, 853 cases (12.61%) with HbA1c levels ranging from 6.5% to 7% and 1,925 cases (28.5%) with HbA1c > 7%. HbA1c percentages were correlated with age, MA and 1,5-AG serum concentrations (P < 0.001). The serum uric acid concentration (P < 0.001) was significantly lower in elevated MA (P < 0.001) and 24-hour urinary protein (P = 0.024) patients. Hb1Ac percentages (P < 0.001) were significantly enhanced in patients with 1,5-AG serum concentrations ≤10 mg/L compared to >10 mg/L. With a derived receiver operating characteristic (ROC) curve, a 1,5-AG cut-off value of 11.55 mg/L for hyperglycemia could be diagnosed with a specificity of 71.2 (69.7–72.6) and a sensitivity of 75.3 (73.6–76.9). The serum 1,5-AG concentration is a marker for hyperglycemia and may be particularly useful as an indicator for short-term glycemic excursions in order to improve treatments in T2DM patients.
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Affiliation(s)
- Cong Ma
- Department of Endocrinology, Xuhui District Central Hospital, No. 966, Huaihai Zhong Road, Shanghai 200031, China
| | - Junqin Sheng
- Department of Nephrology, Xuhui District Central Hospital, No. 966, Huaihai Zhong Road, Shanghai 200031, China
| | - Zhiwen Liu
- Department of Endocrinology, Xuhui District Central Hospital, No. 966, Huaihai Zhong Road, Shanghai 200031, China
| | - Minghao Guo
- Department of Endocrinology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, No. 639 Zhizaoju Road, Shanghai 200011, China
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Cikrikcioglu MA, Erturk Z, Kilic E, Celik K, Ekinci I, Yasin Cetin AI, Ozkan T, Cetin G, Dae SA, Kazancioglu R, Erkoc R. Endocan and albuminuria in type 2 diabetes mellitus. Ren Fail 2016; 38:1647-1653. [DOI: 10.1080/0886022x.2016.1229966] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Mehmet Ali Cikrikcioglu
- Department of Internal Medicine, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Zeynep Erturk
- Department of Internal Medicine, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Elif Kilic
- Department of Biochemistry, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Kenan Celik
- Department of Internal Medicine, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Iskender Ekinci
- Department of Internal Medicine, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Ayse Irem Yasin Cetin
- Department of Internal Medicine, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Tuba Ozkan
- Department of Internal Medicine, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Guven Cetin
- Department of Internal Medicine, Division of Hematology, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Shute Ailia Dae
- Department of Internal Medicine, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Rumeyza Kazancioglu
- Department of Internal Medicine, Division of Nephrology, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Reha Erkoc
- Department of Internal Medicine, Division of Nephrology, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
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Thiazolidinediones and Edema: Recent Advances in the Pathogenesis of Thiazolidinediones-Induced Renal Sodium Retention. PPAR Res 2015; 2015:646423. [PMID: 26074951 PMCID: PMC4446477 DOI: 10.1155/2015/646423] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/03/2015] [Indexed: 02/07/2023] Open
Abstract
Thiazolidinediones (TZDs) are one of the major classes of antidiabetic drugs that are used widely. TZDs improve insulin resistance by activating peroxisome proliferator-activated receptor gamma (PPARγ) and ameliorate diabetic and other nephropathies, at least, in experimental animals. However, TZDs have side effects, such as edema, congestive heart failure, and bone fracture, and may increase bladder cancer risk. Edema and heart failure, which both probably originate from renal sodium retention, are of great importance because these side effects make it difficult to continue the use of TZDs. However, the pathogenesis of edema remains a matter of controversy. Initially, upregulation of the epithelial sodium channel (ENaC) in the collecting ducts by TZDs was thought to be the primary cause of edema. However, the results of other studies do not support this view. Recent data suggest the involvement of transporters in the proximal tubule, such as sodium-bicarbonate cotransporter and sodium-proton exchanger. Other studies have suggested that sodium-potassium-chloride cotransporter 2 in the thick ascending limb of Henle and aquaporins are also possible targets for TZDs. This paper will discuss the recent advances in the pathogenesis of TZD-induced sodium reabsorption in the renal tubules and edema.
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Speeckaert MM, Vanfraechem C, Speeckaert R, Delanghe JR. Peroxisome proliferator-activated receptor agonists in a battle against the aging kidney. Ageing Res Rev 2014; 14:1-18. [PMID: 24503003 DOI: 10.1016/j.arr.2014.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 01/24/2014] [Indexed: 12/19/2022]
Abstract
As aging is a complex phenomenon characterized by intraindividual and interindividual diversities in the maintenance of the homeostatic condition of cells and tissues, changes in renal function are not uniform and depend on associated diseases and environmental factors. Multiple studies have investigated the possible underlying mechanisms of age-related decline in kidney function. Evolutionary, molecular, cellular and systemic theories have been postulated to explain the primary disease independent age-related changes and adaptive responses. As peroxisome proliferator-activated receptors (PPARs) are involved in a broad spectrum of biological processes, PPAR activation might have an effect on the prevention of cell senescence. In this review, we will focus on the experimental and clinical evidence of PPAR agonists in a battle against the aging kidney.
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Affiliation(s)
| | | | | | - Joris R Delanghe
- Department of Clinical Chemistry, Ghent University Hospital, Gent, Belgium
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Kweon SS, Shin MH, Lee YH, Choi JS, Nam HS, Park KS, Kim DH, Jeong SK. Higher normal ranges of urine albumin-to-creatinine ratio are independently associated with carotid intima-media thickness. Cardiovasc Diabetol 2012; 11:112. [PMID: 22995288 PMCID: PMC3537598 DOI: 10.1186/1475-2840-11-112] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 09/19/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High normal values of urine albumin-to-creatinine ratio (UACR) have been reported to have predictive values for hypertension, incident stroke, and higher mortality in the general population. This study aimed to investigate the association between normal ranges of UACR and carotid intima-media thickness (CIMT) in adult population. METHODS We performed a cross-sectional study in adults aged 45 to 74 years who were living in Namwon City, South Korea. Both common CIMTs were measured, and mean values were calculated. Normal values of UACR were defined as <30mg/g and categorized into quintiles; less than 6.50, 6.51-9.79, 9.80-13.49, 13.50-18.89, and more than 18.90 mg/g. The association between the quintiles of UACR and common CIMT was analyzed and stratified by sex. RESULTS A total of 7555 participants (3084 men and 4471 women) with normal UACR were enrolled in the present study. Common CIMT was positively and independently associated with increasing quintiles of UACR in men and women, even after adjusting for potential confounders including age and cardiovascular risk factors. Compared to the first quintile, the fifth quintile showed odds ratios of 1.80 (95% confidence intervals, 1.26-2.55) and 1.97 (1.28-3.04) for increased CIMT (>0.9mm) in men and women, respectively. CONCLUSION Higher UACR values within normal ranges (<30 mg/g) were positively and independently associated with CIMT in a Korean general population, suggesting that higher normal values of UACR might be a risk marker of subclinical carotid atherosclerosis.
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Affiliation(s)
- Sun-Seog Kweon
- Department of Preventive Medicine, Chonnam National University Medical School, Gwangju, South Korea
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Abdel-Rahman EM, Saadulla L, Reeves WB, Awad AS. Therapeutic modalities in diabetic nephropathy: standard and emerging approaches. J Gen Intern Med 2012; 27:458-68. [PMID: 22005942 PMCID: PMC3304033 DOI: 10.1007/s11606-011-1912-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 08/09/2011] [Accepted: 09/21/2011] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus is the leading cause of end stage renal disease and is responsible for more than 40% of all cases in the United States. Current therapy directed at delaying the progression of diabetic nephropathy includes intensive glycemic and optimal blood pressure control, proteinuria/albuminuria reduction, interruption of the renin-angiotensin-aldosterone system through the use of angiotensin converting enzyme inhibitors and angiotensin type-1 receptor blockers, along with dietary modification and cholesterol lowering agents. However, the renal protection provided by these therapeutic modalities is incomplete. More effective approaches are urgently needed. This review highlights the available standard therapeutic approaches to manage progressive diabetic nephropathy, including markers for early diagnosis of diabetic nephropathy. Furthermore, we will discuss emerging strategies such as PPAR-gamma agonists, Endothelin blockers, vitamin D activation and inflammation modulation. Finally, we will summarize the recommendations of these interventions for the primary care practitioner.
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Affiliation(s)
- Emaad M. Abdel-Rahman
- Department of Medicine, Division of Nephrology, University of Virginia, Charlottesville, VA USA
| | - Lawand Saadulla
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, College of Medicine, Hershey, PA USA
| | - W. Brian Reeves
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, College of Medicine, Hershey, PA USA
| | - Alaa S. Awad
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, College of Medicine, Hershey, PA USA
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Bolignano D, Zoccali C. Glitazones in chronic kidney disease: potential and concerns. Nutr Metab Cardiovasc Dis 2012; 22:167-175. [PMID: 22364889 DOI: 10.1016/j.numecd.2011.11.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 11/07/2011] [Accepted: 11/13/2011] [Indexed: 11/17/2022]
Abstract
AIMS Glitazones rank now among the most used hypoglycemic agents in patients with type-2 diabetes. This systematic review focuses on the cardiovascular and renal outcomes in chronic kidney disease (CKD) patients treated with these drugs. DATA SYNTHESIS Data from randomized clinical trials and a meta-analysis indicate that glitazones (particularly rosiglitazone) may increase the risk of myocardial infarction, heart failure and cardiovascular death in type-2 diabetics. Observational studies looking at survival and cardiovascular outcomes in diabetic patients with kidney failure show controversial results. Studies in experimental models and clinical studies suggest that glitazones may have favorable effects on renal disease progression, because these drugs coherently reduce urinary albumin excretion and proteinuria in diabetic and non-diabetic nephropathies. No clinical trial based on clinical end-points like kidney failure has until now tested the effect of glitazones on the evolution of chronic renal failure in these patients. CONCLUSIONS Whether the use of glitazones has a positive or a negative impact upon major cardiovascular and renal outcomes in diabetic patients remains an open, unanswered question. Specific studies are needed to assess the efficacy and safety of glitazones in a high risk population like type-2 diabetics with chronic kidney disease.
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Affiliation(s)
- D Bolignano
- CNR-IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, Reggio Calabria, Italy
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Jain R, Mullins CD, Lee H, Wong W. Use of rosiglitazone and pioglitazone immediately after the cardiovascular risk warnings. Res Social Adm Pharm 2012; 8:47-59. [DOI: 10.1016/j.sapharm.2010.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 12/09/2010] [Accepted: 12/09/2010] [Indexed: 10/18/2022]
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Yoo JS, Lee YM, Lee EH, Kim JW, Lee SY, Jeong KC, Kang SA, Park JS, Nam JY, Ahn CW, Song YD, Kim KR. Serum cystatin C reflects the progress of albuminuria. Diabetes Metab J 2011; 35:602-9. [PMID: 22247903 PMCID: PMC3253971 DOI: 10.4093/dmj.2011.35.6.602] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 06/14/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Research on the relationship between urinary albumin excretion and serum cystatin C in diabetes is restricted to cross-sectional studies. In this study, we investigated how well serial measurements of serum cystatin C level reflect changes in the urinary albumin excretion rate. METHODS We enrolled and retrospectively collected data on 1,058 participants with type 2 diabetes who were older than 18 years and who had more than 3 years of follow-up with serial measurements of albuminuria and serum cystatin C at an outpatient clinic. RESULTS With the use of a linear mixed model, we found that the albuminuria level for each patient over time corresponded with the annual change in serum cystatin C-based estimated glomerular filtration rate (cysC-eGFR) but did not correspond with the creatinine-based eGFR calculated by the modification of diet in renal disease formula (MDRD-eGFR). The discrepancy in the direction of the trend was smaller with cysC-eGFR than with MDRD-eGFR. CONCLUSION Serum cystatin C level reflects the trend in albuminuria level more accurately than serum creatinine level in Korean type 2 diabetes mellitus patients.
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Affiliation(s)
- Jeong Seon Yoo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Mi Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Hae Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Woon Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Shin Young Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ki-Cheon Jeong
- Department of Internal Medicine, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Shin Ae Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Suk Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University, Seoul, Korea
| | - Joo Young Nam
- Department of Internal Medicine, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Chul Woo Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University, Seoul, Korea
| | - Young Duk Song
- Department of Internal Medicine, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Kyung Rae Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Sarafidis PA, Stafylas PC, Georgianos PI, Saratzis AN, Lasaridis AN. Effect of thiazolidinediones on albuminuria and proteinuria in diabetes: a meta-analysis. Am J Kidney Dis 2010; 55:835-47. [PMID: 20110146 DOI: 10.1053/j.ajkd.2009.11.013] [Citation(s) in RCA: 145] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Accepted: 11/12/2009] [Indexed: 01/11/2023]
Abstract
BACKGROUND Because of the major clinical and economic burden of diabetic nephropathy, new therapeutic tools to delay its progression are needed. Recent studies suggest that thiazolidinediones have renal benefits. We aimed to evaluate the effect of thiazolidinediones on urinary albumin and protein excretion in patients with diabetes mellitus. STUDY DESIGN Systematic review and meta-analysis by searching MEDLINE/PubMed, EMBASE, and Cochrane CENTRAL databases (1991 to September 2009). SETTING & POPULATION Patients with diabetes mellitus. SELECTION CRITERIA FOR STUDIES Randomized controlled trials. INTERVENTION Thiazolidinediones (rosiglitazone and pioglitazone) compared with placebo or other antidiabetic agents. OUTCOMES Weighted (WMDs) and standardized mean differences (SMDs) for changes in urine albumin or protein excretion between the thiazolidinedione and control groups. RESULTS Of 171 originally identified articles, 15 studies (5 with rosiglitazone and 10 with pioglitazone) involving 2,860 patients were included in the analysis. In participants with baseline normo- or microalbuminuria, the WMD of proportional changes between the thiazolidinedione and control groups in urinary albumin excretion measured using time-specified collections was -64.8% (95% CI, -75.6 to -53.9) and the WMD of changes in albumin-creatinine ratio was -24.8% (95% CI, -39.6 to -10.0). Overall, in participants with normo- and microalbuminuria, thiazolidinedione treatment was associated with a significant decrease in urinary albumin excretion (SMD, -0.6 units of standard deviation [SD]; 95% CI, -0.8 to -0.4). Similarly, thiazolidinediones were associated with a significant decrease in urinary protein excretion in patients with proteinuria (SMD, -1.1 units of SD; 95% CI, -1.8 to -0.4). LIMITATIONS Significant heterogeneity across included studies in several subgroup analyses; patient-level data not available. CONCLUSIONS Treatment with thiazolidinediones significantly decreases urinary albumin and protein excretion in patients with diabetes. This finding calls for clinical trials with hard renal outcomes to elucidate the potential benefits of thiazolidinediones on diabetic nephropathy.
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Affiliation(s)
- Pantelis A Sarafidis
- Section of Nephrology and Hypertension, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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High ambient glucose induces angiotensin-independent AT-1 receptor activation, leading to increases in proliferation and extracellular matrix accumulation in MES-13 mesangial cells. Biochem J 2009; 423:129-43. [DOI: 10.1042/bj20082277] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diabetic nephropathy is associated with mesangial ECM (extracellular matrix) accumulation. We have shown that AT-1R [Ang II (angiotensin II) type I receptor] signalling induces ECM proteins via transactivation of PI3K (phosphoinositide 3-kinase) in mesangial cells. In the present study, we examined the mechanisms underlying the effect of high ambient glucose on cell proliferation and ECM expansion in a mesangial context. High glucose induced increases in PI3K activity, proliferation and ECM accumulation in mesangial cells. These effects were abrogated by losartan, an AT-1R antagonist, but not by [Sar1,Thr8]-Ang II (Sar is sarcosine), an inactive analogue of Ang II, or by a neutralizing antibody against Ang I/II. Overexpression of a constitutively active PI3Kα or AT-1R alone was sufficient to induce similar changes by high glucose. In contrast, overexpression of an inactive AT-1R lowered the basal levels and rendered the cells non-responsive to high glucose. Moreover, cells overexpressing wild-type AT-1R had enhanced sensitivity to acute Ang II stimulation. These cells, however, did not respond to conditioned medium obtained from mesangial cells cultured in high glucose. We further demonstrated that iAng (intracellular Ang II) can be induced by high glucose but only under certain conditions. Efficient suppression of iAng by short hairpin RNA against angiotensinogen, however, did not affect high glucose-induced effects on MES-13 cells. These results suggest that high ambient glucose induces activation of AT-1R in an Ang II-independent manner to transactivate PI3K, resulting in proliferation and ECM accumulation in mesangial cells.
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Schernthaner G. Pleiotropic effects of thiazolidinediones on traditional and non-traditional atherosclerotic risk factors. Int J Clin Pract 2009; 63:912-29. [PMID: 19490202 DOI: 10.1111/j.1742-1241.2009.02025.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The thiazolidinediones pioglitazone and rosiglitazone have established efficacy in improving insulin sensitivity, glycaemic control, dyslipidaemia, hypertension and microalbuminuria in patients with type 2 diabetes. As specific agonists of peroxisome proliferator-activated receptor-gamma, thiazolidinediones have also demonstrated protective effects on a variety of atherosclerosis biomarkers and surrogate measures of cardiovascular disease. AIM This paper reviews the evidence for pleiotropic effects on a variety of non-traditional atherosclerotic risk factors. DISCUSSION Thiazolidinediones attenuate circulating levels of pro-inflammatory mediators in patients with type 2 diabetes, including C-reactive protein, interleukin-6, CD40L, monocyte chemoattractant protein-1 and metalloproteinase-9. These agents also increase levels of the vascular protective adipokine, adiponectin. The clinical significance of these findings is supported by evidence of improved endothelial dysfunction, reduced carotid intima media thickness and improvements in stenosis following coronary artery stent implantation in patients treated with thiazolidinediones. Limited data suggest that thiazolidinediones might also improve the circulating levels and functional activity of angiogenic endothelial progenitor cells, which independently predict the incidence of cardiovascular events and death. It should be noted that the US Food and Drug Administration and the European Medicines Agency have requested changes to the prescribing information for rosiglitazone to highlight the possibility of an increased risk with this agent in patients with ischaemic heart disease; on review, no such amendment was required for the pioglitazone prescribing information. Both agencies continue to suggest that the benefits of both thiazolidinediones outweight any possible detrimental effects. Further research remains to be conducted to elucidate the potentially differential vascular protective effects of thiazolidinediones. In the US, there are black box heart failure warnings for both agents. CONCLUSION In light of the established importance of reducing cardiovascular risk in patients with type 2 diabetes, current evidence continues to support the use of pioglitazone within multifactorial risk management strategies.
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Affiliation(s)
- G Schernthaner
- Department of Medicine, Rudolfstiftung Hospital, Vienna, Austria.
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Peroxisome proliferator-activated receptors in diabetic nephropathy. PPAR Res 2009; 2008:879523. [PMID: 19277201 PMCID: PMC2652581 DOI: 10.1155/2008/879523] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Accepted: 12/08/2008] [Indexed: 02/08/2023] Open
Abstract
Diabetic nephropathy is a leading cause of end-stage renal disease, which is increasing in incidence worldwide, despite intensive treatment approaches such as glycemic and blood pressure control in patients with diabetes mellitus. New therapeutic strategies are needed to prevent the onset of diabetic nephropathy. Peroxisome proliferator-activated receptors (PPARs) are ligand-activated nuclear transcription factors that play important roles in lipid and glucose homeostases. These agents might prevent the progression of diabetic nephropathy, since PPAR agonists improve dyslipidemia and insulin resistance. Furthermore, data from murine models suggest that PPAR agonists also have independent renoprotective effects by suppressing inflammation, oxidative stress, lipotoxicity, and activation of the renin-angiotensin system. This review summarizes data from clinical and experimental studies regarding the relationship between PPARs and diabetic nephropathy. The therapeutic potential of PPAR agonists in the treatment of diabetic nephropathy is also discussed.
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Sarafidis PA. Thiazolidinediones and diabetic nephropathy: need for a closer examination? ACTA ACUST UNITED AC 2008; 2:297-301. [PMID: 18059215 DOI: 10.1111/j.1559-4564.2007.07834.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Diabetic nephropathy is an important public health issue and a major challenge for modern nephrology, as it is the primary cause of end-stage renal disease. In addition to established risk factors for diabetic nephropathy progression (ie, hyperglycemia and hypertension), current knowledge suggests that other factors can be involved. Population studies show that insulin resistance and hyperinsulinemia are also associated with chronic kidney disease, and several background mechanisms could explain this relationship. The hypoglycemic class of thiazolidinediones that act through reduction of insulin resistance were found to protect against renal injury in diabetic animals and to reduce urinary albumin excretion in patients with type 2 diabetes and microalbuminuria. This renoprotective action is supported by relevant studies showing that thiazolidinediones act beneficially on most of the players involved in diabetic nephropathy progression. Recent studies have raised uncertainty about the cardiovascular safety of thiazolidinediones. After the latter issue is resolved, however, it would appear very interesting to conduct specific studies in patients with overt diabetic nephropathy to determine the effect of these agents on proteinuria and kidney disease progression.
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Affiliation(s)
- Pantelis A Sarafidis
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA University Hospital, Aristotle University, Thessaloniki, Greece.
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Dandona P, Ghanim H, Chaudhuri A, Mohanty P. Thiazolidinediones-improving endothelial function and potential long-term benefits on cardiovascular disease in subjects with type 2 diabetes. J Diabetes Complications 2008; 22:62-75. [PMID: 18191079 DOI: 10.1016/j.jdiacomp.2006.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 10/12/2006] [Accepted: 10/26/2006] [Indexed: 12/18/2022]
Abstract
Endothelial dysfunction, which leads to impaired vasodilation, is an early event in the development of atherosclerosis. A number of mechanisms involving, for example, cell adhesion molecules, chemokines, and cytokines, contribute to this inflammatory disease, and insulin resistance plays a cardinal role in accelerating these processes. Hyperglycemia and other metabolic abnormalities that are commonly associated with insulin resistance also contribute to impaired endothelial function. In addition, the important role of the endothelium in damage repair following a cardiovascular event is emerging. The combination of proatherogenic factors in patients with type 2 diabetes results in blunted endothelial function and an increased risk of cardiovascular disease. Insulin-sensitizing agents such as thiazolidinediones have demonstrated a number of clinical benefits, including anti-inflammatory and antithrombotic properties, which may impact on the course of atherosclerosis. Recent studies have demonstrated that thiazolidinediones improve endothelial function in subjects with and without type 2 diabetes.
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Affiliation(s)
- Paresh Dandona
- Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo and Kaleida Health, 3 Gates Circle, Buffalo, NY 14209, USA.
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Yang X, Ma RC, So WY, Ko GT, Kong AP, Lam CW, Ho CS, Cockram CS, Wong VC, Tong PC, Chan JC. Impacts of chronic kidney disease and albuminuria on associations between coronary heart disease and its traditional risk factors in type 2 diabetic patients - the Hong Kong diabetes registry. Cardiovasc Diabetol 2007; 6:37. [PMID: 18053157 PMCID: PMC2219954 DOI: 10.1186/1475-2840-6-37] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Accepted: 12/02/2007] [Indexed: 02/02/2023] Open
Abstract
Background Glycated haemoglobin (HbA1c), blood pressure and body mass index (BMI) are risk factors for albuminuria, the latter in turn can lead to hyperlipidaemia. We used novel statistical analyses to examine how albuminuria and chronic kidney disease (CKD) may influence the effects of other risk factors on coronary heart disease (CHD). Methods A prospective cohort of 7067 Chinese type 2 diabetic patients without history of CHD enrolled since 1995 were censored on July 30th, 2005. Cox proportional hazard regression with restricted cubic spline was used to auto-select predictors. Hazard ratio plots were used to examine the risk of CHD. Based on these plots, non-linear risk factors were categorised and the categorised variables were refitted into various Cox models in a stepwise manner to confirm the findings. Results Age, male gender, duration of diabetes, spot urinary albumin: creatinine ratio, estimated glomerular filtration rate, total cholesterol (TC), high density lipoprotein cholesterol (HDL-C) and current smoking status were risk factors of CHD. Linear association between TC and CHD was observed only in patients with albuminuria. Although in general, increased HDL-C was associated with decreased risk of CHD, full-range HDL-C was associated with CHD in an A-shaped manner with a zenith at 1.1 mmol/L. Albuminuria and CKD were the main contributors for the paradoxically positive association between HDL-C and CHD for HDL-C values less than 1.1 mmol/L. Conclusion In type 2 diabetes, albuminuria plays a linking role between conventional risk factors and CHD. The onset of CKD changes risk associations between lipids and CHD.
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Affiliation(s)
- Xilin Yang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Balkrishnan R, Arondekar BV, Camacho FT, Shenolikar RA, Horblyuk R, Anderson RT. Comparisons of Rosiglitazone Versus Pioglitazone Monotherapy Introduction and Associated Health Care Utilization in Medicaid-Enrolled Patients with Type 2 Diabetes Mellitus. Clin Ther 2007; 29:1306-15. [DOI: 10.1016/j.clinthera.2007.06.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2007] [Indexed: 11/24/2022]
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Ajjan RA, Grant PJ. Cardiovascular disease prevention in patients with type 2 diabetes: The role of oral anti-diabetic agents. Diab Vasc Dis Res 2006; 3:147-58. [PMID: 17160909 DOI: 10.3132/dvdr.2006.023] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Multiple risk factor intervention is essential in order to prevent cardiovascular (CV) disease in patients with diabetes. Therefore, to reduce atherothrombotic events, an ideal oral anti-diabetic agent should be able to modulate most, and preferably all, cardiovascular risk factors associated with diabetes. Of the currently available agents, the insulin sensitisers (metformin, thiazolidinediones) seem to have most promise in cardiovascular protection. Metformin has a positive effect on several CV risk factors; outcome studies have shown that this agent reduces cardiac events in overweight subjects with diabetes. In a similar manner, thiazolidinediones (rosiglitazone, pioglitazone) have a wide spectrum of activity, favourably modulating most risk factors, with evidence to suggest a reduction in CV events with this class of drugs. Agents in the sulphonylurea group have beneficial, though inconsistent, effects on some risk factors but outcome studies have failed to show a cardioprotective role for these agents. New classes of drugs to manage type 2 diabetes are currently at various stages of development and their role in prevention of cardiovascular disease awaits evaluation. At present, first-line management of insulin-resistant type 2 diabetes should utilise metformin, with the addition of thiazolidinediones and sulphonylureas to achieve optimal glycaemic control.
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Affiliation(s)
- Ramzi A Ajjan
- Acadamic Unit of Molecular Vascular Medicine, Leeds Institute of Genetics Health and Therapeutics, Faculty of Medicine and Health, University of Leeds, UK
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23
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Sarafidis PA, Bakris GL. Protection of the kidney by thiazolidinediones: An assessment from bench to bedside. Kidney Int 2006; 70:1223-33. [PMID: 16883325 DOI: 10.1038/sj.ki.5001620] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The global epidemic of diabetes mellitus has led to a continuous increase in the prevalence of diabetic nephropathy over the past years. Thus, diabetic nephropathy is currently the number one cause of end-stage renal disease in the Western world. It represents a major public health problem for which more effective prevention and treatment strategies are needed. Thiazolidinediones (TZDs) are a class of agents that lower blood glucose through reduction of insulin resistance in patients with type 2 diabetes. Growing evidence support the concept that TZDs have several beneficial effects on the cardiovascular system beyond their effects on glycemic control. These benefits include: blood pressure lowering, triglyceride reduction, high-density lipoprotein-cholesterol elevation, and reduction in subclinical vascular inflammation. Moreover, data from several animal and human studies support the notion that TZDs reduce urine albumin excretion and may prevent development of renal injury. The relative lack of evidence, however, demonstrating the effects of TZDs on hard renal outcomes mandates the need for well-designed trials with this particular objective. This paper summarizes all the data from clinical and experimental studies relevant to a possible renoprotective effect of TZDs and discusses actions of these compounds that may contribute toward this effect.
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Affiliation(s)
- P A Sarafidis
- Department of Preventive Medicine, Hypertension/Clinical Research Center, Rush University Medical Center, Chicago, Illinois 60612, USA
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Boulanger H, Mansouri R, Gautier JF, Glotz D. Are peroxisome proliferator-activated receptors new therapeutic targets in diabetic and non-diabetic nephropathies? Nephrol Dial Transplant 2006; 21:2696-702. [PMID: 16880183 DOI: 10.1093/ndt/gfl448] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Henri Boulanger
- Department of Nephrology and Transplantation, Saint-Louis Hospital, 1 avenue Claude-Vellefaux, 75475 Paris Cedex 10, France.
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25
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Balkrishnan R, Rajagopalan R, Shenolikar RA, Camacho FT, Anderson RT. Outcomes associated with introduction of thiazolidinedione therapy in Medicaid enrolled patients with type 2 diabetes: an updated and expanded retrospective analysis. Curr Med Res Opin 2006; 22:551-9. [PMID: 16574038 DOI: 10.1185/030079906x96263] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES In an earlier analysis, differences in health-care costs, medication adherence, and persistence were examined between patients with type 2 diabetes, enrolled in the North Carolina Medicaid, who had newly started thiazolidinedione (TZD) therapy and those starting other oral antidiabetic agents. In this analysis, the size of the cohort was increased by including 18 months of additional Medicaid data (until December 2004) and sought to: (1) replicate the results of the original study in a larger cohort; and (2) extend the original analysis by providing an additional 18 months of observational follow-up. METHODS A total of 2660 patients newly starting TZD therapy between July 2001 and December 2003 were compared to 2050 patients starting other oral antidiabetic medication for health-care costs and outcomes in the post-medication start year. In addition, the initial cohort was followed for an additional 18 months to examine if there were any differences in outcomes, such as hospitalization and total health-care costs, that could be associated with the type of therapy. Multivariate regression techniques, incorporating health-care utilization in the year prior to start of new therapy, were used to determine the net cost impact of one therapy versus the other. RESULTS Multiple regression analyses found that patients starting TZD have better treatment persistence in the post-medication start year compared to patients starting other oral antidiabetic agents (4% increase in therapy persistence index, p < 0.001). In addition, patients starting TZDs had 18.9% lower total annual health-care costs (p < 0.01) compared to patients starting other oral antidiabetic agents. Examination of the original cohort of 3191 patients, for up to an additional 18 months, showed TZD's association with improved adherence rates but not with persistence. Importantly, treatment adherence remained the strongest independent predictor of decreased hospitalization risk and health-care cost reduction in this population. CONCLUSIONS Introduction of thiazolidinedione therapy in a Medicaid-enrolled type 2 diabetic population was associated with significantly greater treatment adherence, in the post-start year, compared to patients starting other oral antidiabetic agents.
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Affiliation(s)
- Rajesh Balkrishnan
- Department of Pharmacy Practice and Administration, Ohio State University, Columbus, Ohio 43210, USA.
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Waugh J, Keating GM, Plosker GL, Easthope S, Robinson DM. Pioglitazone: a review of its use in type 2 diabetes mellitus. Drugs 2006; 66:85-109. [PMID: 16398569 DOI: 10.2165/00003495-200666010-00005] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pioglitazone is an antihyperglycaemic agent that, in the presence of insulin resistance, increases hepatic and peripheral insulin sensitivity, thereby inhibiting hepatic gluconeogenesis and increasing peripheral and splanchnic glucose uptake. Pioglitazone is generally well tolerated, weight gain and oedema are the most common emergent adverse events, and there are no known drug interactions between pioglitazone and other drugs. In clinical trials in patients with type 2 diabetes mellitus, pioglitazone as monotherapy, or in combination with metformin, repaglinide, insulin or a sulphonylurea, induced both long- and short-term improvements in glycaemic control and serum lipid profiles. Pioglitazone was also effective in reducing some measures of cardiovascular risk and arteriosclerosis. Pioglitazone thus offers an effective treatment option for the management of patients with type 2 diabetes.
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Affiliation(s)
- John Waugh
- Adis International Limited, Auckland, New Zealand
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27
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Irons BK, Greene RS, Mazzolini TA, Edwards KL, Sleeper RB. Implications of Rosiglitazone and Pioglitazone on Cardiovascular Risk in Patients with Type 2 Diabetes Mellitus. Pharmacotherapy 2006; 26:168-81. [PMID: 16466323 DOI: 10.1592/phco.26.2.168] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Clinical data suggest that thiazolidinediones--specifically, rosiglitazone and pioglitazone--may improve cardiovascular risk factors through multiple mechanisms. Low insulin sensitivity has been described as an independent risk factor for coronary artery disease and cerebrovascular disease. Patients with insulin resistance often have several known risk factors, such as obesity, dyslipidemia, and hypertension. Other emerging risk factors may be prevalent in patients with insulin resistance, such as hyperinsulinemia, elevated C-reactive protein, elevated plasminogen activator inhibitor levels, and small, dense, low-density lipoproteins. The only available drug class that primarily targets insulin resistance is the thiazolidinediones. These drugs have shown efficacy in affecting surrogate markers of cardiovascular risk in patients with diabetes mellitus. Alterations in these risk factors are likely due to their effects on improving insulin sensitivity and/or glycemic control. Trials to assess whether thiazolidinediones actually reduce cardiovascular outcomes are continuing.
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Affiliation(s)
- Brian K Irons
- Department of Pharmacy Practice, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, Texas 79430-8162, USA.
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Agarwal R, Saha C, Battiwala M, Vasavada N, Curley T, Chase SD, Sachs N, Semret MH. A pilot randomized controlled trial of renal protection with pioglitazone in diabetic nephropathy. Kidney Int 2005; 68:285-92. [PMID: 15954919 DOI: 10.1111/j.1523-1755.2005.00416.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Diabetic nephropathy progresses relentlessly to end-stage renal disease (ESRD). Animal experiments have found that peroxisome proliferator activated receptor-gamma (PPAR-gamma)-based therapy can have a glucose independent effect on renal protection. We hypothesized that PPAR-gamma-based antidiabetic therapy would result in greater reduction in proteinuria compared to sulfonylurea-based therapy. METHODS In 44 patients with overt diabetic nephropathy, an open-label, blinded end point trial was conducted in which subjects were randomized to either pioglitazone or glipizide to achieve similar glucose control. Proteinuria was assessed by two collections of 24-hour urine samples each month for 4 months. RESULTS The glipizide group had an adjusted mean increase in proteinuria of 6.1% (95% CI -11.7%, 23.8%), whereas the pioglitazone group had a reduction of 7.2% (95% CI -24.9%, 10.6%). The adjusted reduction with pioglitazone of 13.2% (95% CI -38.4%, 11.9%) was not statistically significant (P= 0.294). Baseline proteinuria, diastolic ambulatory blood pressure, and serum albumin concentration were independent predictors of reduction in proteinuria. The frequency and patterns of adverse events were similar in the two groups. CONCLUSION In patients with advanced diabetic nephropathy, we found no reduction in proteinuria over 4 months. These data are useful to design larger studies with longer duration of follow-up to demonstrate renal protection of PPAR-gamma agonists.
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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McMahon GT, Plutzky J, Daher E, Bhattacharyya T, Grunberger G, DiCarli MF. Effect of a peroxisome proliferator-activated receptor-gamma agonist on myocardial blood flow in type 2 diabetes. Diabetes Care 2005; 28:1145-50. [PMID: 15855580 PMCID: PMC4231709 DOI: 10.2337/diacare.28.5.1145] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The relationship between coronary endothelial function and insulin resistance remains speculative. We sought to determine whether pioglitazone, an insulin-sensitizing peroxisome proliferator-activated receptor (PPAR)-gamma agonist, improves cardiac endothelial function in individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS Sixteen subjects with insulin-treated type 2 diabetes and without overt cardiovascular disease were randomly assigned to receive either 45 mg of pioglitazone or matching placebo for 3 months. Rest and adenosine-stimulated myocardial blood flow (MBF) were quantified with [(13)N]ammonia and positron emission tomography at baseline and study conclusion. RESULTS After 3 months, HbA(1c) levels dropped by 0.68% in the pioglitazone group and increased by 0.17% in the placebo group (P = 0.009 for difference between groups). Triglyceride (-93 vs. -39 mg/dl, P = 0.026) and HDL concentrations (+4.8 vs. -6.0 mg/dl, P = 0.014) improved significantly in the pioglitazone group compared with placebo. Despite these favorable changes, there was no demonstrable change in baseline MBF (-0.05 +/- 0.24 vs. -0.09 +/- 0.24 ml . min(-1) . g(-1), P = 0.45), adenosine-stimulated MBF (0.10 +/- 0.75 vs. 0.14 +/- 0.31 ml . min(-1) . g(-1), P = 0.25), or coronary flow reserve (0.45 +/- 1.22 vs. 0.35 +/- 0.72 ml . min(-1) . g(-1), P = 0.64) after 12 weeks of exposure to pioglitazone or placebo, respectively. Regression analysis revealed that lower glucose concentration at the time of the study was associated with higher coronary flow reserve (P = 0.012). CONCLUSIONS Pioglitazone treatment for 12 weeks in subjects with insulin-requiring type 2 diabetes had no demonstrable effect on coronary flow reserve despite metabolic improvements. Higher ambient glucose levels contribute to impaired vascular reactivity in individuals with diabetes.
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Affiliation(s)
- Graham T McMahon
- Brigham and Women's Hospital, Division of Nuclear Medicine, 75 Francis Street, Boston, MA 02115, USA
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Balkrishnan R, Rajagopalan R, Shenolikar RA, Camacho FT, Whitmire JT, Anderson RT. Healthcare costs and prescription adherence with introduction of thiazolidinedione therapy in Medicaid type 2 diabetic patients: a retrospective data analysis. Curr Med Res Opin 2004; 20:1633-40. [PMID: 15462696 DOI: 10.1185/030079904x4789] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Outcomes in patients with type 2 diabetes may vary depending on the antidiabetic medication used. Observational studies of outcomes of diabetes pharmacotherapy are needed to understand the implications of choice of controller in different populations. This study compared differences in total health care costs, medication adherence, and persistence in patients with type 2 diabetes enrolled in the North Carolina Medicaid Program that were newly started on thiazolidinedione (TZD) therapy with patients starting other oral antidiabetics during the same period. In addition differences among the TZDs with respect to these outcomes were examined. METHODS A total of 1774 patients newly starting TZD therapy between July 2001 and June 2002 were compared to 1709 patients starting other oral antidiabetic medication (metformin or sulfonylureas) for health care costs and outcomes in the post-medication start year. In addition, a sub-group analysis of health care costs in patients starting either TZD (pioglitazone [n = 1086] versus rosiglitazone [N = 688]) was compared. All included patients had complete enrollment for the 24 months of follow-up. Multivariate techniques incorporating health care utilization in the year prior to start of new therapy were utilized to determine the cost impact of one therapy versus another. RESULTS Results of multiple regression analyses suggest that patients starting TZD have better treatment adherence and persistence in the post-medication start year compared to patients starting other oral antidiabetics (13% increase in Medication Possession Ratios, and 10% increase in therapy persistence index, both p < 0.001). In addition, patients starting TZDs had 16.1% lower total annual health care costs (p < 0.01) compared to patients starting other oral antidiabetics. There were no differences in adherence and cost outcomes between the 2 TZDs. CONCLUSIONS Introduction of thiazolidinedione therapy in a Medicaid-enrolled type 2 diabetic population was associated with significantly improved treatment adherence, persistence, and lower annual health care costs in the post-start year compared to patients starting other oral antidiabetics.
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Affiliation(s)
- Rajesh Balkrishnan
- Division of Management and Policy Sciences, University of Texas School of Public Health, Houston, TX 77030, USA.
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