High-density lipoprotein cholesterol and the risk of nephropathy in type 2 diabetic patients

Lipid variability and risk of microvascular complications in patients with diabetes: a systematic review and meta-analysis

BACKGROUND AND AIMS

The current systematic review aimed to elucidate the effects of lipid variability on microvascular complication risk in diabetic patients. The lipid components studied were as follows: High-density lipoprotein (HDL), High-density lipoprotein (LDL), Triglyceride (TG), Total Cholesterol (TC), and Remnant Cholesterol (RC).

METHOD

We carried out a systematic search in multiple databases, including PubMed, Web of Science, and SCOPUS, up to October 2nd, 2023. After omitting the duplicates, we screened the title and abstract of the studies. Next, we retrieved and reviewed the full text of the remaining articles and included the ones that met our inclusion criteria in the study.

RESULT

In this research, we examined seven studies, comprising six cohort studies and one cross-sectional study. This research was conducted in Hong Kong, China, Japan, Taiwan, Finland, and Italy. The publication years of these articles ranged from 2012 to 2022, and the duration of each study ranged from 5 to 14.3 years. The study group consisted of patients with type 2 diabetes aged between 45 and 84 years, with a diabetes history of 7 to 12 years. These studies have demonstrated that higher levels of LDL, HDL, and TG variability can have adverse effects on microvascular complications, especially nephropathy and neuropathic complications. TG and LDL variability were associated with the development of albuminuria and GFR decline. Additionally, reducing HDL levels showed a protective effect against microalbuminuria. However, other studies did not reveal an apparent relationship between lipid variations and microvascular complications, such as retinopathy. Current research lacks geographic and demographic diversity. Increased HDL, TG, and RC variability have been associated with several microvascular difficulties. Still, the pathogenic mechanism is not entirely known, and understanding how lipid variability affects microvascular disorders may lead to novel treatments. Furthermore, the current body of this research is restricted in its coverage. This field's lack of thorough investigations required a more extensive study and comprehensive effort.

CONCLUSION

The relationship between lipid variation (LDL, HDL, and TG) (adverse effects) on microvascular complications, especially nephropathy and neuropathic (and maybe not retinopathy), is proven. Physicians and health policymakers should be highly vigilant to lipid variation in a general population.

The role of lipotoxicity in kidney disease: From molecular mechanisms to therapeutic prospects

Lipotoxicity is the dysregulation of the lipid environment and/or intracellular composition that leads to accumulation of harmful lipids and ultimately to organelle dysfunction, abnormal activation of intracellular signaling pathways, chronic inflammation and cell death. It plays an important role in the development of acute kidney injury and chronic kidney disease, including diabetic nephropathy, obesity-related glomerulopathy, age-related kidney disease, polycystic kidney disease, and the like. However, the mechanisms of lipid overload and kidney injury remain poorly understood. Herein, we discuss two pivotal aspects of lipotoxic kidney injury. First, we analyzed the mechanism of lipid accumulation in the kidney. Accumulating data indicate that the mechanisms of lipid overload in different kidney diseases are inconsistent. Second, we summarize the multiple mechanisms by which lipotoxic species affect the kidney cell behavior, including oxidative stress, endoplasmic reticulum stress, mitochondrial dysfunction, dysregulated autophagy, and inflammation, highlighting the central role of oxidative stress. Blocking the molecular pathways of lipid accumulation in the kidney and the damage of the kidney by lipid overload may be potential therapeutic targets for kidney disease, and antioxidant drugs may play a pivotal role in the treatment of kidney disease in the future.

Risk Factors of Microalbuminuria among Patients with Type 2 Diabetes Mellitus in Korea: A Cross-Sectional Study Based on 2019-2020 Korea National Health and Nutrition Examination Survey Data

Diabetes mellitus is a chronic disease with high economic and social burdens. This study aimed to determine the risk factors of microalbuminuria among patients with type 2 diabetes mellitus. Microalbuminuria is predictive of early-stage renal complications and subsequent progression to renal dysfunction. We collected data on type 2 diabetes patients who participated in the 2019-2020 Korea National Health and Nutrition Examination Survey. The risk factors for microalbuminuria among patients with type 2 diabetes were analyzed using logistic regression. As a result, the odds ratios were 1.036 (95% confidence interval (CI) = 1.019-1.053, p < 0.001) for systolic blood pressure, 0.966 (95% CI = 0.941-0.989, p = 0.007) for high-density lipoprotein cholesterol level, 1.008 (95% CI = 1.002-1.014, p = 0.015) for fasting blood sugar level, and 0.855 (95% CI = 0.729-0.998, p = 0.043) for hemoglobin level. A significant strength of this study is the identification of low hemoglobin level (i.e., anemia) as a risk factor for microalbuminuria in patients with type 2 diabetes. This finding implies that the early detection and management of microalbuminuria can prevent the development of diabetic nephropathy.

Relationship between periodontal status and dyslipidemia in patients with type 2 diabetic nephropathy and chronic periodontitis: A cross-sectional study

OBJECTIVE

The aim of this study was to investigate the association between periodontitis and total serum cholesterol level in patients with type 2 diabetic nephropathy (T2DN).

BACKGROUND

Periodontitis is now recognized as the sixth complication of diabetes and can also affect other complications of diabetes, including nephropathy and coronary artery diseases. Studies have considered dyslipidemia as a risk factor for exacerbation of periodontitis.

METHODS

A total of 119 T2DN patients with chronic periodontitis were included in this observational study. Participants were stratified into the Normal (serum total cholesterol <5.17 mmol/L, n = 89) and the Dyslipidemia groups (serum total cholesterol ≥5.17 mmol/L, n = 30). Participants completed a validated questionnaire that collected information on oral hygiene behaviors and knowledge of oral health and underwent a clinical oral examination. The number of remaining teeth, probing depth (PD), clinical attachment level (CAL), and bleeding index (BI) was recorded. Physical examination and laboratory tests (fasting plasma glucose, serum glycosylated hemoglobin (HbA1c), total cholesterol, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), triglyceride, and high-sensitivity C-reactive protein levels) were performed.

RESULTS

Means of CAL and BI were significantly higher in the Dyslipidemia group compared with the Normal group. In the Dyslipidemia group, PD and percent of sites with PD ≥4 mm were positively correlated with urinary albumin/creatinine ratios; PD and percent of sites with PD ≥4 and PD ≥5 mm were positively correlated with HbA1c level; a number of remaining teeth were negatively correlated with serum LDL-C level. After adjusting for age, gender, body mass index, smoking, FPG, and serum HbA1c and triglyceride levels, BI was found to be positively associated with dyslipidemia in T2DN patients with periodontitis.

CONCLUSION

T2DN patients with chronic periodontitis had a 2.355-fold higher risk of developing dyslipidemia, implying an important relationship between periodontitis and blood lipid control among T2DN patients.

Lipid variability and risk of microvascular complications in Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial: A post hoc analysis

BACKGROUND

Greater lipid variability may cause adverse health events among diabetic patients. We aimed to examine the effect of lipid variability on the risk of diabetic microvascular outcomes among type 2 diabetes mellitus patients.

METHODS

We assessed the association between visit-to-visit variability (measured by variability independent of mean) in high-density lipoprotein (HDL) cholesterol, low-density lipoprotein-cholesterol (LDL), triglyceride, and remnant cholesterol (RC) measurements among participants involved in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and the risk of incident microvascular outcomes, including nephropathy, neuropathy, and retinopathy. Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs), adjusted for potential confounders.

RESULTS

There were 2400, 2470, and 2468 cases of nephropathy, neuropathy, and retinopathy during a follow-up period of 22 600, 21 542, and 26 701 person-years, respectively. Higher levels of HDL, triglyceride, and RC variability were associated with an increased risk of incident nephropathy and neuropathy. Compared with the lowest quartile, the fully adjusted HRs (95% CI) for the highest quartile of HDL, triglyceride, and RC variability for nephropathy risk were 1.57 (1.22, 2.01), 1.50 (1.18, 1.92), and 1.40 (1.09, 1.80), respectively; and for neuropathy, the corresponding risks were 1.36 (1.05, 1.75), 1.47 (1.14, 1.91), and 1.35 (1.04, 1.74), respectively. Null association was observed between LDL variability and all microvascular complications. Additionally, all associations of variability in the other lipids with retinopathy risk were null.

CONCLUSION

Among individuals with type 2 diabetes mellitus, HDL, triglyceride, and RC variability were associated with increased risks of nephropathy and neuropathy but not retinopathy.

TRIAL REGISTRATION

ClinicalTrials.gov., no. NCT00000620.

Prognostic significance of visit-to-visit variability, and maximum and minimum LDL cholesterol in diabetes mellitus

Background

Current guidelines for dyslipidemia management recommend that the LDL-C goal be lower than 70 mg/dL. The present study investigated the prognostic significance of visit-to-visit variability in LDL-C, and minimum and maximum LDL-C during follow-up in diabetes mellitus.

Methods

The risk of outcomes in relation to visit-to-visit LDL-C variability was investigated in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Lipid trial. LDL-C variability indices were coefficient of variation (CV), variability independent of the mean (VIM), and average real variability (ARV). Multivariable Cox proportional hazards models were employed to estimate the adjusted hazard ratio (HR) and 95% confidence interval (CI).

Results

Compared with the placebo group (n=2667), the fenofibrate therapy group (n=2673) had a significantly (P<0.01) lower mean plasma triglyceride (152.5 vs. 178.6 mg/dL), and total cholesterol (158.3 vs.162.9 mg/dL) but a similar mean LDL-C during follow-up (88.2 vs. 88.6 mg/dL, P>0.05). All three variability indices were associated with primary outcome, total mortality and cardiovascular mortality both in the total population and in the fenofibrate therapy group but only with primary outcome in the placebo group. The minimum LDL-C but not the maximum during follow-up was significantly associated with various outcomes in the total population, fenofibrate therapy and placebo group. The minimum LDL-C during follow-up ≥70 mg/dL was associated with an increased risk for various outcomes.

Conclusions

Visit-to-visit variability in LDL-C was a strong predictor of outcomes, independent of mean LDL-C. Patients with LDL-C controlled to less than 70 mg/dL during follow-up might have a benign prognosis.

ClinicalTrials.gov number: NCT 00000620.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12944-022-01628-8.

The Association of Postprandial Triglyceride Variability with Renal Dysfunction and Microalbuminuria in Patients with Type 2 Diabetic Mellitus: A Retrospective and Observational Study

OBJECTIVE

We examined whether or not day-to-day variations in lipid profiles, especially triglyceride (TG) variability, were associated with the exacerbation of diabetic kidney disease.

METHODS

We conducted a retrospective and observational study. First, 527 patients with type 2 diabetes mellitus (DM) who had had their estimated glomerular filtration rate (eGFR) checked every 6 months since 2012 for over 5 years were registered. Variability in postprandial TG was determined using the standard deviation (SD), SD adjusted (Adj-SD) for the number of measurements, and maximum minus minimum difference (MMD) during the first three years of follow-up. The endpoint was a ≥40% decline from baseline in the eGFR, initiation of dialysis or death. Next, 181 patients who had no micro- or macroalbuminuria in February 2013 were selected from among the 527 patients for an analysis. The endpoint was the incidence of microalbuminuria, initiation of dialysis, or death.

RESULTS

Among the 527 participants, 110 reached a ≥40% decline from baseline in the eGFR or death. The renal survival was lower in the higher-SD, higher-Adj-SD, and higher-MMD groups than in the lower-SD, lower-Adj-SD, and lower-MMD groups, respectively (log-rank test p = 0.0073, 0.0059, and 0.0195, respectively). A lower SD, lower Adj-SD, and lower MMD were significantly associated with the renal survival in the adjusted model (hazard ratio, 1.62, 1.66, 1.59; 95% confidence intervals, 1.05-2.53, 1.08-2.58, 1.04-2.47, respectively). Next, among 181 participants, 108 developed microalbuminuria or death. The nonincidence of microalbuminuria was lower in the higher-SD, higher-Adj-SD, and higher-MMD groups than in the lower-SD, lower-Adj-SD, and lower-MMD groups, respectively (log-rank test p = 0.0241, 0.0352, and 0.0474, respectively).

CONCLUSIONS

Postprandial TG variability is a novel risk factor for eGFR decline and the incidence of microalbuminuria in patients with type 2 DM.

Development and External Validation of a Nomogram and a Risk Table for Prediction of Type 2 Diabetic Kidney Disease Progression Based on a Retrospective Cohort Study in China

PURPOSE

Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease worldwide. Risk assessment provides information about patient prognosis, contributing to the risk stratification of patients and the rational allocation of medical resources. We aimed to develop a model for individualized prediction of renal function decline in patients with type 2 DKD (T2DKD).

PATIENTS AND METHODS

In a retrospective observational study, we followed 307 T2DKD patients and evaluated the determinants of 1) risk of doubling in serum creatinine (Scr), 2) risk of eGFR<15 mL/min/1.73m² using potential risk factors at baseline. A prediction model represented by a nomogram and a risk table was developed using Cox regression and externally validated in another cohort with 206 T2DKD patients. The discrimination and calibration of the prediction model were evaluated by the concordance index (C-index) and calibration curve, respectively.

RESULTS

Four predictors were selected to establish the final model: Scr, urinary albumin/creatinine ratio, plasma albumin, and insulin treatment. The nomogram achieved satisfactory prediction performance, with a C-index of 0.791 [95% confidence interval (CI) 0.762-0.820] in the derivation cohort and 0.793 (95% CI 0.746-0.840) in the external validation cohort. Then, all predictors were scored according to their weightings. A risk table with the highest score of 11.5 was developed. The C-index of the risk table was 0.764 (95% CI: 0.731-0.797), which was similar to the external validation cohort (0.763; 95% CI: 0.714-0.812). Additionally, the patients were divided into two groups based on the risk table, and significant differences in the probability of outcome events were observed between the high-risk (score >2) and low-risk (score ≤2) groups in the derivation and external validation cohorts (P < 0.001).

CONCLUSION

The nomogram and the risk table using readily available clinical parameters could be new tools for bedside prediction of renal function decline in T2DKD patients.

REG1A and RUNX3 Are Potential Biomarkers for Predicting the Risk of Diabetic Kidney Disease

Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease. Clinical features are traditionally used to predict DKD, yet with low diagnostic efficacy. Most of the recent biomarkers used to predict DKD are based on transcriptomics and metabolomics; however, they also should be used in combination with many other predictive indicators. The purpose of this study was thus to identify a simplified class of blood biomarkers capable of predicting the risk of developing DKD. The Gene Expression Omnibus database was screened for DKD biomarkers, and differentially expressed genes (DEGs) in human blood and kidney were identified via gene expression analysis and the Least Absolute Shrinkage and Selection Operator regression. A comparison of the area under the curve (AUC) profiles on multiple receiver operating characteristic curves of the DEGs in DKD and other renal diseases revealed that REG1A and RUNX3 had the highest specificity for DKD diagnosis. The AUCs of the combined expression of REG1A and RUNX3 in kidney (AUC = 0.929) and blood samples (AUC = 0.917) of DKD patients were similar to each other. The AUC of blood samples from DKD patients and healthy individuals obtained for external validation further demonstrated that REG1A combined with RUNX3 had significant diagnostic efficacy (AUC=0.948). REG1A and RUNX3 expression levels were found to be positively and negatively correlated with urinary albumin creatinine ratio and estimated glomerular filtration rate, respectively. Kaplan-Meier curves also revealed the potential of REG1A and RUNX3 for predicting the risk of DKD. In conclusion, REG1A and RUNX3 may serve as biomarkers for predicting the risk of developing DKD.

Efficacy and Safety of Esaxerenone in Hypertensive Patients with Diabetic Kidney Disease: A Multicenter, Open-Label, Prospective Study

INTRODUCTION

Clinical data of esaxerenone in hypertensive patients with diabetic kidney disease (DKD) are lacking. We evaluated the efficacy and safety of esaxerenone in patients with DKD and an inadequate response to blood pressure (BP)-lowering treatment.

METHODS

In this multicenter, open-label, prospective study, patients were divided into urinary albumin-to-creatinine ratio subcohorts (UACR < 30, 30 to < 300, and 300 to < 1000 mg/gCr). Esaxerenone was initiated at 1.25 mg/day and followed by incremental dose escalation based on BP and serum potassium level monitoring. The treatment period was 12 weeks. The primary endpoint was change in morning home systolic BP/diastolic BP (SBP/DBP) from baseline to end of treatment (EOT). Secondary endpoints included achievement rate of target BP, change in UACR from baseline, and safety.

RESULTS

In total, 113 patients were enrolled. Morning home SBP/DBP significantly decreased from baseline to EOT in the total population (- 11.6/- 5.2 mmHg, both p < 0.001) and in all UACR subcohorts (all p < 0.001). The target BP achievement rate was 38.5%. Significant reductions in bedtime home and office BPs were also shown in the total population and all UACR subcohorts. UACR significantly improved from baseline to EOT in the total (- 50.9%, p < 0.001) and all UACR subcohorts (all p < 0.001). Incidence of serum potassium elevation as drug-related treatment emergent adverse events was 2.7%. The change from baseline in estimated glomerular filtration rate (eGFR) was - 4.8 mL/min/1.73 m².

CONCLUSION

Esaxerenone demonstrated a BP-lowering effect and improved albuminuria. The effects were consistent regardless of the severity of albuminuria without clinically relevant serum potassium elevation and eGFR reduction.

CLINICAL TRIAL REGISTRATION

jRCTs06119002.

Epidemiological characteristics of diabetic kidney disease in Taiwan

Diabetic kidney disease (DKD) is a critical microvascular complication of diabetes. With the continuous increase in the prevalence of diabetes since 2000, the prevalence of DKD has also been increasing in past years. The prevalence of DKD among individuals with type 2 diabetes in Taiwan increased from 13.32% in 2000 to 17.92% in 2014. The cumulative incidence of DKD among individuals with type 1 diabetes in Taiwan was higher than 30% during 1999-2012. DKD is the leading cause of end-stage renal disease (ESRD), with a prevalence of approximately 45% in a population on chronic dialysis in Taiwan. Among individuals with type 2 diabetes, the prevalence of ESRD in the receipt of dialysis also increased from 1.32% in 2005 to 1.47% in 2014. Risk factors for DKD development are age, race, family history, hyperglycemia, hypertension, dyslipidemia, dietary patterns, and lifestyles. Prognostic factors that aggravate DKD progression include age, family history, sex, glycemic control, blood pressure (BP), microvascular complications, and atherosclerosis. This review summarizes updated information on the onset and progression of DKD, particularly in the Taiwanese population. Translating these epidemiological features is essential to optimizing the kidney care and improving the prognosis of DKD in Asian populations.

Remnant cholesterol predicts progression of diabetic nephropathy and retinopathy in type 1 diabetes

BACKGROUND

We aimed to assess whether remnant cholesterol concentration and variability predict the progression of diabetic nephropathy (DN) and severe diabetic retinopathy (SDR) in type 1 diabetes.

METHODS

This observational prospective study covered 5150 FinnDiane Study participants. Remnant cholesterol was calculated as total cholesterol - LDL cholesterol - HDL cholesterol and variability as the coefficient of variation. DN category was based on consensus albuminuria reference limits and the progression status was confirmed from medical files. SDR was defined as retinal laser treatment. For 1338 individuals, the severity of diabetic retinopathy (DR) was graded using the ETDRS classification protocol. Median (IQR) follow-up time was 8.0 (4.9-13.7) years for DN and 14.3 (10.4-16.3) for SDR.

RESULTS

Remnant cholesterol (mmol L^-1 ) was higher with increasing baseline DN category (P < 0.001). A difference was also seen comparing non-progressors (0.41 [0.32-0.55]) with progressors (0.55 [0.40-0.85]), P < 0.001. In a Cox regression analysis, remnant cholesterol predicted DN progression, independently of diabetes duration, sex, HbA_1c , systolic blood pressure, smoking, BMI, estimated glucose disposal rate and estimated glomerular filtration rate (HR: 1.51 [1.27-1.79]). Remnant cholesterol was also higher in those who developed SDR (0.47 [0.36-0.66]) than those who did not (0.40 [0.32-0.53]), P < 0.001, and the concentration increased stepwise with increasing DR severity (P < 0.001). Regarding SDR, the HR for remnant cholesterol was 1.52 (1.26-1.83) with the most stringent adjustment. However, remnant cholesterol variability was not independently associated with the outcomes.

CONCLUSIONS

Remnant cholesterol concentration, but not variability, predicts DN progression and development of SDR. However, it remains to be elucidated whether the associations are causal or not.

Variability of risk factors and diabetes complications

Several studies suggest that, together with glucose variability, the variability of other risk factors, as blood pressure, plasma lipids, heart rate, body weight, and serum uric acid, might play a role in the development of diabetes complications. Moreover, the variability of each risk factor, when contemporarily present, may have additive effects. However, the question is whether variability is causal or a marker. Evidence shows that the quality of care and the attainment of the target impact on the variability of all risk factors. On the other hand, for some of them causality may be considered. Although specific studies are still lacking, it should be useful checking the variability of a risk factor, together with its magnitude out of the normal range, in clinical practice. This can lead to an improvement of the quality of care, which, in turn, could further hesitate in an improvement of risk factors variability.

Greater variability in lipid measurements associated with kidney diseases in patients with type 2 diabetes mellitus in a 10-year diabetes cohort study

This study aimed to evaluate the associations between variability of lipid parameters and the risk of kidney disease in patients with type 2 diabetes mellitus. Low-density lipoprotein-cholesterol, total cholesterol to high-density lipoprotein-cholesterol ratio and triglyceride were specifically addressed in this study. This retrospective cohort study included 105,552 patients aged 45–84 with type 2 diabetes mellitus and normal kidney function who were managed under Hong Kong public primary care clinics during 2008–2012. Those with kidney disease (estimated glomerular filtration rate < 60 mL/min/1.73 m² or urine albumin to creatinine ratio ≥ 3 mg/mmol) were excluded. Variabilities of low-density lipoprotein-cholesterol, total cholesterol to high-density lipoprotein-cholesterol ratio and triglyceride were determined using the standard deviation of the respective parameter obtained from a mixed effects model to minimize regression dilution bias. The associations between lipid variability and renal outcomes including incident kidney disease, renal function decline defined as ≥ 30% reduction in estimated glomerular filtration rate since baseline, and end-stage renal disease (estimated glomerular filtration rate < 15 mL/min/1.73 m²) were evaluated by multivariable Cox regression. After a median follow-up of 66.5 months (0.5 million person-years in total), 49,653 kidney disease, 29,358 renal function decline, and 1765 end-stage renal disease cases were recorded. Positive linear associations between low-density lipoprotein-cholesterol and total cholesterol to high-density lipoprotein-cholesterol ratio variabilities and the risk of all renal outcomes were demonstrated. However, no association between triglyceride variability and any outcome was found. Each mmol/L increase in low-density lipoprotein-cholesterol variability was associated with 20% (Hazard ratio 1.20 [95% CI 1.15–1.25]), 38% (Hazard ratio 1.37 [95% CI 1.30–1.45]), and 108% (Hazard ratio 2.08 [95% CI 1.74–2.50]) higher risk in incident kidney disease, renal function decline and end-stage renal disease respectively. Similarly, each unit increase in total cholesterol to high-density lipoprotein-cholesterol ratio variability was associated with 35% (Hazard ratio 1.15 [95% CI 1.10–1.20]), 33% (Hazard ratio 1.33 [95% CI 1.26–1.40]), and 75% (Hazard ratio 1.75 [95% CI 1.46–2.09]) heightened risk in incident kidney disease, renal function decline and end-stage renal disease respectively. Cholesterol variability may potentially be a useful predictor of kidney diseases in patients with type 2 diabetes mellitus. Attention should be drawn to cholesterol variability when managing diabetic patients and further research is warranted to investigate the modifiable risk factors for lipid variability.

Kidney failure risk in type 1 vs. type 2 childhood-onset diabetes mellitus

BACKGROUND

Diabetic kidney disease (DKD) is becoming increasingly common among children. We aimed to estimate the risk of end-stage renal disease (ESKD) and mortality among adolescents with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) and normal renal function compared with non-diabetics. We hypothesized that childhood onset T1DM vs. T2DM would be associated with a different risk profile for developing ESKD and its complications.

METHODS

A nationwide, population-based, retrospective cohort study, including 1,500,522 adolescents examined for military service between 1967 and 1997, which were classified according to the presence and type of diabetes. Data were linked to the Israeli ESKD registry. Cox proportional-hazards models were used to estimate the hazard ratio (HR) for ESKD.

RESULTS

At study enrolment, 1183 adolescents had T1DM and 196 had T2DM. ESKD developed in 2386 non-diabetic individuals (0.2%) compared with 72 individuals (6.1%) with T1DM and 8 individuals (4.1%) with T2DM. Participants with T1DM were younger at ESKD onset than participants with T2DM (median age, 36.0 vs. 40.5 years, P < 0.05). In a multivariate model adjusted for age, sex, paternal origin, enrollment year, BMI, and blood pressure, T1DM and T2DM were associated with HR of 36.4 (95% CI 28.3-46.9) and 19.3 (95% CI 9.6-38.8) for ESKD, respectively. Stratification according to sex, ethnicity, immigration, and socioeconomic status did not materially change the HR. During the follow-up period, mortality rates were higher in T2DM as compared with T1DM and controls (8.7 %, 2.2%, and 2.7% respectively).

CONCLUSIONS

T1DM and T2DM in adolescents with normal renal function confer a significantly increased risk for ESKD. T1DM is associated with younger age at ESKD onset while T2DM is associated with higher mortality rate.

Chronic Kidney Disease among Diabetes Patients in Ethiopia: A Systematic Review and Meta-Analysis

Background

Though different primary studies have reported the burden of chronic kidney disease among diabetes patients, their results have demonstrated substantial variation regarding its prevalence in Ethiopia. Therefore, this study aimed to estimate the pooled prevalence of chronic kidney disease and its associated factors among diabetes patients in Ethiopia.

Method

PubMed, African Journals Online, Google Scholar, Scopus, and Wiley Online Library were searched to identify relevant studies. The I² statistic was used to check heterogeneity across the included studies. A random-effects model was applied to estimate the pooled effect size across studies. A funnel plot and Egger's regression test were used to determine the presence of publication bias. All statistical analyses were performed using STATA™ version 14 software.

Result

In this meta-analysis, a total of 12 studies with 4,075 study participants were included. The estimated prevalence of CKD among diabetes patients was found to be 35.52% (95% CI: 25.9–45.45, I² = 96.3%) for CKD stages 1 to 5 and 14.5% (95% CI: 10.5–18.49, I² = 91.1%) for CKD stages 3 to 5. Age greater than 60 years (OR = 2.99; 95% CI: 1.56–5.73), female sex (OR = 1.68; 95% CI: 1.04–2.69), duration of diabetes >10 years (OR = 2.76; 95% CI: 1.38–5.51), body mass index >30 kg/m² (OR = 2.06; 95% CI: 1.41–3.00), type 2 diabetes (OR = 2.54; 95% CI: 1.73–3.73), poor glycemic control (OR = 2.01; 95% CI: 1.34–3.02), fasting blood glucose >150 mg/dl (OR = 2.58; 95% CI: 1.79–3.72), high density lipoprotein >40 mg/dl (OR = 0.48; 95% CI: 0.30–0.85–25), systolic blood pressure>140 mmHg (OR = 3.26; 95% CI: 2.24–4.74), and diabetic retinopathy (OR = 4.54; CI: 1.08–25) were significantly associated with CKD.

Conclusion

This study revealed that the prevalence of chronic kidney disease remains high among diabetes patients in Ethiopia. This study found that a long duration of diabetes, age>60 years, diabetic retinopathy, female sex, family history of kidney disease, poor glycemic control, systolic blood pressure, overweight, and high level of high-density lipoprotein were associated with chronic kidney disease among diabetic patients. Therefore, situation-based interventions and context-specific preventive strategies should be developed to reduce the prevalence and risk factors of chronic kidney disease among diabetes patients.

Impact of Mean and Variability of High-Density Lipoprotein-Cholesterol on the Risk of Myocardial Infarction, Stroke, and Mortality in the General Population

Background

A low level of high‐density lipoprotein‐cholesterol (HDL‐C) is a well‐known risk factor for cardiovascular events. Recent studies have also suggested that HDL‐C variability has a predictive role in patients with coronary artery disease. We investigated the combined effect of the mean and variability of HDL‐C on the risk of myocardial infarction (MI), stroke, and mortality in the general population.

Methods and Results

We selected 5 433 098 subjects in the Korean National Health Insurance System cohort who had no history of MI or stroke and who underwent ≥3 health examinations between 2009 and 2013. Visit‐to‐visit HDL‐C variability was calculated using the coefficient of variation, variability independent of the mean and average real variability. The low‐mean and high‐variability groups were defined as the lowest and highest quartiles of HDL‐C mean and variability, respectively. There were 27 605 cases of MI, 31 162 cases of stroke, and 50 959 deaths during the median follow‐up of 5.1±0.6 years. A lower mean or higher variability (coefficient of variation) of HDL‐C was associated with a higher risk of adverse outcomes, and the 2 measures had an additive effect. In the multivariable‐adjusted model, the hazard ratios (95% CIs) of the low‐mean/high‐variability group compared with the high‐mean/low‐variability group were 1.47 (1.41–1.54) for MI, 1.23 (1.18–1.28) for stroke, and 1.41 (1.36–1.45) for all‐cause mortality. Results were consistent when variability was modeled using variability independent of the mean or average real variability, and in various sensitivity and subgroup analyses.

Conclusions

Low mean and high variability of HDL‐C is associated with an increased risk of MI, stroke, and mortality.

HDL-Cholesterol, Its Variability, and the Risk of Diabetes: A Nationwide Population-Based Study

CONTEXT

The bidirectional relationship between low high-density lipoprotein cholesterol (HDL-C) and glucose intolerance is well established. Recent studies suggested an association of lipid variability with various health outcomes.

OBJECTIVE

To investigate the combined effect of HDL-C levels and their variability on the risk of diabetes.

DESIGN

A population-based cohort study.

SETTING AND PARTICIPANTS

In all, 5,114,735 adults without known diabetes in the Korean National Health Insurance System cohort who underwent three or more health examinations from 2009 to 2013 were included. Visit-to-visit HDL-C variability was calculated using variability independent of the mean (VIM) and the coefficient of variation (CV). Low mean and high variability groups were defined as the lowest and highest quartiles of HDL-C mean and variability, respectively.

MAIN OUTCOME MEASURES

Newly developed diabetes.

RESULTS

There were 122,192 cases (2.4%) of incident diabetes during the median follow-up of 5.1 years. Lower mean or higher variability of HDL-C was associated with higher risk of diabetes in a stepwise manner, and an additive effect of the two measures was noted. In the multivariable-adjusted model, the hazard ratios and 95% CIs for incident diabetes were 1.20 (1.18 to 1.22) in the high mean/high VIM group, 1.35 (1.33 to 1.37) in the low mean/low VIM group, and 1.40 (1.38 to 1.42) in the low mean/high VIM group compared with the high mean/low VIM group. Similar results were observed when modeling the variability using CV and in various subgroup analyses.

CONCLUSIONS

Low mean and high variability in HDL-C were independent predictors of diabetes with an additive effect. Both elevating and stabilizing HDL-C may be important goals for reducing diabetes risk.

Lonicera japonica extract increases metformin distribution in the liver without change of systemic exposed metformin in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Flower and flower bud of Lonicera japonica, Lonicerae Flos, have been popularly used as medicinal plant for the treatment of clearing heat and thirst, thereby improving diabetic or diabetic associated symptoms (thirst and poor eyesight).

AIM OF THE STUDY

Organic cation transporters (OCTs) and multi-drug and toxin extrusion proteins (MATEs) are known to play important roles in metformin transport in the liver and kidneys. Thus, there might be interactions between Lonicerae Flos and metformin via OCTs and MATEs. Also treatment period has been issued in transporter-mediated drug interactions. The objective of this study was to determine the effect of Lonicerae Flos ethanol extract (LJ) on metformin pharmacokinetics and its glucose lowering activity in different treatment periods.

MATERIALS AND METHODS

Effect of LJ on metformin uptake was evaluated in vitro HEK-293 cells expressing human OCTs or MATEs. Treatment period-dependent impact of LJ on systemic exposure and hepatic distribution of metformin as well as its glucose tolerance activity were assessed in in vivo rats.

RESULTS

LJ substantially inhibited MATE1-mediated metformin uptake in vitro. In evaluating treatment period effects of LJ and metformin, 1-, 7-, and 28-day co-treatments of LJ with metformin did not change systemic exposure of metformin compared to those in metformin alone. Whereas, 28-day co-treatment of LJ with metformin increased metformin concentration in liver as a pharmacological target site of metformin. It could be due to the reduced MATE1-mediated metformin efflux from hepatocytes to bile by MATE1 inhibition in liver. Glucose tolerance activity was also enhanced by 28-day co-treatment of LJ and metformin compared to metformin alone.

CONCLUSIONS

In 28-day co-treatment of LJ and metformin, LJ increased metformin concentration in liver and improved glucose tolerance activity without systemic exposure change of metformin, suggesting the importance to consider treatment period effect and both systemic exposure and tissue distribution in drug interactions.

Effects of Variability in Blood Pressure, Glucose, and Cholesterol Concentrations, and Body Mass Index on End-Stage Renal Disease in the General Population of Korea

Aim: Metabolic parameters, such as blood pressure, glucose, lipid levels, and body weight, can interact with each other, and this clustering of metabolic risk factors is related to the progression to end-stage renal disease (ESRD). The effect of variability in metabolic parameters on the risk of ESRD has not been studied previously. Methods: Using nationally representative data from the Korean National Health Insurance System, 8,199,135 participants who had undergone three or more health examinations between 2005 and 2012 were included in this analysis. Intraindividual variability in systolic blood pressure (SBP), fasting blood glucose (FBG), total cholesterol (TC), and body mass index (BMI) was assessed by examining the coefficient of variation, variability independent of the mean, and average real variability. High variability was defined as the highest quartile of variability and low variability was defined as the lower three quartiles of variability. Results: Over a median (5–95%) of 7.1 (6.5–7.5) years of follow-up after the variability assessment period, 13,600 (1.7/1000 person-years) participants developed ESRD. For each metabolic parameter, an incrementally higher risk of ESRD was observed for higher variability quartiles compared with the lowest quartile. The risk of ESRD was 46% higher in the highest quartile of SBP variability, 47% higher in the highest quartile of FBG variability, 56% higher in the highest quartile of BMI variability, and 108% higher in the highest quartile of TC variability. Compared with the group with low variability for all four parameters, the group with high variability for all four parameters had a significantly higher risk for incident ESRD (hazard ratio (HR) 4.12; 95% CI 3.72–4.57). Conclusions: Variability in each metabolic parameter was an independent predictor of the development of ESRD among the general population. There was a composite effect of the variability in additional metabolic parameters on the risk of ESRD.

Genome-wide association study identifies novel loci for type 2 diabetes-attributed end-stage kidney disease in African Americans

BACKGROUND

End-stage kidney disease (ESKD) is a significant public health concern disproportionately affecting African Americans (AAs). Type 2 diabetes (T2D) is the leading cause of ESKD in the USA, and efforts to uncover genetic susceptibility to diabetic kidney disease (DKD) have had limited success. A prior genome-wide association study (GWAS) in AAs with T2D-ESKD was expanded with additional AA cases and controls and genotypes imputed to the higher density 1000 Genomes reference panel. The discovery analysis included 3432 T2D-ESKD cases and 6977 non-diabetic non-nephropathy controls (N = 10,409), followed by a discrimination analysis in 2756 T2D non-nephropathy controls to exclude T2D-associated variants.

RESULTS

Six independent variants located in or near RND3/RBM43, SLITRK3, ENPP7, GNG7, and APOL1 achieved genome-wide significant association (P < 5 × 10-8) with T2D-ESKD. Following extension analyses in 1910 non-diabetic ESKD cases and 908 non-diabetic non-nephropathy controls, a meta-analysis of 5342 AA all-cause ESKD cases and 6977 AA non-diabetic non-nephropathy controls revealed an additional novel all-cause ESKD locus at EFNB2 (rs77113398; P = 9.84 × 10-9; OR = 1.94). Exclusion of APOL1 renal-risk genotype carriers identified two additional genome-wide significant T2D-ESKD-associated loci at GRAMD3 and MGAT4C. A second variant at GNG7 (rs373971520; P = 2.17 × 10-8, OR = 1.46) remained associated with all-cause ESKD in the APOL1-negative analysis.

CONCLUSIONS

Findings provide further evidence for genetic factors associated with advanced kidney disease in AAs with T2D.

Variability in Total Cholesterol Concentration Is Associated With the Risk of Dementia: A Nationwide Population-Based Cohort Study

Introduction: Although total cholesterol (TC) variability is suggested as a risk factor for cardiovascular and cerebrovascular disease, there is no previous study to evaluate the association between TC variability and the development of dementia. Methods: Using the Korean National Health Insurance Service-Health Screening Cohort (NHIS-HEALS), the main outcomes were newly diagnosed all-cause dementia, Alzheimer's disease (AD), or vascular dementia (VaD) between January 1, 2008, and December 31, 2015. Visit-to-visit TC variability was measured as variability independent of the mean (TC-VIM), coefficient variance (TC-CV), and standard deviation (TC-SD). Results: In a total of 131,965 Koreans, there were 3,722 all-cause dementia (2.82%), 2,776 AD (2.10%), and 488 VaD (0.37%) during the median follow-up of 8.4 years. Kaplan-Meier curves showed increased cumulative incidences for all in the group of the highest quartiles of TC variability compared to the others. Regression using the Fine and Gray hazards model showed a steadily increasing risk of all-cause dementia with higher quartiles of TC variability. After adjusting for confounders including mean TC level and comparing the highest and lowest TC-VIM quartiles, the hazard ratios (HRs) for all-cause dementia and AD were 1.15 [95% confidence interval (CI) = 1.05-1.27; P = 0.003] and 1.12 (95% CI = 1.00-1.25; P = 0.040), respectively. The incidence of VaD was not significantly higher in the higher-quartile groups compared to that in the lowest-quartile group in TC-VIM variability (HR 1.22; 95% CI = 0.95-1.59; P = 0.122). These associations were consistent with TC variability defined by TC-CV or TC-SD. Conclusions: For the first time, we have demonstrated that a higher visit-to-visit variability in TC independent of mean TC is associated with an increased risk of all-cause dementia and AD in the general population.

Are blood lipids associated with microvascular complications among type 2 diabetes mellitus patients? A cross-sectional study in Shanghai, China

BACKGROUND

Although there are several studies to investigate the association between blood lipids and microvascular complications, these studies reported conflicting results. The aim of the current study was to explore the association between blood lipid parameters and the risk of microvascular complications, especially the dose-response association between them, among community patients with type 2 diabetes mellitus (T2DM) in Shanghai, China.

METHODS

The cross-sectional study was conducted in 6 community health service centers in Shanghai between December 2014 and December 2016.The associations between blood lipids and diabetic kidney disease (DKD) or diabetic retinopathy (DR) were assessed using multiple logistic regression. Restricted cubic spline (RCS) was employed to estimate the dose-response relation of blood lipids and the risk of microvascular complications.

RESULTS

A total of 3698 participants were included in the final analysis to study the association between blood lipids and DKD, wherein 33.2% of participants had DKD and 1374 were included for the analysis of the association between blood lipids and DR, wherein 23.2% of participants had DR. DKD odds ratio was increased by 1.16(95%CI,1.08-1.25), 1.21(95%CI,1.13-1.30), 1.18(95%CI,1.10-1.26) for comparing fourth to first quartiles of triglycerides (TG), TG/high-density lipoprotein cholesterol (HDL-C), non-HDL-C/HDL-C, respectively, and decreased by 0.83(95%CI,0.78-0.89) for comparing fourth to first quartiles of HDL-C. Furthermore, the dose-response association between TG, HDL-C, TG/HDL-C, non-HDL-C/HDL-C and the risk of DKD demonstrated turning points in TG of 1.90 mmol/L, HDL-C of 1.62 mmol/L, TG/HDL-C of 2.00, non-HDL-C/HDL-C of 3.09, respectively. However, no significant association was found between blood lipid parameters and DR.

CONCLUSIONS

This community-based study indicated that TG, HDL-C, TG/HDL-C, non-HDL-C/HDL-C were independently associated with DKD but not DR.

Natural history and risk factors for diabetic kidney disease in patients with T2D: lessons from the AMD-annals

The Associazione Medici Diabetologi (AMD) annals initiative is an ongoing observational survey promoted by AMD. It is based on a public network of about 700 Italian diabetes clinics, run by specialists who provide diagnostic confirmation and prevention and treatment of diabetes and its complications. Over the last few years, analysis of the AMD annals dataset has contributed several important insights on the clinical features of type-2 diabetes kidney disease and their prognostic and therapeutic implications. First, non-albuminuric renal impairment is the predominant clinical phenotype. Even though associated to a lower risk of progression compared to overt albuminuria, it contributes significantly to the burden of end-stage renal disease morbidity. Second, optimal blood pressure control provides significant but incomplete renal protection. It reduces albuminuria but there may be a J curve phenomenon with eGFR at very low blood pressure values. Third, hyperuricemia and diabetic hyperlipidemia, namely elevated triglycerides and low HDL cholesterol, are strong independent predictors of chronic kidney disease (CKD) onset in diabetes, although the pathogenetic mechanisms underlying these associations remain uncertain. Fourth, the long-term intra-individual variability in HbA1c, lipid parameters, uric acid and blood pressure plays a greater role in the appearance and progression of CKD than the absolute value of each single variable. These data help clarify the natural history of CKD in patients with type 2 diabetes and provide important clues for designing future interventional studies.

Effect of visit-to-visit LDL-, HDL-, and non-HDL-cholesterol variability on mortality and cardiovascular outcomes after percutaneous coronary intervention

BACKGROUND AND AIMS

Visit-to-visit variability in biological measures has been suggested as an independent predictor of cardiovascular disease (CVD). Although low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) are important risk factors of CVD, there are few studies investigating the effect of variability in LDL-C and HDL-C on cardiovascular outcomes. We investigated the association between visit-to-visit variability in LDL-C, HDL-C, and non-HDL-C and major adverse cardiovascular and cerebrovascular events (MACCE) in patients who underwent percutaneous coronary intervention (PCI).

METHODS

Data from 1792 subjects who underwent PCI from January 2004 to December 2009 were analyzed. Visit-to-visit variability was calculated using various indices: standard deviation (SD), coefficient of variation, and corrected variability independent of mean (cVIM). MACCE comprised all-cause death, non-fatal myocardial infarction, and stroke.

RESULTS

During a median follow-up period of 65 months, 114 subjects (6.4%) experienced MACCE: 68 (3.8%) all-cause death; 43 (2.4%) stroke, and 15 (0.8%) non-fatal myocardial infarction. Visit-to-visit variability in LDL-C, HDL-C, and non-HDL-C was significantly higher in the MACCE group compared to the non-MACCE group. In multiple regression analysis, all LDL-C, HDL-C, and non-HDL-C variability parameters were independent predictors for MACCE after adjusting for potential confounding factors. Each 1-SD increase of cVIM in LDL-C, HDL-C, and non-HDL-C increased the risk of MACCE by 34% (HR 1.34 [95% CI, 1.18-1.52]), 50% (HR 1.50 [95% CI 1.32-1.71]), and 37% (HR 1.37 [95% CI, 1.20-1.57]), respectively. These relationships were observed in various subgroups according to age, sex, and diabetes status.

CONCLUSIONS

Visit-to-visit variability in LDL-C, HDL-C, and non-HDL-C is associated with MACCE in subjects with previous PCI.

Association of serum high-density lipoprotein cholesterol with microalbuminuria in type 2 diabetes patients

BACKGROUND

The association of serum high-density lipoprotein cholesterol (HDL-C) with microalbuminuria in type 2 diabetes mellitus (T2DM) remains controversial. Therefore, a cross-sectional study was conducted on patients with T2DM to investigate the relationship of HDL-C with microalbuminuria.

METHODS

A total of 524 participants with T2DM were recruited in this cross-sectional study. The patients were divided into four groups according to serum HDL-C quartile. A nonparametric test was employed to assess the relationships across quartiles with clinical parameters and demographics. Multivariate logistic regression analysis was further performed.

RESULTS

Of the 524 patients, 138 (26.3%) were found to have microalbuminuria by urinary albumin excretion rate determination. Serum HDL-C levels in microalbuminuria group were significantly lower than those in non-microalbuminuria group (1.04 (0.90-1.21) vs. 1.10 (0.94-1.31) mmol/L, P = 0.002). The nonparametric test for trend showed that the prevalence of microalbuminuria was significantly reduced for subjects of the fourth quartile of HDL-C compared to the first to third quartile (13.5% vs. 33.1%, 28.6%, 29.4%, P = 0.001). Multivariate logistic regression showed that subjects within the highest quartile of HDL-C had lower odds of microalbuminuria than those within the lowest quartile of HDL-C (OR = 0.17, 95% CI 0.15-0.52, P = 0.004).

CONCLUSIONS

Higher levels of serum HDL-C were associated with decreased rates of microalbuminuria in T2DM patients.

Clinical and pathological factors associated with progression of diabetic nephropathy

As an important complication of diabetic mellitus, diabetic kidney disease (DKD) is becoming a major cause of morbidity and mortality worldwide. Given the diminished quality of life and the economic cost, identification of the risk factors for DKD and initiation of in-time therapies are of great importance. The initiators of DKD include hyperglycemia and predisposing genes, while the promotors of DKD include hyperglycemia, albuminuria, hypertension, dyslipdemia, insulin resistance, anemia, long duration of diabetes, smoking, ethnicity, westernization, sex, age, and so on. This article summarizes the values and limitations of some factors in the development and progression of DKD. Further study is needed to establish whether modulating these factors can improve the outcomes of DKD.

Herba Artemisiae Capillaris Extract Prevents the Development of Streptozotocin-Induced Diabetic Nephropathy of Rat

Diabetic nephropathy (DN) is a major cause of end-stage renal disease throughout the world; until now there is no specific drug available. In this work, we use herba artemisiae capillaris extract (HACE) to alleviate renal fibrosis characterized by the excessive accumulation of extracellular matrix (ECM) in rats, aiming to investigate the protective effect of the HACE on DN. We found that the intragastric treatment of high-dose HACE could reverse the effect of streptozotocin not only to decrease the level of blood glucose and blood lipid in different degree but also further to improve renal functions. It is worth mentioning that the effect of HACE treatment was comparable to the positive drug benazepril. Moreover, we found that HACE treatment could on one hand inhibit oxidative stress in DN rats through regulating enzymatic activity for scavenging reactive oxygen species and on the other hand increase the ECM degradation through regulating the activity of metalloproteinase-2 (MMP-2) and the expression of tissue transglutaminase (tTG), which explained why HACE treatment inhibited ECM accumulation. On the basis of above experimental results, we conclude that HACE prevents DN development in a streptozotocin-induced DN rat model, and HACE is a promising candidate to cure DN in clinic.

[Diabetic dyslipidemia and microvascular complications of diabetes]

Diabetic dyslipidemia is one of the main risk factors for atherosclerosis. Although its participation in diabetic microvascular complications is not that dominant, dyslipidemia may play an important role in formation and progression of these complications. Pathophysiological mechanisms by which diabetic dyslipidemia affects the etiopathogenesis of diabetic nephropathy, retinopathy, neuropathy and diabetic foot are presented. The data from clinical studies and treatment possibilities for particular microvascular complications using lipid-lowering therapy are discussed.Key words: diabetes mellitus - diabetic foot - dyslipidemia - nephropathy - neuropathy - retinopathy.

Greater low-density lipoprotein cholesterol variability is associated with increased progression to dialysis in patients with chronic kidney disease stage 3

Increasing evidence suggests that lipid variability may be a predictor of cardiovascular events. However, few studies have evaluated the association between lipid variability and renal outcomes in patients with moderate-to-advanced chronic kidney disease (CKD). Therefore, the aims of this study were to assess whether lipid variability is associated with progression to dialysis in patients with CKD stage 3–5, and to evaluate the risk factors of lipid variability. This longitudinal study enrolled 725 patients with CKD stage 3–5. Intra-individual lipid variability was defined as the standard deviations (SDs) of lipid levels. The renal end-point was defined as commencing dialysis. During a mean follow-up period of 3.2 years, 208 patients (28.7%) started dialysis. The patients with CKD stage 3 with high low-density lipoprotein (LDL) cholesterol SD (per 1 mg/dL; hazard ratio, 1.035; 95% confidence interval, 1.003 to 1.067; p = 0.003) were associated with an increased risk of progression to dialysis, however this association was not seen in the patients with CKD stage 4 or 5. Furthermore, in the patients with CKD stage 3, a high urine protein-to-creatinine ratio (p < 0.001) and the use of statins (p < 0.001) were significantly associated with an increased LDL-cholesterol SD. Greater LDL-cholesterol variability was associated with an increased risk of progression to dialysis in patients with CKD stage 3, but not in those with CKD stage 4 or 5. These findings support the potential role of aggressive lipid control on clinical outcomes and highlight its importance in patients with CKD stage 3.

Variability in HbA1c, blood pressure, lipid parameters and serum uric acid, and risk of development of chronic kidney disease in type 2 diabetes

AIM

Variability in HbA1c and blood pressure is associated with the risk of diabetic kidney disease (DKD). No evidence exists on the role of variability in lipids or serum uric acid (UA), or the interplay between the variability of different parameters, in renal outcomes.

METHODS

Within the AMD Annals database, we identified patients with ≥5 measurements of HbA1c, systolic blood pressure (SBP) and diastolic blood pressure (DBP), total-, high-density lipoprotein (HDL)- and low-density lipoprotein (LDL)-cholesterol, triglycerides, and UA. Patients were followed-up for up to 5 years. The impact of measures of variability on the risk of DKD was investigated by Cox regression analysis and recursive partitioning techniques.

RESULTS

Four-thousand, two-hundred and thirty-one patients were evaluated for development of albuminuria, and 7560 for decreased estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m² ). A significantly higher risk of developing albuminuria was associated with variability in HbA1c [upper quartile hazard ratio (HR) = 1.3; 95% confidence interval (CI) 1.1-1.6]. Variability in SBP, DBP, HDL-C, LDL-C and UA predicted the decline in eGFR, the association with UA variability being particularly strong (upper quartile HR = 1.8; 95% CI 1.3-2.4). The concomitance of high variability in HbA1c and HDL-C conferred the highest risk of developing albuminuria (HR = 1.47; 95% CI 1.17-1.84), while a high variability in UA (HR = 1.54; 95% CI 1.19-1.99) or DBP (HR = 1.47; 95% CI 1.11-1.94) conferred the highest risk of decline in eGFR.

CONCLUSION

The variability of several parameters influences the development of DKD, having a different impact on albuminuria development and on the decline in GFR.

Effect of high density lipoprotein cholesterol on the relationship of serum iron and hemoglobin with kidney function in diabetes

Findings of increased hemoglobin inside the HDL proteome among persons with diabetes who have haptoglobin 2-2 genotype suggest that iron-induced lipid peroxidation may be involved in diabetic kidney disease. We investigated the relationships of serum hemoglobin and iron with kidney function, and whether this varied by level of HDLc, in 5296 adults with and 49,161 without diabetes. Estimated eGFR was our marker of kidney function. Hemoglobin was positively associated with eGFR among those with diabetes and inversely among those without diabetes (interaction p-value <0.0001). Iron was inversely associated with eGFR regardless of diabetes status. When stratified by median HDLc and median hemoglobin, among persons with diabetes mean eGFR was highest in those with high hemoglobin and low HDLc and lowest in those with both low hemoglobin and low HDLc. This divergent relationship was not observed in the non-diabetic population. In contrast to hemoglobin, high iron and low HDLc were associated with a lower mean eGFR regardless of diabetes status. Our data suggest that among persons with diabetes, both hemoglobin and iron are harmful to kidney function at high levels. Our data also suggest that HDLc may play a role in the relationship of high hemoglobin in kidney function in diabetes.

Risk Factors for the Development and Progression of Diabetic Kidney Disease in Patients with Type 2 Diabetes Mellitus and Advanced Diabetic Retinopathy

BACKGROUND

Some patients with type 2 diabetes mellitus (T2DM) do not develop diabetic kidney disease (DKD) despite the presence of advanced diabetic retinopathy (DR). We aimed to investigate the presence of DKD and its risk factors in patients with T2DM and advanced DR.

METHODS

We conducted a cross-sectional study in 317 patients with T2DM and advanced DR. The phenotypes of DKD were divided into three groups according to the urine albumin/creatinine ratio (uACR, mg/g) and estimated glomerular filtration rate (eGFR, mL/min/1.73 m²): no DKD (uACR <30 and eGFR ≥60), non-severe DKD (uACR ≥30 or eGFR <60), and severe DKD (uACR ≥30 and eGFR <60). Mean systolic and diastolic blood pressure, mean glycosylated hemoglobin (HbA1c) level, and HbA1c variability (standard deviation [SD] of serial HbA1c values or HbA1c-SD) were calculated for the preceding 2 years.

RESULTS

The prevalence of no DKD, non-severe DKD, and severe DKD was 37.2% (n=118), 37.0% (n=117), and 25.8% (n=82), respectively. HbA1c-SD and the triglyceride/high density lipoprotein cholesterol (TG/HDL-C) ratio correlated positively with uACR and negatively with eGFR. Multiple linear regression analyses showed that the HbA1c-SD and TG/HDL-C ratio were significantly related with eGFR. Multiple logistic regression analyses after adjusting for several risk factors showed that HbA1c-SD and the TG/HDL-C ratio were significant risk factors for severe DKD.

CONCLUSION

The prevalence of DKD was about 60% in patients with T2DM and advanced DR. HbA1c variability and TG/HDL-C ratio may affect the development and progression of DKD in these patients.

Relationship between kidney function decline and initial risk factors for the progression of diabetic kidney disease: a retrospective analysis of 91 Japanese patients with type 2 diabetes

BACKGROUND

Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease (ESRD) in Japan. The clinical course and factors related to the progression of DKD to ESRD are important issues when treating patients with DKD.

METHODS

Ninety-one type 2 diabetic patients with DKD that had progressed from chronic kidney disease (CKD) stages G1-3 on their initial clinical visit to ESRD were enrolled. The decline in the estimated glomerular filtration rate (eGFR) was analyzed and the initial clinical factors that influenced the decline rate were explored.

RESULTS

There was a linear decline in eGFR before progression to ESRD, with a median annual decline rate (∆eGFR) of 9.2 mL/min/1.73 m2. In all patients, a history of coronary artery disease and increased levels of initial eGFR and high-density lipoprotein cholesterol (HDL-C) were positive predictors of log ∆eGFR, whereas age, history of cerebral infarction (CI), and an increased level of serum albumin were negative predictors of log ∆eGFR. In patients with CKD stages G1-2 on their first visit, male sex and increased diastolic blood pressure were positive predictors. In patients with CKD stage G3 on their first visit, an increased level of LDL-C was a positive predictor, whereas a history of CI and an increased level of serum total bilirubin (TBil) were negative predictors.

CONCLUSION

In addition to the common risk factors, initial eGFR, HDL-C, and TBil were identified as novel risk factors for ESRD. These risk factors may differ between patients with early and advanced stages of CKD.

Serum uric acid level as an indicator for CKD regression and progression in patients with type 2 diabetes mellitus-a 4.6-year cohort study

BACKGROUND

To investigate the association of serum uric acid level with renal function change in patients with type 2 diabetes mellitus (T2DM).

METHODS

T2DM patients who had been followed-up for at least 3 years were included. Participants were categorized into stable, progression, or regression groups according to their change in chronic kidney disease (CKD) stage. During the follow-up period, all numeric values of metabolic factors, including the uric acid level and the medication possession rate, were calculated in order to investigate their associations with CKD development. Multivariate Cox regression analyses were used to identify independent factors associated with change in CKD.

RESULTS

A total of 2367 T2DM patients were enrolled in this study and followed-up for a mean of 4.6 years. The numbers of patients in the stable, progression and regression groups were 1133 (47.9%), 487 (20.6%), and 747 (31.5%), respectively. The progression group had the highest serum uric acid level (6.9 ± 1.8 mg/dL), and the regression group had the lowest uric acid level (5.4 ± 1.5 mg/dL). In addition, we found that the serum uric acid level was an independent factor associated with CKD progression when the value exceeded 6.3 mg/dL. A lower uric acid level could be beneficial for CKD improvement in T2DM patients with stage 3-5 CKD.

CONCLUSIONS

Our data indicated that the serum uric acid level is associated with CKD regression and progression and suggested that a high normal serum uric acid level should be closely monitored in patients with T2DM. Copyright © 2015 John Wiley & Sons, Ltd.

Clinical predictive factors in diabetic kidney disease progression

Diabetic kidney disease (DKD) represents a major component of the health burden associated with type 1 and type 2 diabetes. Recent advances have produced an explosion of ‘novel’ assay‐based risk markers for DKD, though clinical use remains restricted. Although many patients with progressive DKD follow a classical albuminuria‐based pathway, non‐albuminuric DKD progression is now well recognized. In general, the following clinical and biochemical characteristics have been associated with progressive DKD in both type 1 and type 2 diabetes: increased hemoglobin A1c, systolic blood pressure, albuminuria grade, early glomerular filtration rate decline, duration of diabetes, age (including pubertal onset) and serum uric acid; the presence of concomitant microvascular complications; and positive family history. The same is true in type 2 diabetes for male sex category, in patients following an albuminuric pathway to DKD, and also true for the presence of increased pulse wave velocity. The following baseline clinical characteristics have been proposed as risk factors for DKD progression, but with further research required to assess the nature of any relationship: dyslipidemia (including low‐density lipoprotein, total and high‐density lipoprotein cholesterol); elevated body mass index; smoking status; hyperfiltration; decreases in vitamin D, hemoglobin and uric acid excretion (all known consequences of advanced DKD); and patient test result visit‐to‐visit variability (hemoglobin A1c, blood pressure and high‐density lipoprotein cholesterol). The development of multifactorial ‘renal risk equations’ for type 2 diabetes has the potential to simplify the task of DKD prognostication; however, there are currently none for type 1 diabetes‐specific populations. Significant progress has been made in the prediction of DKD progression using readily available clinical data, though further work is required to elicit the role of several variables, and to consolidate data to facilitate clinical implementation.

Changes in high-density-lipoprotein cholesterol upon statin treatment in type 2 diabetic patients: a meta-analysis

BACKGROUND AND AIM

To investigate the diversity of change in high-density-lipoprote in cholesterol (HDL-C) after statin treatment in patients with type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

A systemic review searched for trials that reported a serum change in HDL-C in patients with T2DM after statin treatment, and extracted data for meta-analysis. Of 6709 articles surveyed, 160 articles were identified as eligible articles. In the analysis of simvastatin, serum HDL-C was increased in Non-Asian and Asian patients with T2DM by 2.17 mg/dl (95% CI 1.43 ∼ 2.90 mg/dl, p < 0.001) and 2.31 mg/dl (95% CI 1.37 ∼ 3.25 mg/dl, p < 0.001), respectively. In the analysis of atorvastatin, although significant, serum HDL-C was subtly increased in Non-Asian patients with T2DM by 1.14 mg/dl (95% CI 0.28 ∼ 2.01 mg/dl, p = 0.010) mg/dl; however, atorvastatin treatment did not significantly change the serum HDL-C by 0.12 mg/dl (95% CI -1.04 ∼ 1.27 mg/dl, p = 0.839) mg/dl in Asian patients with T2DM. According to meta-regression analysis, the baseline HDL-C did not affect the change in serum HDL-C in Asian patients with T2DM after either simvastatin or atorvastatin treatment. However, contrary to simvastatin, the coefficient of regression (r) showed a significant negative association (r = -0.18; 95% CI -0.32 to -0.04; p = 0.01) between baseline HDL-C and the change of HDL-C in non-Asian patients with T2DM after atorvastatin treatment.

CONCLUSION

We have demonstrated for the first time that there may be a discrepancy in the change of serum HDL-C in Asian patients with T2DM after atorvastatin treatment.

Paradoxical negative HDL cholesterol response to atorvastatin and simvastatin treatment in Chinese type 2 diabetic patients

OBJECTIVES

There is extensive but controversial evidence on the diverse effects of statins on the level of high-density lipoprotein cholesterol (HDL-C). Some of these effects may limit the benefits of statins in terms of cardiovascular risk reduction. To identify the conditions for beneficial effects, this study investigated the response to atorvastatin and simvastatin treatment in type 2 diabetic patients with elevated low-density lipoprotein cholesterol (LDL-C).

METHODS

2,872 subjects with type 2 diabetes from a disease management program were investigated. Patients with LDL-C ≥130 mg/dl or total cholesterol ≥200 mg/dl were put onto statin therapy by the National Health Insurance system in Taiwan.

RESULTS

1,080 patients who completed 1 year of statin treatment were analyzed. There were significant reductions in LDL-C in both the atorvastatin (37.1%) and simvastatin (34.3%) group after one year of treatment compared with baseline levels. Unexpectedly, the majority of diabetic patients who received atorvastatin or simvastatin did not show an increase in HDL-C levels. 59.8% of patients had a significant HDL-C reduction (ΔHDL-C ≤ -3%) after atorvastatin treatment. Multivariate logistic regression analysis showed that the following patients were at higher risk of HDL-C reduction after 12 months: (i) patients in whom statin therapy was initiated aged <65 years and who had a BMI ≥24 kg/m(2), (ii) male patients with a baseline HDL-C >40 mg/dl, and (iii) female patients with a baseline HDL-C >50 mg/dl. However, diabetic patients with severe atherogenic dyslipidemia (LDL-C ≥130, TG ≥204, and HDL-C ≤34 mg/dl) obtained more benefits in terms of HDL-C change after statin therapy.

CONCLUSIONS

Diabetic patients, except those with severe atherogenic dyslipidemia, are prone to a decrease in serum HDL-C level after statin treatment, particularly after atorvastatin treatment.