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Claudel SE, Waikar SS. Imprecise, Measure it Twice? Dealing With the Biological Variability of Albuminuria in Diabetes. Am J Kidney Dis 2024; 84:1-3. [PMID: 38661613 DOI: 10.1053/j.ajkd.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 02/23/2024] [Accepted: 03/02/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Sophie E Claudel
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts.
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Fangel MV, Nielsen PB, Kristensen JK, Larsen TB, Overvad TF, Lip GY, Jensen MB. Albuminuria and Risk of Cardiovascular Events and Mortality in a General Population of Patients with Type 2 Diabetes Without Cardiovascular Disease: A Danish Cohort Study. Am J Med 2020; 133:e269-e279. [PMID: 32205071 DOI: 10.1016/j.amjmed.2019.10.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Albuminuria level is associated with cardiovascular events and mortality in patients with diabetes. However, little is known about the association between albuminuria level in diabetes patients without overt cardiovascular disease. We aimed to examine the association between albuminuria level and the risk of ischemic stroke, myocardial infarction, and all-cause mortality in patients with type 2 diabetes without overt cardiovascular disease. METHODS We linked Danish nationwide registries to identify patients with type 2 diabetes without cardiovascular disease from May 2005 through June 2015. Patients were followed for the outcomes ischemic stroke, myocardial infarction, and all-cause mortality until December 31, 2015. Albuminuria level was based on 2 consecutive measurements of the urinary albumin excretion rate or albumin-to-creatinine ratio. Associations between albuminuria level and incidence of cardiovascular disease and mortality were evaluated with Cox proportional hazard regression. RESULTS The study population consisted of 69,532 patients with type 2 diabetes without cardiovascular disease. When comparing patients with microalbuminuria to patients with normoalbuminuria, in an analysis adjusted for cardiovascular risk factors, we found hazard ratios of 1.28 (95% confidence interval [CI], 1.07-1.52), 1.34 (95% CI, 1.10-1.62), and 1.48 (95% CI, 1.36-1.61) for ischemic stroke, myocardial infarction, and all-cause mortality, respectively. For macroalbuminuria, the hazard ratios were 1.81 (95% CI, 1.46-2.23), 1.99 (95% CI, 1.59-2.48), and 1.83 (95% CI, 1.64-2.04). Similar results were found after adjusting for concomitant medication. CONCLUSIONS This study showed that albuminuria level is associated with higher risk of incident ischemic stroke, myocardial infarction, and all-cause mortality in Type 2 diabetes patients without overt cardiovascular disease.
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Affiliation(s)
- Mia Vicki Fangel
- Center for General Practice at Aalborg University, Aalborg, Denmark.
| | - Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Cardiology, Atrial Fibrillation Study Group, Aalborg University Hospital, Aalborg, Denmark
| | | | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Cardiology, Atrial Fibrillation Study Group, Aalborg University Hospital, Aalborg, Denmark
| | - Thure Filskov Overvad
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Medicine, North Denmark Regional Hospital, Hjørring, Denmark
| | - Gregory Yh Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
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Mottl AK, Buse JB, Ismail-Beigi F, Sigal RJ, Pedley CF, Papademetriou V, Simmons DL, Katz L, Mychaleckyj JC, Craven TE. Long-Term Effects of Intensive Glycemic and Blood Pressure Control and Fenofibrate Use on Kidney Outcomes. Clin J Am Soc Nephrol 2018; 13:1693-1702. [PMID: 30361335 PMCID: PMC6237052 DOI: 10.2215/cjn.06200518] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 08/16/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES In people with type 2 diabetes, aggressive control of glycemia, BP, and lipids have resulted in conflicting short-term (<5 years) kidney outcomes. We aimed to determine the long-term kidney effects of these interventions. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Action to Control Cardiovascular Risk in Diabetes (ACCORD) was a multifactorial intervention study in people with type 2 diabetes at high risk for cardiovascular disease (n=10,251), to examine the effects of intensive glycemic control (hemoglobin A1c <6.0% versus 7%-7.9%), BP control (systolic BP <120 mm Hg versus <140 mm Hg) or fenofibrate versus placebo added to simvastatin on cardiovascular events and death. The glycemia trial lasted 3.7 years and participants were followed for another 6.5 years in ACCORDION, the ACCORD Follow-On Study. The post hoc primary composite kidney outcome was defined as incident macroalbuminuria, creatinine doubling, need for dialysis, or death by any cause. Cox proportional hazards regression estimated the effect of each intervention on the composite outcome and individual components. In secondary outcome analyses, competing risk regression was used to account for the risk of death in incident kidney outcomes. Analyses were adjusted for sociodemographics, randomization groups, and clinical factors. RESULTS There were 988 cases of incident macroalbuminuria, 954 with doubling of creatinine, 351 requiring dialysis, and 1905 deaths. Hazard ratios (HRs) for the composite outcome with intensive glycemic, BP control, and fenofibrate use compared with standard therapy were 0.92 (95% confidence interval [95% CI], 0.86 to 0.98), 1.16 (95% CI, 1.05 to 1.28), and 1.16 (95% CI, 1.06 to 1.27). Multivariable, secondary outcome analyses showed that in the glycemia trial, only macroalbuminuria was significantly decreased (HR, 0.68; 95% CI, 0.59 to 0.77). In the BP and lipid trials, only creatinine doubling was affected (HR, 1.64; 95% CI, 1.30 to 2.06 and HR, 2.00; 95% CI, 1.61 to 2.49, respectively). CONCLUSIONS In people with type 2 diabetes at high risk for cardiovascular disease, intensive glycemic control may result in a long-term reduction in macroalbuminuria; however, intensive BP control and fenofibrates may increase the risk for adverse kidney events.
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Affiliation(s)
| | - John B. Buse
- University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Ronald J. Sigal
- Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carolyn F. Pedley
- General Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | | | - Debra L. Simmons
- Division of Endocrinology, Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Lois Katz
- Veterans Affairs New York Harbor Healthcare System, New York, New York
| | - Josyf C. Mychaleckyj
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia; and
| | - Timothy E. Craven
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Aisa MC, Cappuccini B, Barbati A, Orlacchio A, Baglioni M, Di Renzo GC. Biochemical parameters of renal impairment/injury and surrogate markers of nephron number in intrauterine growth-restricted and preterm neonates at 30-40 days of postnatal corrected age. Pediatr Nephrol 2016; 31:2277-2287. [PMID: 27557556 DOI: 10.1007/s00467-016-3484-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 07/31/2016] [Accepted: 08/02/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Premature and/or intrauterine growth-restricted neonates have an increased risk of developing postnatal renal injuries in later life. Studies on renal physiology in these neonates at a corrected age of 30-40 days are scarce and mostly relate to preterm infants. The data from these studies often lack the results of correlation analyses between biochemical parameters and nephron number-data which could provide additional insight and/or improve recognition of individuals at higher risk of renal failure. METHODS Urinary total protein and albumin levels and N-acetyl-β-D-glucosaminidase and cathepsin B activity were evaluated in preterm and intrauterine growth-restricted infants at a corrected age of 30-40 days and compared to data from a healthy control neonate population. The data were then associated with predominant susceptibility factors of renal damage related to low nephron number, such as gestational age, birth weight, total renal volume and renal cortex volume. RESULTS Compared to the control neonate population, we found significantly increased levels of all biochemical parameters tested in the intrauterine growth-restricted neonates, whereas in the preterm infants we observed a significant increase in cathepsin B activity, total protein level and, to a lesser extent, albumin level. Cathepsin B activity showed a significant, strong and inverse correlation with all surrogate markers of nephron number and was also strongly and positively correlated with urinary albumin level. CONCLUSIONS At this postnatal age, we found that lower nephron number in low birth weight neonates was associated to tubular impairment/injury that could be concurrent with a dysfunction of glomerular permeability. Urinary cathepsin B activity may be a candidate marker for the early prediction of renal susceptibility to damage in low birth weight neonates.
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Affiliation(s)
- Maria Cristina Aisa
- Section of Obstetrics and Gynecology, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy. .,Section of Biochemistry, Department of Agricultural Sciences, Food and Environment, University of Perugia, Perugia, Italy.
| | - Benito Cappuccini
- Department of Neonatology, Hospital S. M. della Misericordia, Perugia, Italy.,Centre of Perinatal Medicine, University of Perugia, Perugia, Italy.,GeBiSa, Research Foundation, Perugia, Italy
| | - Antonella Barbati
- Section of Obstetrics and Gynecology, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Aldo Orlacchio
- Centre of Perinatal Medicine, University of Perugia, Perugia, Italy.,GeBiSa, Research Foundation, Perugia, Italy
| | | | - Gian Carlo Di Renzo
- Section of Obstetrics and Gynecology, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy.,Centre of Perinatal Medicine, University of Perugia, Perugia, Italy.,GeBiSa, Research Foundation, Perugia, Italy
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Kröpelin TF, de Zeeuw D, Remuzzi G, Bilous R, Parving HH, Heerspink HJL. Determining the Optimal Protocol for Measuring an Albuminuria Class Transition in Clinical Trials in Diabetic Kidney Disease. J Am Soc Nephrol 2016; 27:3405-3412. [PMID: 27056294 DOI: 10.1681/asn.2015101150] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 03/04/2016] [Indexed: 11/03/2022] Open
Abstract
Albuminuria class transition (normo- to micro- to macroalbuminuria) is used as an intermediate end point to assess renoprotective drug efficacy. However, definitions of such class transition vary between trials. To determine the most optimal protocol, we evaluated the approaches used in four clinical trials testing the effect of renin-angiotensin-aldosterone system intervention on albuminuria class transition in patients with diabetes: the BENEDICT, the DIRECT, the ALTITUDE, and the IRMA-2 Trial. The definition of albuminuria class transition used in each trial differed from the definitions used in the other trials by the number (one, two, or three) of consecutively collected urine samples at each study visit, the time interval between study visits, the requirement of an additional visit to confirm the class transition, and the requirement of a percentage increase in albuminuria from baseline in addition to the class transition. In Cox regression analysis, neither increasing the number of urine samples collected at a single study visit nor differences in the other variables used to define albuminuria class transition altered the average drug effect. However, the SEM of the treatment effect increased (decreased precision) with stricter end point definitions, resulting in a loss of statistical significance. In conclusion, the optimal albuminuria transition end point for use in drug intervention trials can be determined with a single urine collection for albuminuria assessment per study visit. A confirmation of the end point or a requirement of a minimal percentage change in albuminuria from baseline seems unnecessary.
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Affiliation(s)
- Tobias F Kröpelin
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Giuseppe Remuzzi
- Unit of Nephrology and Dialysis, Azienda Ospedaliera Papa Giovanni XXIII, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy.,Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Rudy Bilous
- Institute of Cellular Medicine, Newcastle University, Middlesbrough, United Kingdom; and
| | - Hans-Henrik Parving
- Department of Medical Endocrinology, Rigshospitalet University Hospital of Copenhagen, Copenhagen, Denmark
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands;
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Consecutive first-morning urine samples to measure change in the albumin-to-creatinine ratio: a pilot study of a home urine collection protocol. Can J Kidney Health Dis 2016; 3:3. [PMID: 26835152 PMCID: PMC4734866 DOI: 10.1186/s40697-016-0095-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 01/05/2016] [Indexed: 01/13/2023] Open
Abstract
Background Multiple first-morning urine samples are recommended for measuring the urine albumin-to-creatinine ratio (ACR); however, this can be challenging in community-based research. Methods The objectives of the study are to pilot-test a home urine collection protocol and examine how the average and variance of ACR varied with the number of urine collections and time to laboratory analysis. This is a prospective observational pilot study. This study was conducted in London, Ontario, Canada at the London Health Sciences Centre (2012–2013). The patients were adults with chronic kidney disease (mean estimated glomerular filtration rate, 36 mL/min/1.73 m2). Participants collected a first-morning 20-mL urine sample on three consecutive days. This process was repeated after 3 months. Samples were picked up by hospital courier and analyzed for ACR on the same day; additional aliquots were analyzed after a delay of 24–48 h (stored at 4 °C) and 3–9 months (stored at –80 °C). The geometric mean of the percentage change in ACR between baseline and 3 months was calculated and compared between single samples and the average of two vs. three consecutive samples. Results Of 31 patients enrolled, 26 (83.9 %) submitted all six urine samples. The geometric mean of ACR for three consecutive samples at baseline was 87, 83, and 80 mg/mmol, and the corresponding percentage increase from baseline to 3 months was 15 % (95 % confidence interval (CI), −9 to 46 %), 33 % (95 % CI, 10 to 59 %), and 22 % (95 % CI, −6 to 57 %). Compared with single urine collections at baseline and follow-up, averaging ACR values from two consecutive first-morning urine samples improved the sample variance and reduced the required sample size to detect a given treatment effect by approximately 30 %. No further gain in statistical efficiency was achieved with three urine samples. Results were similar when the laboratory analysis was delayed by 24–48 h, but a delay of 3–9 months resulted in systematic overestimation of the ACR. Our study’s generalizability is limited by its small sample size and reliance on a clinic-based population from a single urban center. Conclusions We successfully used a home urine collection protocol to obtain multiple first-morning urine samples in patients with chronic kidney disease. Statistical efficiency was improved by averaging ACR values from two consecutive first-morning urine samples at baseline and follow-up.
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Kröpelin TF, de Zeeuw D, Andress DL, Bijlsma MJ, Persson F, Parving HH, Heerspink HJL. Number and frequency of albuminuria measurements in clinical trials in diabetic nephropathy. Clin J Am Soc Nephrol 2015; 10:410-6. [PMID: 25568217 PMCID: PMC4348688 DOI: 10.2215/cjn.07780814] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 11/26/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Albuminuria change is often used to assess drug efficacy in intervention trials in nephrology. The change is often calculated using a variable number of urine samples collected at baseline and end of treatment. Yet more albuminuria measurements usually occur. Because albuminuria shows a large day-to-day variability, this study assessed to what extent the average and the precision of the antialbuminuric drug effect varies with the number of urine collections at each visit and the number of follow-up visits. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study used data from three randomized intervention trials (Aliskiren Combined with Losartan in Type 2 Diabetes and Nephropathy, Selective Vitamin D Receptor Activation for Albuminuria Lowering, and Residual Albuminuria Lowering with Endothelin Antagonist Atrasentan) including patients with type 2 diabetes and macroalbuminuria. Albuminuria-lowering drug effects were estimated from one, two, or three urine collections at consecutive days before each study visit and reported as albuminuria change from baseline to end of treatment or the change over time considering an average of all follow-up albuminuria measurements. RESULTS Increasing the number of urine collections for an albuminuria measurement at baseline and end of treatment or using all study visits during follow-up did not alter the average drug effect. The precision of the drug effect increased (decreased SEM) when the number of study visits and the number of urine collections per visit were increased. Using all albuminuria measurements at all study visits led to a 4- to 6-fold reduction in sample size to detect a 30% albuminuria-lowering treatment effect with 80% power compared with using baseline and end-of-treatment albuminuria measurements alone. CONCLUSIONS Increasing the number of urine collections per study visit and the number of visits over time does not change the average drug effect estimate but markedly increases the precision, thereby enhancing statistical power. Thus, clinical trial designs in diabetic nephropathy using albuminuria as an end point can be significantly improved, leading to smaller sample sizes and less complex trials.
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Affiliation(s)
- Tobias F Kröpelin
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Maarten J Bijlsma
- Pharmacoepidemiology and Pharmacoeconomics Unit, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | | | - Hans-Henrik Parving
- Department of Medical Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; and Faculty of Health Science, Aarhus University, Aarhus, Denmark
| | - Hiddo J Lambers Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands;
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Zemaitis P, Liu K, Jacobs DR, Cushman M, Durazo-Arvizu R, Shoham D, Palmas W, Cooper R, Kramer H. Cumulative systolic BP and changes in urine albumin-to-creatinine ratios in nondiabetic participants of the multi-ethnic study of atherosclerosis. Clin J Am Soc Nephrol 2014; 9:1922-9. [PMID: 25200476 DOI: 10.2215/cjn.02450314] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Cumulative exposure to elevated systolic BP (cumSBP) may affect progression of urine albumin excretion in the absence of diabetes. The objective of this study was to examine the association between cumSBP exposure and progression of spot urine albumin-to-creatinine ratio (UACR) in a multi-ethnic cohort of adults without diabetes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The analysis included 3789 participants without severely increased urine albumin excretion or diabetes in the Multi-Ethnic Study of Atherosclerosis, a cohort of 6814 adults aged 45-84 years. UACR was measured at baseline and approximately 1.6, 3.1, and 9.4 years after the baseline examination. cumSBP was calculated as the summed average systolic BP (SBP; mmHg) between two consecutive examinations multiplied by the time between the two examinations (mmHg × year) and categorized as ≤ 1128 (SBP<120 mmHg), 1129-1222 (SBP ≥ 120-129 mmHg), 1223-1316 (SBP ≥ 130-130 mmHg), and > 1316 (SBP ≥ 140 mmHg). Baseline UACR was categori zed as normal, mildly increased, or moderately increased, and definite progression of UACR was defined as a persistently higher UACR category at subsequent examinations. No UACR progression was defined as remaining in the same UACR category across all examinations or regressing. RESULTS In fully adjusted models, compared with cumSBP ≤ 1128 mmHg, cumSBP 1223-1316 and >1316 mmHg was associated with a 85% and 130% significantly higher odds of definite UACR progression (95% confidence interval, 24% to 178% and 56% to 243%, respectively) versus no UACR progression. Every 100-mmHg higher level of cumSBP was associated with a 1.23-fold higher odds of definite UACR progression (95% confidence interval, 1.13 to 1.34) versus no UACR progression. CONCLUSION Exposure to higher cumSBP was associated with increased UACR progression among adults without diabetes.
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Affiliation(s)
| | - Kiang Liu
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David R Jacobs
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota; Department of Nutrition, University of Oslo, Oslo, Norway
| | - Mary Cushman
- Department of Pathology, University of Vermont, Colchester, Vermont; and
| | | | | | - Walter Palmas
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Holly Kramer
- Department of Public Health Sciences and Department of Medicine, Division of Nephrology and Hypertension, Loyola University Health Sciences Center, Maywood, Illinois;
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Hanh Tien NT, Lam PK, Duyen HTL, Ngoc TV, Ha PTT, Kieu NTT, Simmons C, Wolbers M, Wills B. Assessment of microalbuminuria for early diagnosis and risk prediction in dengue infections. PLoS One 2013; 8:e54538. [PMID: 23349922 PMCID: PMC3551767 DOI: 10.1371/journal.pone.0054538] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 12/13/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Dengue is the most important arboviral infection of humans. Following an initial febrile period, a small proportion of infected patients develop a vasculopathy, with children at particular risk for severe vascular leakage and shock. Differentiation between dengue and other common childhood illnesses is difficult during the early febrile phase, and risk prediction for development of shock is poor. The presence of microalbuminuria is recognized as a useful early predictor for subsequent complications in a number of other disorders with vascular involvement. Significant proteinuria occurs in association with dengue shock syndrome and it is possible that early-phase microalbuminuria may be helpful both for diagnosis of dengue and for identification of patients likely to develop severe disease. METHODOLOGY/PRINCIPAL FINDINGS We measured formal urine albumin to creatinine ratios (UACRs) in daily samples obtained from a large cohort of children with suspected dengue recruited at two outpatient clinics in Ho Chi Minh City, Vietnam. Although UACRs were increased in the 465 confirmed dengue patients, with a significant time trend showing peak values around the critical period for dengue-associated plasma leakage, urine albumin excretion was also increased in the comparison group of 391 patients with other febrile illnesses (OFI). The dengue patients generally had higher UACRs than the OFI patients, but microalbuminuria, using the conventional cutoff of 30 mg albumin/g creatinine discriminated poorly between the two diagnostic groups in the early febrile phase. Secondly UACRs did not prove useful in predicting either development of warning signs for severe dengue or need for hospitalization. CONCLUSION/SIGNIFICANCE Low-level albuminuria is common, even in relatively mild dengue infections, but is also present in many OFIs. Simple point-of-care UACR tests are unlikely to be useful for early diagnosis or risk prediction in dengue endemic areas.
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Affiliation(s)
- Nguyen Thi Hanh Tien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam
| | - Phung Khanh Lam
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam
| | - Huynh Thi Le Duyen
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam
| | - Tran Van Ngoc
- Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam
| | | | - Nguyen Tan Thanh Kieu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam
| | - Cameron Simmons
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Marcel Wolbers
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Bridget Wills
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Abstract
PURPOSE Although microalbuminuria is known as a predictor of clinical nephropathy and cardiomyopathy, few studies have investigated the incidence and reference range of microalbuminuria in healthy children. This study aimed to establish a reference range and to study the age-related trend for spot urine microalbumin/creatinine ratio in a Korean pediatric population. MATERIALS AND METHODS 352 healthy children were studied from July 2007 through March 2010. Height, weight, serum creatinine, spot urine microalbumin/creatinine ratio, and glomerular filtration rate (GFR) were obtained for each subject. We divided the study population into 5 groups according to age, and compared the spot urine microalbumin/creatinine ratio with other variables using one-way analysis of variance (ANOVA), regression analysis and Pearson's correlation analysis. RESULTS In this study, the data showed that the spot urine microalbumin/creatinine ratio decreased with age: 1-12 months, 22.72 ± 13.80 mg/mmol (2SD: 3.33-54.40 mg/mmol); 13-28 months, 16.34 ± 9.58 mg/mmol (2SD: 3.16-35.19 mg/mmol); 29-48 months, 13.12 ± 9.74 mg/mmol (2SD: 3.01-41.57 mg/mmol); 4-6 years, 10.58 ± 8.13 mg/mmol (2SD: 0.00-30.19 mg/mmol); and 7-19 years, 5.13±5.44 mg/mmol (2SD: 0.45-14.45 mg/mmol). The spot urine microalbumin/creatinine ratio showed correlation with age, height, height z-score, weight, weight z-score, GFR, body mass index (BMI) and body surface area (BSA). CONCLUSION The spot urine microalbumin/creatinine ratio in normal Korean children decreased with age. This ratio could potentially be used to establish reference ranges and cutoff values for Korean children and to predict nephropathy and cardiomyopathy.
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Affiliation(s)
- Byung Ok Kwak
- Department of Pediatrics, School of Medicine, Konkuk University, Gwangjin-gu, Seoul 143-729, Korea.
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Multicentric validation of proteomic biomarkers in urine specific for diabetic nephropathy. PLoS One 2010; 5:e13421. [PMID: 20975990 PMCID: PMC2958112 DOI: 10.1371/journal.pone.0013421] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 09/13/2010] [Indexed: 11/19/2022] Open
Abstract
Background Urine proteome analysis is rapidly emerging as a tool for diagnosis and prognosis in disease states. For diagnosis of diabetic nephropathy (DN), urinary proteome analysis was successfully applied in a pilot study. The validity of the previously established proteomic biomarkers with respect to the diagnostic and prognostic potential was assessed on a separate set of patients recruited at three different European centers. In this case-control study of 148 Caucasian patients with diabetes mellitus type 2 and duration ≥5 years, cases of DN were defined as albuminuria >300 mg/d and diabetic retinopathy (n = 66). Controls were matched for gender and diabetes duration (n = 82). Methodology/Principal Findings Proteome analysis was performed blinded using high-resolution capillary electrophoresis coupled with mass spectrometry (CE-MS). Data were evaluated employing the previously developed model for DN. Upon unblinding, the model for DN showed 93.8% sensitivity and 91.4% specificity, with an AUC of 0.948 (95% CI 0.898-0.978). Of 65 previously identified peptides, 60 were significantly different between cases and controls of this study. In <10% of cases and controls classification by proteome analysis not entirely resulted in the expected clinical outcome. Analysis of patient's subsequent clinical course revealed later progression to DN in some of the false positive classified DN control patients. Conclusions These data provide the first independent confirmation that profiling of the urinary proteome by CE-MS can adequately identify subjects with DN, supporting the generalizability of this approach. The data further establish urinary collagen fragments as biomarkers for diabetes-induced renal damage that may serve as earlier and more specific biomarkers than the currently used urinary albumin.
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Chadban S, Howell M, Twigg S, Thomas M, Jerums G, Cass A, Campbell D, Nicholls K, Tong A, Mangos G, Stack A, MacIsaac RJ, Girgis S, Colagiuri R, Colagiuri S, Craig J. Assessment of kidney function in type 2 diabetes. Nephrology (Carlton) 2010; 15 Suppl 1:S146-61. [DOI: 10.1111/j.1440-1797.2010.01239.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Keijzer-Veen MG, Kleinveld HA, Lequin MH, Dekker FW, Nauta J, de Rijke YB, van der Heijden BJ. Renal function and size at young adult age after intrauterine growth restriction and very premature birth. Am J Kidney Dis 2007; 50:542-51. [PMID: 17900453 DOI: 10.1053/j.ajkd.2007.06.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2006] [Accepted: 06/13/2007] [Indexed: 01/08/2023]
Abstract
BACKGROUND Premature birth and intrauterine growth restriction may increase the risk of developing renal disease at adult age. Renal function may already be impaired at young adult age. STUDY DESIGN Cross-sectional study. SETTING & PARTICIPANTS Very premature individuals (gestational age < 32 weeks) recruited from Project on Premature and Small for Gestational Age Infants and full-term-born controls (37 to 42 weeks) recruited from a children's hospital in Rotterdam, The Netherlands. All individuals were 20 years of age at the time of study. PREDICTORS Gestational age and birth weight: premature and small for gestational age (SGA; n = 23), premature and appropriate for gestational age (n = 29), and controls (n = 30). OUTCOMES & MEASUREMENTS Glomerular filtration rate (GFR), effective renal plasma flow (ERPF), and filtration fraction before and after renal stimulation with low-dose dopamine infusion and oral amino-acid intake. Urine albumin and renal ultrasound. RESULTS Height, weight, kidney length and volume, GFR, and ERPF were significantly lower in the SGA group than in controls. After adjustment for body surface area, GFR did not differ significantly among groups. Mean ERPF was 71 mL/min/1.73 m(2) (95% confidence interval [CI], 3 to 139) less, but filtration fraction was only 1.3% (95% CI, -0.3 to 3.0) greater, in the SGA group than controls. Renal stimulation significantly increased GFR and ERPF and decreased filtration fraction in all groups. After renal stimulation, ERPF was 130 mL/min/1.73 m(2) (95% CI, 21 to 238) greater in the SGA group than controls, but GFR and filtration fraction did not differ significantly among groups. Microalbuminuria was present in 2 patients (8.7%) in the SGA group, but none in the appropriate-for-gestational-age group or controls. Renal function correlated with renal size. LIMITATIONS Small sample size. CONCLUSIONS Our findings do not fully support the hypothesis that preterm birth in combination with intrauterine growth restriction contributes to renal function alterations at young adult age. Larger studies are needed to evaluate this hypothesis.
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Affiliation(s)
- Mandy G Keijzer-Veen
- Department of Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, The Netherlands.
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Ghoddousi H, Edler R, Haers P, Wertheim D, Greenhill D. Comparison of three methods of facial measurement. Int J Oral Maxillofac Surg 2007; 36:250-8. [PMID: 17113754 DOI: 10.1016/j.ijom.2006.10.001] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Revised: 08/16/2006] [Accepted: 10/03/2006] [Indexed: 11/17/2022]
Abstract
The aims of this study were to assess the accuracy of measurements recorded by 3D stereophotogrammetry and to compare three methods of facial measurement: manual anthropometry, 3D stereophotogrammetry and 2D photography. Measurements were taken from 14 landmarks on each of six volunteers and compared. In addition, the variability of the methods was assessed. Three-dimensional measurements were shown to compare well with manual measurements on volunteers as well as test objects for which the mean difference was 0.23 mm (shortest distance) and 0.13 mm (surface). All the three methods of measurement were found to have good levels of repeatability. Two-dimensional measurements were more variable than manual measurements (P=0.021). Three-dimensional stereophotogrammetric measurements were shown to compare well with manual measurements although the values obtained were mostly slightly larger. Stereophotogrammetry allows images to be taken in a Medical Photography Department, facilitating the accurate measurement of facial morphology from digitized data, including changes associated with treatment or growth. There are clear potential benefits of using 3D measurements in the assessment of facial deformity.
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Affiliation(s)
- H Ghoddousi
- South Thames Cleft Service, Floor 12, Guy's Tower, Guy's Hospital, London Bridge, London SE1 9RT, UK.
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Keijzer-Veen MG, Schrevel M, Finken MJJ, Dekker FW, Nauta J, Hille ETM, Frölich M, van der Heijden BJ. Microalbuminuria and Lower Glomerular Filtration Rate at Young Adult Age in Subjects Born Very Premature and after Intrauterine Growth Retardation. J Am Soc Nephrol 2005; 16:2762-8. [PMID: 15987756 DOI: 10.1681/asn.2004090783] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This prospective follow-up study of 422 19-yr-old subjects born very preterm in The Netherlands was performed to determine whether intrauterine growth retardation (IUGR) predisposes to abnormal GFR and microalbuminuria in adolescents. GFR (ml/min per 1.73 m2) was estimated using the Cockcroft-Gault equation, and albumin-creatinine ratio (mg/mmol) was calculated in a cohort of 19-yr-old subjects born very preterm (gestational age <32 wk) in 1983. Birth weights were adjusted for gestational age and expressed as standard deviation scores (sds) as a measure of IUGR. All subjects had normal renal function. Birth weight (sds) was associated negatively with serum creatinine concentration (micromol/L) (beta = -1.0 micromol/L, 95% confidence interval [CI]: -1.9 to -0.2), positively with GFR (beta = 3.0, 95% CI: 1.7 to 4.2), and negatively with the logarithm of albumin-creatinine ratio (beta = -0.05, 95% CI: -0.09 to -0.01) in young adults born very preterm. IUGR is associated with unfavorable renal functions at young adult age in subjects born very premature. These data suggest that intrauterine growth-retarded subjects born very premature have an increased risk to develop progressive renal failure in later life.
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Affiliation(s)
- Mandy G Keijzer-Veen
- Department Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Hernández C, Simó R. Albumin excretion rate is not affected by asymptomatic urinary tract infection: a prospective study. Diabetes Care 2004; 27:1565-9. [PMID: 15220229 DOI: 10.2337/diacare.27.7.1565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of the study was to evaluate whether asymptomatic urinary tract infection (UTI) significantly influences the level of albumin excretion rate (AER) in diabetic patients. RESEARCH DESIGN AND METHODS We screened prospectively for UTI and AER in 765 type 2 diabetic subjects. AER was determined before and after antimicrobial therapy in those patients in whom an asymptomatic UTI was diagnosed (n = 59). To interpret the clinical significance of AER changes, the coefficient of biological variation (CVb) of the AER (CVb-AER) was assessed in a control group of type 2 diabetic patients without UTI (n = 56). RESULTS AER did not change after antimicrobial treatment either in the whole group of patients with UTI (pre: 13.8 microg/min [0.1-195] vs. post: 8.5 microg/min [0.1-185]; P = 0.1) or in those patients in whom the infection was eradicated (pre: 11.7 microg/min [0.1-195] vs. post: 7.1 microg/min [0.1-185]; NS). The CVb-AER was 64% in the control group and was inversely correlated with AER (r = -0.44; P = 0.001). The decrease of AER after antimicrobial therapy (55%) did not exceed the biological variation of AER (64%). Finally, UTI did not significantly influence the classification of diabetic patients as normo- or microalbuminuric. CONCLUSIONS Asymptomatic UTI does not increase AER in type 2 diabetic patients. Therefore, our results suggest that testing for UTI is not necessary when AER is measured in diabetic patients.
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Affiliation(s)
- Cristina Hernández
- Diabetes Research Unit, Division of Endocrinology, Hospital Universitari Vall d'Hebron, Pg. Vall d'Hebron, Barcelona, Spain
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