Increasing incidence of proteinuria and declining incidence of end-stage renal disease in diabetic Pima Indians

Comprehending the Role of Metabolic and Hemodynamic Factors Alongside Different Signaling Pathways in the Pathogenesis of Diabetic Nephropathy

Diabetic nephropathy (DN) is a progressive microvascular disorder of diabetes that contributes as a primary reason for end-stage renal disease worldwide. The pathological hallmarks of DN include diffuse mesangial expansion, thicker basement membrane of glomeruli, and arteriole hyalinosis. Hypertension and chronic hyperglycemia are the primary risk factors contributing to the occurrence of DN. The complex pathophysiology of DN involves the interplay amongst metabolic and hemodynamic pathways, growth factors and cytokines production, oxidative stress, and ultimately impaired kidney function. Hyperglycemia-induced vascular dysfunction is the main pathological mechanism that initiates DN. However, several other pathogenic mechanisms, such as oxidative stress, inflammatory cell infiltration, and fibrosis, contribute to disease progression. Different vasoactive hormone processes, including endothelin and renin-angiotensin, are activated as a part of the pathophysiology of DN, which also involves increased intraglomerular and systemic pressure. The pathophysiology of DN will continue to be better understood because of recent developments in genomics and molecular biology, but attempts to develop a comprehensive theory that explains all existing cellular and biochemical pathways have been thwarted by the disease's multifactorial nature. This review extensively discusses the current understanding regarding the metabolic and hemodynamic pathological mechanisms, along with other signaling pathways and molecules responsible for the pathogenesis of DN. This work will encourage a greater in-depth understanding and investigation of the present status of the biochemical mechanistic processes underlying the pathogenesis of DN, which may assist in the determination of different biomarkers and help in the design and development of novel drug candidates in the near future.

Prevalence of Diabetic Macular Edema Using Optical Coherence Tomography in Type 2 Diabetics With Nephropathy in Comparison With Type 2 Diabetics Without Nephropathy

INTRODUCTION

 The primary vision-threatening complication in patients with diabetic retinopathy (DR) is diabetic macular edema (DME). Diabetic nephropathy (DN) often has DR that threatens their vision and has a risk of developing DME. Hence, the presence of DN could be the only risk factor for developing DME without the presence of other factors. Hence, this study proposes to predict the prevalence of DME using optical coherence tomography (OCT) in type 2 diabetics with nephropathy in comparison with diabetics without nephropathy.

METHODS

This is a cross-sectional study done on patients visiting the Ophthalmology Department at Saveetha Medical College and Hospital, Chennai, for one year. A total of 120 patients were included in the study, with 60 diabetic patients without nephropathy in Group 1 and 60 diabetic patients with nephropathy in Group 2. A detailed history was recorded. Their recent blood reports of fasting blood sugar, postprandial blood sugar, hemoglobin A1c (HbA1c), renal function test, and urine protein/creatinine ratio were all noted. Chronic kidney disease (CKD) staging in nephropathy patients as done by the nephrologist was also documented. The best corrected visual acuity (BCVA) was assessed for distant and near vision. A slit lamp examination and dilated fundus examination were done. Fundus findings were independently graded according to the Early Treatment Diabetic Retinopathy Study (ETDRS) classification. OCT was done in all patients to confirm DME.

RESULTS

In our study. males and females were 60 each in number. The majority of patients (32.5%) were >70 years old. A small percentage of patients (1.7%) in Group 1 had DM of >10 years, and 41.7% of the patients in Group 2 had DM of >10 years. Meanwhile, 73.3% of the patients in Group 1 had an HbA1c level between 6% and 7.5%, and 83.3% of the patients in Group 2 had an HbA1c level >7.5%. The percentage of patients with DME in Group 1 was 1.7%, and that in Group 2 was 21.7%. The majority of patients who had BCVA of 6/6 were in Group 1. The majority of patients with DME (46.4%) had stage V nephropathy.

CONCLUSION

The coexistence of nephropathy in diabetic patients increases the incidence of DME. With long-standing diabetes and uncontrolled blood sugar levels being risk factors for developing DN and subsequently DME, such patients are to be screened regularly and advised on adequate glycemic control for achieving good visual prognosis and limit retinopathy progression. Moreover, the severity of DN should be kept in mind by nephrologists, and patients are to be promptly referred to the ophthalmology department for complete evaluation.

Interpretable subgroup learning-based modeling framework: Study of diabetic kidney disease prediction

OBJECTIVES

Complex diseases, like diabetic kidney disease (DKD), often exhibit heterogeneity, challenging accurate risk prediction with machine learning. Traditional global models ignore patient differences, and subgroup learning lacks interpretability and predictive efficiency. This study introduces the Interpretable Subgroup Learning-based Modeling (iSLIM) framework to address these issues.

METHODS

iSLIM integrates expert knowledge with a tree-based recursive partitioning approach to identify DKD subgroups within an EHR dataset of 11,559 patients. It then constructs separate models for each subgroup, enhancing predictive accuracy while preserving interpretability.

RESULTS

Five clinically relevant subgroups are identified, achieving an average sensitivity of 0.8074, outperforming a single global model by 0.1104. Post hoc analyses provide pathological and biological evidence supporting subgroup validity and potential DKD risk factors.

CONCLUSION

The iSLIM surpasses traditional global model in predictive performance and subgroup-specific risk factor interpretation, enhancing the understanding of DKD's heterogeneous mechanisms and potentially increasing the adoption of machine learning models in clinical decision-making.

Insulin resistance before type 2 diabetes onset is associated with increased risk of albuminuria after diabetes onset: A prospective cohort study

AIM

Reduced renal insulin signalling is implicated in the pathogenesis of albuminuria. We sought to investigate whether insulin action and secretion, measured before diabetes onset, are associated with the development of albuminuria after diabetes onset.

MATERIALS AND METHODS

Baseline body composition, insulin sensitivity by hyperinsulinaemic-euglycaemic clamp at submaximal and maximal insulin stimulation (240 and 2400 pmol/m2/min; M-low and M-high), and insulin secretion by intravenous glucose tolerance test [acute insulin response (AIR)] were measured in 170 Southwestern Indigenous American adults who subsequently developed diabetes. After diabetes onset and during the median follow-up of 13.6 years, 81 participants (48%) developed albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g). Separate associations of M-low, M-high and AIR (per 1-SD change) with the risk of albuminuria were assessed by Cox regression models adjusted for age, sex and body fat (%).

RESULTS

Participants who developed albuminuria were of similar age (26.4 ± 5.4 vs. 27.5 ± 6.1 years), sex (46% vs. 48% male), body fat (36.4 ± 7.5 vs. 35.7 ± 7.9%) and AIR [2.3 ± 0.3 vs. 2.3 ± 0.3, pmol/L (log)] as those who did not develop albuminuria but had lower insulin sensitivity [M-low: 0.33 ± 0.08 vs. 0.36 ± 0.12, p = .03; M-high: 0.87 ± 0.11 vs. 0.91 ± 0.12, p = .02; mg/kg-metabolic body size/min (log)]. In separate adjusted models, lower M-low and M-high were both associated with an increased risk for albuminuria [hazard ratio (HR) 1.51, 95% confidence interval (CI) 1.14, 2.00, p = .004; HR 1.31, 95% CI 1.06, 1.63, p = .01), whereas AIR was not (HR 1.15, 95% CI 0.87, 1.56, p = .3).

CONCLUSIONS

Lower insulin sensitivity is associated with the development of albuminuria, suggesting a role for insulin signalling in the pathogenesis of proteinuria.

A Quest for Potential Role of Vitamin D in Type II Diabetes Mellitus Induced Diabetic Kidney Disease

Diabetes mellitus is a metabolic disorder characterized by high blood sugar levels. In recent years, T2DM has become a worldwide health issue due to an increase in incidence and prevalence. Diabetic kidney disease (DKD) is one of the devastating consequences of diabetes, especially owing to T2DM and the key clinical manifestation of DKD is weakened renal function and progressive proteinuria. DKD affects approximately 1/3rd of patients with diabetes mellitus, and T2DM is the predominant cause of end-stage kidney disease (ESKD). Several lines of studies have observed the association between vitamin D deficiency and the progression and etiology of type II diabetes mellitus. Emerging experimental evidence has shown that T2DM is associated with various kinds of kidney diseases. Recent evidence has also shown that an alteration in VDR (vitamin D receptor) signaling in podocytes leads to DKD. The present review aims to examine vitamin D metabolism and its correlation with T2DM. Furthermore, we discuss the potential role of vitamin D and VDR in diabetic kidney disease.

Pima Indian Contributions to Our Understanding of Diabetic Kidney Disease

Prospective studies in informative populations are crucial to increasing our knowledge of disease. In this perspective, we describe a half century of studies in an American Indian population that transformed our understanding of kidney disease in type 2 diabetes, now recognized as the leading cause of kidney failure worldwide. Serial examinations conducted for many years that included the collection of data and samples across multiple domains captured an unprecedented volume of clinical, physiologic, morphometric, genomic, and transcriptomic data. This work permitted us to extensively characterize the course and determinants of diabetic kidney disease, its pathophysiologic underpinnings, and important secular trends of urgent concern to populations worldwide, including the emergence of youth-onset type 2 diabetes and its effect on development of diabetic kidney disease in midlife. By combining these data using the tools of integrative biology, we are developing new mechanistic insights into the development and progression of diabetic kidney disease in type 2 diabetes. These insights have already contributed to the identification and successful therapeutic targeting of a novel pathway in DKD. We anticipate that this work will continue to expand our understanding of this complex disease and influence its management in the coming years.

Diabetic kidney disease in patients with type 2 diabetes mellitus: a cross-sectional study

Aim

Diabetic kidney disease (DKD) is a major long-term complication of diabetes mellitus (DM). Given the paucity of data on DKD in Jordan, we aimed to evaluate the prevalence, characteristics and correlates of DKD in Jordanian patients with type 2 DM.

Methods

This cross-sectional study included 1398 adult patients with type 2 DM who sought medical advice in the endocrinology clinic between March and September 2019. Demographic, clinical and laboratory data were reviewed. DKD was defined as reduced eGFR, and/or albuminuria. Three regression models were constructed to identify factors associated with CKD stages, albuminuria and DKD.

Results

Overall, 701 (50.14%) patients had DKD, with a median age of 59.71 ± 11.36  years. Older age, high triglycerides, and low high-density lipoprotein were associated with DKD (multivariable odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.01–1.03, p < 0.01; OR: 1.1, 95% CI: 1.01–1.2; and OR: 0.98, 95% CI: 0.97–0.99, p < 0.01 respectively). Metformin and renin-angiotensin system blockers were negatively associated with albuminuria and chronic kidney disease stages (p < 0.01).

Conclusion

Our study demonstrated that approximately one half of patients with type 2 DM had DKD. Further studies are necessary to understand this high prevalence and the underlying factors. Future research are needed to assess implementing targeted community-based intervention.

The expression profile of circANKRD36 and ANKRD36 as diagnostic biomarkers of chronic kidney disease in patients with type 2 diabetes mellitus

Background

The molecular mechanisms for chronic kidney disease (CKD) remain largely unknown and appear to be multifactorial. In the current study, we aimed to study the circulatory levels of circular ankyrin repeat domain 36 (circANKRD36) and ANKRD36 in Egyptian patients with type 2 diabetes mellitus (T2DM) and CKD and to explore their associations with the progression of CKD. This cross-sectional controlled study enrolled 60 patients with T2DM and 40 controls. Real-time polymerase chain reaction (RT-PCR) and real-time quantitative PCR (RT-qPCR) analyses were used to detect the expression levels of circANKRD36 and ANKRD36.

Results

Our results detected that the relative expression levels of circANKRD36 and ANKRD36 were significantly higher in patients with T2DM compared to controls. CircANKRD36 and ANKRD36 were significantly overexpressed in patients with macroalbuminuria (0.2316±0.096, 0.0086±0.0035, respectively) compared microalbuminuria (0.1347±0.032, 0.0037±0.0008, respectively) as well as normoalbuminuria (0.1261±0.018, 0.0027±0.0004, respectively), p˂0.001*.

Conclusion

The relative expression levels of circANKRD36 and ANKRD36 were significantly increased in patients with T2DM more specifically in patients with diabetic nephropathy (DN) and macroalbuminuria.

CD28 Genetic Variants Increase Susceptibility to Diabetic Kidney Disease in Chinese Patients with Type 2 Diabetes: A Cross-Sectional Case Control Study

Few studies have illuminated the genetic role of T cell costimulatory molecule CD28/CD80/CTLA4 variants in diabetic kidney disease (DKD) susceptibility. We aimed to investigate the causal role of genetic polymorphisms in CD28/CD80/CTLA4 with DKD susceptibility in patients with T2DM. A total of 3253 patients with T2DM were recruited for genotyping: including 204 DKD patients and 371 controls in stage 1 and 819 DKD patients and 563 controls in stage 2; besides, 1296 T2DM patients were selected for the analysis of association between loci and DKD-related traits. A subset of 227 T2DM patients (118 patients with DKD and 109 patients without DKD) from the total population above were selected to assess serum soluble CD28 (sCD28) levels. Then, we performed a candidate gene association study to identify single-nucleotide polymorphisms (SNPs) associated with DKD susceptibility and further used those SNPs to perform Mendelian randomization analyses of serum sCD28 level and DKD susceptibility. Under additive genetic models, CD28-rs3116494 (OR = 1.29 [95% CI 1.11, 1.51], P = 0.0011) and CD80-rs3850890 (OR = 1.16 [95% CI 1.02, 1.31], P = 0.0283) were associated with DKD susceptibility adjusted for age, gender, body mass index (BMI), duration of diabetes, and HbA1c. CD28-rs3116494 was associated with serum sCD28 level (β = 0.26 [95% CI 0.08, 0.44], P = 0.0043). The Mendelian randomization analysis showed that CD28-rs3116494 played a causal role in DKD by influencing serum sCD28 levels (β = 1.15 [95% CI 0.46, 1.83], P = 0.0010). In conclusion, we identified that two novel SNPs, CD28-rs3116494 and CD80-rs3850890, were associated with DKD susceptibility. Using the Mendelian randomization analysis, our study provided evidence for a causal relationship between serum CD28 levels and DKD with T2DM in the Chinese population.

Impact of chronic kidney disease definition on assessment of its incidence and risk factors in patients with newly diagnosed type 1 and type 2 diabetes in the UK: A cohort study using primary care data from the United Kingdom

AIM

To estimate the incidence and risk factors of chronic kidney disease (CKD) in patients with newly-diagnosed diabetes using different CKD definitions.

METHODS

Using UK primary care data, patients with diabetes (type 1, 4691; type 2, 109,365) and no CKD were followed to identify newly-diagnosed CKD, classified by a broad and narrow CKD definition (to capture diabetes-induced CKD, termed diabetic kidney disease, DKD). Adjusted incidence rates of CKD/DKD were calculated, and risk factors identified using Cox regression.

RESULTS

There were 404 CKD cases and 147 DKD cases among patients with type 1 diabetes (T1D), and 29,104 CKD cases, 9284 DKD cases among patients with type 2 diabetes (T2D). Adjusted incidence rates of CKD per 100 years were 5.4 (T1D) and 5.5 (T2D); for DKD they were 1.9 and 1.5, respectively. Risk factors for CKD/DKD were older age, high social deprivation, obesity, cardiovascular disease, hypertension and smoking. Poor glycaemic control in the year after diabetes diagnosis was a strong predictor of CKD/DKD occurrence beyond this first year, and a risk factor for CKD/DKD in T2D.

CONCLUSIONS

CKD and DKD remain common in diabetics in the decade after diagnosis. Early prevention of T2D and aggressive treatment of risk factors is urgent.

Renal histology in diabetic nephropathy predicts progression to end-stage kidney disease but not the rate of renal function decline

Background

While histopathologic changes correlate with functional impairment in cross-sectional studies of diabetic nephropathy (DN), whether these findings predict future rate of kidney function loss remains uncertain. We thus sought to examine the relationship between kidney histopathology, incidence of end-stage kidney disease (ESKD), and rate of estimated glomerular filtration rate (eGFR) loss in DN.

Methods

In this longitudinal cohort study, we studied 50 adults diagnosed with biopsy-proven DN. We analyzed the histopathologic parameters of each patient’s kidney biopsy, as defined by the Renal Pathology Society classification system for DN, and tracked all available eGFR measurements post-biopsy. We additionally collected baseline clinical parameters (at the time of biopsy), including eGFR, albumin-to-creatinine ratio (ACR), and hemoglobin A_1c. Multivariable linear regression was used to assess the relationship between histologic and clinical parameters at the time of the biopsy and eGFR slope. Kaplan-Meier curves and Cox regression were used to evaluate the association between histologic and clinical parameters and ESKD incidence.

Results

Progression to ESKD was associated with worsening interstitial fibrosis score (p = 0.05), lower baseline eGFR (p = 0.02), higher ACR (p = 0.001), and faster eGFR decline (p < 0.001). The rate of eGFR decline did not associate with any histologic parameter. Baseline ACR was the only studied variable correlating with eGFR slope (rho = − 0.41).

Conclusions

Renal histology predicts ultimate progression to ESKD, but not the rate of progression. Future work is required to identify novel predictors of rapid functional decline in patients with diabetic nephropathy.

Roles of kininogen-1, basement membrane specific heparan sulfate proteoglycan core protein, and roundabout homolog 4 as potential urinary protein biomarkers in diabetic nephropathy

Diabetic nephropathy, a major complication of diabetes mellitus (DM), is increasing worldwide and the large majority of patients have type 2 DM. Microalbuminuria has been used as a diagnostic marker of diabetic nephropathy. But owing to its insufficient sensitivity and specificity, other biomarkers are being sought. In addition, the pathophysiology of diabetic nephropathy is not fully understood and declines in renal function occur even without microalbuminuria. In this study, we investigated urinary proteins from three study groups (controls, and type 2 diabetic subjects with or without microalbuminuria). Non-targeted label-free Nano-LC QTOF analysis was conducted to discover underlying mechanisms and protein networks, and targeted label-free Nano-LC QTOF with SWATH was performed to qualify discovered protein candidates. Twenty-eight proteins were identified as candidates and functionally analyzed via String DB, gene ontology and pathway analysis. Four predictive mechanisms were analyzed: i) response to stimulus, ii) platelet activation, signaling and aggregation, iii) ECM-receptor interaction, and iv) angiogenesis. These mechanisms can provoke kidney dysfunction in type 2 diabetic patients via endothelial cell damage and glomerulus structural alteration. Based on these analyses, three proteins (kininogen-1, basement membrane-specific heparan sulfate proteoglycan core protein, and roundabout homolog 4) were proposed for further study as potential biomarkers. Our findings provide insights that may improve methods for both prevention and diagnosis of diabetic nephropathy.

Chronic kidney disease in type 2 diabetes: Implications for managing glycaemic control, cardiovascular and renal risk

This review examines the current literature relating to diabetes related kidney disease (DKD) and the optimal management of cardio-renal risk. DKD develops in approximately 40% of patients with type 2 diabetes mellitus. The mainstay of therapy is to reduce the progression of DKD by optimising hyperglycaemia, blood pressure, lipids and lifestyle. Evidence supports the role for renin-angiotensin system blockade in limiting the progression of DKD. Recent data from diabetes related cardiovascular outcome trials and renal specific trials have provided a novel insight on the additional benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in reducing the progression of DKD as well as cardiovascular risk. Lessons have been learnt from CREDENCE and there are expectations that DAPA-CKD and EMPA-KIDNEY will further support the benefits of SGLT2 inhibition in relation to DKD. As a consequence, international guidelines have been updated to reflect the positive benefits. In addition, novel steroidal mineralocorticoid receptor antagonists offer a potential role in future years. The review examines the current evidence and future approach to optimising outcomes for renal protection in patients with diabetes.

Diabetic nephropathy: recent advances in pathophysiology and challenges in dietary management

BACKGROUND

Diabetic nephropathy (DN) or diabetic kidney disease refers to the deterioration of kidney function seen in chronic type 1 and type 2 diabetes mellitus patients. The progression of the disease is known to occur in a series of stages and is linked to glycemic and blood pressure control. However, despite aggressive blood sugar control the prevalence of chronic kidney disease (CKD) in diabetic patients has not witnessed any decrease in the last two decades; which has lead to identification of additional factors in its progression. The nutritional status of patients is an important and modifiable factor that may influence CKD processes and outcome. It directly stems from the traditional dietary choices that patients make due to poor nutritional awareness. Dietary management of DN patients is challenging, as the twin factors of diet overload on kidney function needs to be balanced with malnutrition. Patient education seems to be the key in avoiding overindulgence of carbohydrate and protein-rich foods while favoring inclusion of essential fats in their diet.

CONCLUSION

This review will summarize current advances in staging and molecular pathogenesis of DN. It will highlight recent studies focusing on patient-customized dietary interventions that offer new hope as an effective tool in improving quality of life and delaying disease progression in DN patients.

Prevalence of chronic kidney disease using estimated glomerular filtration rate among diabetes patients attending a tertiary clinic in Botswana

OBJECTIVES

Diabetes mellitus (DM) is one of the most common contributors of chronic kidney disease (CKD). The epidemiology of CKD, a concern among patients with DM, has not been studied in Botswana. Consequently, the objective of this study was to estimate its prevalence among these patients in Botswana to provide future guidance to both government personnel and physicians.

METHODS

Observational cross-sectional study in a leading clinic in Botswana. Demographic and clinical data were obtained from patients through interviews and from their notes using a standard questionnaire. The study was conducted from July to October 2015. The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet for Renal Disease equation. CKD was defined as an eGFR < 60 ml/min/1.73 m². Multivariable logistic regression analyses were performed to assess the associations between CKD and potential factors.

RESULTS

The mean age and duration of DM among study participants were 54.67 years (range 21-92 years) and 5.0 years, respectively. Over half, i.e. 213/370 (57.6%) and 232/370 (62.7%), had an average blood pressure greater than 140/90 mmHg and poor glycemic control (HbA1c > 7%), respectively. 31/370 patients (8.4%) had CKD. However, only 18/370 (4.9%) had a diagnosis of CKD documented in their charts. Age, level of education, and duration of diabetes were independently associated with CKD.

CONCLUSION

The prevalence of CKD by estimated eGFR was low compared to most previous studies. However, half of patients with CKD are not documented resulting in the potential for prescription errors and drug toxicity. A substantial number of our patients had uncontrolled hypertension and poor glycemic control. Older age, low level of education and longer duration of DM were associated with CKD. There is a need to carry out prospective studies to determine the association and role of glycemic and blood pressure control in CKD causation among patients with DM in Botswana.

The Constellation of Macrovascular Risk Factors in Early Onset T2DM: A Cross-Sectional Study in Xinjiang Province, China

BACKGROUND

Despite a rapid popular of early onset type 2 diabetes (defined as diagnosis at <40 years old) recently, there is a lack of studies on this population in economically undeveloped area. We aimed to investigate the risk factors of macrovascular complications in the early onset T2DM patients in Xinjiang, China.

METHODS

A cross-sectional survey of 1736 consecutive patients with T2DM was conducted. Macrovascular complications and risk factors were documented. Another nondiabetic population matched with age and sex was as a control group. Logistic regression analysis was performed to obtain odds ratios (OR) for macrovascular complications in early and late onset T2DM, respectively.

RESULTS

The final analysis consisted of 1036 late onset and 219 early onset T2DM patients. The mean HbA_1c in the early onset group was higher than that in the late onset group (9.1 ± 2.4% versus 8.3 ± 2.2%, P=0.039) despite a higher proportion of patients in the early onset group receiving insulin treatment (73.1% versus 58.7%, P < 0.001). Compared to the control, early onset patients had higher blood pressure and worse lipid profiles (all P < 0.01). More than half of the early onset T2DM patients already had macro- and microvascular complications, despite of their young age (39.5 ± 10.8) and short DM duration (6.6 ± 8.0). In the early onset group, women had a ~3-fold hazard of atherosclerotic plaques compared with men (OR 3.22, 95% CI 1.53-6.78).

CONCLUSIONS

Patients with early onset T2DM have worse glycemic control and higher burden of atherogenic risk factors. The prevalence of macro- and microvascular complications is astonishingly high in these young adults with T2DM. Moreover, young women with T2DM are more susceptible to cardiovascular complications than their male counterpart.

Diabetic Nephropathy: New Risk Factors and Improvements in Diagnosis

Diabetic nephropathy is the leading cause of end-stage renal disease. Patients with diabetic nephropathy have a high cardiovascular risk, comparable to patients with coronary heart disease. Accordingly, identification and management of risk factors for diabetic nephropathy as well as timely diagnosis and prompt management of the condition are of paramount importance for effective treatment. A variety of risk factors promotes the development and progression of diabetic nephropathy, including elevated glucose levels, long duration of diabetes, high blood pressure, obesity, and dyslipidemia. Most of these risk factors are modifiable by antidiabetic, antihypertensive, or lipid-lowering treatment and lifestyle changes. Others such as genetic factors or advanced age cannot be modified. Therefore, the rigorous management of the modifiable risk factors is essential for preventing and delaying the decline in renal function. Early diagnosis of diabetic nephropathy is another essential component in the management of diabetes and its complications such as nephropathy. New markers may allow earlier diagnosis of this common and serious complication, but further studies are needed to clarify their additive predictive value, and to define their cost-benefit ratio. This article reviews the most important risk factors in the development and progression of diabetic nephropathy and summarizes recent developments in the diagnosis of this disease.

Prevalence of Obesity and Overweight in an Indigenous Population in Central Brazil: A Population-Based Cross-Sectional Study

OBJECTIVE

To estimate the prevalence of obesity and overweight and associated factors in indigenous people of the Jaguapiru village in Central Brazil.

METHODS

We conducted a population-based cross-sectional study between January 2009 and July 2011 in the adult native population of the Jaguapiru village, Central Brazil. Sociodemographic and lifestyle data were obtained; anthropometric measures, arterial blood pressure, and blood glucose were measured. The independent variables were tested by Poisson regression, and the interactions between them were analyzed.

RESULTS

1,608 indigenous people (982 females, mean age 37.7 ± 15.1 years) were included. The prevalence of obesity was 23.2% (95% CI 20.9-25.1%). Obesity was more prevalent among 40- to 49-year-old and overweight among 50- to 59-year-old persons. Obesity was positively associated with female sex, higher income, and hypertension. Among indigenous people, interactions were found with hypertension and sedentary lifestyle - hypertension in males and sedentary lifestyle in females.

CONCLUSIONS

The prevalence of obesity and overweight in indigenous people of the Jaguapiru village is high. Males as well as hypertensive and higher family income individuals have higher rates. Sedentary lifestyle and hypertension leverage the rates of obesity. Prevention and adequate public health policies can be critical for the control of excess weight and its comorbidities among Brazilian indigenous people.

Role of endoplasmic reticulum stress in apoptosis of differentiated mouse podocytes induced by high glucose

Podocytes are terminally differentiated epithelial cells lacking the ability to proliferate. The loss of podocytes is a hallmark of progressive kidney diseases, including diabetic nephropathy (DN). Endoplasmic reticulum stress (ERS)-induced apoptosis is involved in a number of pathological conditions, including DN. The aim of the present study was to investigate whether a high glucose environment induces the apoptosis of podocytes through ERS. Differentiated mouse podocytes were divided into three groups: the normal glucose group (NG, 1 g/l D-glucose), the high glucose group (HG, 4.5 g/l D-glucose) and the mannitol group (M, 1 g/l D-glucose plus 24.4 mM mannitol). The cells were harvested following stimulation with the indicated treatments for 12, 24, 48 and 72 h. Podocyte apoptosis was determined using TUNEL assay and flow cytometry (propidium iodide staining). Glucose-regulated protein 78 (GRP78), CCAAT/enhancer-binding protein (C/EBP) homologous protein (CHOP/GADD153) and caspase-12 expression was analyzed by RT-PCR, western blot analysis and immunocytochemistry. The apoptotic rate increased significantly in the HG group compared with the NG and M groups at 48 and 72 h (all P<0.01). GRP78 expression, an indicator of ERS, was increased from 12 h, indicating that ERS was activated. Subsequently, two ER-associated death (ERAD) pathways, the CHOP/GADD153- and caspase‑12-dependent pathways, were detected. CHOP/GADD153 expression reached its peak at 48 h, and caspase-12 expression gradually increased with time. Spearman's correlation analysis revealed that caspase-12 and CHOP/GADD153 positively correlated with the apoptotic rate (r=0.915, P<0.01 and r=0.639, P<0.01). Our results demonstrated that hyperglycemia (high glucose) induced apoptosis partly through ERS in the differentiated mouse podocytes, which possibly contributes to the pathogenesis of DN.

Association between First Nations ethnicity and progression to kidney failure by presence and severity of albuminuria

BACKGROUND

Despite a low prevalence of chronic kidney disease (estimated glomerular filtration rate [GFR]<60 mL/min per 1.73 m2), First Nations people have high rates of kidney failure requiring chronic dialysis or kidney transplantation. We sought to examine whether the presence and severity of albuminuria contributes to the progression of chronic kidney disease to kidney failure among First Nations people.

METHODS

We identified all adult residents of Alberta (age≥18 yr) for whom an outpatient serum creatinine measurement was available from May 1, 2002, to Mar. 31, 2008. We determined albuminuria using urine dipsticks and categorized results as normal (i.e., no albuminuria), mild, heavy or unmeasured. Our primary outcome was progression to kidney failure (defined as the need for chronic dialysis or kidney transplantation, or a sustained doubling of serum creatinine levels). We calculated rates of progression to kidney failure by First Nations status, by estimated GFR and by albuminuria category. We determined the relative hazard of progression to kidney failure for First Nations compared with non-First Nations participants by level of albuminuria and estimated GFR.

RESULTS

Of the 1 816 824 participants we identified, 48 669 (2.7%) were First Nations. First Nations people were less likely to have normal albuminuria compared with non-First Nations people (38.7% v. 56.4%). Rates of progression to kidney failure were consistently 2- to 3-fold higher among First Nations people than among non-First Nations people, across all levels of albuminuria and estimated GFRs. Compared with non-First Nations people, First Nations people with an estimated GFR of 15.0-29.9 mL/min per 1.73 m2 had the highest risk of progression to kidney failure, with similar hazard ratios for those with normal and heavy albuminuria.

INTERPRETATION

Albuminuria confers a similar risk of progression to kidney failure for First Nations and non-First Nations people.

Neutrophil-to-lymphocyte ratio as a predictor of worsening renal function in diabetic patients (3-year follow-up study)

BACKGROUND

Previous studies have demonstrated the role of inflammation in diabetic nephropathy (DN). Neutrophil to lymphocyte ratio (NLR) rather than other white cell parameters was found to be a useful inflammatory marker to predict adverse outcomes in medical and surgical conditions. Nevertheless, the value of NLR in predicting DN has not been elucidated.

METHOD

An observational study included 338 diabetic patients, who were followed at our clinic between 2007 and 2009. We arranged our patients into tertiles according to their 2007 NLR. The primary outcome was continuous decrease of GFR >12 mL/min between 2007 and 2009 with the last GFR <60 mL/min.

RESULT

The lowest NLR tertile had fewer patients (2.7%) with primary outcome (i.e., worsening renal function) compared with middle and highest NLR tertiles, which had more patients with primary outcomes (8.7% and 11.5%, respectively) with a significant p-value 0.0164. When other potential confounders were individually analyzed with NLR tertile, the NLR tertiles remained a significant predictor of poor GFR outcome in the presence of other variables (hemoglobin A1C, systolic blood pressure, diastolic blood pressure, age, and congestive heart failure with p-values 0.018, 0.019, 0.017, 0.033, and 0.022, respectively).

CONCLUSION

NLR predicted the worsening of the renal function in diabetic patients. Further studies are needed to confirm this result.

Factors affecting the progression of diabetic nephropathy and its complications: a single-center experience in Saudi Arabia

BACKGROUND AND OBJECTIVES

One out of five Saudi diabetics develops end-stage renal disease (ESRD). Factors associated with progressive loss of renal function have not been extensively studied and reported in our community. We sought to evaluate the pattern and progression in glomerular filtration rate (GFR) and investigate the potential risk factors associated with progression to diabetic nephropathy (DN) among Saudi patients.

DESIGN AND SETTING

Hospital-based retrospective analysis of type 2 diabetic patients seen between January 1989 and January 2004 at Security Forces Hospital and King Saud University in Riyadh, Saudi Arabia.

PATIENTS AND METHODS

DN was defined as persistent proteinuria assessed by urine dipstick [at least twice for at least two consecutive years and/or serum creatinine >130 μmol/L; and/or GFR <60 mL/min/1.73m(2) ].

RESULTS

Of 1952 files reviewed, 621 (31.8%) met the criteria for DN, and 294 (47%) were males. The mean (SD) age of the patients at baseline was 66.9 (11.4) years, and mean duration of diabetes was 15.4 (7.5) years. GFR deteriorated from a baseline value of 78.3 (30.3) mL/min/1.73m(2) to 45.1 (24.1) mL/min/1.73m(2) at the last visit, with a mean rate of decline in GFR of 3.3 mL/min/year. Progression of nephropathy was observed in 455 (73.3%) patients, with 250 (40.3%) patients doubling their first-hospital-visit serum creatinine level in a mean of 10.0 (6.0) years. At the end of the study, 16.5% of the cohort developed ESRD and were dialyzed. GFR >90 mL/min/1.73m(2) at the first hospital visit; duration of diabetes >10 years; persistent proteinuria; systolic blood pressure >130 mm Hg; and presence of retinopathy were significant markers associated with progression of nephropathy.

CONCLUSION

Diabetic nephropathy tends to be progressive among Saudis, with GFR deteriorating at a rate of 3.3 mL/year and with a doubling of serum creatinine level in 40.3% of patients in 9.9 years.

Secular trends in treatment and control of type 2 diabetes in an American Indian population: a 30-year longitudinal study

OBJECTIVE

Treatment guidelines for diabetes have become increasingly stringent as most research shows that more aggressive intervention reduces the risks for complications. Community data on the effect of these interventions are lacking.

RESEARCH DESIGN AND METHODS

Changes in the pharmacologic treatment of diabetes, blood pressure, and cholesterol in adults with diabetes were analyzed in a longitudinal population-based study of American Indians from 10 independent 3-year time intervals between 1975 and 2004. Trends in drug use were assessed by logistic regression models and trends in glycemia, blood pressure, and cholesterol were assessed by linear models.

RESULTS

Among the study participants, the use of any medicine for the treatment of diabetes increased from 53% in 1975-1978 to 67% in 2002-2004, Ptrend<0.0001. The use of insulin as a single agent declined, and the use of combinations of insulin and oral agents increased. In 1990-1992, 23% of subjects had an A1C<7% and by 2002-2004, the proportion had increased to 33%, Ptrend<0.0001. The use of anti-hypertensive medicine increased from 21% in 1975-1977 to 58% in 2002-2004, Ptrend<0.0001, coincident with a decline in mean systolic blood pressure from 137 mmHg in 1975-1977 to 123 mmHg in 2002-2004, Ptrend<0.0001. The use of lipid-lowering medicine also increased with an accompanying increase in HDL and a decrease in non-HDL cholesterol concentration.

CONCLUSIONS

Major changes in community treatment patterns for diabetes and related conditions coincided with improvements in glycemia, blood pressure, and cholesterol.

Effect of intrauterine diabetes exposure on the incidence of end-stage renal disease in young adults with type 2 diabetes

OBJECTIVE

We examined the effect of intrauterine diabetes exposure (IDE) on the incidence of diabetic end-stage renal disease (ESRD) in Pima Indians with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Individuals were followed from their first diabetic examination until December 2006, death, ESRD, or age of 45 years.

RESULTS

Among the 1,850 diabetic participants, 102 had IDE. ESRD developed in 57, 5 of whom had IDE. Cumulative incidence of ESRD by age 45 was 19.3% in participants with IDE and 5.1% in those without; the age- and sex-adjusted incidence rate ratio was 4.12 (95% CI 1.54-11.02). After additional adjustment for age at diabetes onset, ESRD incidence was similar in the two groups (incidence rate ratio 1.38, 95% CI 0.45-4.24).

CONCLUSIONS

IDE increases the age- and sex-adjusted incidence of ESRD fourfold in young adults with type 2 diabetes, mediated primarily by the earlier onset of type 2 diabetes in those with IDE.

Reducing health disparities in American Indians with chronic kidney disease

American Indians and Alaska Natives comprise a diverse population with an increased burden of chronic kidney disease (CKD), largely owing to diabetes. Although transportation to rural dialysis units impairs access, quality of dialysis care appears similar to the US population. Similar to other racial and ethnic minorities, American Indians and Alaska Natives are less likely to receive kidney transplants. The causes of these disparities are as diverse as the population. The application of the chronic care model to CKD by the Indian Health Service is associated with a decrease in incidence of end-stage renal disease among diabetic patients and may be a useful model for reducing disparities in other populations at risk for CKD.

Diabetes prevalence, incidence, complications and mortality among Alaska Native people 1985-2006

OBJECTIVES

To examine trends in diabetes prevalence, incidence, complications and mortality between 1985 and 2006 among Alaska Native people.

STUDY DESIGN

We used data from the population-based Alaska Native Diabetes Registry, which includes all people who receive care in the Alaska Tribal Health System.

METHODS

We compared the periods of 1986-1990 and 2002-2006 for diabetes-related amputations, renal replacement and mortality using Poisson regression. Complications and mortality data were examined for trends using Poisson regression. Survival analyses for those diagnosed since 31 December 1985 were performed using the Cox proportional hazard model.

RESULTS

Age-adjusted diabetes prevalence increased from 17.3 in 1985 to 47.6/1,000 in 2006. The number of Alaska Native people living in Alaska with diabetes increased from 610 in 1985 to 3,386 in 2006. Diabetes incidence rates have also increased. Comparing age-adjusted rates for the 5-year periods 1986-1990 and 2002-2006, amputations decreased from 5.3 to 2.6/1,000, renal replacement decreased from 3.3 to 1.2/1,000 and mortality decreased from 41.7 to 33.2/1,000. Yearly analyses showed a downward trend for amputations, renal replacement and mortality rates. Survival analyses showed a significantly higher hazard ratio for any amputations, major amputations and renal replacement for the earlier time period compared to the most recent time period.

CONCLUSIONS

An increase in risk factors, awareness, funding and case-finding may be contributing to the increase in prevalence and incidence of diagnosed diabetes. While diabetes prevalence and incidence are increasing among Alaska Native people, our results suggest that even in remote, rural areas, complications and mortality can be reduced.

Diabetic CKD/ESRD 2010: a progress report?

Both in the United States and many regions of the world, chronic kidney disease and end-stage renal disease (ESRD) in patients with diabetes mellitus have reached epidemic proportions in recent years. The large prevalent diabetic ESRD population in the US involves remarkable risk in African Americans and an increasing population of elderly diabetic patients, including many octogenarians. In the US and globally, over 90% of diabetic ESRD patients have type 2 diabetes. The multinational epidemic of diabetic ESRD has been linked to increases in the prevalence of diabetes in many populations, related to obesity, ageing, and physical inactivity. It is anticipated that the worldwide prevalence of diabetes over the next 20 years will reach a level twice that of the year 2000. The excessive morbidity and mortality of the diabetic ESRD population are well documented. However, the growth in incidence and prevalence rates for diabetic ESRD has remained somewhat stable in the US in recent years, and new data suggest that the incidence of ESRD expressed per diabetic population may finally be declining, suggesting that proven therapies are making "progress on progression."

Molecular variation at the HLA-A, B, C, DRB1, DQA1, and DQB1 loci in full heritage American Indians in Arizona: private haplotypes and their evolution

A sample of 492 full heritage, unrelated residents of the Gila River Indian Community (GRIC) of Arizona were characterized for their high-resolution DNA alleles at the HLA-A, B, C, DRB1, DQA1, and DQB1 loci. Only five allelic categories are found at HLA-A, 10 at HLA-B, 8 at HLA-C and HLA-DR, and 4 at DQA1 and DQB1. There is little evidence for population structure at the 6 loci. Two 'private' alleles, B*5102 and B*4005, which are found nearly exclusively in American Indian populations in the desert southwest and northern Mexico, are likely new mutations after the first inhabitation of the area, the evolution of which are reflected in the contemporary distribution of their respective haplotypes. DRB1*1402 has the highest reported frequency of any specificity at the DRB1 locus, 0.7461, and serves as a sensitive probe for locating related east Asian populations. The haplotypes in this population also exhibit a highly restricted distribution and strong genetic disequilibria, which has important implications for matching solid organ and bone marrow allografts. It is shown that, when one considers HLA-A-B-DRB1 homozygotes as allograft donors for all full heritage members of the GRIC, 50% of the community would find a non-mismatched organ within the homozygotes for the six most common haplotypes. This raises questions about transplantation policy and whether, in the presence of high-frequency private alleles and a restricted number of haplotypes, the full heritage American Indian community of the desert southwest should act as its own pool of donors for its affected members.

Change in the distribution of albuminuria according to estimated glomerular filtration rate in Pima Indians with type 2 diabetes

OBJECTIVE

We examined secular trends in the frequency distribution of albuminuria and estimated glomerular filtration rate (eGFR) in subjects with type 2 diabetes in 1982-1988 and 2001-2006, two periods associated with major changes in the management of diabetes.

RESEARCH DESIGN AND METHODS

The cross-sectional study included Pima Indians > or =15 years old with type 2 diabetes and measures of serum creatinine and urinary albumin-to-creatinine ratios (ACR). The continuous probability density distributions of ACR and eGFR were compared for the two time periods. eGFR was calculated using the Modification of Diet in Renal Disease Study equation.

RESULTS

The overall standardized distribution of ACR shifted toward lower values between time periods (P = 0.001), whereas the standardized distribution of eGFR did not (P = 0.45). In the first period, eGFR was <60 ml/min per 1.73 m(2) in 6.5% of the 837 subjects. Of these, 9.3% had normal ACR, 7.4% had microalbuminuria, and 83.3% had macroalbuminuria. In the second period, the prevalence of low eGFR was similar (6.6% of the 1,310 subjects). Among those with low eGFR, normal ACR prevalence doubled to 17.2%, microalbuminuria prevalence nearly tripled to 19.5%, and macroalbuminuria prevalence declined to 63.2%. Twice as many subjects in the second period received antihypertensive medicines and 30% more received hypoglycemic medicines than in the first period.

CONCLUSIONS

The distribution of albuminuria changed significantly among diabetic Pima Indians over the past 20 years, as treatment with medicines to control hyperglycemia and hypertension increased. The distribution of eGFR, however, remained unchanged. Consequently, the frequency of chronic kidney disease characterized by normoalbuminuria and low eGFR doubled.

Diabetic nephropathy in American Indians, with a special emphasis on the Pima Indians

Diabetes affects American Indians disproportionately compared with other racial/ethnic groups in the United States and is almost exclusively type 2 diabetes. Much of our knowledge about diabetes in American Indians comes from studies in a few tribes. The most extensively studied American Indians are the Pima Indians from the Gila River Indian Community in Arizona, who participated in a longitudinal study of diabetes and its complications between 1965 and 2007. They have one of the highest reported incidence and prevalence of type 2 diabetes in the world, and kidney disease attributable to diabetes is a major cause of morbidity and mortality. In this article, we examine the course, determinants, and trends of diabetic kidney disease in American Indians, with special emphasis on studies conducted in the Pima Indians. We also review therapeutic strategies for managing diabetic kidney disease.

Changing course of diabetic nephropathy in the Pima Indians

Pima Indians from the Gila River Indian Community in Arizona have a high incidence rate of type 2 diabetes, and kidney disease attributable to diabetes is a major cause of morbidity and mortality in this population. Since 1965, each member of the population at least 5 years of age is invited to participate in a research examination every other year. During the past 43 years, the overall incidence of diabetes in the Pima Indians has not changed, but the incidence of diabetes among those less than 15 years of age has increased nearly 6-fold, as an increasing prevalence and degree of obesity in the youth have shifted the onset of diabetes to younger ages. The rising frequency of diabetes in the youth has led, in turn, to the emergence in mid-life of the major complications of diabetes, including kidney disease. On the other hand, the introduction and widespread use of medicines to control blood pressure, reduce hyperglycemia, and block the renin-angiotensin system (RAS) have lead to improvements in the average blood pressure and glycosylated hemoglobin levels in the diabetic population. These countervailing forces have influenced the course of diabetic nephropathy in a generally favorable direction in the past few years, as evidenced by the decline in the overall incidence of end-stage kidney disease since 1990. A continued increase in the incidence of type 2 diabetes in youth, however, threatens to reverse this trend.

Diabetes and chronic kidney disease: lessons from the Pima Indians

Although diabetic nephropathy is a very rare cause of kidney failure during childhood, the underlying events leading to progressive kidney injury begin during childhood in many patients with type 1 diabetes mellitus (T1DM) and in increasing numbers of children with type 2 diabetes mellitus (T2DM). The Pima Indians of Arizona represent an exceptionally thoroughly studied population suffering from very high rates of T2DM and diabetic nephropathy (T2DN). This population well illustrates the often inexorable progression from glomerular hyperfiltration to microalbuminuria to overt proteinuria and loss of glomerular filtration rate (GFR), paralleled by the accumulation of mesangial matrix and basement membrane, glomerular hypertrophy, loss of podocytes and eventual glomerular sclerosis and interstitial fibrosis. Structural changes quantitatively account for the loss of GFR in T2DN. The mechanism of albuminuria (and its relationship to GFR loss) is much less clear. There is strong functional and structural evidence for defects in glomerular size-selectivity (shunts) due to podocyte pathology, but only beginning at relatively high levels of proteinuria (albumin/creatinine ratios > 3000 mg/g). Podocyte loss accompanies, and may underlie, the loss of glomeruli to sclerosis. At this point, most evidence in humans suggests detachment of intact podocytes from the glomerular basement membrane, rather than apoptosis, as the predominant mechanism of podocyte loss.

Global complication rates of type 2 diabetes in Indigenous peoples: A comprehensive review

INTRODUCTION AND OBJECTIVE

The world's Indigenous peoples are experiencing an unprecedented epidemic of type 2 diabetes [T2DM] but little has been published describing the complications burden. The objective of this paper was to conduct a systematic review of T2DM complications in Indigenous populations worldwide.

METHODS

A literature review was conducted using PubMed and EMBASE to examine available complications data. Country, Indigenous population, authors, publication year, total sample size, Indigenous sample size, age, methodology, and prevalence of nephropathy, end-stage renal disease, retinopathy, neuropathy, lower extremity amputations, cardiovascular disease, hospitalizations and mortality due to diabetes were recorded.

RESULTS

One-hundred and eleven studies were selected. Results revealed a disproportionate burden of disease complications among all Indigenous peoples regardless of their geographic location. Complication rates were seen to vary widely across Indigenous groups.

DISCUSSION

Gaps were found in the published literature on complications among Indigenous populations, especially those living in underdeveloped countries. These gaps may be in part due to the challenges caused by varying operational practices, research methodologies, and definitions of the term Indigenous, making documentation of rates among these peoples problematic. Comprehensive surveillance applying standardized definitions and methodologies is needed to design targeted prevention and disease management strategies for Indigenous peoples with T2DM.

Reducing the burden of chronic kidney disease among American Indians

American Indians (AIs) and Alaska Natives (ANs) have experienced a dramatic rise in type 2 diabetes and associated complications, including chronic kidney disease (CKD) over the past half century. At the end of 2005, the national prevalence of end-stage renal disease (ESRD) in AIs/ANs was 2.5 times greater than that for white Americans, with rates significantly higher among communities of the southwest United States. Evidence of CKD among AIs/ANs with diabetes includes abnormal protein excretion in 30% and estimated glomerular filtration rate (eGFR) <60 mL/min/m(2) in 17%. In order to address the growing burden of CKD, the Indian Health Service established the Kidney Disease Program to improve the screening of and the management of diabetics with CKD. Routine reporting of eGFR, yearly monitoring of protein excretion, utilization of renin-angiotensin system (RAS) antagonists, and aggressive control of blood pressure were implemented in association with enhanced patient and provider education. By 2006, 82% of hypertensive diabetics were receiving a RAS antagonist. Implementation of these efforts has been associated with a 31% decrease in ESRD incidence among AIs/ANs with diabetes. This program of improvements in CKD care implemented by a federal agency serving a high-risk population with limited resources may be a useful model for others.

Prevalence of chronic kidney disease and survival among aboriginal people

Globally, it is known that the incidence of end-stage renal disease is higher among Aboriginals, but it is unknown whether this is due to an increased prevalence of chronic kidney disease or other unidentified factors. We studied 658,664 people of non-First Nations and 14,989 people of First Nations and found that the age- and sex-adjusted prevalence of chronic kidney disease was significantly higher among those of non-First Nations compared to those of First Nations (67.5 versus 59.5 per 1000 population; P < 0.0001). However, severe chronic kidney disease (estimated glomerular filtration rate <30 ml/min per 1.73 m2) was almost two-fold higher among people of First Nations (P < 0.0001). Cox proportional hazards models suggested that compared to people of non-First Nations, those of First Nations with chronic kidney disease had a 77% increased risk of death after adjusting for age, gender, diabetes and baseline eGFR. In conclusion, whether the higher incidence of end-stage renal disease among people of First Nations is due to suboptimal management of chronic kidney disease and its associated comorbidities, more rapid loss of kidney function, or other unidentified factors remains to be determined.