Cardiovascular complications of diabetic kidney disease

Frequency and sequence of proteinuria positivity and clinical outcomes in patients with diabetes: A nationwide cohort study

AIMS

Proteinuria is a risk factor for end-stage kidney disease (ESKD) and cardiovascular disease (CVD) in patients with diabetes. However, the clinical implications of fluctuating proteinuria are unclear. We investigated the proteinuria burden and the risks of clinical outcomes in patients with diabetes using the Korean National Health Insurance Service database.

MATERIALS AND METHODS

This retrospective cohort study included patients with diabetes who participated in a national health screening between 2015 and 2016, with records of three previous health screenings. Each end-point was followed until 31 December 2022. The proteinuria burden (range: 0-4) was defined as the cumulative number of positive urine protein dipstick tests at each health screening. The outcomes included ESKD, CVD and all-cause mortality.

RESULTS

Among 1 264 699 patients, 86.3%, 9.4%, 2.5%, 1.2% and 0.6% had proteinuria burdens of 0 to 4, respectively. The proteinuria burden and risks of clinical outcomes had dose-dependent associations; compared to proteinuria burden 0, the adjusted hazard ratio (95% confidence interval) of proteinuria burdens 1, 2, 3 and 4, respectively, were as follows: ESKD, 3.539 (3.326-3.766), 9.373 (8.816-9.965), 14.539 (13.652-15.484) and 19.704 (18.412-21.087); CVD, 1.247 (1.214-1.280), 1.530 (1.465-1.599), 1.815 (1.713-1.923) and 2.032 (1.883-2.192); and all-cause mortality, 1.335 (1.302-1.369), 1.703 (1.635-1.774), 1.959 (1.855-2.068) and 2.092 (1.945-2.250). Within the same proteinuria burdens, late-positive proteinuria was associated with worse outcomes than early-positive proteinuria.

CONCLUSIONS

The proteinuria burden was dose-dependently associated with clinical outcomes in patients with diabetes. Even a single positive dipstick test requires active management.

Cardiac arrhythmia and hypoglycaemia among individuals with and without diabetes receiving haemodialysis (the CADDY study): a Danish multicentre cohort study

AIMS/HYPOTHESIS

We aimed to examine arrhythmias and hypoglycaemia among individuals with and without diabetes who are receiving haemodialysis and to investigate the association between arrhythmias and hypoglycaemia, hyperglycaemia and glycaemic variability.

METHODS

This prospective multicentre cohort study included 70 participants on maintenance haemodialysis (35 with diabetes and 35 without diabetes). We employed implantable cardiac monitors for continuous heart rhythm monitoring in combination with periodic use of continuous glucose monitoring. Logistic-regression-type linear mixed models were used to examine associations between arrhythmias and glycaemic measures.

RESULTS

During 18 months of follow-up, clinically significant arrhythmias (bradyarrhythmia and ventricular tachycardia) were identified in 12 (34%) participants with diabetes and 11 (31%) without diabetes. Atrial fibrillation was detected in 13 (37%) participants with diabetes and 14 (40%) without, while other supraventricular tachycardia was detected in seven (20%) and 11 (31%) participants with and without diabetes, respectively. Hypoglycaemia (sensor glucose <3.9 mmol/l) was observed in 27 (77%) participants with diabetes and 32 (91%) without diabetes. Compared with euglycaemia, hypoglycaemia was associated with an increased rate of arrhythmias among participants without diabetes (incidence rate ratio [IRR] 3.13 [95% CI 1.49, 6.55]), while hyperglycaemia (sensor glucose >10.0 mmol/l) was associated with a decreased rate of arrhythmias among participants with diabetes (IRR 0.58 [95% CI 0.37, 0.92]). Glycaemic variability showed no association with arrhythmias regardless of the presence of diabetes.

CONCLUSIONS/INTERPRETATION

Arrhythmias and hypoglycaemia were common in those undergoing haemodialysis regardless of diabetes status. Our data suggest a temporal relationship between arrhythmias and glucose level in both individuals with and without diabetes.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04841304.

Obstructive sleep apnea is associated with cardiac structural and functional alterations in patients with advanced diabetic kidney disease

AIMS

Obstructive sleep apnea (OSA) is common in type 2 diabetes mellitus (T2DM), but its association with cardiac structure and function in advanced diabetic kidney disease (DKD) remains unclear.

METHODS

T2DM patients with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 and albuminuria were assessed for OSA using the apnea-hypopnea index (AHI). Cardiac structure and function were assessed by transthoracic echocardiography following standard guidelines. 39 patients without OSA (AHI < 5) were compared to 34 patients with moderate-severe OSA (AHI ≥ 15).

RESULTS

Mean age was 71.4 ± 9.4 years (73 % male), and eGFR was 32.1 ± 12.3 mL/min/1.73 m2. DKD patients with moderate-severe OSA had a higher left atrial volume index (LAVI: 36.6 ± 13.9 vs. 28.1 ± 10.5 mL/m2, p < 0.01) left ventricular mass index (LVMI: 48.8 ± 11.7 vs. 41.8 ± 9.7 g/m2.7, p < 0.01) and right ventricular diameter (RVD: 34.1 ± 5.8 vs. 28.4 ± 4.4 mm, p < 0.001) than DKD patients without OSA. Left ventricular ejection fraction (LVEF) did not differ, but global longitudinal strain (GLS) was reduced (-15.1 ± 3.0 vs. -16.6 ± 2.8 %, p < 0.05). In multivariable linear regression analyses, moderate-severe OSA remained significantly associated with LAVI, LVMI, RVD, and GLS but not with LVEF.

CONCLUSIONS

Moderate-severe OSA is associated with cardiac hypertrophy and chamber dilatation, potentially contributing to cardiovascular risk in advanced DKD.

Clinical staging to guide management of metabolic disorders and their sequelae: a European Atherosclerosis Society consensus statement

Obesity rates have surged since 1990 worldwide. This rise is paralleled by increases in pathological processes affecting organs such as the heart, liver, and kidneys, here termed systemic metabolic disorders (SMDs). For clinical management of SMD, the European Atherosclerosis Society proposes a pathophysiology-based system comprising three stages: Stage 1, where metabolic abnormalities such as dysfunctional adiposity and dyslipidaemia occur without detectable organ damage; Stage 2, which involves early organ damage manifested as Type 2 diabetes, asymptomatic diastolic dysfunction, metabolic-associated steatohepatitis (MASH), and chronic kidney disease (CKD); and Stage 3, characterized by more advanced organ damage affecting multiple organs. Various forms of high-risk obesity, driven by maintained positive energy balance, are the most common cause of SMD, leading to ectopic lipid accumulation and insulin resistance. This progression affects various organs, promoting comorbidities such as hypertension and atherogenic dyslipidaemia. Genetic factors influence SMD susceptibility, and ethnic disparities in SMD are attributable to genetic and socioeconomic factors. Key SMD features include insulin resistance, inflammation, pre-diabetes, Type 2 diabetes, MASH, hypertension, CKD, atherogenic dyslipidaemia, and heart failure. Management strategies involve lifestyle changes, pharmacotherapy, and metabolic surgery in severe cases, with emerging treatments focusing on genetic approaches. The staging system provides a structured approach to understanding and addressing the multi-faceted nature of SMD, which is crucial for improving health outcomes. Categorization of SMD abnormalities by presence and progression is aimed to improve awareness of a multi-system trait and encourage a tailored and global approach to treatment, ultimately aiming to reduce the burden of obesity-related comorbidities.

Uncontrolled Diabetes is a Strong Predictor of Amputation in End Stage Renal Disease Patients on Hemodialysis

BACKGROUND

Diabetic nephropathy remains a strong risk factor for chronic kidney disease progression. Hemoglobin A1C (HBA1C) has historically been used as a marker for complications related to diabetes. The purpose of this study is to examine the relationship between HBA1C and clinical complications in a patient population with end stage renal disease.

METHODS

This was a prospective study performed using patients from multiple outpatient dialysis centers in Texas, United States. All patients included patients must have end stage renal disease and were receiving either hemodialysis or peritoneal dialysis. An HBA1C ≥ 6.5% was used as a cutoff to differentiate patients with well controlled versus uncontrolled diabetes in this population.

RESULTS

HBA1C ≥ 6.5% was strongly associated with both minor (P = 0.0014) and major (P = 0.006)amputation. Patients with HBA1C ≥ 6.5% was associated with lower mortality compared to patients with HBA1C < 6.5%, P = 0.007.

CONCLUSION

HBA1C remains a reliable marker for amputation in patients with end-stage renal disease; however, there is skepticism in using HBA1C as a marker for survival in these patients.

Impact of Acute Kidney Injury, Co-Existing with and without Chronic Kidney Disease on the Short-Term Adverse Outcomes Following Atherosclerotic Cardiovascular Disease Events in Patients with Diabetes

Background/Objective

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality among patients with diabetes mellitus (DM). Although ASCVD risk is elevated in diabetic populations, the effect of acute kidney injury (AKI), especially when chronic kidney disease (CKD) is present, on post-ASCVD outcomes remain unclear. This study investigates the association between AKI-with or without co-existing CKD-and short-term adverse outcomes in diabetic patients following their first ASCVD event.

Methods

This retrospective cohort study analyzed data from the Taipei Medical University Clinical Research Database (2004-2020), which includes anonymized electronic health records from three affiliated hospitals. Patients with DM who experienced the first ASCVD event were categorized by kidney function: no known kidney disease (NKD), AKI, CKD, and acute-on-CKD (AoCKD). The impact of kidney dysfunction on outcomes was assessed using Cox proportional-hazards models, with hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

Out of 4525 patients, those with CKD and AoCKD exhibited significantly higher 1-year all-cause mortality (HR: 1.24 and 1.68, respectively) and risks of cardiovascular death, recurrent ASCVD-related hospitalizations, and heart failure, compared with NKD patients. Diuretic use was associated with increased all-cause mortality in AoCKD and CKD groups. In the contrary, the use of metformin was associated with a lower risk of all-cause mortality in AoCKD and CKD groups.

Conclusion

AoCKD significantly increases short-term mortality and cardiovascular complications in diabetic patients post-ASCVD period, whereas AKI alone does not confer additional risk. These findings highlight the need for dedicated case-managed, personalized and multidisciplinary interventions for cardiorenal health. The early nephrologist consultation, echocardiography with speckle-tracking strain, urine albumin-to-creatinine ratio, pharmacologic strategies, such as cautious use of diuretics, use of sodium-glucose transport protein 2 inhibitors, statin or metformin are recommended to improve outcomes in this high-risk group.

Can Lipoprotein(a) Predict the Risk of Diabetic Nephropathy in Type 2 Diabetes Mellitus?: A Systematic Review and Meta-Analysis

We aimed to examine if serum lipoprotein(a) [Lp(a)] values could be used to predict the risk of diabetic nephropathy (DN) in type 2 diabetes mellitus (T2DM). English-language observational studies available as full-texts on PubMed, Embase, Scopus, and Web of Science databases up to 28th November 2024 were included in the review. Studies were to assess the association between Lp(a) and DN and report adjusted effect size. Random-effects meta-analysis was conducted. Five cross-sectional, two case-control, and eight studies prospective cohort were included. Six studies used Lp(a) as a continuous variable while eight used it as a categorical variable. Two studies used Lp(a) as both. Meta-analysis showed that an incremental increase in Lp(a) was associated with a small increase in the risk of DN (OR: 1.03 95% CI: 1.01, 1.04 I2=86%). Meta-analysis also showed that high levels of Lp(a) were associated with a significant increase in the risk of DN (OR: 1.64 95% CI: 1.24, 2.17 I2=67%). Subgroup analysis based on study design, location, sample size, T2DM duration, baseline HbA1c, and definition of DN yielded mixed results. Lp(a) could be a potential marker for DN in T2DM. Further investigations may provide better evidence.

Association of cardiovascular-kidney-metabolic health and apolipoprotein E4 genotype with risk of dementia and mortality

BackgroundPoor cardiovascular-kidney-metabolic (CKM) health is becoming prevalent; however, sparse data exist regarding the association of CKM health with incident dementia and all-cause mortality.ObjectiveThis study aimed to examine whether poor CKM health is associated with a higher risk of dementia and all-cause mortality, regardless of APOE4 carrier status.MethodsIn this prospective cohort study, 352,364 participants from the UK Biobank were included. CKM syndrome was identified as a medical condition with the presence of metabolic risk factors, cardiovascular disease, and chronic kidney disease, and was classified into five stages (stage 0 to 4). Cox proportional hazards models were applied to explore the association of CKM health with incident dementia and all-cause mortality.ResultsParticipants in stage 2-3 and stage 4 had 1.12-fold (95% CI: 1.02-1.23, p = 0.023) and 2.18-fold (95% CI: 1.96-2.43, p < 0.001) increased risk of incident all-cause dementia compared with those in stage 0. Similarly, participants in stage 4 also had an increased risk of Alzheimer's disease (HR = 1.51, 95% CI: 1.28-1.78, p < 0.001) and vascular dementia (HR = 4.62, 95% CI: 3.54-6.03, p < 0.001). Participants in later stages were at higher risk of all-cause mortality. We found an interaction between CKM health and APOE4 carrier status (p for interaction <0.001), and the relationship between CKM health and dementia was more pronounced in non-APOE4 carriers. Moreover, there were significant additive interactions between APOE4 carrier status and CKM health on the risk of dementia.ConclusionsPoor CKM health is independently associated with an increased risk of dementia, regardless of APOE4 carrier status, and all-cause mortality. These findings imply that promoting CKM health may help to reduce the risk of subsequent dementia and mortality.

Sodium-Glucose Cotransporter 2 Inhibitors as Potential Antioxidant Therapeutic Agents in Cardiovascular and Renal Diseases

Redox (reduction-oxidation) imbalance is a physiological feature regulated by a well-maintained equilibrium between reactive oxygen species (ROS) and oxidative stress (OS), the defense system of the body (antioxidant enzymes). The redox system comprises regulated levels of ROS in the cells, tissues and the overall organ system. The levels of ROS are synchronized by gradients of electrons that are generated due to sequential reduction and oxidation of various biomolecules by various enzymes. Such redox reactions are present in each cell, irrespective of any tissue or organ. Failure in such coordinated regulation of redox reactions leads to the production of excessive ROS and free radicals. Excessively produced free radicals and oxidative stress affect various cellular and molecular processes required for cell survival and growth, leading to pathophysiological conditions and, ultimately, organ failure. Overproduction of free radicals and oxidative stress are the key factors involved in the onset and progression of pathophysiological conditions associated with various cardiovascular and renal diseases. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) are glucose-lowering drugs prescribed to diabetic patients. Interestingly, apart from their glucose-lowering effect, these drugs exhibit beneficial effects in non-diabetic patients suffering from various cardiovascular and chronic kidney diseases, perhaps due to their antioxidant properties. Recently, it has been demonstrated that SGLT2is exhibit strong antioxidant properties by reducing ROS and OS. Hence, in this review, we aim to present the novel antioxidant role of SGLT2is and their consequent beneficial effects in various cardiovascular and renal disease states.

Risk factors and transitional probability of clinical events in Korean CKD patients using the multistate model

Korean chronic kidney disease (CKD) patients have relatively low cardiovascular disease (CVD) and high end stage kidney disease (ESKD) incidence rates. Using the multi-state model this study analyzed the 5- and 10-year cumulative hazard estimates, transition probabilities and risk factors associated with the five clinical transitions; ESKD, CVD, CVD to death, ESKD to death and death. CKD stages 1-4 patients from the KoreaN Cohort Study for Outcome in Patients With Chronic Kidney Disease cohort were included. Multivariable multi-state model analysis was performed to investigate the study outcomes associated with the five transitions. Among the 1502 patients (median age 54 years, male 61.3%), the overall prevalence of clinical events were: ESKD (22.6%), CVD (7.5%), death after ESKD (3.6%), death (3.3%) and death after CVD (1.2%). Patients who experienced intermediate ESKD event had higher risk of death than those who experienced CVD event (10-year cumulative hazard: 0.35; 95% CI: 0.23, 0.48 vs. 0.27; 95% CI: 0.15, 0.40). The 10-year transition probability was highest for enrollment to ESKD (0.27; 95% CI: (0.23, 0.31)) followed by enrollment to CVD (0.08; 95% CI: 0.07, 0.10). Different clinical risk factors were associated with each of the five transitions. Patients who experienced intermediate ESKD event were more exposed to death risk than those who experienced CVD and the highest 10-year progression probability was for enrollment to ESKD followed by death after ESKD. Different risk factors were associated with varying transitions. These findings correlate with the distinctive clinical features of Korean CKD patients.

Association between non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and cardiovascular disease mortality in patients with type 2 diabetes mellitus and diabetic kidney disease

Purpose

Non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) represents an essential lipid index and is closely related to the occurrence and development of diabetes and cardiovascular diseases (CVDs). Therefore, this study is intended to further investigate the association between the NHHR index and the mortality rate of CVDs in patients with type 2 diabetes mellitus (T2DM) and diabetic kidney disease (DKD).

Methods

The research sample was selected from the NHANES (National Health and Nutrition Examination Survey) database, and 5136 individuals were categorized based on quartiles of the NHHR index. Restricted cubic plots and COX regression models were utilized to examine the thresholds and patterns of the NHHR index in relation to the risk of CVDs mortality among T2DM patients as well as those with DKD. Subgroup analyses and p-values were used to evaluate interactions between different variables.

Results

The NHHR index shows a nonlinear association with cardiovascular mortality in two patient groups, following an L-shaped pattern. In individuals with T2DM, a lower NHHR index (<1.68) correlates with an increased risk of death, demonstrating a 72.8% reduction in mortality risk for each unit increase in NHHR below this threshold. Similarly, among patients with DKD, a lower NHHR index (<1.82) is associated with heightened cardiovascular mortality risk, indicating a 48.2% reduction in death risk for each unit increase in NHHR beneath the specified threshold. In patients diagnosed with T2DM, the third quartile of the NHHR index was significantly linked to reduced mortality risk; the association remained consistent even when additional variables were considered [Hazard Ratio (HR), 0.82; 95% Confidence Interval (CI) (0.69-0.97); P=0.019]. Among patients with DKD, cardiovascular mortality was notably higher in the third and fourth quartiles of the NHHR index [Quartile3 HR, 1.57; 95% CI (1.10-2.24), P=0.013; Quartile4 HR, 2.04; 95% CI (1.28-3.26), P=0.003].

Conclusions

The NHHR is below 1.68, and an increase in the NHHR index is associated with a reduced risk of CVD mortality in patients with T2DM. Similarly, when the NHHR falls below 1.82, an elevation in the NHHR index correlates with a decreased risk of CVD mortality in patients with DKD.

Serum adropin levels as a potential biomarker for predicting diabetic kidney disease progression

Background

To investigate the value of serum adropin in predicting chronic kidney disease (CKD) progression in subjects with type 2 diabetes (T2D).

Materials and methods

Serum adropin levels were measured in normal control and T2D patients with various stage of CKD. CKD progression was defined as ≥ 30% decline from the baseline estimated glomerular filtration rate. Logistic regression analysis was applied to assess the association between adropin levels and CKD progression.

Results

The study included 58 subjects with T2D (18 early CKD and 40 advanced CKD) and 9 subjects without diabetes (control). Subjects with T2D had significantly higher adropin levels than controls (6393.10 ± 1611.84 vs. 3470.30 ± 1284.41 pg/ml; P < 0.001). Meanwhile, T2D patients with advanced CKD had higher adropin levels than those with early CKD (6848.89 ± 1287.04 vs. 5380.25 ± 1826.44 pg/ml; P = 0.003). Among T2D patients, subjects experienced CKD progression had higher adropin levels than those without (7520.15 ± 843.21 vs. 6151.16 ± 1661.61 pg/mL, P =0.003). Thus, adropin predicts CKD progression in T2D patients with 86% sensitivity and 70% specificity at 6872.24 pg/ml cutoff value. The association with CKD progression was still significant after adjusting for age, gender and body mass index (adjusted odds ratio = 27.188, 95% confidence interval 1.415-522.527, P =0.029).

Conclusions

The above findings suggest that serum adropin could be applied as a potential biomarker for predicting CKD progression in subjects with T2D. Further research is needed to validate these results and explore the underlying mechanisms.

Effects of Sodium-Glucose Cotransporter-2 Inhibitors on Kidney Outcomes across Baseline Cardiovascular-Kidney-Metabolic Conditions: A Systematic Review and Meta-Analyses

Key Points

Sodium-glucose cotransporter-2 (SGLT2) inhibitors slowed the rate of eGFR slope decline in patients with heart failure, CKD, and type 2 diabetes mellitus and in all combinations of multimorbid conditions among these diseases. SGLT2 inhibitors decreased kidney composite outcomes among all disease states and different combinations of multimorbidity, except in patients with heart failure with preserved ejection fraction and heart failure without type 2 diabetes mellitus. SGLT2 inhibitors were found to decrease the risk of kidney failure in patients with type 2 diabetes mellitus and also in those with CKD.

Background

The effects of sodium-glucose cotransporter-2 inhibitors (SGLT2is) on kidney outcomes in patients with varying combinations of heart failure, CKD, and type 2 diabetes mellitus have not been quantified.

Methods

PubMed and Scopus were queried up to December 2023 for primary and secondary analyses of placebo-controlled trials of SGLT2is in patients with heart failure, CKD, or type 2 diabetes mellitus. Outcomes of interest were composite kidney end point (combination of eGFR <15 ml/min per 1.73 m2, sustained doubling of serum creatinine, varying percent change in eGFR, and need for KRT), rate of eGFR slope decline, and albuminuria progression. Hazard ratios (HRs) and mean differences with their 95% confidence intervals (CIs) were extracted onto an Excel sheet, and the results were then pooled using a random-effect model through Review Manager (version 5.3, Cochrane Collaboration).

Results

Eleven trials (n =80,928 patients) were included. Compared with the placebo, SGLT2is reduced the risk of the composite kidney end point by 41% (HR, 0.59; 95% CI, 0.42 to 0.83) in heart failure with reduced ejection fraction, 36% (HR, 0.64; 95% CI, 0.55 to 0.73) in CKD, and 38% (HR, 0.62; 95% CI, 0.56 to 0.69) in type 2 diabetes mellitus. A similar pattern of benefit was observed in combinations of these comorbidities and in patients without baseline heart failure, CKD, or type 2 diabetes mellitus. SGLT2is slowed the rate of eGFR slope decline and reduced the risk of sustained doubling of serum creatinine by 36% (HR, 0.64; 95% CI, 0.56 to 0.72) in the overall population, and a consistent effect on kidney outcomes was observed in most subpopulations with available data.

Conclusions

SGLT2i improved kidney outcomes in cohorts with heart failure, CKD, and type 2 diabetes mellitus, and these effects were consistent across patients with different combinations of these comorbidities.

Morphological data of the superior vena cava predicted by multiple linear regression equations

This study explores the main surface markers in the hemodialysis puncture catheterization pathway and the relative spatial position of venous vessels in the puncture results, providing data support for venous puncture. Seventy cadavers were studied; angles of vertical axis with superior vena cava, left and right brachiocephalic vein at the confluence and circumference of superior vena cava were the primary parameters. Bivariate correlation analysis was used to determine in relation to other body parameters, and a regression equation was also obtained. The angle of the vertical axis with the superior vena cava at the confluence was linearly correlated with the distances between the coracoid processes and the jugular notch to coracoid processes. The angle of the vertical axis with left brachiocephalic vein was linearly correlated with the thickness of thorax and the length from the upper pericardial margin to the confluence. The angle of the vertical axis with right brachiocephalic vein was correlated with clavicular midline length, acromial distance, intersection point of clavicle to clavicular midline, confluence to clavicular midline, superior edge of the blood vessels to superior edge of clavicle at the right intersection, and superior edge of pericardium to confluence. There is a linear relationship between the superior vena cava circumference and the distance from the superior vena cava to the aorta. A number of parameters influence angles of the vertical axis with superior vena cava, left and right brachiocephalic veins and the superior vena cava circumference which can provide guidance for intubation.

Comparative cardiovascular and renal outcomes of Liraglutide versus Dulaglutide in Asian type 2 diabetes patients

Given the limited head-to-head comparison of cardiovascular and renal outcomes between liraglutide and dulaglutide, our study aimed to investigate the clinical outcomes between dulaglutide and liraglutide in a real-world setting. In this new-user design, comparative and retrospective cohort study, patients with type 2 diabetes mellitus with prescription for GLP-1RAs from January 1, 2016 to December 31, 2022 (n = 8,278) were included. Primary outcome was composite cardiovascular outcomes which was composed of cardiovascular death, non-fatal myocardial infarction, and non-fatal ischemic stroke. The composite renal outcome was also interested, including new macroalbuminuria, doubling of serum creatinine, worsening of estimated glomerular filtration rate (eGFR), and progression to dialysis. A total of 3,210 subjects receiving liraglutide and 5,068 subjects receiving dulaglutide were identified. In the adjusted cohort by applying inverse probability of treatment weighting, the incidence of composite cardiovascular outcomes was 18.4 and 18.7 events per 1000 person-years in the liraglutide and dulaglutide groups, respectively. The risk of cardiovascular outcomes did not significantly differ between groups (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.85-1.15). Moreover, the risk of composite renal outcomes was also comparable between groups (subdistribution HR 1.07, 95% CI 0.995-1.16). Liraglutide and dulaglutide demonstrated comparable cardiovascular and renal outcomes in a real-world setting.

The early diagnostic value of serum renalase level in diabetic kidney disease and diabetic macroangiopathy: a retrospective case-control study

Background

Diabetic kidney disease (DKD) is a severe complication of diabetes mellitus and is associated with an increased risk of end-stage renal disease (ESRD) and cardiovascular events. Early diagnosis and monitoring of DKD are crucial for implementing appropriate interventions. This study aimed to investigate the relationship between serum renalase (RNLS) levels, DKD, and diabetic macroangiopathy in patients with type 2 diabetes mellitus (T2DM).

Objectives

This study aims to evaluate the diagnostic value of serum renalase levels in DKD and diabetic macroangiopathy.

Design

This is a retrospective case-control study.

Methods

A total of 233 participants were recruited for the study, including 115 T2DM patients without DKD or diabetic retinopathy, and 118 T2DM patients with DKD. Serum RNLS levels were measured using an enzyme-linked immunosorbent assay. Kidney function parameters and diabetic macroangiopathy risk factors were evaluated in relation to serum RNLS levels.

Results

Serum RNLS levels were significantly higher in DKD patients compared to T2DM controls (34.82 (31.68, 39.37) vs 30.52 (28.58, 33.16), p < 0.01). Multiple linear regression analysis indicated that kidney function parameters and carotid intima-media thickness were independently related to RNLS levels. The study population was divided into four groups: no DKD and no diabetic macroangiopathy, DKD without diabetic macroangiopathy, diabetic macroangiopathy without DKD, and both DKD and diabetic macroangiopathy. Analysis results showed that patients with both DKD and diabetic macroangiopathy had the highest RNLS levels. Receiver operating characteristic curve analysis demonstrated the diagnostic value of RNLS for DKD (0.76 (95% confidence interval (CI) = 0.70-0.82, p < 0.01)) and diabetic macroangiopathy (0.75 (95% CI = 0.66-0.84, p < 0.01)).

Conclusion

Circulating RNLS levels were significantly increased in patients with DKD and diabetic macroangiopathy, suggesting that RNLS may serve as an early diagnostic marker.

An integrative exploration of environmental stressors on the microbiome-gut-brain axis and immune mechanisms promoting neurological disorders

The microbiome-gut-brain axis is altered by environmental stressors such as heat, diet, and pollutants as well as microbes in the air, water, and soil. These stressors might alter the host's microbiome and symbiotic relationship by modifying the microbial composition or location. Compartmentalized mutualistic microbes promote the beneficial interactions in the host leading to circulating metabolites and hormones such as insulin and leptin that affect inter-organ functions. Inflammation and oxidative stress induced by environmental stressors may alter the composition, distribution, and activities of the microbes in the microbiomes such that the resultant metabolite and hormone changes are no longer beneficial. The microbiome-gut-brain axis and immune adverse changes that may accompany environmental stressors are reviewed for effects on innate and adaptive immune cells, which may make host immunity less responsive to pathogens and more reactive to self-antigens. Cardiovascular and fluid exchanges to organs might adversely alter organ functionality. Organs, especially the brain, need a consistent supply of nutrients and clearance of debris; disruption of these exchanges by stressors, and involvement of gut microbiome are discussed regarding neural dysfunctions with Alzheimer's disease, autistic spectrum disorders, viral infections, and autoimmune diseases. The focus of this review includes the manner in which environmental stressors may disrupt gut microbiota leading to adverse immune and hormonal influences on development of neuropathology related to hyperhomocysteinemia, inflammation, and oxidative stress, and how certain therapeutics may be beneficial. Strategies are explored to lessen detrimental effects of environmental stressors on central and peripheral health navigated toward (1) understanding neurological disorders and (2) promoting environmental and public health and well-being.

Development of a machine learning-based model for the prediction and progression of diabetic kidney disease: A single centred retrospective study

BACKGROUND

Diabetic kidney disease (DKD) is a diabetic microvascular complication often characterized by an unpredictable progression. Hence, early detection and recognition of patients vulnerable to progression is crucial.

OBJECTIVE

To develop a prediction model to identify the stages of DKD and the factors contributing to progression to each stage using machine learning.

METHODOLOGY

A retrospective study was conducted in a South Indian tertiary care hospital and collected the details of patients diagnosed with DKD from January 2017 to January 2022. Bayesian optimization-based machine learning techniques such as classification and regression were employed. The model was developed with the help of an optimization framework that effectively balances classification, prediction accuracy, and explainability.

RESULTS

Of the 311 patients diagnosed with DKD, 227 were selected for the study. A system for predicting DKD has been created for a patient dataset utilizing a variety of machine-learning approaches. The eXtreme gradient (XG) Boost method excelled, achieving 88.75% accuracy, 88.57% precision, 91.4% sensitivity,100% specificity, and 89.49% F1-score. An interpretable data-driven method highlights significant features for early DKD diagnosis. The best explainable prediction model uses the XG Boost classifier, revealing serum uric acid, urea, phosphorous, red blood cells, calcium, and absolute eosinophil count as the major predictors influencing the progression of DKD. In the case of regression models, the gradient boost regressor performed the best, with an R2 score of 0.97.

CONCLUSION

Machine learning algorithms can effectively predict the stages of DKD and thus help physicians in providing patients with personalized care at the right time.

Pentoxifylline ameliorates subclinical atherosclerosis progression in patients with type 2 diabetes and chronic kidney disease: a randomized pilot trial

BACKGROUND

Diabetic kidney disease (DKD) is associated with a higher risk of cardiovascular disease (CVD). Pentoxifylline (PTF), a nonselective phosphodiesterase inhibitor with anti-inflammatory, antiproliferative, and antifibrotic actions, has demonstrated renal benefits in both clinical trials and meta-analyses. The present work aimed to study the effects of PTF on the progression of subclinical atherosclerosis (SA) in a population of patients with diabetes and moderate to severe chronic kidney disease (CKD).

METHODS

In this open-label, randomized controlled, prospective single-center pilot study the evolution of carotid intima-media thickness (CIMT) and ankle-brachial index (ABI) were determined in 102 patients with type 2 diabetes mellitus and CKD assigned to PTF, aspirin or control groups during 18 months. We also determined the variations in the levels of inflammatory markers and Klotho (KL), a protein involved in maintaining cardiovascular health, and their relationship with the progression of SA.

RESULTS

Patients treated with PTF presented a better evolution of CIMT, increased KL mRNA levels in peripheral blood cells (PBCs) and reduced the inflammatory state. The progression of CIMT values was inversely related to variations in KL both in serum and mRNA expression levels in PBCs. Multiple regression analysis demonstrated that PTF treatment and variations in mRNA KL expression in PBCs, together with changes in HDL, were significant determinants for the progression of CIMT (adjusted R2 = 0.24, P < 0.001) independently of traditional risk factors. Moreover, both variables constituted protective factors against a worst progression of CIMT [OR: 0.103 (P = 0.001) and 0.001 (P = 0.005), respectively].

CONCLUSIONS

PTF reduced SA progression assessed by CIMT variation, a beneficial effect related to KL gene expression in PBCs.

TRIAL REGISTRATION

The study protocol code is PTF-AA-TR-2009 and the trial was registered on the European Union Drug Regulating Authorities Clinical Trials (EudraCT #2009-016595-77). The validation date was 2010-03-09.

Triglyceride Glucose Index for the Detection of Diabetic Kidney Disease and Diabetic Peripheral Neuropathy in Hospitalized Patients with Type 2 Diabetes

INTRODUCTION

The triglyceride-glucose index (TyG) has been identified as a dependable and simple indicator marker of insulin resistance (IR). Research has demonstrated a correlation between macrovascular complications and TyG. However, limited research exists regarding the relationship between TyG and diabetic microvascular complications. Consequently, the objective of this study is to investigate the association between TyG and diabetic kidney disease (DKD) and diabetic peripheral neuropathy (DPN).

METHODS

This is a cross-sectional, observational study. A total of 2048 patients from Tongren Hospital, Shanghai Jiao Tong University School of Medicine were enrolled. The primary outcomes are DKD and DPN. Quantile regression analysis was employed to investigate the implicit factors of TyG quartiles. Subsequently, based on implicit factors, logistic regression models were constructed to further examine the relationship between TyG and DKD and DPN.

RESULTS

In the baseline, TyG exhibited higher values across patients with DKD, DPN, and co-existence of DKD and DPN (DKD + DPN) in type 2 diabetes (T2D). Univariate logistic regressions demonstrated a significant association between an elevated TyG and an increased risk of DKD (OR = 1.842, [95% CI] 1.317-2.578, P for trend < 0.01), DPN (OR = 1.516, [95% CI] 1.114-2.288, P for trend < 0.05), DKD + DPN (OR = 2.088, [95% CI] 1.429-3.052, P for trend < 0.05). Multivariable logistic regression models suggested a statistically significant increase in the risk of DKD (OR = 1.581, [95% CI] 1.031-2.424, p < 0.05), DKD + DPN (OR = 1.779, [95% CI] 1.091-2.903, p < 0.05) after adjusting the implicit factors of TyG quartiles. However, no significant relationship was observed between TyG and DPN in the multivariable regression analysis.

CONCLUSIONS

Elevated TyG was significantly associated with an increased risk of DKD in T2D, but no significant relationship was shown with DPN. This finding provided further evidence for the clinical significance of integrating TyG into the initial assessment of diabetic microvascular complications.

Impact of chronic kidney disease and end-stage renal disease on the mid-term adverse outcomes in diabetic patients with cardiovascular diseases

The evidence for the impact of renal dysfunction in patients with diabetes mellitus (DM) and first cardiovascular diseases on mid-term adverse outcomes remain scarce. This study included the data of patients with DM having first atherosclerotic cardiovascular disease (ASCVD) or congestive heart failure (CHF) from the Taipei Medical University Clinical Research Database. A Cox proportional hazards regression model was used to assess the impact of chronic kidney disease (CKD) or end-stage renal disease (ESRD) on the 1-year mortality and recurrent ASCVD/CHF outcomes. We enrolled 21,320 patients with DM hospitalized for ASCVD or CHF; of them, 18,185, 2639, and 496 were assigned to the non-CKD, CKD, and ESRD groups, respectively. After propensity score matching, compared with the non-CKD group, the CKD and ESRD groups had higher mid-term all-cause mortality (adjusted hazard ratio 1.72 [95% confidence interval 1.48-1.99] and 2.77 [2.05-3.73], respectively), cardiovascular death (1.84 [1.44-2.35] and 1.87 [1.08-3.24], respectively), and recurrent hospitalization for ASCVD (1.44 [1.24-1.68] and 2.33 [1.69-3.23], respectively) and CHF (2.08 [1.75-2.47] and 1.50 [1.04-2.17], respectively). The advancing age was associated with mortality in CKD/ESRD groups. In CKD group, male sex was associated with all-cause mortality and recurrent ASCVD risk; the diuretics usage was associated with mortality and recurrent CHF risks. Our findings suggest that CKD and ESRD are significant risk factors for mid-term adverse outcomes in patients with DM and established cardiovascular diseases. Additionally, old age, male sex and diuretics usage requires attention. Further good quality studies are needed in the future.

Modification of coronary artery disease clinical risk factors by coronary artery disease polygenic risk score

BACKGROUND

The extent to which the relationships between clinical risk factors and coronary artery disease (CAD) are altered by CAD polygenic risk score (PRS) is not well understood. Here, we determine whether the interactions between clinical risk factors and CAD PRS further explain risk for incident CAD.

METHODS

Participants were of European ancestry from the UK Biobank without prevalent CAD. An externally trained genome-wide CAD PRS was generated and then applied. Clinical risk factors were ascertained at baseline. Cox proportional hazards models were fitted to examine the incident CAD effects of CAD PRS, risk factors, and their interactions. Next, the PRS and risk factors were stratified to investigate the attributable risk of clinical risk factors.

FINDINGS

A total of 357,144 individuals of European ancestry without prevalent CAD were included. During a median of 11.1 years of follow-up (interquartile range 10.4-14.1 years), CAD PRS was associated with 1.35-fold (95% confidence interval [CI] 1.332-1.368) risk per SD for incident CAD. The prognostic relevance of the following risk factors was relatively diminished for those with high CAD PRS on a continuous scale: type 2 diabetes (hazard ratio [HR]interaction 0.91, 95% CIinteraction 0.88-0.94), increased body mass index (HRinteraction 0.97, 95% CIinteraction 0.96-0.98), and increased C-reactive protein (HRinteraction 0.98, 95% CIinteraction 0.96-0.99). However, a high CAD PRS yielded joint risk increases with low-density lipoprotein cholesterol (HRinteraction 1.05, 95% CIinteraction 1.04-1.06) and total cholesterol (HRinteraction 1.05, 95% CIinteraction 1.03-1.06).

CONCLUSION

The CAD PRS is associated with incident CAD, and its application improves the prognostic relevance of several clinical risk factors.

FUNDING

P.N. (R01HL127564, R01HL151152, and U01HG011719) is supported by the National Institutes of Health.

2023 Diabetic Kidney Disease Fact Sheet in Korea

BACKGRUOUND

To investigate the prevalence, incidence, comorbidities, and management status of diabetic kidney disease (DKD) and diabetes-related end-stage kidney disease (ESKD) in South Korea.

METHODS

We used the Korea National Health and Nutrition Examination Survey data (2019 to 2021, n=2,665) for the evaluation of prevalence, comorbidities, control rate of glycemia and comorbidities in DKD, and the Korean Health Insurance Service-customized database (2008 to 2019, n=3,950,857) for the evaluation of trends in the incidence and prevalence rate of diabetes-related ESKD, renin-angiotensin system (RAS) blockers and sodium glucose cotransporter 2 (SGLT2) inhibitors use for DKD, and the risk of atherosclerotic cardiovascular disease (ASCVD) and mortality according to DKD stages. DKD was defined as albuminuria or low estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 in patients with diabetes mellitus.

RESULTS

The prevalence of DKD was 25.4% (albuminuria, 22.0%; low eGFR, 6.73%) in patients with diabetes mellitus aged ≥30 years. Patients with DKD had a higher rate of comorbidities, including hypertension, dyslipidemia, and central obesity; however, their control rates were lower than those without DKD. Prescription rate of SGLT2 inhibitors with reduced eGFR increased steadily, reaching 5.94% in 2019. Approximately 70% of DKD patients were treated with RAS blockers. The prevalence rate of diabetesrelated ESKD has been steadily increasing, with a higher rate in older adults. ASCVD and mortality were significantly associated with an in increase in DKD stage.

CONCLUSION

DKD is prevalent among Korean patients with diabetes and is an independent risk factor for cardiovascular morbidity and mortality, which requiring intensive management of diabetes and comorbidities. The prevalence of diabetes-related ESKD has been increasing, especially in the older adults, during past decade.

SGLT2 knockdown restores the Th17/Treg balance and suppresses diabetic nephropathy in db/db mice by regulating SGK1 via Na. Mol Cell Endocrinol 2024;584:112156. [PMID: 38278341 DOI: 10.1016/j.mce.2024.112156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

The imbalance between T helper 17 (Th17) and regulatory T (Treg) cells is an important mechanism in the pathogenesis of diabetic nephropathy (DN). Serum/glucocorticoid regulated kinase 1 (SGK1) is a serine-threonine kinase critical for stabilizing the Th17 cell phenotype. Sodium-glucose cotransporter 2 (SGLT2) is a glucose transporter that serves as a treatment target for diabetes. Our study investigated the regulatory role of SGLT2 in the development of DN. The results revealed that SGLT2 knockdown suppressed high glucose-induced excessive secretion of sodium (Na+) and inflammatory cytokines in mouse renal tubular epithelial TCMK-1 cells. High Na+ content induced Th17 differentiation and upregulated SGK1, phosphorylated forkhead box protein O1 (p-FoxO1), and the interleukin 23 receptor (IL-23 R) in primary mouse CD4+ T cells. Co-culture of CD4+ T cells with the culture medium of TCMK-1 cells with insufficient SGLT2 expression significantly suppressed cell migration ability, reduced the production of pro-inflammatory cytokines, and inhibited Th17 differentiation possibly by downregulating SGK1, p-FoxO1, and IL-23 R. In addition, in vivo data demonstrated that SGLT2 knockdown markedly downregulated SGK1 in db/db mice. Insufficient SGLT2 or SGK1 expression also ameliorated the Th17/Treg imbalance, suppressed the development of DN, and regulated the expression of IL-23 R and p-FoxO1. In conclusion, this study showed that SGLT2 knockdown restored the Th17/Treg balance and suppressed DN possibly by regulating the SGK1/p-FoxO1/IL-23 R axis by altering Na+ content in the local environment. These findings highlight the potential use of SGLT2 and SGK1 for the management of DN.

Therapeutic effect of ferrous sulfate in diabetic patients with iron deficiency anaemia: a randomised controlled trial

Iron deficiency anaemia (IDA) and diabetes mellitus (DM) are most prevalent disease, that diabetic patients are more prone to IDA. Therefore, the main aim of this study was to investigate the relationship between patients with diabetes and IDA in relation to taking iron pills daily and every other day to reduce the effects related to it. Ninety-one participants were enroled and randomly divided into two groups, with a final analysis cohort of 72 patients. The primary focus was on changes in serum Hb and Ferritin levels. The screening phase lasted 24 weeks, leading to 72 eligible participants meeting the criteria for entry into the study. Additionally, the study examined alternations in Hb and Hb A1C levels after treating patients with iron deficiency. The Hb and ferritin level contrasts between groups were not significant (P = 0.096 and P = 0.500, respectively). The relationship between Hb A1C and Hb levels before and after treatment was positive and significant (r 2 = 0.187). The results of the present study show that although the effectiveness of using oral iron supplements did not have a significant difference in terms of increasing haemoglobin and ferritin, the use of oral iron once every other day was more effective than the use of oral iron every day, and also in this study Like other studies, this result concluded that there is a negative correlation between Hb A1C and Hb, and to check the status of Hb A1C in diabetics, the level of Hb should be considered first.

Kidney and heart failure events are bidirectionally associated in patients with type 2 diabetes and cardiovascular disease

AIMS

This study aimed to evaluate the bidirectional relationship between kidney and cardiovascular (CV) events in trial participants with type 2 diabetes and CV disease.

METHODS AND RESULTS

Post hoc analyses of EMPA-REG OUTCOME using Cox regression models were performed to assess the association of baseline factors with risk of a kidney event and bidirectional associations of incident kidney events and CV events. Among placebo-treated participants, baseline factors significantly associated with greater kidney event risk included lower baseline estimated glomerular filtration rate, albuminuria, higher uric acid, low-density lipoprotein cholesterol levels, and prior heart failure (HF). Coronary artery disease was not associated with increased risk. In placebo-treated participants, occurrence of an incident non-fatal kidney event increased the subsequent risk of hospitalization for HF (HHF) but not 3-point major adverse CV events (non-fatal stroke, non-fatal myocardial infarction, and CV death). Vice versa, HHF (but not myocardial infarction/stroke) increased the risk of subsequent kidney events. These associations were generally also seen in empagliflozin-treated participants and in the overall population. Interestingly, the risk of kidney events following HHF was not significantly increased in the relatively small number of placebo-treated participants already diagnosed with HF at baseline.

CONCLUSIONS

These findings demonstrate a bidirectional inter-relationship between HHF and kidney events. Further exploration of this relationship and strategies to optimize the use of therapies to reduce both kidney and HF outcomes is warranted.

Finerenone: From the Mechanism of Action to Clinical Use in Kidney Disease

Diabetic kidney disease is a frequent microvascular complication of diabetes and is currently the leading cause of chronic kidney disease and end-stage kidney disease worldwide. Although the prevalence of other complications of diabetes is falling, the number of diabetic patients with end-stage kidney disease in need of kidney replacement therapy is rising. In addition, these patients have extremely high cardiovascular risk. It is more than evident that there is a high unmet treatment need in patients with diabetic kidney disease. Finerenone is a novel nonsteroidal mineralocorticoid receptor antagonist used for treating diabetic kidney disease. It has predominant anti-fibrotic and anti-inflammatory effects and exhibits several renal and cardiac protective effects. This review article summarizes the current knowledge and future prospects of finerenone in treating patients with kidney disease.

A late eating midpoint is associated with increased risk of diabetic kidney disease: a cross-sectional study based on NHANES 2013-2020

BACKGROUND

Modifying diet is crucial for diabetes and complication management. Numerous studies have shown that adjusting eating habits to align with the circadian rhythm may positively affect metabolic health. However, eating midpoint, eating duration, and their associations with diabetic kidney disease (DKD) are poorly understood.

METHODS

The National Health and Nutrition Examination Survey (2013-2020) was examined for information on diabetes and dietary habits. From the beginning and ending times of each meal, we calculated the eating midpoint and eating duration. Urinary albumin-to-creatinine ratio (UACR) ≥ 30 mg/g and/or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 were the specific diagnostic criteria for DKD.

RESULTS

In total, details of 2194 subjects with diabetes were collected for analysis. The overall population were divided into four subgroups based on the eating midpoint quartiles. The prevalence of DKD varied noticeably (P = 0.037) across the four categories. When comparing subjects in the second and fourth quartiles of eating midpoint to those in the first one, the odds ratios (ORs) of DKD were 1.31 (95% CI, 1.03 to 1.67) and 1.33 (95% CI, 1.05 to 1.70), respectively. And after controlling for potential confounders, the corresponding ORs of DKD in the second and fourth quartiles were 1.42 (95% CI, 1.07 to 1.90) and 1.39 (95% CI, 1.04 to 1.85), respectively.

CONCLUSIONS

A strong correlation was found between an earlier eating midpoint and a reduced incidence of DKD. Eating early in the day may potentially improve renal outcomes in patients with diabetes.

The impact of GLP-1 receptor agonist liraglutide on blood pressure profile, hydration, natriuresis in diabetic patients with severely impaired kidney function

Chronic treatment with GLP-1R agonists may moderately lower blood pressure due to increased natriuresis and RAAS inhibition. Short-term effect of these drugs on blood pressure may be opposite and its mechanism remains unclear. We investigated the effect of a single dose of liraglutide on diurnal blood pressure profile, natriuresis, hydration and serum concentration of renin, aldosterone and atrial natriuretic peptide (ANP) in diabetic kidney disease (DKD). 17 patients with eGFR < 30 ml/min/1.73 m2 and 17 with > 60 ml/min/1.73 m2 received in a random order a single subcutaneous dose 1.2 mg liraglutide and placebo with subsequent 24 h blood pressure and natriuresis monitoring. Before and after each medication thoracic fluid index and plasma renin, aldosterone and ANP were also assessed. The blood pressure load in the daytime and nighttime were significantly increased after liraglutide compared to placebo in patients with eGFR < 30 ml/min/1.73 m2. In patients with eGFR > 60 ml/min/1.73 m2 the changes of arterial pressure were comparable, while the morning surge was significantly reduced after liraglutide compared to placebo. After liraglutide 24 h urine sodium excretion increased in both groups vs. placebo (p < 0.001), the effect was greatest in subjects with eGFR > 60 ml/min/1.73 m2. Plasma ANP increased after liraglutide in both groups, most in patients with eGFR < 30 ml/min/1.73 m2 group. Plasma aldosterone (p = 0.013) and thoracic fluid index (p = 0.01) decreased after liraglutide compared to placebo (p = 0.013 and p + 0.01, respectively. Plasma renin concentration remained unchanged. In severe chronic kidney disease liraglutide induces a transient increase of blood pressure due to reduced natriuresis. The natriuretic effect of liraglutide in DKD may be related to increased ANP and decreased aldosterone secretion.

Low Levels of Metrnl are Linked to the Deterioration of Diabetic Kidney Disease

Objective

Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease. Metrnl is a secreted protein that plays an important role in kidney disease. The aim of this study was to investigate DKD-related factors and the correlation between serum Metrnl levels and the severity of DKD.

Methods

Ninety-six type 2 diabetes mellitus (T2DM) patients and 45 DKD patients were included in the study. A range of parameters were measured simultaneously, including waist-to-hip ratio (WHR), body mass index (BMI), urinary albumin/creatinine ratio (UACR), monocyte-lymphocyte ratio (MLR), albumin/globulin (A/G), liver and kidney function, blood lipid profile, islet function, and others. Subsequently, the related factors and predictive significance of DKD were identified. The correlation between the relevant factors of DKD and serum Metrnl levels with DKD was evaluated.

Results

The duration of the disease (OR: 1.12, 95% CI: 1.01-1.24, P=0.031), hypertension (OR: 4.86, 95% CI: 1.16-20.49, P=0.031), fasting blood glucose (OR: 1.23, 95% CI: 1.03-1.48, P=0.025), WHR (OR: 2.53, 95% CI: 1.03-6.22, P=0.044), and MLR (OR: 1.91, 95% CI: 1.18-3.08, P=0.008) are independent risk factors for DKD (P < 0.05). Conversely, A/G (OR: 0.13, 95% CI: 0.02-0.76, P=0.024) and Metrnl (OR: 0.99, 95% CI: 0.98-1.00, P=0.001) have been identified as protective factors against DKD. Furthermore, the level of Metrnl was negatively correlated with the severity of DKD (rs=-0.447, P<0.001). The area under receiver operating characteristic (ROC) curves for the diagnostic accuracy of Metrnl for DKD is 0.765 (95% CI: 0.686-0.844).

Conclusion

The duration of the disease, hypertension, fasting blood glucose, WHR, and MLR are major risk factors for DKD. Metrnl and A/G are protective factors for DKD. Serum Metrnl concentrations are inversely correlated with DKD severity.

The role of endoplasmic reticulum-mitochondria-associated membranes in diabetic kidney disease

Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease worldwide. The pathomechanisms of DKD are multifactorial, yet haemodynamic and metabolic changes in the early stages of the disease appear to predispose towards irreversible functional loss and histopathological changes. Recent studies highlight the importance of endoplasmic reticulum-mitochondria-associated membranes (ER-MAMs), structures conveying important cellular homeostatic and metabolic effects, in the pathology of DKD. Disruption of ER-MAM integrity in diabetic kidneys is associated with DKD progression, but the regulation of ER-MAMs and their pathogenic contribution remain largely unknown. Exploring the cell-specific components and dynamic changes of ER-MAMs in diabetic kidneys may lead to the identification of new approaches to detect and stratify diabetic patients with DKD. In addition, these insights may lead to novel therapeutic approaches to target and/or reverse disease progression. In this review, we discuss the association of ER-MAMs with key pathomechanisms driving DKD such as insulin resistance, dyslipidaemia, ER stress, and inflammasome activation and the importance of further exploration of ER-MAMs as diagnostic and therapeutic targets in DKD.

Association between controlling nutritional status score and chronic kidney disease in diabetic patients: a cross-sectional study based on the National Health and Nutrition Examination Survey

PURPOSE

This study aimed to explore the association between controlling nutritional status (CONUT) score and chronic kidney disease (CKD) in type-2 diabetes mellitus (T2DM) patients.

METHODS

This was a cross-sectional study based on the National Health and Nutrition Examination Survey (NHANES). The data on demographic characteristics, physical examination, lifestyle behaviors, comorbidities, medicine use, laboratory values, and energy were extracted. Nutritional status was assessed using CONUT score, and patients were divided into normal nutrition group and malnutrition group. Association between CONUT score and CKD in T2DM patients was assessed using logistic regression analysis, and odds ratio (OR) and 95% confidence intervals (CIs) were reported. Subgroup analysis based on age, body mass index (BMI), cardiovascular disease (CVD), diabetic retinopathy, and hyperlipidemia was performed.

RESULTS

A total of 4581 patients were finally included for analysis. In the adjusted model, high CONUT score was found to be associated with the high odds of CKD (OR = 1.28, 95% CI 1.05-1.56). Also, high CONUT score was associated with the high odds of CKD in T2DM patients with age ≥ 65 years, with BMI < 25 kg/m2, with BMI ≥ 25 kg/m2, without CVD, without diabetic retinopathy, with hyperlipidemia, or without hyperlipidemia (all P < 0.05).

CONCLUSIONS

Malnutrition was associated with the high odds of CKD in T2DM patients, indicating that actively monitoring the nutritional status is important for the management of CKD in T2DM patients.

Effect of Resveratrol on Endothelial Function in Patients with CKD and Diabetes: A Randomized Controlled Trial

BACKGROUND

Patients with CKD and diabetes are at higher risk of developing cardiovascular disease, in part, because of impaired endothelial function. Cardioprotective compounds such as resveratrol could improve endothelial function and attenuate the cardiovascular burden in patients with CKD and diabetes. We hypothesized that resveratrol supplementation would improve endothelial function in patients with CKD and diabetes.

METHODS

Twenty-eight adults aged 68±7 years (84% men) with stage 3 CKD and diabetes were enrolled in a randomized, double-blind, placebo-controlled, crossover study to investigate the effects of 6-week resveratrol supplementation (400 mg/d) on endothelial function. Endothelial function was determined through brachial artery flow-mediated dilation.

RESULTS

The mean values for eGFR and hemoglobin A 1c were 40±9 ml/min per 1.73 m 2 and 7.36%±0.72%, respectively. Compared with placebo, resveratrol supplementation increased flow-mediated dilation (ratio of geometric mean changes and 95% confidence interval for between-group comparisons, 1.43 (1.15 to 1.77); P value = 0.001). eGFR, hemoglobin A 1c , BP, and nitroglycerin-mediated dilation were unchanged with resveratrol or placebo ( P = 0.15), suggesting the observed change in flow-mediated dilation was likely independent of changes in traditional cardiovascular risk factors.

CONCLUSIONS

Resveratrol supplementation improved endothelial function in patients with CKD and diabetes.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Resveratrol and Vascular Function in CKD, NCT03597568 .

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_11_20_CJN0000000000000337.mp3.

Role of GLP-1 Receptor Agonist in Diabetic Cardio-renal Disorder: Recent Updates of Clinical and Pre-clinical Evidence

Cardiovascular complications and renal disease is the growing cause of mortality in patients with diabetes. The subversive complications of diabetes such as hyperglycemia, hyperlipidemia and insulin resistance lead to an increase in the risk of myocardial infarction (MI), stroke, heart failure (HF) as well as chronic kidney disease (CKD). Among the commercially available anti-hyperglycemic agents, incretin-based medications appear to be safe and effective in the treatment of type 2 diabetes mellitus (T2DM) and associated cardiovascular and renal disease. Glucagon-like peptide 1 receptor agonists (GLP-1RAs) have been shown to be fruitful in reducing HbA1c, blood glucose, lipid profile, and body weight in diabetic patients. Several preclinical and clinical studies revealed the safety, efficacy, and preventive advantages of GLP-1RAs against diabetes- induced cardiovascular and kidney disease. Data from cardio-renal outcome trials had highlighted that GLP-1RAs protected people with established CKD from significant cardiovascular disease, lowered the likelihood of hospitalization for heart failure (HHF), and lowered all-cause mortality. They also had a positive effect on people with end-stage renal disease (ESRD) and CKD. Beside clinical outcomes, GLP-1RAs reduced oxidative stress, inflammation, fibrosis, and improved lipid profile pre-clinically in diabetic models of cardiomyopathy and nephropathy that demonstrated the cardio-protective and reno-protective effect of GLP-1RAs. In this review, we have focused on the recent clinical and preclinical outcomes of GLP-1RAs as cardio-protective and reno-protective agents as GLP-1RAs medications have been demonstrated to be more effective in treating T2DM and diabetes-induced cardiovascular and renal disease than currently available treatments in clinics, without inducing hypoglycemia or weight gain.

Midnight Cortisol is Associated with Changes in Systolic Blood Pressure and Diabetic Neuropathy in Subjects with Type 1 Diabetes Undergoing Simultaneous Kidney-Pancreas Transplantation

INTRODUCTION

An increased midnight cortisol (MC) has been described in end-stage kidney disease (ESKD) and type 1 diabetes (T1D). Lower circulating levels of the cytokine soluble tumor necrosis factor (TNF)-like weak inducer of apoptosis (sTWEAK) have been found in T1D and ESKD and associated with cardiovascular (CV) events in the latter. We aimed to study MC and sTWEAK in simultaneous pancreas-kidney transplant (SPKT) recipients, and the association of these markers with CV risk factors and transplant outcomes.

METHODS

This was a retrospective cohort study including subjects with T1D who received a first SPKT between 2008 and 2020. MC and sTWEAK at baseline were correlated with CV risk factors and evolution 1 year after SPKT.

RESULTS

We included 29 subjects (58.6% women, mean age 43.5 ± 7.5 years, diabetes duration 31.9 ± 9.4 years). Systolic blood pressure (SBP) increased directly with MC quartiles, despite similar hypertension prevalence (p < 0.05). At 1 year, antihypertensive treatment was deintensified in those in lower MC quartiles (p < 0.05). Diabetic neuropathy prevalence decreased progressively in higher cortisol quartiles (p for trend = 0.005). Low MC was associated with delayed kidney graft function (p for trend = 0.044), and high sTWEAK with kidney graft rejection (p for trend = 0.018). In multivariate analyses, MC (standardized-β 0.505, p = 0.004) and age (standardized-β - 0.460, p = 0.040) were independently correlated with SBP, and MC was independently associated with the presence of diabetic neuropathy (OR 0.633, 95% CI 0.425-0.944, p = 0.025), adjusted for confounders.

CONCLUSIONS

In this exploratory study, lower MC was associated with a lower baseline SBP, an improvement of antihypertensive treatment 1 year after transplant, and a higher diabetic neuropathy prevalence in SPKT recipients.

Effect of weight loss on proteinuria in adults with type 2 diabetes: A real-world study

AIMS

To assess the impact of weight loss on proteinuria in patients with type 2 diabetes (T2DM) in real-world settings.

METHODS

A total of 1054 participants were categorized based on weight change from baseline to one-year follow-up: weight gain (≥3%), stable weight, or weight loss (≥3%). Proteinuria outcomes were defined as urinary albumin/creatinine ratio (UACR) progression (≥30 % increase), UACR regression (≥30 % reduction), or UACR stable. Ordered logistic regression analysis evaluated the relationship between weight loss and UACR regression.

RESULTS

Of the 1054 participants, 44.5 % were overweight, and 24.1 % were obese. Patients with obesity were at higher risk of developing proteinuria (OR, 1.783; 95 %CI, 1.195 to 2.659). Weight loss was associated with an 83.3 % increase in UACR regression compared to weight gain (OR, 1.833; 95 % CI, 1.262 to 2.663; P = 0.001). This association remained consistent across most subgroups and stronger in males (P for interaction = 0.023), with a 6 % UACR regression for every 1 kg weight loss (OR, 1.06; 95 % CI, 1.02 to 1.10; P = 0.003).

CONCLUSIONS

Our real-world study reveals that weight reduction is associated with UACR regression in patients with T2DM, regardless of the approach used for weight management, and the association was much stronger in males.

Pathomechanisms of Diabetic Kidney Disease

The worldwide occurrence of diabetic kidney disease (DKD) is swiftly rising, primarily attributed to the growing population of individuals affected by type 2 diabetes. This surge has been transformed into a substantial global concern, placing additional strain on healthcare systems already grappling with significant demands. The pathogenesis of DKD is intricate, originating with hyperglycemia, which triggers various mechanisms and pathways: metabolic, hemodynamic, inflammatory, and fibrotic which ultimately lead to renal damage. Within each pathway, several mediators contribute to the development of renal structural and functional changes. Some of these mediators, such as inflammatory cytokines, reactive oxygen species, and transforming growth factor β are shared among the different pathways, leading to significant overlap and interaction between them. While current treatment options for DKD have shown advancement over previous strategies, their effectiveness remains somewhat constrained as patients still experience residual risk of disease progression. Therefore, a comprehensive grasp of the molecular mechanisms underlying the onset and progression of DKD is imperative for the continued creation of novel and groundbreaking therapies for this condition. In this review, we discuss the current achievements in fundamental research, with a particular emphasis on individual factors and recent developments in DKD treatment.

Lewis acidic Fe3+-driven catalytic active Ni3+ formation in Fe-free metal-organic framework for enhanced electrochemical glucose sensing

Manipulating metal valence states and porosity in the metal-organic framework (MOF) by alloying has been a unique tool for creating high-valent metal sites and pore environments in a structure that are inaccessible by other methods, favorable for accelerating the catalytic activity towards sensing applications. Herein, we report Fe3+-driven formation of catalytic active Ni3+ species in the amine-crafted benzene-dicarboxylate (BDC-NH2)-based MOF as a high-performance electrocatalyst for glucose sensing. This work took the benefit of different bonding stability between BDC-NH2 ligand, and Fe3+ and Ni2+ metal precursor ions in the heterometallic NixFe(1-x)-BDC-NH2 MOF. The FeCl3 that interacts weakly with ligand, oxidizes the Ni2+ precursor to Ni3+-based MOF owing to its Lewis acidic behavior and was subsequently removed from the structure supported by Ni atoms, during solvothermal synthesis. This enables to create mesopores within a highly stable Ni-MOF structure with optimal feed composition of Ni0.7Fe0.3-BDC-NH2. The Ni3+-based Ni0.7Fe0.3-BDC-NH2 demonstrates superior catalytic properties towards glucose sensing with a high sensitivity of 13,435 µA mM-1 cm-2 compared to the parent Ni2+-based Ni-BDC-NH2 (10897 μA mM-1cm-2), along with low detection limit (0.9 μM), short response time (≤5 s), excellent selectivity, and higher stability. This presented approach for fabricating high-valent nickel species, with a controlled quantity of Fe3+ integrated into the structure allowing pore engineering of MOFs, opens new avenues for designing high-performing MOF catalysts with porous framework for sensing applications.

Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association

Cardiovascular-kidney-metabolic health reflects the interplay among metabolic risk factors, chronic kidney disease, and the cardiovascular system and has profound impacts on morbidity and mortality. There are multisystem consequences of poor cardiovascular-kidney-metabolic health, with the most significant clinical impact being the high associated incidence of cardiovascular disease events and cardiovascular mortality. There is a high prevalence of poor cardiovascular-kidney-metabolic health in the population, with a disproportionate burden seen among those with adverse social determinants of health. However, there is also a growing number of therapeutic options that favorably affect metabolic risk factors, kidney function, or both that also have cardioprotective effects. To improve cardiovascular-kidney-metabolic health and related outcomes in the population, there is a critical need for (1) more clarity on the definition of cardiovascular-kidney-metabolic syndrome; (2) an approach to cardiovascular-kidney-metabolic staging that promotes prevention across the life course; (3) prediction algorithms that include the exposures and outcomes most relevant to cardiovascular-kidney-metabolic health; and (4) strategies for the prevention and management of cardiovascular disease in relation to cardiovascular-kidney-metabolic health that reflect harmonization across major subspecialty guidelines and emerging scientific evidence. It is also critical to incorporate considerations of social determinants of health into care models for cardiovascular-kidney-metabolic syndrome and to reduce care fragmentation by facilitating approaches for patient-centered interdisciplinary care. This presidential advisory provides guidance on the definition, staging, prediction paradigms, and holistic approaches to care for patients with cardiovascular-kidney-metabolic syndrome and details a multicomponent vision for effectively and equitably enhancing cardiovascular-kidney-metabolic health in the population.

Cardiovascular Disease in Diabetes and Chronic Kidney Disease

Chronic kidney disease (CKD) is a common occurrence in patients with diabetes mellitus (DM), occurring in approximately 40% of cases. DM is also an important risk factor for cardiovascular disease (CVD), but CKD is an important mediator of this risk. Multiple CVD outcomes trials have revealed a greater risk for CVD events in patients with diabetes with CKD versus those without. Thus, reducing the risk of CKD in diabetes should result in improved CVD outcomes. To date, of blood pressure (BP) control, glycemic control, and inhibition of the renin-angiotensin system (RASI), glycemic control appears to have the best evidence for preventing CKD development. In established CKD, especially with albuminuria, RASI slows the progression of CKD. More recently, sodium glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide receptor agonists (GLP1RA) have revolutionized the care of patients with diabetes with and without CKD. SGLT2i and GLP1RA have proven to reduce mortality, heart failure (HF) hospitalizations, and worsening CKD in patients with diabetes with and without existing CKD. The future of limiting CVD in diabetes and CKD is promising, and more evidence is forthcoming regarding combinations of evidence-based therapies to further minimize CVD events.

Comparison of Type 2 Diabetes Mellitus Control at Home Healthcare and Hospital Clinic Care at King Salman Armed Forces Hospital (2021-2022): A Retrospective Cohort Study

BACKGROUND

Home healthcare represents a great necessity for patients with diabetes mellitus (DM). Although there are numerous studies on geriatric diabetic patients, there are few studies on diabetic home care versus hospital care.

AIM

This study aimed to compare the effect of home healthcare services to hospital care for controlling type 2 diabetes mellitus (T2DM) at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia.

METHODS

This retrospective cohort study included patients with type 2 diabetes mellitus at King Salman Armed Forces Hospital. The home healthcare group included 128 participants who received frequent follow-up visits at home. The hospital care group included 128 participants from the primary care clinic. Glycosylated hemoglobin (HbA1c) was used to measure glycemic control. Logistic regression analysis was done to detect factors related to achieving glycemic control.

RESULTS

Home healthcare care had a greater impact on the reduction of baseline glycosylated hemoglobin levels (p=0.0053). The target glycosylated hemoglobin was achieved by patients who received home healthcare (p=0.020). Using the multivariate regression analysis, home healthcare, married patients, those who can do full daily life activities without assistance, and those who were treated with only insulin had significant correlations to meet the target glycosylated hemoglobin level (odds ratio: 0.814, 0.541, 0.448, and 0.144; 95% confidence intervals: 0.72-0.94, 0.30-0.99, 0.31-0.65, and 0.08-0.25, respectively).

CONCLUSIONS

Home care strategy for patients suffering from type 2 diabetes mellitus provides better glycemic control compared to hospital care. Home care, marriage, doing full daily activities, and insulin treatment are important factors affecting glycemic control.

Cardiovascular and renal outcomes of GLP-1 receptor agonists vs. DPP-4 inhibitors and basal insulin in type 2 diabetes mellitus: A systematic review and meta-analysis

OBJECTIVE

To compare the cardiovascular and renal outcomes of GLP-1 RA versus DPP4i and basal insulin in the management of T2DM.

METHODS

Data from 22 studies involving over 200,000 participants were pooled using the inverse variance method and random-effects meta-analysis. The review was reported in accordance with PRISMA.

RESULTS

Compared with DPP4i, treatment with GLP-1 RA was associated with a greater benefit on composite cardiovascular outcomes (HR:0.77, 95% CI:0.69-0.87), myocardial infarction (HR:0.82, 95% CI:0.69-0.97), stroke (HR:0.83, 95% CI: 0.74-0.93), cardiovascular mortality (HR:0.76, 95% CI:0.68-0.85) and all-cause mortality (HR:0.65, 95% CI:0.48-0.90). There was no difference in effect on heart failure (HR:0.97, 95% CI:0.82-1.15). Compared with basal insulin, GLP-1 RA was associated with better effects on composite cardiovascular outcomes (HR:0.62, 95% CI:0.48-0.79), heart failure (HR:0.57, 95% CI:0.35-0.92), myocardial infarction (HR:0.70, 95% CI:0.58-0.85), stroke (HR:0.50, 95% CI:0.40-0.63) and all-cause mortality (HR:0.31, 95% CI:0.20-0.48). Evidence from a small number of studies suggests that GLP-1 RA had better effects on composite and individual renal outcomes, such as eGFR, compared with either DPP4i and basal insulin.

CONCLUSION

Available evidence suggests that treating T2DM with GLP-1 RA can yield better benefits on composite and specific cardiorenal outcomes than with DPP4i and basal insulin.

PROSPERO REGISTRATION NUMBER

CRD42022335504.

Cardiac arrhythmia and hypoglycaemia in patients receiving haemodialysis with and without diabetes (the CADDY study): protocol for a Danish multicentre cohort study

INTRODUCTION

Patients receiving haemodialysis are at increased risk of arrhythmias and sudden cardiac death, but data on arrhythmia burden and the pathophysiology remain limited. Among potential risk factors, hypoglycaemia is proposed as a possible trigger of lethal arrhythmias. The development of implantable loop recorders (ILR) and continuous glucose monitoring (CGM) enables long-term continuous ECG and glycaemic monitoring. The current article presents the protocol of a study aiming to increase the understanding of arrhythmias and risk factors in patients receiving haemodialysis. The findings will provide a detailed exploration of the burden and nature of arrhythmias in these patients including the potential association between hypoglycaemia and arrhythmias.

METHODS AND ANALYSIS

The study is an investigator-initiated, prospective, multicentre cohort study recruiting 70 patients receiving haemodialysis: 35 with diabetes and 35 without diabetes. Participants are monitored with ILRs and CGM for 18 months follow-up. Data collection further includes a monthly collection of predialysis blood samples and dialysis parameters. The primary outcome is the presence of clinically significant arrhythmias defined as a composite of bradycardia, ventricular tachycardia, or ventricular fibrillation. Secondary outcomes include the characterisation of clinically significant arrhythmias and other arrhythmias, glycaemic characteristics, and mortality. The data analyses include an assessment of the association between arrhythmias and hypoglycaemia and hyperglycaemia, baseline clinical variables, and parameters related to kidney failure and the haemodialysis procedure.

ETHICS AND DISSEMINATION

The study has been approved by the Ethics Committee of the Capital Region of Denmark (H-20069767). The findings will be presented at national and international congresses as well as in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04841304.

IGF1 and PPARG polymorphisms are associated with reduced estimated glomerular filtration rate in a cohort of children and adolescents with type 1 diabetes

INTRODUCTION

Several genetic loci have been associated with diabetic nephropathy; however, the underlying genetic mechanisms are still poorly understood, with no robust candidate genes identified yet.

AIM

We aimed to determine whether two polymorphisms, previously associated with renal decline, influence kidney impairment evaluating their association with markers of renal function in a pediatric population with type 1 diabetes (T1D).

MATERIAL AND METHODS

Renal function was evaluated by glomerular filtration rate (eGFR) and albumin-to-creatinine ratio (ACR) in a cohort of pediatric subjects with T1D (n = 278). Risk factors for diabetes complications (diabetes duration, blood pressure, HbA1c) were assessed. The IGF1 rs35767 and PPARG rs1801282 SNPs were genotyped by TaqMan RT-PCR system. An additive genetic interaction was calculated. Association analysis between markers of renal function and both SNPs or their additive interaction were performed.

RESULTS

Both SNPs showed a significant association with eGFR: the A allele of rs35767 or the C allele of rs1801282 were associated to reduced eGFR compared to G alleles. Multivariate regression analysis adjusted for age, sex, z-BMI, T1D duration, blood pressure and Hba1c values showed that the additive genetic interaction was independently associated with lower eGFR (β = -3.59 [-6.52 to -0.66], p = 0.017). No associations were detected between SNPs, their additive interaction and ACR.

CONCLUSIONS

These results provide new insight into the genetic predisposition to renal dysfunction, showing that two polymorphisms in IGF1 and PPARG genes can lead to a reduction in renal filtration rate leading these patients to be exposed to a higher risk of early renal complications.

The potential of cardiac biomarkers, NT-ProBNP and troponin T, in predicting the progression of nephropathy in diabetic patients: A meta-analysis of prospective cohort studies

AIMS

A meta-analysis was done to investigate the association of two cardiac biomarkers of N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) and circulating troponin T (TnT) with the progression of diabetic nephropathy (DN).

METHODS

A thorough search of the PubMed, Scopus, and Web of Science databases was done until June 2022. The outcome (progression of DN) was described as either of the followings: a) eGFR decline, b) albuminuria, c) end-stage renal disease, or d) mortality. A pooled analysis of eligible studies was performed using random-effect models to compensate for the differences in measurement standards between the studies. We further carried out subgroup analyses to examine our results' robustness and find the source of heterogeneity. A sensitivity analysis was performed to assess the influence of individual studies on the pooled result and the funnel plot and Egger's test were used to assess publication bias.

RESULTS

For NT-proBNP, 8741 participants from 14 prospective cohorts, and for TnT, 7292 participants from 9 prospective cohorts were included in the meta-analysis. Higher NT-proBNP levels in diabetic patients were associated with a higher probability of DN progression (relative risk [RR]: 1.67, 95% confidence interval [CI]: 1.44 to 1.92). Likewise, elevated levels of TnT were associated with an increased likelihood of DN (RR: 1.57, 95% CI: 1.34 to 1.83). The predictive power of both biomarkers for DN remained significant when the subgroup analyses were performed. The risk estimates were sensitive to none of the studies. The funnel plot and Egger's tests indicated publication bias for both biomarkers. Hence, trim and fill analysis was performed to compensate for this putative bias and the results remained significant both for NT-proBNP (RR: 1.50, 95% CI: 1.31 to 1.79) and TnT (RR: 1.35, 95% CI 1.15 to 1.60).

CONCLUSIONS

The increased blood levels of TnT and NT-proBNP can be considered as predictors of DN progression in diabetic individuals. PROSPERO registration code: CRD42022350491.

Serum bicarbonate concentration and the risk of death in type 2 diabetes: the Fremantle Diabetes Study Phase II

AIMS

To examine whether all-cause mortality is independently associated with serum bicarbonate concentration below the laboratory reference interval in a representative, well-characterised community-based cohort of people with type 2 diabetes.

METHODS

1478 FDS2 participants with type 2 diabetes (mean age 65.8 years, 51.6% males, median diabetes duration 9.0 years) from the longitudinal, observational Fremantle Diabetes Study Phase II (FDS2) were followed from study entry to death or end-2016. Independent associates of a low baseline serum bicarbonate (< 22 mmol/L) were determined using multiple logistic regression. The role of important covariates in influencing the association between bicarbonate and mortality was assessed by a stepwise Cox regression approach.

RESULTS

A low serum bicarbonate was associated with increased all-cause mortality in unadjusted analysis (hazard ratio (HR) 1.90 (95% confidence limits (CL) 1.39, 2.60 per mmol/L). Mortality remained significantly associated with low serum bicarbonate (HR 1.40 (95% CL 1.01, 1.94) per mmol/L) in a Cox regression model with adjustment for factors associated with mortality but not low serum bicarbonate, but inclusion of estimated glomerular filtration rate categories rendered the association non-significant (HR 1.16 (95% CL 0.83, 1.63) per mmol/L).

CONCLUSIONS

A low serum bicarbonate is not an independent prognostic marker in people with type 2 diabetes but it may be a manifestation of the pathway between the development of impaired renal function and death.

Transcriptomic analysis of diabetic kidney disease and neuropathy in mouse models of type 1 and type 2 diabetes

Diabetic kidney disease (DKD) and diabetic peripheral neuropathy (DPN) are common complications of type 1 (T1D) and type 2 (T2D) diabetes. However, the mechanisms underlying pathogenesis of these complications are unclear. In this study, we optimized a streptozotocin-induced db/+ murine model of T1D and compared it to our established db/db T2D mouse model of the same C57BLKS/J background. Glomeruli and sciatic nerve transcriptomic data from T1D and T2D mice were analyzed by self-organizing map and differential gene expression analysis. Consistent with prior literature, pathways related to immune function and inflammation were dysregulated in both complications in T1D and T2D mice. Gene-level analysis identified a high degree of concordance in shared differentially expressed genes (DEGs) in both complications and across diabetes type when using mice from the same cohort and genetic background. As we have previously shown a low concordance of shared DEGs in DPN when using mice from different cohorts and genetic backgrounds, this suggests that genetic background may influence diabetic complications. Collectively, these findings support the role of inflammation and indicate that genetic background is important in complications of both T1D and T2D.