Long-term Visit-to-Visit Variability in Hemoglobin A1c and Kidney-Related Outcomes in Persons With Diabetes

Stress hyperglycemia ratio as a predictor of acute kidney injury and its outcomes in critically ill patients

This study investigated stress hyperglycemia ratio (SHR) for acute kidney injury (AKI) and clinical outcomes in intensive care unit (ICU). Key outcomes were AKI within 48 h after ICU admission, acute kidney disease (AKD), ICU mortality, 28-day mortality, 90-day mortality and 1-year mortality. The associations between SHR and outcomes was estimated via logistic regression, Cox proportional hazards regression, and restricted cubic spline (RCS) analyses. Subgroup analyses assessed the consistency of these associations. Totally 3,714 patients were included from the Medical Information Mart for Intensive Care IV. SHR was associated with an increased risk of AKI (ORadjusted 1.29 95%CI 1.05-1.59). Among AKI patients, SHR was associated with increased risks of AKD (ORadjusted 1.94 95%CI 1.57-2.39), ICU mortality (ORadjusted 2.31 95%CI 1.60-3.32), 28-day mortality (HRadjusted 1.39 95%CI 1.29-1.50), 90-day mortality (HRadjusted 1.37 95%CI 1.26-1.48), and 1-year mortality (HRadjusted 1.37 95%CI 1.27-1.47). RCS analysis revealed a linear relationship with AKI, a J-shaped relationship with AKD, and a U-shaped relationship with mortality. Subgroup analysis confirmed the consistency of relationship between SHR and AKI. SHR demonstrates significant associations with AKI incidence, and correlates with AKD progression/mortality in critically ill adult ICU patients, suggesting its potential as a risk stratification and prognostic tool for AKI management, though further prospective validation is required.

Impact of HbA1c Reduction on Major Kidney Outcomes in Type 2 Diabetes With Poor Glycemic Control and Advanced CKD

Aims: In subjects with type 2 diabetes (DM), poor glycemic control, and advanced chronic kidney disease (CKD), the kidney benefit of the reduction of glycated hemoglobin (HbA1c) is not well established. Methods: In a retrospective cohort, we included patients with DM, CKD grade 3b-5, and HbA1c > 9% to evaluate the risk of developing major adverse kidney events (MAKE) defined as the start of kidney replacement therapy (KRT), ≥ 25% or ≥ 40% decline in the glomerular filtration rate (eGFR) from baseline, and death; patients were divided according to the HbA1c levels at the end of the follow-up into the following groups: > 75 mmol/mol (≥ 9.0%), 74-64 mmol/mol (8.9%-8.0%), 64-53 mmol/mol (7.9%-7.0%), and < 52 mmol/mol (< 7.0%). We described their characteristics and analyzed their risks, adjusting for confounding variables. Results: From 2015 to 2023, 111 patients were included. In 46 patients (41.4%), the HbA1c at the end of follow-up (60 months) was still > 75 mmol/mol (≥ 9%), and each patient had a mean of 4.9 HbA1c measurements. The mean age was 59 years, and 46% were male; the baseline eGFR was 25 mL/min/1.73 m2. MAKE occurred in 67% of cases. In a multivariate analysis, the risk of MAKE was not associated with the HbA1c groups, nor was it associated with any of the MAKE components individually, nor in certain subgroups. When evaluating the magnitude of percentage changes in HbA1 with the initiation of KRT, we did not find any association. Conclusions: With advanced CKD and poor glycemic control, changes in HbA1c during long follow-up are not associated with MAKE or its individual components.

Non-recovery acute kidney injury and additional risk factors for short-term and long-term hypoglycemia: A multi-institutional cohort study

BACKGROUND

Acute kidney injury (AKI) is associated with increased in-hospital and short-term hypoglycemia risk. However, the impact of non-recovery of renal function before discharge on hypoglycemia risk in AKI survivors after discharge have not been well studied. We aim to analyze the association between non-recovery of AKI and hypoglycemia, hyperglycemia crisis risk, to identify additional risk factors for hypoglycemia, and to examine the impact of AKI non-recovery on HbA1c variability.

METHODS

This multi-institutional retrospective cohort study based on Chang Gung Research Database included type 2 diabetes patients with first admission for AKI. Participants were categorized into renal recovery or non-recovery groups. Hypoglycemia, hyperglycemia crisis, new insulin use, re-AKI admission, all-cause mortality and HbA1c variability within 2 years after discharge were assessed. IPTW was used for covariate balance.

RESULTS

A total of 16,796 participants were enrolled. AKI non-recovery was associated with increased higher hypoglycemia risk (HR: 1.19; 95% CI: 1.11-1.28), increased new insulin prescriptions (HR: 1.21; 95% CI: 1.14-1.27), and lower mean HbA1c levels compared to the recovery group. Subgroup analysis showed higher hypoglycemia risk in the non-recovery group with post-AKI anemia/hypoalbuminemia status (HR: 1.39; 95% CI: 1.23-1.55). De novo CKD development in AKI non-recovery group was a protective factor for hyperglycemia crisis (HR: 0.77; 95% CI: 0.69-0.87).

CONCLUSIONS

Non-recovery AKI is associated with an increased risk of hypoglycemia, regardless of whether de novo CKD develops, and is linked to lower mean A1c level within two-years post-discharge. Identifying high-risk individuals for post-AKI hypoglycemia is vital for optimal patient care.

Association between annual changes and visit-to-visit variability of serum uric acid and the kidney outcome in a general population

BACKGROUND

To determine whether variability of serum uric acid (UA) is associated with risk of chronic kidney disease (CKD) in a healthy population.

METHODS

Retrospective, longitudinal cohort study was conducted at a health examination center in China. The study enrolled subjects who had a minimum of three visits between 2011 and 2018. We assessed UA change and visit-to-visit UA variability including standard deviation (SD), coefficient of variation (CV), variability independent of the mean (VIM), and average real variability (ARV). Rapid estimated glomerular filtration rate (eGFR) decline was defined by annual eGFR change < -4 mL/min/1.73 m2/year. We conducted a multivariable-adjusted logistic regression analysis.

RESULTS

Ten thousand seven hundred and thirty-eight participants were included. During 4.43 ± 1.31 years follow-up, there were 535 cases with rapid eGFR decline and 240 cases developed CKD. Compared to the non-rapid eGFR decline group and non-CKD group, the UA annual changes and variability were higher in the rapid eGFR decline group and CKD group. The highest quartile of UA annual changes and variability showed a higher incident rate of rapid eGFR decline and that of CKD. After adjusting for covariates, OR for eGFR rapid decline in UA variability were 1.69 [1.53, 1.86] for annual changes of UA, 1.17 [1.08, 1.27] for SD of UA, 1.16 [1.06, 1.25] for CV of UA, 1.16 [1.07, 1.25] for VIM of UA, and 1.10 [1.02, 1.19] for ARV of UA. Consistent results were observed when CKD is used as the outcome.

CONCLUSIONS

Higher variability of serum UA was independently associated with the risk of kidney impairment.

Analysis of the global burden of CKD-T2DM in young and middle-aged adults in 204 countries and territories from 2000 to 2019: A systematic study of the global burden of disease in 2019

BACKGROUND

Diabetes stands as a principal risk factor for severe complications including renal and cardiovascular diseases. The gradual rise in type 2 diabetes cases globally, coupled with a trend towards younger demographics, has led to an escalating prevalence of chronic kidney disease. However, its etiology is multifaceted, necessitating individualized treatment and refinement, particularly crucial in screening and managing the burden of CKD-T2DM. A comprehensive analysis of CKD-T2DM burden at global, regional, and national levels from 2000 to 2019, based on the latest data, can inform screening, early diagnostics, and treatment strategies, thereby optimizing healthcare resource allocation.

METHODS

Utilizing data sourced from the Global Burden of Disease (GBD) database, we delineated the incidence, mortality, and DALYs rates of CKD-T2DM from 2000 to 2019 across global, regional, and national scales. We summarized the age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), and age-standardized death rate (ASDR) of CKD-T2DM globally, regionally, and nationally, presenting them visually. Moreover, we calculated and visually depicted the estimated annual percentage change (EAPC) of various CKD-T2DM indicators at these levels. Additionally, CKD-T2DM patients were stratified by age to compare the age distribution of patient deaths and the age burden between 2000 and 2019.

FINDINGS

The disease burden of CKD-T2DM among young and middle-aged individuals globally has shown a sustained increase from 2000 to 2019. Incidence, mortality, and DALYs rates have exhibited an overall upward trend, with males showing higher rates compared to females. Significant disparities exist among different countries and regions, with India, China, and Mexico emerging as the countries with the highest number of new cases. Nicaragua, Mexico, and the United Arab Emirates have the highest age-standardized incidence rates, whereas Uganda, Ethiopia, and Burundi have the lowest. At the age level, the burden of CKD-T2DM exhibits varying trends among different age groups but generally shows an upward trajectory, particularly in the 45-49 age bracket. High systolic blood pressure and high BMI stand as the primary contributing factors to mortality and DALYs, with variations in their influence observed across different regions and levels of development.

INTERPRETATION

ver the past 20 years, the burden of CKD-T2DM among young and middle-aged individuals globally has continued to increase, with disparities existing among different countries, regions, and age groups, but overall showing an upward trend. The reasons for this trend are multifaceted, including global lifestyle changes such as dietary shifts, sedentary lifestyles, obesity, as well as population aging and inadequate preventive measures in certain regions. Addressing these challenges necessitates optimizing screening methods, adjusting lifestyles, enhancing management strategies, improving medical care and awareness levels, particularly intensifying awareness and screening efforts among males, reinforcing prevention and control measures for the 45-49 age group, enhancing infrastructure and healthcare resources in developing countries, fostering international collaboration, and implementing context-specific measures.

The Association of HbA1c Variability with 12 Week and 12 Month Outcomes on Diabetes Related Foot Ulcer Healing

INTRODUCTION

This study aimed to determine the relationship between HbA1c variability and foot ulcer healing at 12 weeks and 12 months.

METHODS

Using National Diabetic Foot Care Audit (NDFA) and hospital records, demographics, baseline ulcer characteristics and healing outcomes for subjects presenting with a foot ulcer between 2017-2022 were collected at 12 weeks and 12 months. Subjects had diabetes duration > 3 years and ≥ 3 HbA1c recordings in the 5 years prior to presentation.

RESULTS

At 12 weeks, factors associated with an active ulcer were presence on hind foot (adjusted odds ratios) (2.1 [95% CI 1.3-3.7]), ischaemia (2.1 [95% CI:1.4-3.2]), area > 1 cm2 (2.7 [95% CI:1.7-4.2]) and diabetes duration > 24 years vs 3-10 (AOR 2.0 [95% CI 1.2-3.5]). After adjustment, HbA1c variability 6-10 mmol/mol and > 14.5 mmol/mol had AOR of 1.76 (95% CI 1.1-2.8; p = 0.0192) and 1.5 (95% CI 0.9-2.6; p = 0.1148) of an active ulcer at 12 weeks vs variability < 6 mmol/mol. At 12 months, ischaemia (AOR 2.4 [95% CI 1.5-3.8]) and diabetes duration > 24 years vs 3-10 years (AOR 3.3 [95% CI 1.7-6.4] were significant factors. HbA1c variability was not significant at 12 months.

CONCLUSION

In keeping with the national NDFA data, in our cohort ulcer characteristics, but not HbA1c variability, were the key factors associated with ulcer healing at 12 weeks and 12 months.

The Effect of Sodium Glucose Cotransporter-2 Inhibitors on Hemoglobin A1c Variability and Acute Kidney Injury: A Causal Mediation Analysis

PURPOSE

The role of lower hemoglobin A1c (HbA1c) variability in the effect of sodium glucose cotransporter-2 inhibitors (SGLT2i) on acute kidney injury (AKI) remains unclear. We compared AKI risk between SGLT2i and dipeptidyl peptidase 4 inhibitors (DPP4i) initiators. Additionally, we aimed to explore the extent to which SGLT2i's influence on AKI risk is mediated by reducing long-term HbA1c variability.

METHODS

Using 2018-2022 year data in Yinzhou Regional Health Care Database, we included adult, type 2 diabetes patients who were new users of SGLT2i or DPP4i. The effect of SGLT2i versus DPP4i on AKI, HbA1c variability, and AKI through HbA1c variability was compared using inverse probability of treatment weighted Cox proportional hazards models, median regression models, and causal mediation analysis.

RESULTS

With a median follow-up of 1.76 years, 19 717 adults (for SGLT2i, n = 6008; for DPP4i, n = 13 709) with type 2 diabetes were included. The adjusted hazard ratio for SGLT2i versus DPP4i was 0.79 (95% confidence interval [CI] 0.64-0.98) for AKI. The adjusted differences in median HbA1c variability score (HVS) and HbA1c reduction were -16.67% (95% CI: -27.71% to -5.62%) and -1.98% (95% CI: -14.34% to 10.38%), respectively. Furthermore, lower AKI risk associated with SGLT2i was moderately mediated (22.77%) through HVS. The results remained consistent across various subgroups and sensitivity analyses.

CONCLUSIONS

Compared to DPP4i, lower AKI risk associated with SGLT2i is moderately mediated through HbA1c variability. These findings enhance our understanding of the effect of SGLT2i on AKI and underscore the importance of considering HbA1c variability in diabetes treatment and management.

Effect of probiotics at different intervention time on glycemic control in patients with type 2 diabetes mellitus: a systematic review and meta-analysis

Background

Type 2 diabetes mellitus(T2DM) is characterized by hyperglycemia. Gut microbiome adjustment plays a positive part in glucose regulation, which has become a hotspot. Probiotics have been studied for their potential to control the gut flora and to treat T2DM. However, the conclusion of its glucose-lowering effect is inconsistent based on different probiotic intervention times.

Objectives

To comprehensively evaluate how various probiotic intervention times affect glycemic control in people with T2DM.

Methods

We retrieved PubMed, Embase, Web of Science, and Cochrane Library on randomized controlled trials(RCTs)regarding the impact of probiotics on glycemic control in patients with T2DM from the inception to November 16, 2023. Separately, two researchers conducted a literature analysis, data extraction, and bias risk assessment of the involved studies. We followed the PRISMA guidelines, used RevMan 5.4 software for meta-analysis, and assessed the risk of bias by applying the Cochrane Handbook for Systematic Reviews 5.1.0.

Results

We included eight RCTs with 507 patients. Meta-analysis revealed that the use of probiotics might considerably reduce levels of glycosylated hemoglobin (HbA1c) {mean deviation (MD) = -0.33, 95% confidence interval (CI) (-0.59, -0.07), p = 0.01}, Insulin {standard mean deviation (SMD) = -0.48, 95% CI (-0.74, -0.22), p = 0.0003} and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR){SMD = -1.36, 95% CI (-2.30, -0.41), p = 0.005} than placebo group. No statistically significant differences were found regarding fasting blood glucose (FBG) and body mass index (BMI) {SMD = -0.39, 95% CI (-0.83, 0.05), p = 0.08}, {SMD = -0.40, 95% CI (-1.07, 0.27), p = 0.25}, respectively. Subgroup analyses, grouped by intervention times, showed that six to eight weeks of intervention improved HbA1c compared to the control group (p < 0.05), both six to eight weeks and 12-24 weeks had a better intervention effect on Insulin, and HOMA-IR (p < 0.05).In contrast, there was no statistically significant variation in the length between FBG and BMI regarding duration.

Conclusion

This meta-analysis found probiotics at different intervention times play a positive role in modulating glucose in T2DM, specifically for HbA1c in six to eight weeks, Insulin and HOMA-IR in six to eight weeks, and 12-24 weeks. To confirm our findings, further excellent large-sample research is still required.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42023483325.

Rodent models of AKI and AKI-CKD transition: an update in 2024

Despite known drawbacks, rodent models are essential tools in the research of renal development, physiology, and pathogenesis. In the past decade, rodent models have been developed and used to mimic different etiologies of acute kidney injury (AKI), AKI to chronic kidney disease (CKD) transition or progression, and AKI with comorbidities. These models have been applied for both mechanistic research and preclinical drug development. However, current rodent models have their limitations, especially since they often do not fully recapitulate the pathophysiology of AKI in human patients, and thus need further refinement. Here, we discuss the present status of these rodent models, including the pathophysiologic compatibility, clinical translational significance, key factors affecting model consistency, and their main limitations. Future efforts should focus on establishing robust models that simulate the major clinical and molecular phenotypes of human AKI and its progression.