1
|
Vitale M, Orsi E, Solini A, Garofolo M, Grancini V, Bonora E, Fondelli C, Trevisan R, Vedovato M, Penno G, Nicolucci A, Pugliese G. Association between age at diagnosis and all-cause mortality in type 2 diabetes: the Renal Insufficiency and Cardiovascular Events (RIACE) Italian Multicenter Study. Acta Diabetol 2024:10.1007/s00592-024-02294-1. [PMID: 38714557 DOI: 10.1007/s00592-024-02294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/14/2024] [Indexed: 05/10/2024]
Abstract
AIMS It is unclear whether type 2 diabetes diagnosed in young adulthood is associated with increased severity than that occurring later in life beyond longer lifetime exposure to hyperglycemia. This study aimed at assessing the independent association of age at type 2 diabetes diagnosis with all-cause mortality. METHODS This prospective cohort study enrolled 15,773 Caucasian patients with type 2 diabetes in 19 Italian centers in 2006-2008. Cardiometabolic risk profile and presence of complications and comorbidities were assessed at baseline and participants were stratified by quartiles of age at diabetes diagnosis. All-cause mortality was verified on 31 October 2015. RESULTS Valid information on vital status was retrieved for 15,656 participants (99.3%). Patients in the lowest quartile had the longest diabetes duration, the worst glycemic control and the highest prevalence of insulin treatment, obesity, atherogenic dyslipidemia, and smoking habits. All complications were inversely associated with age at diabetes diagnosis after adjustment for age and sex, but not after further adjustment for diabetes duration. Percentages of death, Kaplan-Meier estimates, and unadjusted hazard ratios and mortality rates increased from the lowest to the highest quartile. In contrast, when adjusting for age and sex, participants falling in the lowest quartile, showed the highest mortality risk [hazard ratio 1.321 (95% confidence interval 1.196-1.460), P < 0.0001]. However, differences among quartiles disappeared after adjustment for diabetes duration, complications/comorbidities, or other cardiovascular risk factors. CONCLUSIONS Type 2 diabetes onset in young adulthood is associated with increased mortality that is mainly driven by longer diabetes duration favoring the development of complications. TRIAL REGISTRATION ClinicalTrials.gov, NCT00715481, retrospectively registered 15 July, 2008.
Collapse
Affiliation(s)
- Martina Vitale
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via Di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Emanuela Orsi
- Diabetes Unit, Fondazione IRCCS "Cà Granda - Ospedale Maggiore Policlinico", Milan, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Monia Garofolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Valeria Grancini
- Diabetes Unit, Fondazione IRCCS "Cà Granda - Ospedale Maggiore Policlinico", Milan, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via Di Grottarossa, 1035-1039, 00189, Rome, Italy.
| |
Collapse
|
2
|
Vitale M, Orsi E, Solini A, Garofolo M, Resi V, Bonora E, Fondelli C, Trevisan R, Vedovato M, Penno G, Pugliese G. Independent association of history of diabetic foot with all-cause mortality in patients with type 2 diabetes: the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study. Cardiovasc Diabetol 2024; 23:34. [PMID: 38218843 PMCID: PMC10787405 DOI: 10.1186/s12933-023-02107-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/28/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Foot ulcers and/or infections are common long-term complications of diabetes and are associated with increased mortality, especially from cardiovascular disease, though only a few studies have investigated the independent contribution of these events to risk of death. This study aimed at assessing the association of history of diabetic foot with all-cause mortality in individuals with type 2 diabetes, independent of cardiovascular risk factors, other complications, and comorbidities. METHODS This prospective cohort study enrolled 15,773 Caucasian patients in 19 Italian centers in the years 2006-2008. Prior lower extremity, coronary, and cerebrovascular events and major comorbidities were ascertained by medical records, diabetic retinopathy by fundoscopy, diabetic kidney disease by albuminuria and estimated glomerular filtration rate, cardiovascular risk factors by standard methods. All-cause mortality was retrieved for 15,656 patients on 31 October 2015. RESULTS At baseline, 892 patients (5.7%) had a history of diabetic foot, including ulcer/gangrene and/or amputation (n = 565; 3.58%), with (n = 126; 0.80%) or without (n = 439; 2.78%) lower limb revascularization, and revascularization alone (n = 330; 2.09%). History of diabetic foot was associated with all-cause death over a 7.42-year follow-up (adjusted hazard ratio, 1.502 [95% confidence interval, 1.346-1.676], p < 0.0001), independent of confounders, among which age, male sex, smoking, hemoglobin A1c, current treatments, other complications, comorbidities and, inversely, physical activity level and total and HDL cholesterol were correlated independently with mortality. Both ulcer/gangrene and amputation alone were independently associated with death, with a higher strength of association for amputation than for ulcer/gangrene (1.874 [1.144-3.070], p = 0.013 vs. 1.567 [1.353-1.814], p < 0.0001). Both ulcer/gangrene/amputation and lower limb revascularization alone were independently associated with death; mortality risk was much higher for ulcer/gangrene/amputation than for revascularization (1.641 [1.420-1.895], p < 0.0001 vs. 1.229 [1.024-1.475], p = 0.018) and further increased only slightly for combined ulcer/gangrene/amputation and revascularization (1.733 [1.368-2.196], p < 0.0001). CONCLUSIONS In patients with type 2 diabetes, an history of diabetic foot event, including ulcer/gangrene, amputation, and lower limb revascularization, was associated with a ~ 50% increased risk of subsequent death, independent of cardiovascular risk factors, other complications and severe comorbidities, which were also significantly associated with mortality. The association with mortality was greatest for amputation, whereas that for revascularization alone was relatively modest. TRIAL REGISTRATION ClinicalTrials.gov, NCT00715481, retrospectively registered 15 July, 2008.
Collapse
Grants
- NA Fondazione Diabete Ricerca
- NA Fondazione Diabete Ricerca
- NA Fondazione Diabete Ricerca
- NA Fondazione Diabete Ricerca
- NA Fondazione Diabete Ricerca
- NA Fondazione Diabete Ricerca
- NA Fondazione Diabete Ricerca
- NA Fondazione Diabete Ricerca
- NA Fondazione Diabete Ricerca
- NA Fondazione Diabete Ricerca
- NA Fondazione Diabete Ricerca
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Diabetes, Endocrinology and Metabolism Foundation
- NA Eli Lilly and Company
- NA Eli Lilly and Company
- NA Eli Lilly and Company
- NA Eli Lilly and Company
- NA Eli Lilly and Company
- NA Eli Lilly and Company
- NA Eli Lilly and Company
- NA Eli Lilly and Company
- NA Eli Lilly and Company
- NA Eli Lilly and Company
- NA Eli Lilly and Company
- NA Sigma-tau
- NA Sigma-tau
- NA Sigma-tau
- NA Sigma-tau
- NA Sigma-tau
- NA Sigma-tau
- NA Sigma-tau
- NA Sigma-tau
- NA Sigma-tau
- NA Sigma-tau
- NA Sigma-tau
- NA Boehringer Ingelheim
- NA Boehringer Ingelheim
- NA Boehringer Ingelheim
- NA Boehringer Ingelheim
- NA Boehringer Ingelheim
- NA Boehringer Ingelheim
- NA Boehringer Ingelheim
- NA Boehringer Ingelheim
- NA Boehringer Ingelheim
- NA Boehringer Ingelheim
- NA Boehringer Ingelheim
- NA Chiesi Farmaceutici
- NA Chiesi Farmaceutici
- NA Chiesi Farmaceutici
- NA Chiesi Farmaceutici
- NA Chiesi Farmaceutici
- NA Chiesi Farmaceutici
- NA Chiesi Farmaceutici
- NA Chiesi Farmaceutici
- NA Chiesi Farmaceutici
- NA Chiesi Farmaceutici
- NA Chiesi Farmaceutici
- NA Takeda Pharmaceutical Company
- NA Takeda Pharmaceutical Company
- NA Takeda Pharmaceutical Company
- NA Takeda Pharmaceutical Company
- NA Takeda Pharmaceutical Company
- NA Takeda Pharmaceutical Company
- NA Takeda Pharmaceutical Company
- NA Takeda Pharmaceutical Company
- NA Takeda Pharmaceutical Company
- NA Takeda Pharmaceutical Company
- NA Takeda Pharmaceutical Company
Collapse
Affiliation(s)
- Martina Vitale
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, Rome, 1035-1039 - 00189, Italy
| | - Emanuela Orsi
- Diabetes Unit, Fondazione IRCCS "Cà Granda - Ospedale Maggiore Policlinico", Milan, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Monia Garofolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Veronica Resi
- Diabetes Unit, Fondazione IRCCS "Cà Granda - Ospedale Maggiore Policlinico", Milan, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, Rome, 1035-1039 - 00189, Italy.
| |
Collapse
|
3
|
Murakoshi M, Kamei N, Suzuki Y, Kubota M, Sanuki M, Tashiro H, Iwasawa T, Kato K, Tanaka M, Furuhashi M, Gohda T. Circulating tumor necrosis factor-related biomarkers predict kidney function decline in Japanese patients with diabetes: An observational cohort study. Diabetes Res Clin Pract 2023; 206:111017. [PMID: 37972856 DOI: 10.1016/j.diabres.2023.111017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/04/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
AIMS Tumor necrosis factor (TNF) receptors (TNFRs: TNFR1 and, TNFR2) are reportedly associated with chronic kidney disease (CKD) progression chiefly in Caucasian patients with diabetes. We assessed the prognostic value of TNF-related biomarkers for CKD progression in Japanese patients with diabetes. METHODS We estimated TNF-related biomarkers using an enzyme-linked immunosorbent assay in 640 patients with diabetes. Cox proportional hazards analysis was performed to estimate hazard ratios (HRs) per one standard deviation (SD) increase in a log-transformed biomarker. The kidney and the composite outcome were defined as a 30% reduction in estimated glomerular filtration rate (eGFR) from baseline, and kidney outcome plus death before kidney outcome, respectively. RESULTS During the median follow-up of 5.4 years, 75 (11.7%) patients reached the kidney outcome and 37 (5.8%) died before reaching the kidney outcome. Each SD increase in baseline circulating TNFR1, TNFR2, and ephrin type-A receptor 2 (EphA2) was associated with a higher risk of the kidney outcome independently from baseline eGFR and urine albumin-to-creatinine ratio. However, circulating osteoprotegerin was associated with the composite outcome only. CONCLUSIONS Elevated TNFR1, TNFR2, and EphA2 were associated with both kidney and composite outcomes in Japanese patients with diabetes.
Collapse
Affiliation(s)
- Maki Murakoshi
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Nozomu Kamei
- Department of Endocrinology and Metabolism, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan; Institute for Clinical Research, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Mitsunobu Kubota
- Department of Endocrinology and Diabetology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Michiyoshi Sanuki
- Institute for Clinical Research, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hirotaka Tashiro
- Department of Surgery, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Takumi Iwasawa
- Institute of Life Innovation Studies, Toyo University, Tokyo, Japan
| | - Kazunori Kato
- Institute of Life Innovation Studies, Toyo University, Tokyo, Japan
| | - Marenao Tanaka
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masato Furuhashi
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tomohito Gohda
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan.
| |
Collapse
|
4
|
Orsi E, Solini A, Bonora E, Vitale M, Garofolo M, Fondelli C, Trevisan R, Vedovato M, Cavalot F, Zerbini G, Nicolucci A, Pugliese G. Retinopathy as an independent predictor of all-cause mortality in individuals with type 2 diabetes. DIABETES & METABOLISM 2023; 49:101413. [PMID: 36460217 DOI: 10.1016/j.diabet.2022.101413] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022]
Abstract
AIMS To assess whether the presence and grade of diabetic retinopathy (DR) predict all-cause mortality, independent of risk factors for cardiovascular disease (CVD) and other complications, including diabetes-related kidney disease (DKD) and CVD, in individuals with type 2 diabetes mellitus. METHODS Prospective cohort study that enroled 15,773 patients in 19 Italian centers in 2006-2008. DR ascertained by fundoscopy, DKD by albuminuria and estimated glomerular filtration rate, and prior CVD by hospital discharge records. All-cause mortality retrieved for 15,656 patients on 31 October 2015. RESULTS The adjusted risk of death was increased in patients with any DR (hazard ratio, 1.136 [95% confidence interval, 1.054;1.224] P < 0.0001), advanced DR, including severe non-proliferative and proliferative DR and diabetic macula edema (1.213 [1.097;1.340] P < 0.0001), and especially proliferative DR alone (1.381 [1.207;1.580] P < 0.0001), compared with those without DR. The impact of DR was more evident in patients without than in those with DKD or CVD. Mortality risk was increased in participants with DR alone, though much less than in those with DKD or CVD alone and particularly in those with both DR and DKD or CVD. DR grade was related to mortality in individuals without DKD or CVD, whereas it conferred no additional risk to those with albuminuric or nonalbuminuric DKD or established CVD. CONCLUSIONS In patients with type 2 diabetes mellitus, the excess mortality risk conferred by DR is relatively small and higher in those without DKD and CVD, suggesting that it may be mediated by the concurrent presence of these complications, even at a subclinical level.
Collapse
Affiliation(s)
- Emanuela Orsi
- Diabetes Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, Milan, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | - Martina Vitale
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, Rome 00189 , Italy
| | - Monia Garofolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Franco Cavalot
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
| | - Gianpaolo Zerbini
- Complications of Diabetes Unit, Division of Metabolic and Cardiovascular Sciences, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Nicolucci
- Centre for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, Rome 00189 , Italy.
| | | |
Collapse
|
5
|
Orsi E, Solini A, Bonora E, Vitale M, Garofolo M, Fondelli C, Trevisan R, Vedovato M, Cavalot F, Laviola L, Morano S, Pugliese G. Risk of all-cause mortality according to the European Society of Cardiology risk categories in individuals with type 2 diabetes: the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study. Acta Diabetol 2022; 59:1369-1381. [PMID: 35902419 PMCID: PMC9402482 DOI: 10.1007/s00592-022-01942-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022]
Abstract
AIMS The 2019 and 2021 European Society of Cardiology (ESC) classifications stratified patients with type 2 diabetes into three categories according to the 10-year risk of death from atherosclerotic cardiovascular disease (ASCVD). The very high-risk category included individuals with established ASCVD, target organ damage (TOD), and/or, in the 2019 classification only, ≥ 3 additional ASCVD risk factors. We assessed risk of all-cause mortality according to the two ESC classifications in the Renal Insufficiency And Cardiovascular Events cohort. METHODS Participants (n = 15,773) were stratified based on the presence of ASCVD, TOD, and ASCVD risk factors at baseline (2006-2008). Vital status was retrieved in 2015. RESULTS Less than 1% of participants fell in the moderate-risk category. According to the 2019 classification, ~ 1/3 fell in the high-risk and ~ 2/3 in the very high-risk category, whereas the opposite occurred with the 2021 classification. Mortality risk increased across categories according to both classifications. Among very high-risk patients, mortality was much lower in those with ≥ 3 additional ASCVD risk factors and almost equal in those with TOD and ASCVD ± TOD, using the 2019 classification, whereas it was much higher in those with ASCVD + TOD and, to a lesser extent, TOD only than in those with ASCVD only, using the 2021 classification. CONCLUSIONS The negligible number of moderate-risk patients suggests that these classifications might overestimate risk of ASCVD death. Downgrading patients with ≥ 3 additional ASCVD risk factors to the high-risk category is consistent with mortality data. Risk of death is very high in the presence of TOD irrespective of established ASCVD. TRIAL REGISTRATION ClinicalTrials.gov, NCT00715481.
Collapse
Affiliation(s)
- Emanuela Orsi
- Diabetes Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, Milan, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | - Martina Vitale
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Monia Garofolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Franco Cavalot
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
| | - Luigi Laviola
- Department of Emergency and Transplants, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Susanna Morano
- Department of Experimental Medicine, "La Sapienza" University, Rome, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
| |
Collapse
|
6
|
Diabetic kidney disease: new clinical and therapeutic issues. Joint position statement of the Italian Diabetes Society and the Italian Society of Nephrology on "The natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function". J Nephrol 2021; 33:9-35. [PMID: 31576500 PMCID: PMC7007429 DOI: 10.1007/s40620-019-00650-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aims This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents. Data Synthesis Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., “nonalbuminuric renal impairment” and “progressive renal decline”, suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered. Conclusions The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.
Collapse
|
7
|
Penno G, Solini A, Orsi E, Bonora E, Fondelli C, Trevisan R, Vedovato M, Cavalot F, Zerbini G, Lamacchia O, Nicolucci A, Pugliese G. Insulin resistance, diabetic kidney disease, and all-cause mortality in individuals with type 2 diabetes: a prospective cohort study. BMC Med 2021; 19:66. [PMID: 33715620 PMCID: PMC7962330 DOI: 10.1186/s12916-021-01936-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/04/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND It is unclear whether insulin resistance (IR) contributes to excess mortality in patients with type 2 diabetes independent of diabetic kidney disease (DKD), which is strongly associated with IR and is a major risk factor for cardiovascular disease (CVD), the main cause of death in these individuals. We tested this hypothesis in patients with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events Italian Multicentre Study. METHODS This observational, prospective, cohort study enrolled 15,773 patients with type 2 diabetes attending 19 Italian Diabetes Clinics in 2006-2008. Insulin sensitivity was assessed as estimated glucose disposal rate (eGDR), which was validated against the euglycaemic-hyperinsulinemic clamp technique. Vital status on October 31, 2015, was retrieved for 15,656 patients (99.3%). Participants were stratified by eGDR tertiles from T1 (≥ 5.35 mg/kg/min) to T3 (≤ 4.14 mg/kg/min, highest IR). RESULTS CVD risk profile was worse in T2 and T3 vs T1. eGDR tertiles were independently associated with micro- and macroalbuminuria and the albuminuric DKD phenotypes (albuminuria with preserved or reduced estimated glomerular filtration rate [eGFR]) as well as with eGFR categories or the nonalbuminuric DKD phenotype. Over a 7.4-year follow-up, unadjusted death rates and mortality risks increased progressively across eGDR tertiles, but remained significantly elevated after adjustment only in T3 vs T1 (age- and gender- adjusted death rate, 22.35 vs 16.74 per 1000 person-years, p < 0.0001, and hazard ratio [HR] adjusted for multiple confounders including DKD, 1.140 [95% confidence interval [CI], 1.049-1.238], p = 0.002). However, eGDR was independently associated with mortality in participants with no DKD (adjusted HR, 1.214 [95% CI, 1.072-1.375], p = 0.002) and in those with nonalbuminuric DKD (1.276 [1.034-1.575], p = 0.023), but not in those with the albuminuric DKD phenotypes. Moreover, the association was stronger in males and in younger individuals and was observed in those without but not with prior CVD, though interaction was significant only for age. CONCLUSIONS The proxy of insulin sensitivity eGDR predicts all-cause mortality in type 2 diabetes, independent of confounders including DKD. However, the impact of IR in individuals with albuminuric DKD may be mediated by its relationship with albuminuria. TRIAL REGISTRATION ClinicalTrials.gov , NCT00715481, retrospectively registered 15 July 2008.
Collapse
Affiliation(s)
- Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Emanuela Orsi
- Diabetes Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, Milan, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Franco Cavalot
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
| | - Gianpaolo Zerbini
- Complications of Diabetes Unit, Division of Metabolic and Cardiovascular Sciences, San Raffaele Scientific Institute, Milan, Italy
| | - Olga Lamacchia
- Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Antonio Nicolucci
- Centre for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
| | | |
Collapse
|
8
|
Obstructive sleep apnea is associated with impaired renal function in patients with diabetic kidney disease. Sci Rep 2021; 11:5675. [PMID: 33707611 PMCID: PMC7952421 DOI: 10.1038/s41598-021-85023-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 02/18/2021] [Indexed: 12/11/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a recognized risk factor for the development of diabetic kidney disease (DKD). Our objectives were to compare the urinary albumin-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) of patients with DKD according to OSA severity, and to evaluate the contribution of sleep parameters to their renal function. In a multicenter, observational, cross-sectional study, 214 patients with DKD were recruited. After a sleep study, UACR and eGFR were measured, as well as serum creatinine, fasting glucose, glycated hemoglobin, insulin resistance, lipid profile and C-reactive protein. UACR was higher in severe OSA patients (920 ± 1053 mg/g) than in moderate (195 ± 232 mg/g, p < 0.001) or mild OSA/non-OSA subjects (119 ± 186 mg/g, p < 0.001). At the same time, eGFR showed an OSA severity-dependent reduction (48 ± 23 vs. 59 ± 21 vs. 73 ± 19 ml/min per 1.73 m2, respectively; p < 0.001). Apnea-hypopnea index (AHI and desaturation index (ODI) were identified as independent predictors for UACR and eGFR, respectively. Therefore, in patients with DKD under optimized treatment, severe OSA is associated with a higher UACR and a lower eGFR, reflecting an additional contribution to the impairment of their renal function, although no causality can be inferred.
Collapse
|
9
|
Independent association of atherogenic dyslipidaemia with all-cause mortality in individuals with type 2 diabetes and modifying effect of gender: a prospective cohort study. Cardiovasc Diabetol 2021; 20:28. [PMID: 33516215 PMCID: PMC7847015 DOI: 10.1186/s12933-021-01224-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/22/2021] [Indexed: 11/30/2022] Open
Abstract
Background Atherogenic dyslipidaemia has been implicated in the residual risk for cardiovascular morbidity and mortality, which remains despite attainment of LDL cholesterol goals especially in individuals with type 2 diabetes. However, its relationship with all-cause death has not been sufficiently explored. This analysis evaluated the independent association of increased triglycerides and triglyceride:HDL cholesterol ratio (TG:HDL) and decreased HDL cholesterol with total mortality and the possible modifying effect of gender in a large cohort of patients with type 2 diabetes. Methods This observational, prospective study enrolled 15,773 patients in 19 Diabetes Clinics throughout Italy in the years 2006–2008. Triglycerides and total and HDL cholesterol were measured by colorimetric enzymatic methods. Vital status was retrieved on 31 October 2015 for 15,656 patients (99.3%). Participants were stratified by quartiles of triglycerides, HDL cholesterol, and TG:HDL. Results There were 3,602 deaths over a follow-up 7.42 ± 2.05 years (31.0 × 1000 person-years). In the unadjusted analyses, the highest TG:HDL (but not triglyceride) and the lowest HDL cholesterol quartile were associated with increased death rate and mortality risk. When sequentially adjusting for confounders, including total, LDL, or non-HDL cholesterol and lipid-lowering treatment, mortality risk was significantly higher in the highest triglyceride (hazard ratio 1.167 [95% confidence interval 1.055–1.291], p = 0.003) and TG:HDL (1.192 [1.082–1.314], p < 0.0001) and the lowest HDL cholesterol (1.232 [1.117–1.360], p < 0.0001) quartile, though the association of triglycerides and HDL cholesterol disappeared after further adjustment for each other. Interaction with gender was significant only for HDL cholesterol (p = 0.0009). The relationship with death was stronger for triglycerides in males and HDL cholesterol in females, with these associations remaining significant even after adjustment for HDL cholesterol (1.161 [1.019–1.324], p = 0.025, for the highest vs the lowest triglyceride quartile) and triglycerides (1.366 [1.176–1.587], p < 0.0001, for the lowest vs the highest HDL cholesterol quartile). Conclusions In patients with type 2 diabetes, higher triglycerides and TG:HDL and lower HDL cholesterol were independently associated with increased all-cause mortality, with a modifying effect of gender for triglycerides and HDL cholesterol. These data suggest that atherogenic dyslipidaemia, especially TG:HDL, may serve as predictor of all-cause death in these individuals. Trial registration ClinicalTrials.gov, NCT00715481, 15 July, 2008
Collapse
|
10
|
Zhou Y, Shen L, Dong B, Liu C, Lv W, Chi J, Che K, Gao Y, Wang Y, Wang Y. Elevated circulating luteinizing hormone levels are associated with diabetic macroalbuminuria in Chinese men and postmenopausal women: A cross-sectional study. J Diabetes 2020; 12:819-833. [PMID: 32475064 DOI: 10.1111/1753-0407.13073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/16/2020] [Accepted: 05/27/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Associations between sex hormones and diabetic vascular complications have recently been studied, but the role luteinizing hormone (LH) plays in diabetic kidney disease (DKD) remains uncertain. We aimed to investigate the relationship of LH and DKD in Chinese men and postmenopausal women with type 2 diabetes mellitus (T2DM). METHODS Data were collected from 1775 T2DM men and postmenopausal women in hospital. The odds ratios (OR) and corresponding 95% confidence intervals (CI) in relation to LH quartiles were obtained by multiple logistic regression analysis. RESULTS LH levels were significantly higher in patients with macroalbuminuria than in those with microalbuminuria, but were not higher in patients with microalbuminuria than in those with normoalbuminuria. Consistently, LH in those with an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m2 were significantly higher than in those with eGFR≥60 mL/min/1.73m2 . The prevalence of macroalbuminuria was obviously increased for subjects of the fourth quartile of LH vs the first to third quartile (20.4% vs 6.2%, 8.0%, 12.2% in men; 25.3% vs 5.5%, 3.8%, 9.3% in postmenopausal women). Multivariate logistic regression demonstrated that subjects within the highest quartile of LH had higher odds of macroalbuminuria than those within the lowest quartile (OR 4.00, 95% CI, 1.87-8.55 for men; OR 9.62, 95% CI, 3.42-27.08 for postmenopausal women), independent of age, diabetes duration, or other metabolic factors. The area under the curve for detecting macroalbuminuria based on LH was 0.662 for men, and 0.767 for postmenopausal women. CONCLUSION High LH levels are positively associated with established DKD among Chinese men and postmenopausal women. Elevated LH may be a promising clinical factor for identifying established DKD.
Collapse
Affiliation(s)
- Yue Zhou
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Liyan Shen
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Bingzi Dong
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Chuanfeng Liu
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Wenshan Lv
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Jingwei Chi
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Kui Che
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Yanyan Gao
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Yunyang Wang
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Yangang Wang
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| |
Collapse
|
11
|
Penno G, Orsi E, Solini A, Bonora E, Fondelli C, Trevisan R, Vedovato M, Cavalot F, Gruden G, Laviola L, Nicolucci A, Pugliese G. Renal hyperfiltration is independently associated with increased all-cause mortality in individuals with type 2 diabetes: a prospective cohort study. BMJ Open Diabetes Res Care 2020; 8:8/1/e001481. [PMID: 32665314 PMCID: PMC7365485 DOI: 10.1136/bmjdrc-2020-001481] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/28/2020] [Accepted: 06/12/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In addition to favoring renal disease progression, renal 'hyperfiltration' has been associated with an increased risk of death, though it is unclear whether and how excess mortality is related to increased renal function. We investigated whether renal hyperfiltration is an independent predictor of death in patients with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events Italian multicenter study. RESEARCH DESIGN AND METHODS This observational, prospective cohort study enrolled 15 773 patients with type 2 diabetes consecutively attending 19 Italian diabetes clinics in 2006-2008. Serum creatinine, albuminuria, cardiovascular risk factors, and complications/comorbidities were assessed at baseline. Vital status on 31 October 2015 was retrieved for 15 656 patients (99.26%). Patients were stratified (A) by absolute estimated glomerular filtration rate (eGFR) values in eGFR deciles or Kidney Disease: Improving Global Outcomes (KDIGO) categories and (B) based on age-corrected thresholds or age and gender-specific 95th and 5th percentiles in hyperfiltration, hypofiltration, and normofiltration groups. RESULTS The highest eGFR decile/category and the hyperfiltration group included (partly) different individuals with similar clinical features. Age and gender-adjusted death rates were significantly higher in deciles 1, 9, and 10 (≥103.9, 50.9-62.7, and <50.9 mL/min/1.73 m2, respectively) versus the reference decile 3 (92.9-97.5 mL/min/1.73 m2). Mortality risk, adjusted for multiple confounders, was also increased in deciles 1 (HR 1.461 (95% CI 1.175 to 1.818), p=0.001), 9 (1.312 (95% CI 1.107 to 1.555), p=0.002), and 10 (1.976 (95% CI 1.673 to 2.333), p<0.0001) versus decile 3. Similar results were obtained by stratifying patients by KDIGO categories. Death rates and adjusted mortality risks were significantly higher in hyperfiltering and particularly hypofiltering versus normofiltering individuals. CONCLUSIONS In type 2 diabetes, both high-normal eGFR and hyperfiltration are associated with an increased risk of death from any cause, independent of confounders that may directly impact on mortality and/or affect GFR estimation. Further studies are required to clarify the nature of this relationship. TRIAL REGISTRATION NUMBER NCT00715481.
Collapse
Affiliation(s)
- Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Emanuela Orsi
- Diabetes Service, Endocrinology Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, Milan, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Franco Cavalot
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
| | - Gabriella Gruden
- Department of Internal Medicine, University of Turin, Turin, Italy
| | - Luigi Laviola
- Department of Emergency and Transplants, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Antonio Nicolucci
- Centre for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy
| |
Collapse
|
12
|
Association between On-Treatment Haemoglobin A 1c and All-Cause Mortality in Individuals with Type 2 Diabetes: Importance of Personalized Goals and Type of Anti-Hyperglycaemic Treatment. J Clin Med 2020; 9:jcm9010246. [PMID: 31963486 PMCID: PMC7019548 DOI: 10.3390/jcm9010246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/17/2022] Open
Abstract
The increased mortality reported with intensive glycaemic control has been attributed to an increased risk of treatment-related hypoglycaemia. This study investigated the relationships of haemoglobin (Hb) A1c, anti-hyperglycaemic treatment, and potential risks of adverse effects with all-cause mortality in patients with type 2 diabetes. Patients (n = 15,773) were stratified into four categories according to baseline HbA1c and then assigned to three target categories, based on whether HbA1c was ≤0.5% below or above (on-target), >0.5% below (below-target) or >0.5% above (above-target) their HbA1c goal, personalized according to the number of potential risks among age > 70 years, diabetes duration > 10 years, advanced complication(s), and severe comorbidity (ies). The vital status was retrieved for 15,656 patients (99.26%). Over a 7.4-year follow-up, mortality risk was increased among patients in the highest HbA1c category (≥8.5%) (adjusted hazard ratio, 1.34 (95% confidence interval, 1.22–1.47), p < 0.001) and those above-target (1.42 (1.29–1.57), p < 0.001). Risk was increased among individuals in the lowest HbA1c category (<6.5%) and those below-target only if treated with agents causing hypoglycaemia (1.16 (1.03–1.29), p = 0.01 and 1.10 (1.01–1.22), p = 0.04, respectively). These data suggest the importance of setting both upper and lower personalized HbA1c goals to avoid overtreatment in high-risk individuals with type 2 diabetes treated with agents causing hypoglycaemia.
Collapse
|
13
|
Ameh OI, Ekrikpo UE, Kengne AP. Preventing CKD in Low- and Middle-Income Countries: A Call for Urgent Action. Kidney Int Rep 2019; 5:255-262. [PMID: 32154447 PMCID: PMC7056849 DOI: 10.1016/j.ekir.2019.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 12/14/2022] Open
Abstract
The epidemiologic transition occurring in low- and middle-income countries (LMICs) has led to a surge in chronic kidney disease (CKD) prevalence because of a combination of highly prevalent chronic noncommunicable diseases (NCDs) and communicable diseases (CDs). The progressive rise in CKD prevalence in LMICs threatens the existing weak health systems in these countries as care for advanced CKD remains largely unavailable and unaffordable. An interplay of low literacy levels, poor health-seeking behavior, inadequate health care funding, weak health systems, and lack of skilled nephrology workforce has made it difficult for adequate CKD preventive measures to be implemented. Primary, secondary, and tertiary prevention measures need to be instituted in LMICs by a collaboration of governmental and nongovernmental organizations to stem this tide and help prevent deaths from other NCDs that share similar risk factors with CKD. For these to be effective, locally relevant knowledge is needed to contextualize existing prevention and control solutions, or to develop novel and more appropriate solutions for LMICs.
Collapse
Affiliation(s)
- Oluwatoyin I. Ameh
- Division of Nephrology, Zenith Medical & Kidney Centre, Gudu, Abuja, Nigeria
| | - Udeme E. Ekrikpo
- Renal Unit, Department of Internal Medicine, University of Uyo, Uyo, Nigeria
- Kidney & Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Andre-Pascal Kengne
- Non-communicable Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
- Correspondence: Andre-Pascal Kengne, Non-communicable Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.
| |
Collapse
|
14
|
Pugliese G, Penno G, Natali A, Barutta F, Di Paolo S, Reboldi G, Gesualdo L, De Nicola L. Diabetic kidney disease: New clinical and therapeutic issues. Joint position statement of the Italian Diabetes Society and the Italian Society of Nephrology on "The natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function". Nutr Metab Cardiovasc Dis 2019; 29:1127-1150. [PMID: 31586514 DOI: 10.1016/j.numecd.2019.07.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 02/06/2023]
Abstract
AIMS This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents. DATA SYNTHESIS Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., "nonalbuminuric renal impairment" and "progressive renal decline", suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered. CONCLUSIONS The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.
Collapse
Affiliation(s)
- Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Endocrine and Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy.
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Diabetes Unit, University Hospital, Pisa, Italy
| | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Unit of Internal Medicine, University Hospital, Pisa, Italy
| | - Federica Barutta
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | | | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Nephrology, Dialysis and Transplantation Unit, "Policlinico" University Hospital, Bari, Italy
| | - Luca De Nicola
- Nephrology and Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| |
Collapse
|
15
|
Mengozzi A, Carli F, Biancalana E, Della Latta V, Seghieri M, Gastaldelli A, Solini A. Phthalates Exposure as Determinant of Albuminuria in Subjects With Type 2 Diabetes: A Cross-Sectional Study. J Clin Endocrinol Metab 2019; 104:1491-1499. [PMID: 30462244 DOI: 10.1210/jc.2018-01797] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 11/14/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Recent epidemiological observations have reported an association among phthalates exposure and insulin resistance, obesity, and diabetes but have not related exposure to these environmental pollutants with microvascular complications of diabetes. OBJECTIVE To explore the relationship between phthalates and renal function in subjects with diabetes. DESIGN Cross-sectional, case-only study. Concentrations of three urinary metabolites of di-2-ethylhexylphthalate were quantified in a spot morning urine sample, normalized for creatinine urinary excretion, and related to clinical parameters and phenotype, adjusting for confounders. PATIENTS Two hundred and nine patients with diabetes consecutively referred to our clinic. MAIN OUTCOME MEASURES Relationship between phthalates and renal function [evaluated with estimated glomerular filtration rate (eGFR) and albuminuria]. RESULTS Creatinine-adjusted urinary concentrations of mono-2-ethylhexyl phthalate (MEHP), mono-2-ethyl-5-oxohexyl phthalate (MEOHP), and mono-2-ethyl-5-hydroxyhexyl phthalate were 7.53 µg/g (range, 4.84 to 12.60), 3.04 µg/g (range, 1.03 to 5.14), and 10.70 µg/g (7.02 to 17.40), respectively. Age, sex, body mass index, diabetes duration, smoking, blood pressure, glycated Hb, and eGFR did not influence their levels. Exposure to MEHP and MEOHP was greater in individuals with microalbuminuria/macroalbuminuria (MEHP, P = 0.0173; MEOHP, P = 0.0306). The fourth vs first quartile showed a greater risk of albuminuria (MEHP: OR, 4.83; 95% CI, 1.45 to 16.06; P = 0.0297; MEOHP: OR, 3.29; 95% CI, 1.08 to 10.04); P = 0.0352). MEOHP was greater (P = 0.034) in subjects with cardiovascular events; MEHP showed a positive trend (P = 0.061). CONCLUSION Our findings have revealed an association between exposure to di-2-ethylhexylphthalate metabolites and the degree of albuminuria in subjects with diabetes; the lack of a relationship with eGFR suggests their urinary levels are independent of renal function.
Collapse
Affiliation(s)
- Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabrizia Carli
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Edoardo Biancalana
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Marta Seghieri
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Amalia Gastaldelli
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| |
Collapse
|
16
|
Solini A, Penno G, Orsi E, Bonora E, Fondelli C, Trevisan R, Vedovato M, Cavalot F, Lamacchia O, Baroni MG, Nicolucci A, Pugliese G. Is resistant hypertension an independent predictor of all-cause mortality in individuals with type 2 diabetes? A prospective cohort study. BMC Med 2019; 17:83. [PMID: 31023377 PMCID: PMC6482506 DOI: 10.1186/s12916-019-1313-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 03/25/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Resistant hypertension is independently associated with an increased risk of death in the general hypertensive population. We assessed whether resistant hypertension is an independent predictor of all-cause mortality in individuals with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study. METHODS On 31 October 2015, vital status information was retrieved for 15,656 of the 15,773 participants enrolled in 2006-2008. Based on baseline blood pressure (BP) values and treatment, participants were categorized as normotensive, untreated hypertensive, controlled hypertensive (i.e., on-target with < 3 drugs), uncontrolled hypertensive (i.e., not on-target with 1-2 drugs), or resistant hypertensive (i.e., uncontrolled with > 3 drugs or controlled with > 4 drugs). Kaplan-Meier and Cox proportional hazards regression analyses were used to assess the association with all-cause mortality. RESULTS Using the 130/80 mmHg targets for categorization, crude mortality rates and Kaplan-Meier estimates were highest among resistant hypertension participants, especially those with controlled resistant hypertension. As compared with resistant hypertension, risk for all-cause mortality was significantly lower for all the other groups, including individuals with controlled hypertension (hazard ratio 0.81 [95% confidence interval 0.74-0.89], P < 0.0001), but became progressively similar between resistant and controlled hypertension after adjustment for cardiovascular risk factors and complications/comorbidities. Also when compared with controlled resistant hypertension, mortality risk was significantly lower for all the other groups, including controlled hypertension, even after adjusting for cardiovascular risk factors (0.77 [0.63-0.95], P = 0.012), but not for complications/comorbidities (0.88 [0.72-1.08], P = 0.216). BP was well below target in the controlled hypertensive groups (resistant and non-resistant) and values < 120/70 mmHg were associated with an increased mortality risk. Results changed only partly when using the 140/90 mmHg targets for categorization. CONCLUSIONS In the RIACE cohort, at variance with the general hypertensive population, resistant hypertension did not predict death beyond target organ damage. Our findings may be explained by the high mortality risk conferred by type 2 diabetes and the low BP values observed in controlled hypertensive patients, which may mask risk associated with resistant hypertension. Less stringent BP goals may be preferable in high-risk patients with type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov, NCT00715481 , retrospectively registered 15 July, 2008.
Collapse
Affiliation(s)
- Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Emanuela Orsi
- Diabetes Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, Milan, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Franco Cavalot
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
| | - Olga Lamacchia
- Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Marco G Baroni
- Unit of Endocrinology and Diabetes, Department of Medical Sciences, University of Cagliari, Cagliari, Italy.,Present Address: Department of Experimental Medicine, "La Sapienza" University, Rome, Italy
| | - Antonio Nicolucci
- Centre for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
| | | |
Collapse
|
17
|
Bůžková P, Barzilay JI, Fink HA, Robbins JA, Cauley JA, Ix JH, Mukamal KJ. Higher albumin:creatinine ratio and lower estimated glomerular filtration rate are potential risk factors for decline of physical performance in the elderly: the Cardiovascular Health Study. Clin Kidney J 2019; 12:788-794. [PMID: 31807292 PMCID: PMC6885681 DOI: 10.1093/ckj/sfz024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Indexed: 12/23/2022] Open
Abstract
Introduction Mildly reduced renal function and elevated urine protein levels are each prospectively associated with hip fracture risk in older adults. Here we determine whether these markers are associated with reduced appendicular muscle performance. Methods We prospectively examined the associations of urine albumin:creatinine ratio (ACR) and reduced estimated glomerular filtration rate (eGFR) with longitudinal changes in grip strength and gait speed >2 years in 2317 older community-dwelling men and women (median age 77 years). The median ACR was 9.8 [interquartile range (IQR) 5.40–21.50] mg/g creatinine and the median eGFR was 71.6 (IQR 59.1–83.56) mL/min/1.73 m2. Models were adjusted for demographic factors, clinical history and biochemical measures in four candidate pathways: diabetes, oxidative stress, inflammation and fibrosis. Results In demographic- and covariate-adjusted models, a 2-fold higher baseline urine ACR was associated with longitudinal changes of −0.17 kg [95% confidence interval (CI) −0.29 to −0.06) in grip strength and −1.10 cm/s (95% CI −1.67 to −0.53) gait speed per year. Corresponding estimates for a 10 mL/min/1.73 m2 lower baseline eGFR were −0.13 kg (95% CI −0.23 to −0.04) and −0.89 cm/s (95% CI −1.37 to −0.40), respectively. The associations of a 2-fold higher baseline ACR and a 10 mL/min/1.73 m2 lower baseline eGFR using cystatin C with grip strength and gait speed were equivalent to ∼1.2–1.9 additional years of age. Adjustment for covariates in candidate pathways did not attenuate these estimates. Conclusions In older adults, higher ACR and lower eGFR are potential risk factors for a decline of physical performance >2 years.
Collapse
Affiliation(s)
- Petra Bůžková
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joshua I Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia, Emory University School of Medicine, Atlanta, GA, USA
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, MN, USA
| | - John A Robbins
- Department of Medicine, University of California, Davis, Modesto, CA, USA
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joachim H Ix
- Division of Nephrology, University of California, San Diego, San Diego, CA, USA
| | | |
Collapse
|
18
|
Fadini GP, Solini A, Manca ML, Penno G, Gatti A, Anichini R, Del Prato S, Avogaro A. Effectiveness of dapagliflozin versus comparators on renal endpoints in the real world: A multicentre retrospective study. Diabetes Obes Metab 2019; 21:252-260. [PMID: 30136354 PMCID: PMC6585815 DOI: 10.1111/dom.13508] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/07/2018] [Accepted: 08/18/2018] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the changes in renal endpoints in type 2 diabetes patients treated with dapagliflozin versus other glucose-lowering medications in routine clinical practice. MATERIALS AND METHODS DARWIN-T2D was a retrospective study conducted at 46 outpatient diabetes clinics in Italy. An automated software collected data on 17 285 patients who received dapagliflozin, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, or gliclazide, 6751 of whom had a follow-up visit. We analysed changes in albumin excretion rate (AER) and estimated glomerular filtration rate (eGFR). RESULTS Patients who received dapagliflozin (n = 473) were younger, more obese, and had a poorer glucose control than those who received a comparator (n = 2973). After ~6 months, median (interquartile range) AER declined by 37%, from 19.5 (7.5-78.2) to 13.2 (6.5-45.0) mg/g (P < 0.0001) in the dapagliflozin group and did not change in the comparator group. After adjusting for confounders, therapy with dapagliflozin versus comparators was associated with an AER reduction of 26.4 ± 13.1 mg/g (P = 0.045), and eGFR (mL/min/1.73 m2 ) diminished by 1.1 ± 0.5 (P = 0.049) in the dapagliflozin group and by 0.6 ± 9.1 (P = 0.002) in the comparator group (P = 0.35 between groups). No patient treated with dapagliflozin versus four patients treated with comparators experienced a doubling of serum creatinine. CONCLUSIONS The antiproteinuric effect of dapagliflozin is confirmed here for the first time by real-world data. Despite a mild decline in eGFR, there was no evidence of clinically relevant worsening in renal function.
Collapse
Affiliation(s)
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area PathologyUniversity of PisaPisaItaly
| | - Maria Laura Manca
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | - Giuseppe Penno
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | - Adriano Gatti
- Metabolic Disease Unit, San Gennaro HospitalNaplesItaly
| | - Roberto Anichini
- Diabetes Unit, Department of Internal MedicineSan Jacopo HospitalPistoiaItaly
| | - Stefano Del Prato
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | | | | |
Collapse
|
19
|
Fadini GP, Solini A, Manca ML, Zatti G, Karamouzis I, Di Benedetto A, Frittitta L, Avogaro A. Phenotyping normal kidney function in elderly patients with type 2 diabetes: a cross-sectional multicentre study. Acta Diabetol 2018; 55:1121-1129. [PMID: 30090961 DOI: 10.1007/s00592-018-1194-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/17/2018] [Indexed: 12/26/2022]
Abstract
AIMS Type 2 diabetes (T2D) accelerates the decline in glomerular function; however, some individuals do not develop chronic kidney disease despite advanced age and long-lasting T2D. We aimed to phenotype patients with T2D aged 80 years or older who presented with a fully preserved kidney function. METHODS From an Italian population of 281,217 T2D outpatients, we collected data on demographics, anthropometrics, diabetes duration, HbA1c, fasting plasma glucose, lipids, liver enzymes, estimated glomerular filtration rate (eGFR), albumin excretion rate (AER), chronic complications, and medication use. We primarily compared patients with a fully preserved kidney function (eGFR > 90 ml/min/1.73 m2 and AER < 30 mg/24 h, or G1A1) with those with mild kidney impairment (eGFR 60-90 ml/min/1.73 m2 and AER < 30 mg/24 h, or G2A1). RESULTS N = 113,860 had available data for eGFR and AER, 21,648 of whom were aged ≥ 80. G1A1 (n = 278) and G2A1 (n = 6647) patients represented 1.3 and 30.7% of aged T2D patients, respectively, with an average diabetes duration of 16 years. Differences between the G1A1 and G2A1 groups were entered in a multiple logistic regression analysis with and without imputation of missing data. After adjustment and in both imputed and non-imputed datasets, younger age, lower BMI and lower triglycerides were associated with fully preserved versus mildly impaired kidney function. The comparison between G1A1 and G1A2/3 yielded different results. CONCLUSIONS In a rare population of patients with a fully preserved kidney function despite old age and long-lasting diabetes, lower BMI and triglycerides suggest that protection from lipotoxicity may preserve kidney function over time.
Collapse
Affiliation(s)
- G P Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
| | - A Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - M L Manca
- Department of Mathematics, University of Pisa, Pisa, Italy
| | - G Zatti
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - I Karamouzis
- Ospedale Maggiore di Novara, 28100, Novara, Italy
| | - A Di Benedetto
- Department of Clinical and Experimental Medicine, University of Messina, 98122, Messina, Italy
| | - L Frittitta
- Department of Internal and Special Medicine, University of Catania, 95122, Catania, Italy
| | - A Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| |
Collapse
|
20
|
Penno G, Solini A, Orsi E, Bonora E, Fondelli C, Trevisan R, Vedovato M, Cavalot F, Lamacchia O, Scardapane M, Nicolucci A, Pugliese G. Non-albuminuric renal impairment is a strong predictor of mortality in individuals with type 2 diabetes: the Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicentre study. Diabetologia 2018; 61:2277-2289. [PMID: 30032426 DOI: 10.1007/s00125-018-4691-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 06/12/2018] [Indexed: 02/07/2023]
Abstract
AIMS/HYPOTHESIS Non-albuminuric renal impairment has become the prevailing diabetic kidney disease (DKD) phenotype in individuals with type 2 diabetes and an estimated GFR (eGFR) <60 ml min-1 1.73 m-2. In the present study, we compared the rate and determinants of all-cause death in individuals with this phenotype with those in individuals with albuminuric phenotypes. METHODS This observational prospective cohort study enrolled 15,773 individuals with type 2 diabetes in 2006-2008. Based on baseline albuminuria and eGFR, individuals were classified as having: no DKD (Alb-/eGFR-), albuminuria alone (Alb+/eGFR-), reduced eGFR alone (Alb-/eGFR+), or both albuminuria and reduced eGFR (Alb+/eGFR+). Vital status on 31 October 2015 was retrieved for 15,656 individuals (99.26%). RESULTS Mortality risk adjusted for confounders was lowest for Alb-/eGFR- (reference category) and highest for Alb+/eGFR+ (HR 2.08 [95% CI 1.88, 2.30]), with similar values for Alb+/eGFR- (1.45 [1.33, 1.58]) and Alb-/eGFR+ (1.58 [1.43, 1.75]). Similar results were obtained when individuals were stratified by sex, age (except in the lowest age category) and prior cardiovascular disease. In normoalbuminuric individuals with eGFR <45 ml min-1 1.73 m-2, especially with low albuminuria (10-29 mg/day), risk was higher than in microalbuminuric and similar to macroalbuminuric individuals with preserved eGFR. Using recursive partitioning and amalgamation analysis, prevalent cardiovascular disease and lower HDL-cholesterol were the most relevant correlates of mortality in all phenotypes. Higher albuminuria within the normoalbuminuric range was associated with death in non-albuminuric DKD, whereas the classic 'microvascular signatures', such as glycaemic exposure and retinopathy, were correlates of mortality only in individuals with albuminuric phenotypes. CONCLUSIONS/INTERPRETATION Non-albuminuric renal impairment is a strong predictor of mortality, thus supporting a major prognostic impact of renal dysfunction irrespective of albuminuria. Correlates of death partly differ from the albuminuric forms, indicating that non-albuminuric DKD is a distinct phenotype. TRIAL REGISTRATION ClinicalTrials.gov NCT00715481.
Collapse
Affiliation(s)
- Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Emanuela Orsi
- Diabetes Unit, IRCCS 'Cà Granda - Ospedale Maggiore Policlinico' Foundation, Milan, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Franco Cavalot
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
| | - Olga Lamacchia
- Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Marco Scardapane
- Centre for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Antonio Nicolucci
- Centre for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, 'La Sapienza' University, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
| | | |
Collapse
|
21
|
Orsi E, Solini A, Bonora E, Fondelli C, Trevisan R, Vedovato M, Cavalot F, Gruden G, Morano S, Nicolucci A, Penno G, Pugliese G. Haemoglobin A1c variability is a strong, independent predictor of all-cause mortality in patients with type 2 diabetes. Diabetes Obes Metab 2018; 20:1885-1893. [PMID: 29582548 DOI: 10.1111/dom.13306] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 01/06/2023]
Abstract
AIMS To evaluate various measures of haemoglobin (Hb) A1c variability, compared with average HbA1c, as independent predictors of mortality. MATERIALS AND METHODS The Renal Insufficiency And Cardiovascular Events Italian multicentre study enroled 15 733 patients with type 2 diabetes from 19 diabetes clinics during 2006-2008. A total of 3 to 5 HbA1c measures, obtained during the 2-year period before enrolment, were available from 9 centres (8290 patients) and were used to calculate average HbA1c (HbA1c -MEAN) and HbA1c variability, measured as intra-individual standard deviation (HbA1c-SD), SD adjusted for the number of HbA1c assessments (HbA1c-AdjSD) and coefficient of variation (HbA1c-CV), that is, the HbA1c-SD to HbA1c-MEAN ratio. Vital status on October 31, 2015 was retrieved for 8252 patients (99.5%). RESULTS The measures of HbA1c variability increased according to quartiles of HbA1c-MEAN and vice versa. HbA1c-MEAN and measures of HbA1c variability were associated with all-cause mortality; however, the strength of association of HbA1c-MEAN was lower than that of HbA1c -SD, HbA1c-CV or HbA1c-AdjSD, and disappeared after adjusting for confounders and any of the measures of HbA1c variability. Mortality increased with quartiles of HbA1c-MEAN, HbA1c -SD, HbA1c-CV and HbA1c-AdjSD, but only the association with HbA1c variability measures remained after adjustment for confounders and/or each other measure. In the fully adjusted model, mortality risk was lower for HbA1c-SD below the median and higher for HbA1c-SD above the median, regardless of whether HbA1c-MEAN was below or above the median. Conclusions HbA1c variability is a strong, independent predictor of all-cause mortality in type 2 diabetes and appears to be even more powerful than average HbA1c in predicting mortality.
Collapse
Affiliation(s)
- Emanuela Orsi
- Diabetes Unit, Fondazione IRCCS 'Cà Granda - Ospedale Maggiore Policlinico' and Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | - Cecilia Fondelli
- Diabetes Unit, Azienda Ospedaliera Universitaria Senese, and Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Franco Cavalot
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
| | - Gabriella Gruden
- Department of Internal Medicine, University of Turin, Turin, Italy
| | - Susanna Morano
- Department of Experimental Medicine, 'La Sapienza' University, Rome, Italy
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, 'La Sapienza' University, Rome, Italy
| |
Collapse
|
22
|
Li YH, Sheu WHH, Lee IT. Effects of retinopathy and chronic kidney disease on long-term mortality in type 2 diabetic inpatients with normal urinary albumin or protein: a retrospective cohort study. BMJ Open 2018; 8:e021655. [PMID: 30049696 PMCID: PMC6067336 DOI: 10.1136/bmjopen-2018-021655] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Normoalbuminuric chronic kidney disease (NA-CKD) is recognised as a distinct phenotype of diabetic kidney disease, but the role of diabetic retinopathy (DR) in predicting long-term mortality among these patients remains unclear. Here, we aimed to investigate the effects of DR and CKD on mortality in type 2 diabetic patients with normoalbuminuria. DESIGN We conducted this study as a retrospective cohort study. SETTING We collected clinical information from the medical records of a public medical centre in central Taiwan. PARTICIPANTS Patients with type 2 diabetes (n=665) who were hospitalised due to poor glucose control were consecutively enrolled and followed for a median of 6.7 years (IQR 4.1‒9.6 years). Patients with either urinary protein excretion >150 mg/day or urine albumin excretion >30 mg/day were excluded. PRIMARY OUTCOME MEASURE All-cause mortality served as the primary follow-up outcome, and the mortality data were obtained from the national registry in Taiwan. RESULTS The patients with CKD and DR showed the highest mortality rate (log-rank p<0.001). The risks of all-cause mortality (HR 2.263; 95% CI 1.551 to 3.302) and cardiovascular mortality (HR 2.471; 95% CI 1.421 to 4.297) were significantly greater in patients with CKD and DR than in those without CKD or DR, after adjusting for the associated risk factors. CONCLUSIONS DR is an independent predictor for all-cause and cardiovascular mortality in type 2 diabetic inpatients with normoalbuminuria. Moreover, DR with CKD shows the highest risks of all-cause and cardiovascular mortality among these patients. Funduscopy screening can provide additive information on mortality in patients with type 2 diabetes, even among those with NA-CKD.
Collapse
Affiliation(s)
- Yu-Hsuan Li
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wayne H-H Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - I-Te Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| |
Collapse
|
23
|
Penno G, Solini A, Bonora E, Orsi E, Fondelli C, Zerbini G, Trevisan R, Vedovato M, Cavalot F, Laviola L, Nicolucci A, Pugliese G. Defining the contribution of chronic kidney disease to all-cause mortality in patients with type 2 diabetes: the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study. Acta Diabetol 2018; 55:603-612. [PMID: 29574497 DOI: 10.1007/s00592-018-1133-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/17/2018] [Indexed: 01/09/2023]
Abstract
AIMS To define the contribution of chronic kidney disease (CKD) to excess mortality in patients with type 2 diabetes and identify the baseline variables associated with all-cause death in those with and without CKD using the RECursive Partitioning and Amalgamation (RECPAM) method. METHODS This observational, longitudinal, cohort study enrolled 15,773 consecutive non-dialytic patients with type 2 diabetes in 19 Diabetes Clinics throughout Italy in 2006-2008. Based on the presence of albuminuria ≥ 30 mg day-1 and/or estimated glomerular filtration rate (eGFR) < 60 mL min-1·1.73 m-2 at baseline, patients were classified as having or not CKD. Vital status was verified on October 31, 2015 for 99.26% of patients. RESULTS Mortality increased with increasing albuminuria and eGFR category. Excess risk versus the general population was maximal in patients aged < 55 years in the worse albuminuria or eGFR category. Conversely, in subjects aged ≥ 75 years with albuminuria < 10 mg day-1 or eGFR ≥ 75 mL min-1·1.73 m-2, excess mortality was no longer detectable. At RECPAM analysis, the main correlates of death in the whole cohort were albuminuria > 44 mg day-1, prevalent CVD, and eGFR < ~ 75 mL min-1·1.73 m-2; gender, prevalent CVD, and higher albuminuria in the normoalbuminuric range, in patients without CKD; and CVD, eGFR ~ < 50 mL min-1·1.73 m-2, and albuminuria > 53 mg day-1, in those with CKD. CONCLUSIONS CKD is a major contributor to excess mortality in type 2 diabetes, conferring a very high risk in younger patients and fully accounting for excess risk in the older ones. Higher albuminuria and lower eGFR, even in the normal range, identify individuals with increased mortality risk. Trial registration ClinicalTrials.gov (NCT00715481; https://clinicaltrials.gov/ct2/show/NCT00715481 ).
Collapse
Affiliation(s)
- Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | - Emanuela Orsi
- Diabetes Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, Milan, Italy
| | | | - Gianpaolo Zerbini
- Complications of Diabetes Unit, Division of Metabolic and Cardiovascular Sciences, San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Franco Cavalot
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Turin, Italy
| | - Luigi Laviola
- Department of Emergency and Transplants - Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
| |
Collapse
|
24
|
Lamacchia O, Viazzi F, Fioretto P, Mirijello A, Giorda C, Ceriello A, Russo G, Guida P, Pontremoli R, De Cosmo S. Normoalbuminuric kidney impairment in patients with T1DM: insights from annals initiative. Diabetol Metab Syndr 2018; 10:60. [PMID: 30083251 PMCID: PMC6069993 DOI: 10.1186/s13098-018-0361-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 07/25/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND We described, in a large sample of patients with type 1 diabetes mellitus (T1DM) and GFR ≤ 60 mL/min/1.73 m2 (with or without albuminuria), the differences in the clinical features associated with the two different chronic kidney disease phenotypes and we investigated, in a subset of patients, the modulating role of albuminuria on kidney disease progression. METHODS Clinical data of 1395 patients with T1DM were extracted from electronic medical records. RESULTS Albuminuria was detected in 676 (48.5%) patients, with the remaining 719 (51.5%) patients having normoalbuminuric renal impairment. Those with albuminuria showed an evident worse cardiovascular risk profile as compared to patients with normoalbuminuria. A subgroup of 582 patients was followed up over a 4-year period. One hundred and twenty five patients (21.5%) showed a loss of eGFR > 30%. The proportion of patients reaching the renal outcome was significantly higher among those with baseline albuminuria as compared to patients with normoalbuminuria (P < 0.0001). At the multivariate logistic analysis microalbuminuria, macroalbuminuria and proliferative retinopathy were the only parameters independently associated to eGFR reduction. CONCLUSIONS The proportion of T1DM patients with normoalbuminuria renal impairment is high (about 50%). These patients have a slower eGFR decline as compared to that observed in patients with albuminuria renal impairment.
Collapse
Affiliation(s)
- Olga Lamacchia
- Unit of Endocrinology and Metabolic Diseases, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Paola Fioretto
- Department of Medicine, University of Padova, Padova, Italy
| | - Antonio Mirijello
- Department of Medical Sciences, Scientific Institute “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, FG Italy
| | - Carlo Giorda
- Diabetes and Metabolism Unit ASL Turin 5, Chieri, Italy
| | - Antonio Ceriello
- Institut d’Investigacions Biomèdiques August Pii Sunyer (IDIBAPS) and Centro de Investigación Biomédicaen Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain
- U.O. Diabetologia e Malattie Metaboliche, Multimedica IRCCS, Sesto San Giovanni, Milan, Italy
| | - Giuseppina Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Salvatore De Cosmo
- Department of Medical Sciences, Scientific Institute “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, FG Italy
| |
Collapse
|
25
|
Leong A, Ekinci EI, Nguyen C, Milne M, Hachem M, Dobson M, MacIsaac RJ, Jerums G. Long-term intra-individual variability of albuminuria in type 2 diabetes mellitus: implications for categorization of albumin excretion rate. BMC Nephrol 2017; 18:355. [PMID: 29207965 PMCID: PMC5717840 DOI: 10.1186/s12882-017-0767-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 11/20/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease in the Western world. Early and accurate identification of DKD offers the best chance of slowing the progression of kidney disease. An important method for evaluating risk of progressive DKD is abnormal albumin excretion rate (AER). Due to the high variability in AER, most guidelines recommend the use of more than or equal to two out of three AER measurements within a 3- to 6-month period to categorise AER. There are recognised limitations of using AER as a marker of DKD because one quarter of patients with type 2 diabetes may develop kidney disease without an increase in albuminuria and spontaneous regression of albuminuria occurs frequently. Nevertheless, it is important to investigate the long-term intra-individual variability of AER in participants with type 2 diabetes. METHODS Consecutive AER measurements (median 19 per subject) were performed in 497 participants with type 2 diabetes from 1999 to 2012 (mean follow-up 7.9 ± 3 years). Baseline clinical characteristics were collected to determine associations with AER variability. Participants were categorised as having normo-, micro- or macroalbuminuria according to their initial three AER measurements. Participants were then categorised into four patterns of AER trajectories: persistent, intermittent, progressing and regressing. Coefficients of variation were used to measure intra-individual AER variability. RESULTS The median coefficient of variation of AER was 53.3%, 76.0% and 67.0% for subjects with normo-, micro- or macroalbuminuria at baseline. The coefficient of variation of AER was 37.7%, 66% and 94.8% for subjects with persistent, intermittent and progressing normoalbuminuria; 43%, 70.6%, 86.1% and 82.3% for subjects with persistent, intermittent, progressing and regressing microalbuminuria; and 55.2%, 67% and 82.4% for subjects with persistent, intermittent and regressing macroalbuminuria, respectively. CONCLUSION High long-term variability of AER suggests that two out of three AER measurements may not always be adequate for the optimal categorisation and prediction of AER.
Collapse
Affiliation(s)
- Amanda Leong
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
| | - Elif Ilhan Ekinci
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia.
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
- Menzies School of Health Research, Red 9, Casuarina Campus, University Drive North, Casuarina, Northern Territory, 0811, Australia.
| | - Cattram Nguyen
- Murdoch Children's Research Institute, Flemington Road, Melbourne, Victoria, 3052, Australia
| | - Michele Milne
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
| | - Mariam Hachem
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew Dobson
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, 41 Victoria Parade, Melbourne, Victoria, 3065, Australia
| | - George Jerums
- Austin Health Endocrine Centre, Heidelberg Repatriation Hospital, PO BOX 5444, Melbourne, Victoria, 3081, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
26
|
Ceriello A, De Cosmo S, Rossi MC, Lucisano G, Genovese S, Pontremoli R, Fioretto P, Giorda C, Pacilli A, Viazzi F, Russo G, Nicolucci A. Variability in HbA1c, blood pressure, lipid parameters and serum uric acid, and risk of development of chronic kidney disease in type 2 diabetes. Diabetes Obes Metab 2017; 19:1570-1578. [PMID: 28432733 DOI: 10.1111/dom.12976] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/11/2017] [Accepted: 04/19/2017] [Indexed: 12/20/2022]
Abstract
AIM Variability in HbA1c and blood pressure is associated with the risk of diabetic kidney disease (DKD). No evidence exists on the role of variability in lipids or serum uric acid (UA), or the interplay between the variability of different parameters, in renal outcomes. METHODS Within the AMD Annals database, we identified patients with ≥5 measurements of HbA1c, systolic blood pressure (SBP) and diastolic blood pressure (DBP), total-, high-density lipoprotein (HDL)- and low-density lipoprotein (LDL)-cholesterol, triglycerides, and UA. Patients were followed-up for up to 5 years. The impact of measures of variability on the risk of DKD was investigated by Cox regression analysis and recursive partitioning techniques. RESULTS Four-thousand, two-hundred and thirty-one patients were evaluated for development of albuminuria, and 7560 for decreased estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2 ). A significantly higher risk of developing albuminuria was associated with variability in HbA1c [upper quartile hazard ratio (HR) = 1.3; 95% confidence interval (CI) 1.1-1.6]. Variability in SBP, DBP, HDL-C, LDL-C and UA predicted the decline in eGFR, the association with UA variability being particularly strong (upper quartile HR = 1.8; 95% CI 1.3-2.4). The concomitance of high variability in HbA1c and HDL-C conferred the highest risk of developing albuminuria (HR = 1.47; 95% CI 1.17-1.84), while a high variability in UA (HR = 1.54; 95% CI 1.19-1.99) or DBP (HR = 1.47; 95% CI 1.11-1.94) conferred the highest risk of decline in eGFR. CONCLUSION The variability of several parameters influences the development of DKD, having a different impact on albuminuria development and on the decline in GFR.
Collapse
Affiliation(s)
- Antonio Ceriello
- Insititut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain
- Department of Cardiovascular and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni (MI), Italy
| | - Salvatore De Cosmo
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - Maria Chiara Rossi
- CORESEARCH - Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Giuseppe Lucisano
- CORESEARCH - Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Stefano Genovese
- Department of Cardiovascular and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni (MI), Italy
| | - Roberto Pontremoli
- Department of Cardionephrology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genova, Italy
| | - Paola Fioretto
- Department of Medicine, University of Padua, Padua, Italy
| | - Carlo Giorda
- Department of Internal Medicine, Diabetes and Metabolism Unit, ASL Turin 5, Chieri (TO), Italy
| | - Antonio Pacilli
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - Francesca Viazzi
- Department of Cardionephrology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genova, Italy
| | - Giuseppina Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Nicolucci
- CORESEARCH - Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| |
Collapse
|
27
|
Stadler S, Zimmermann T, Franke F, Rheinberger M, Heid IM, Böger CA, Arzt M. Association of sleep-disordered breathing with diabetes-associated kidney disease. Ann Med 2017; 49:487-495. [PMID: 28281834 DOI: 10.1080/07853890.2017.1306100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Diabetes-associated kidney disease is characterized by impairment of renal function and albuminuria. The aim of the present study was to assess whether sleep-disordered breathing is associated with decreased estimated glomerular filtration rate or increased urine-albumin-to-creatinine-ratio independently from known modulators of diabetes-associated kidney disease. MATERIAL AND METHODS Estimated glomerular filtration rate and urine-albumin-to-creatinine-ratio were determined in the baseline survey of the DIACORE-SDB substudy, a prospectively planned study of Diabetes mellitus 2 patients. As a measure of the severity of sleep-disordered breathing, the apnea-hypopnea-index was assessed using a 2-channel ambulatory SDB-monitoring device. RESULTS A total of 679 patients (mean age 66 years, men 61%, mean body-mass-index 31.2 kg/m2) were analyzed. In multivariable linear regression models adjusting for known modulators of diabetes-associated kidney disease, such as sex, age, body-mass-index, systolic blood pressure, duration of diabetes and HbA1c, apnea-hypopnea-index [beta-estimate -0.2 ml/min/1.73 m2, 95% CI (-0.3; -0.1), p = .004], duration of diabetes and age were associated with estimated glomerular filtration rate. Apnea-hypopnea-index [beta-estimate 0.01 mg/g, 95% CI (0.00; 0.02), p = .009], duration of diabetes, HbA1c and systolic blood pressure were associated with ln(urine-albumin-to-creatinine-ratio). CONCLUSION In patients with diabetes mellitus type 2, more severe sleep-disordered breathing is significantly associated with lower estimated glomerular filtration rate and increased albuminuria, independent of known modulators of diabetes-associated kidney disease.
Collapse
Affiliation(s)
- Stefan Stadler
- a Department of Internal Medicine II , University Hospital Regensburg , Regensburg , Germany
| | - Tanja Zimmermann
- a Department of Internal Medicine II , University Hospital Regensburg , Regensburg , Germany
| | - Franziska Franke
- a Department of Internal Medicine II , University Hospital Regensburg , Regensburg , Germany
| | - Myriam Rheinberger
- b Department of Nephrology , University Hospital Regensburg , Regensburg , Germany
| | - Iris M Heid
- c Department of Genetic Epidemiology , University Regensburg , Regensburg , Germany
| | - Carsten A Böger
- b Department of Nephrology , University Hospital Regensburg , Regensburg , Germany
| | - Michael Arzt
- a Department of Internal Medicine II , University Hospital Regensburg , Regensburg , Germany
| | | |
Collapse
|
28
|
Pacilli A, Viazzi F, Fioretto P, Giorda C, Ceriello A, Genovese S, Russo G, Guida P, Pontremoli R, De Cosmo S. Epidemiology of diabetic kidney disease in adult patients with type 1 diabetes in Italy: The AMD-Annals initiative. Diabetes Metab Res Rev 2017; 33. [PMID: 27935651 DOI: 10.1002/dmrr.2873] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/29/2016] [Accepted: 11/29/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with type 1 diabetes mellitus are at increased risk of death. This risk appears to be modulated by kidney dysfunction. The aim of this study was to evaluate the prevalence of diabetic kidney disease (DKD), its traits, and clinical correlates in a large sample of patients with type 1 diabetes. METHODS Clinical data of 20 464 patients with type 1 diabetes were extracted from electronic medical records. Estimated glomerular filtration rate (eGFR) and increased urinary albumin excretion were considered. RESULTS Mean age of the patients was 46 ± 16 years, 55.0% were males, and duration of diabetes 19 ± 13 years. The frequency of diabetic kidney disease, low eGFR, and albuminuria was 23.5%, 8.1%, and 19.5%, respectively. In the multivariate analysis the presence of diabetic kidney disease was associated with age (odds ratio [OR] = 1.14, 95% confidence interval [CI]: 1.10-1.18), duration of diabetes (OR = 1.05, 95% CI: 1.03-1.07), and worse glycemic control (OR = 1.24, 95% CI: 1.21-1.28, for every 1% glycated hemoglobin increase). Diabetic kidney disease was also independently associated with an atherogenic lipid profile and increased systolic blood pressure. Glucose control, systolic blood pressure, triglycerides, and high density lipoprotein cholesterol were associated with both low eGFR and albuminuria. Male gender, retinopathy and smoke were related to albuminuria, being female was related to low eGFR, while SUA levels were associated with DKD, low eGFR and albuminuria. CONCLUSIONS In our sample of patients with type 1 diabetes, diabetic kidney disease entails an unsafe cardiovascular risk profile. Hyperglycemia, arterial hypertension, and atherogenic lipid profile affected both low eGFR and albuminuria. Retinopathy and smoking were related only to albuminuria while being female and elevated serum uric acid were associated only with low eGFR.
Collapse
Affiliation(s)
- Antonio Pacilli
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - Francesca Viazzi
- Università degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Paola Fioretto
- Department of Medicine, University of Padova, Padua, Italy
| | - Carlo Giorda
- Diabetes and Metabolism Unit, Chieri (TO), Italy
| | - Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pii Sunyer (IDIBAPS) and Centro de Investigación Biomédicaen Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain
- U.O. Diabetologia e Malattie Metaboliche, Multimedica IRCCS, Milan, Italy
| | - Stefano Genovese
- U.O. Diabetologia e Malattie Metaboliche, Multimedica IRCCS, Milan, Italy
| | - Giuseppina Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Roberto Pontremoli
- Università degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Salvatore De Cosmo
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| |
Collapse
|
29
|
Chen J, Tao F, Zhang B, Chen Q, Qiu Y, Luo Q, Gen Y, Meng J, Zhang J, Lu H. Elevated Squamous Cell Carcinoma Antigen, Cytokeratin 19 Fragment, and Carcinoembryonic Antigen Levels in Diabetic Nephropathy. Int J Endocrinol 2017; 2017:5304391. [PMID: 28744310 PMCID: PMC5514347 DOI: 10.1155/2017/5304391] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 05/16/2017] [Accepted: 05/28/2017] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE We aimed to explore whether squamous cell carcinoma antigen (SCC), cytokeratin 19 fragment (Cyfra21-1), neuron-specific enolase (NSE), and carcinoembryonic antigen (CEA) are elevated in diabetic nephropathy (DN) and the association between urinary albumin-to-creatinine ratio (UACR) and tumor markers in diabetic patients. METHODS Nondialysis patients with diabetes (n = 261) and 90 healthy controls were enrolled. DN was defined as an UACR ≥ 30 mg/g in the absence of a urinary tract infection or other renal abnormalities. RESULTS Patients with DN had significantly higher serum SCC, Cyfra21-1, and CEA levels than those with normoalbuminuria and healthy controls. The rates of positive SCC, Cyfra21-1, and CEA significantly increased with increasing urinary albumin excretion (all P for trend < 0.001). In contrast, NSE was not affected by DN. SCC, Cyfra21-1, and CEA were significantly and positively correlated with UACR. In logistic regression, after multivariable adjustment, increased UACR was associated with increased odds ratio of elevated tumor marker levels (all P for trend < 0.05). CONCLUSIONS Serum levels of SCC, Cyfra21-1, and CEA are markedly increased with increasing urinary albumin excretion, which affects the specificity for diagnosis for lung cancer. Appropriate interpretation of tumor markers in diabetic patients is mandatory to avoid unnecessary and even hazardous biopsies.
Collapse
Affiliation(s)
- Jianzhong Chen
- Department of Clinical Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Feng Tao
- Department of Endocrinology and Metabolism, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Bin Zhang
- Department of Clinical Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qingguang Chen
- Department of Endocrinology and Metabolism, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yan Qiu
- Department of Endocrinology and Metabolism, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qian Luo
- Department of Clinical Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yanna Gen
- Department of Endocrinology and Metabolism, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiali Meng
- Department of Clinical Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jue Zhang
- Department of Clinical Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- *Jue Zhang: and
| | - Hao Lu
- Department of Endocrinology and Metabolism, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- *Hao Lu:
| |
Collapse
|
30
|
Conti F, Balducci S, Pugliese L, D'Errico V, Vitale M, Alessi E, Salerno G, Iacobini C, Menini S, Bollanti L, Nicolucci A, Pugliese G. Correlates of Calcaneal Quantitative Ultrasound Parameters in Patients with Diabetes: The Study on the Assessment of Determinants of Muscle and Bone Strength Abnormalities in Diabetes. J Diabetes Res 2017; 2017:4749619. [PMID: 29057273 PMCID: PMC5625809 DOI: 10.1155/2017/4749619] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/12/2017] [Accepted: 07/19/2017] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Quantitative ultrasound (QUS) provides an estimate of bone mineral density (BMD) and also evaluates bone quality, which has been related to increased fracture risk in people with diabetes. This study aimed at assessing the correlates of calcaneal QUS parameters in diabetic subjects encompassing various degrees of micro and macrovascular complications and a wide-range of peripheral nerve function. METHODS Four hundred consecutive diabetic patients were examined by QUS to obtain values of broadband ultrasound attenuation (BUA), the speed of sound (SOS), quantitative ultrasound index (QUI), and BMD. RESULTS Among surrogate measures of complications, sensory and motor nerve amplitude and heart rate response to cough test and standing correlated with QUS parameters at univariate analysis, together with age, body mass index (BMI), waist circumference, lipid profile, and renal function. Multivariate analysis revealed that BUA, SOS, QUI, and BMD were independently associated with age, male gender, hemoglobin A1c, BMI (or fat, but not fat-free mass), and somatic and autonomic nerve function parameters. CONCLUSIONS These data indicate that peripheral nerve dysfunction is associated with worse QUS parameters, possibly contributing to increased fracture risk in diabetes. The positive relation of QUS measures with adiposity needs further investigation. This trial is registered with ClinicalTrials.gov (NCT01600924).
Collapse
MESH Headings
- Adiposity
- Age Factors
- Aged
- Autonomic Nervous System/physiopathology
- Biomarkers/blood
- Body Mass Index
- Bone Density
- Calcaneus/diagnostic imaging
- Calcaneus/physiopathology
- Chi-Square Distribution
- Cross-Sectional Studies
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/diagnostic imaging
- Diabetes Mellitus, Type 1/physiopathology
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/diagnostic imaging
- Diabetes Mellitus, Type 2/physiopathology
- Diabetic Neuropathies/diagnosis
- Diabetic Neuropathies/etiology
- Diabetic Neuropathies/physiopathology
- Female
- Fractures, Bone/diagnosis
- Fractures, Bone/etiology
- Fractures, Bone/physiopathology
- Glycated Hemoglobin/analysis
- Humans
- Linear Models
- Male
- Middle Aged
- Multivariate Analysis
- Predictive Value of Tests
- Prospective Studies
- Risk Factors
- Sex Factors
- Ultrasonography
Collapse
Affiliation(s)
- Francesco Conti
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Via di Grottarossa 1035, 00189 Rome, Italy
- Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Stefano Balducci
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Via di Grottarossa 1035, 00189 Rome, Italy
- Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
- Metabolic Fitness Association, Via Nomentana 27, Monterotondo, 00015 Rome, Italy
| | - Luca Pugliese
- Radiology Unit, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Valeria D'Errico
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Via di Grottarossa 1035, 00189 Rome, Italy
- Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
- Metabolic Fitness Association, Via Nomentana 27, Monterotondo, 00015 Rome, Italy
| | - Martina Vitale
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Via di Grottarossa 1035, 00189 Rome, Italy
- Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Elena Alessi
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Via di Grottarossa 1035, 00189 Rome, Italy
- Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Gerardo Salerno
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Via di Grottarossa 1035, 00189 Rome, Italy
- Laboratory of Clinical Chemistry, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Carla Iacobini
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Stefano Menini
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Lucilla Bollanti
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Via di Grottarossa 1035, 00189 Rome, Italy
- Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology (CORESEARCH), Via Tiziano Vecellio 2, 65124 Pescara, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Via di Grottarossa 1035, 00189 Rome, Italy
- Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| |
Collapse
|
31
|
Rossi L, Nicoletti MC, Carmosino M, Mastrofrancesco L, Di Franco A, Indrio F, Lella R, Laviola L, Giorgino F, Svelto M, Gesualdo L, Procino G. Urinary Excretion of Kidney Aquaporins as Possible Diagnostic Biomarker of Diabetic Nephropathy. J Diabetes Res 2017; 2017:4360357. [PMID: 28246612 PMCID: PMC5299189 DOI: 10.1155/2017/4360357] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/23/2016] [Accepted: 12/26/2016] [Indexed: 11/17/2022] Open
Abstract
Diabetic nephropathy (DN) is a microangiopathic complication of diabetes mellitus (DM) affecting one-third of diabetic patients. The large variability in the clinical presentation of renal involvement in patients with DM makes kidney biopsy a prerequisite for a correct diagnosis. However, renal biopsy is an invasive procedure associated with risk of major complications. Numerous studies aimed to identify a noninvasive biomarker of DN but, so far, none of these is considered to be sufficiently specific and sensitive. Water channel aquaporins (AQPs), expressed at the plasma membrane of epithelial tubular cells, are often dysregulated during DN. In this work, we analyzed the urine excretion of AQP5 and AQP2 (uAQP5 and uAQP2), via exosomes, in 35 diabetic patients: 12 normoalbuminuric with normal renal function (DM), 11 with proteinuric nondiabetic nephropathy (NDN), and 12 with histological diagnosis and classification of DN. ELISA and WB analysis independently showed that uAQP5 was significantly increased in DN patients. Interestingly, linear regression analysis showed a positive correlation between uAQP5 and the histological class of DN. The same analysis, focusing on uAQP2, showed comparable results. Taken together, these data suggest a possible use of AQP5 and AQP2 as novel noninvasive biomarkers to help in classifying the clinical stage of DN.
Collapse
Affiliation(s)
| | - Maria Celeste Nicoletti
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, Bari, Italy
| | - Monica Carmosino
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, Bari, Italy
| | - Lisa Mastrofrancesco
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, Bari, Italy
| | | | | | | | | | | | - Maria Svelto
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, Bari, Italy
| | | | - Giuseppe Procino
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, Bari, Italy
- *Giuseppe Procino:
| |
Collapse
|
32
|
Altaf QA, Sadiqi H, Piya MK, Tahrani AA. Foot insensitivity is associated with renal function decline in patients with type 2 diabetes: a cohort study. BMC Endocr Disord 2016; 16:64. [PMID: 27876022 PMCID: PMC5120531 DOI: 10.1186/s12902-016-0147-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 11/18/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Identifying patients with diabetes at increased risk of chronic kidney disease (CKD) is essential to prevent/slow the progression to end-stage renal disease (ESRD). CKD and diabetic peripheral neuropathy (DPN) share common mechanisms. Hence, we aimed to examine the relationship between foot insensitivity and CKD in patients with Type 2 diabetes. METHODS A prospective observational cohort study in adults with Type 2 diabetes. Patients with ESRD were excluded. Foot insensitivity was assessed using the 10-g monofilament test. Renal function was assessed using estimated glomerular filtration rate (eGFR) based on the MDRD equation. Albuminuria was defined as the presence of urinary albumin/creatinine ratio (ACR) >3.4 mg/mmol. RESULTS Two hundred and twenty eight patients were recruited and followed-up for 2.5 years. One hundred and ninety patients (83.4%) had eGFR ≥ 60 ml/min/1.73 m2. Seventy six (33.3%) patients had foot insensitivity (i.e. abnormal monofilament test). Patients with foot insensitivity had lower eGFR and higher prevalence of albuminuria compared to patients with normal monofilament test. After adjustment for age, gender, ethnicity, diabetes duration, HbA1c, body mass index, insulin treatment, number of anti-hypertensives, history of peripheral vascular disease, and baseline eGFR (R2 0.87), baseline foot insensitivity was associated with study-end eGFR (B = -3.551, p = 0.036). CONCLUSIONS Patients with Type 2 diabetes and foot insensitivity are at increased risk of eGFR decline. Identifying these patients offers an opportunity to intensify metabolic and blood pressure control to prevent/retard the development of CKD. Future studies of larger sample size and longer follow up from multiple centres are needed to assess the diagnostic performance of our findings in predicting CKD development, and to compare the performance of the monofilament test with albuminuria.
Collapse
Affiliation(s)
- Quratul A. Altaf
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Hamed Sadiqi
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Milan K. Piya
- Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Abd A. Tahrani
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems, School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
- Centre of Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TT UK
| |
Collapse
|
33
|
Resistant hypertension in patients with type 2 diabetes: clinical correlates and association with complications. J Hypertens 2016; 32:2401-10; discussion 2410. [PMID: 25198422 DOI: 10.1097/hjh.0000000000000350] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The phenotype of resistant hypertension in patients with type 2 diabetes has been poorly characterized. This cross-sectional analysis of the large cohort from the Renal Insufficiency and Cardiovascular Events (RIACE) study was aimed at assessing the clinical correlates and association with complications of resistant hypertension in patients with type 2 diabetes. METHODS The RIACE study enrolled 15,773 patients consecutively visiting 19 diabetes clinics during the years 2007-2008. Resistant hypertension, defined as BP values not on target (i.e. >130/80 mmHg, respectively) with three antihypertensive agents, was detected in 2363 individuals (15% of the whole RIACE cohort, 17.4% of hypertensive individuals, and 21.2% of treated hypertensive patients). Patients without resistant hypertension [nonresistant hypertension (NRH)], that is on target with one (n = 1569), two (n = 1369), and three (n = 803) drugs, and individuals with uncontrolled hypertension, that is untreated or not on target with less than three drugs (n = 7440), served as controls. RESULTS As compared with NRH and uncontrolled hypertension patients, patients with resistant hypertension were older and more frequently women and had significantly higher waist circumference, albuminuria, and serum creatinine, and lower glomerular filtration rate. Prevalence values of chronic kidney disease and advanced retinopathy were significantly higher in resistant hypertension than in both nonresistant hypertension and uncontrolled hypertension individuals, whereas cardiovascular disease was more frequent in resistant hypertension versus uncontrolled hypertension, but not nonresistant hypertension patients, especially those on 2-3 drugs. CONCLUSIONS Resistant hypertension is relatively common in patients with type 2 diabetes. In these individuals, age, female sex and waist circumference are independent correlates of resistant hypertension, which is strongly associated with microvascular (especially renal) disease, whereas relation with macrovascular complications is unclear.
Collapse
|
34
|
Salvi L, Plateroti P, Balducci S, Bollanti L, Conti FG, Vitale M, Recupero SM, Enrici MM, Fenicia V, Pugliese G. Abnormalities of retinal ganglion cell complex at optical coherence tomography in patients with type 2 diabetes: a sign of diabetic polyneuropathy, not retinopathy. J Diabetes Complications 2016; 30:469-76. [PMID: 26809902 DOI: 10.1016/j.jdiacomp.2015.12.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/23/2015] [Accepted: 12/28/2015] [Indexed: 01/19/2023]
Abstract
AIMS To compare optical coherence tomography (OCT)-derived neuro-retinal parameters in patients with type 2 diabetes and non-diabetic controls and to evaluate their correlation with diabetic retinopathy (DR) and polyneuropathy (DPN). METHODS One-hundred consecutive patients with type 2 diabetes were examined by spectral-domain (SD) OCT for evaluating ganglion cell complex (GCC) and retinal nerve fibre layer (RNFL) thickness and two new pattern-based quantitative measures of GCC damage, global and focal loss volume (GLV and FLV). Fifty sex- and age-matched non-diabetic subjects served as control. RESULTS RNFL thickness (101.0±10.6 vs. 106.4±10.3 μm, P=0.003) was significantly lower and GLV (6.58±4.98 vs. 4.52±3.10 %, P=0.008) and FLV (1.90±1.97 vs. 0.89±0.84 %, P<0.0001) were significantly higher in diabetic versus control subjects. The OCT parameters did not differ significantly according to DR grade. Conversely, RNFL thickness was lower and GLV and FLV were higher in patients with versus those without DPN, and the extent of changes increased significantly with quartiles of DPN score. At both bivariate and multivariate analysis, OCT parameters, especially FLV, correlated significantly with DPN measures. CONCLUSIONS The GCC is significantly affected in patients with type 2 diabetes and SD-OCT might represent a useful tool to detect DPN, but not DR in these individuals.
Collapse
Affiliation(s)
- Laura Salvi
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Pasquale Plateroti
- Department of NESMOS, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Vitreo-Retinal Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Stefano Balducci
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Metabolic Fitness Association, Via Nomentana, 27 - 00015 Monterotondo Scalo Rome, Italy
| | - Lucilla Bollanti
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Francesco G Conti
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Martina Vitale
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Santi Maria Recupero
- Department of NESMOS, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Ophthalmology Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Maurizio Maurizi Enrici
- Department of NESMOS, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Vitreo-Retinal Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Vito Fenicia
- Department of NESMOS, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Vitreo-Retinal Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy.
| |
Collapse
|
35
|
Lee IT, Sheu WHH, Lin SY. The Impact of Creatinine Clearance Rate, Daily Urinary Albumin, and Their Joint Effect on Predicting Death in Diabetic Inpatients After Discharge: An Observational Study. Medicine (Baltimore) 2016; 95:e2804. [PMID: 26871846 PMCID: PMC4753942 DOI: 10.1097/md.0000000000002804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Renal clearance function and urinary albumin excretion are important markers for diabetic nephropathy. We assessed whether the creatinine clearance rate (CCR) and daily urinary albumin (DUA) excretion, which both require 24-hour urine data, are better predictors of mortality in diabetic inpatients compared with the estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (ACR).We enrolled 1011 patients who were hospitalized due to poor glucose control, and collected clinical information, including 24-hour urine data, from their medical records. We determined the mortality rate after discharge by examining the national registry data in Taiwan.The subjects had a median follow-up of 6.5 years (interquartile range between 3.5 and 9.6 years). Subjects with a CCR < 60 mL/min and a DUA ≥ 300 mg/d had the highest mortality rate, with a hazard ratio of 3.373 (95% confidence interval = 2.469-4.609), compared with the mortality rate in subjects with a CCR ≥ 60 mL/min and a DUA < 300 mg/d. In terms of predicting mortality in diabetic inpatients, ACR had a similar sensitivity to DUA (40.3% versus 38.0%), but eGFR provided lower sensitivity than CCR (54.5% versus 66.5%).Creatinine clearance rate and DUA have an additive effect on predicting mortality in diabetic inpatients after discharge. Moreover, CCR is a more sensitive predictor of mortality than eGFR. Therefore, determining CCR using 24-hour urine data, as well as either ACR or DUA, should provide better prediction of mortality in diabetic nephropathy patients.
Collapse
Affiliation(s)
- I-Te Lee
- From the Department of Internal Medicine, Division of Endocrinology and Metabolism, Taichung Veterans General Hospital (ITL, WHHS, SYL); Chung Shan Medical University, Taichung (ITL, WHHS); School of Medicine, National Yang-Ming University, Taipei (ITL, WHHS); and Center for Geriatrics and Gerontology Taichung Veterans General Hospital (SYL), Taichung, Taiwan
| | | | | |
Collapse
|
36
|
Penno G, Solini A, Zoppini G, Fondelli C, Trevisan R, Vedovato M, Cavalot F, Gruden G, Lamacchia O, Laviola L, Orsi E, Pugliese G. Independent correlates of urinary albumin excretion within the normoalbuminuric range in patients with type 2 diabetes: The Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study. Acta Diabetol 2015; 52:971-81. [PMID: 26155957 DOI: 10.1007/s00592-015-0789-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/21/2015] [Indexed: 10/23/2022]
Abstract
AIMS Within the normoalbuminuric range, low albuminuria (LA, 10-29 mg/24 h) is associated with higher adverse cardiovascular and renal outcomes than normal albuminuria (NA, <10 mg/24 h). This cross-sectional analysis of the cohort from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study was aimed at assessing the independent correlates of LA versus NA in patients with type 2 diabetes. METHODS This analysis involved 11,538 normoalbuminuric patients (73.2 % of the entire RIACE cohort): 6023 (52.2 %) with NA and 5515 (47.8 %) with LA. Binary logistic regression analysis with backward conditional variable selection was applied to assess the independent correlates of LA versus NA. RESULTS Compared with NA subjects, LA patients were more frequently males, older and with family history of hypertension, had longer diabetes duration, lower HDL cholesterol, and higher haemoglobin (Hb) A1c, triglycerides, and blood pressure (BP), use of anti-hyperglycaemic and anti-hypertensive drugs, and prevalence of metabolic syndrome, retinopathy, chronic kidney disease, any cardiovascular disease, myocardial infarction, and coronary and peripheral events. Men with LA were also more frequently current or former smokers and had higher body mass index, waist circumference, and non-HDL cholesterol. Independent correlates of LA were age (OR 1.018), family history of hypertension (OR 1.321), smoking status (former, OR 1.158; current, OR 1.237), HbA1c (OR 1.062), waist circumference (OR 1.050), triglycerides (OR 1.001), and diastolic BP (OR 1.014), together with use of anti-hyperglycaemic and anti-hypertensive agents. CONCLUSIONS Several risk factors are associated with increased albuminuria within the normoalbuminuric range. As most of these factors are potentially modifiable, treating them aggressively might reduce the excess risk associated with LA. TRIAL REGISTRATION NCT00715481; www.ClinicalTrials.gov .
Collapse
Affiliation(s)
- Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Anna Solini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giacomo Zoppini
- Division of Endocrinology and Metabolic Diseases, University of Verona, Verona, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Franco Cavalot
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Turin, Italy
| | - Gabriella Gruden
- Department of Internal Medicine, University of Turin, Turin, Italy
| | - Olga Lamacchia
- Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Luigi Laviola
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Emanuela Orsi
- Diabetes Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, Milan, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
| |
Collapse
|
37
|
Abstract
The kidney is arguably the most important target of microvascular damage in diabetes. A substantial proportion of individuals with diabetes will develop kidney disease owing to their disease and/or other co-morbidity, including hypertension and ageing-related nephron loss. The presence and severity of chronic kidney disease (CKD) identify individuals who are at increased risk of adverse health outcomes and premature mortality. Consequently, preventing and managing CKD in patients with diabetes is now a key aim of their overall management. Intensive management of patients with diabetes includes controlling blood glucose levels and blood pressure as well as blockade of the renin-angiotensin-aldosterone system; these approaches will reduce the incidence of diabetic kidney disease and slow its progression. Indeed, the major decline in the incidence of diabetic kidney disease (DKD) over the past 30 years and improved patient prognosis are largely attributable to improved diabetes care. However, there remains an unmet need for innovative treatment strategies to prevent, arrest, treat and reverse DKD. In this Primer, we summarize what is now known about the molecular pathogenesis of CKD in patients with diabetes and the key pathways and targets implicated in its progression. In addition, we discuss the current evidence for the prevention and management of DKD as well as the many controversies. Finally, we explore the opportunities to develop new interventions through urgently needed investment in dedicated and focused research. For an illustrated summary of this Primer, visit: http://go.nature.com/NKHDzg.
Collapse
|
38
|
Schroeder EB, Powers JD, O'Connor PJ, Nichols GA, Xu S, Desai JR, Karter AJ, Morales LS, Newton KM, Pathak RD, Vazquez-Benitez G, Raebel MA, Butler MG, Lafata JE, Reynolds K, Thomas A, Waitzfelder BE, Steiner JF. Prevalence of chronic kidney disease among individuals with diabetes in the SUPREME-DM Project, 2005-2011. J Diabetes Complications 2015; 29:637-43. [PMID: 25936953 DOI: 10.1016/j.jdiacomp.2015.04.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 04/11/2015] [Indexed: 11/19/2022]
Abstract
AIMS Diabetes is a leading cause of chronic kidney disease (CKD). Different methods of CKD ascertainment may impact prevalence estimates. We used data from 11 integrated health systems in the United States to estimate CKD prevalence in adults with diabetes (2005-2011), and compare the effect of different ascertainment methods on prevalence estimates. METHODS We used the SUPREME-DM DataLink (n = 879,312) to estimate annual CKD prevalence. Methods of CKD ascertainment included: diagnosis codes alone, impaired estimated glomerular filtration rate (eGFR) alone (eGFR < 60 mL/min/1.73 m(2)), albuminuria alone (spot urine albumin creatinine ratio > 30 mg/g or equivalent), and combinations of these approaches. RESULTS CKD prevalence was 20.0% using diagnosis codes, 17.7% using impaired eGFR, 11.9% using albuminuria, and 32.7% when one or more method suggested CKD. The criteria had poor concordance. After age- and sex-standardization to the 2010 U.S. Census population, prevalence using diagnosis codes increased from 10.7% in 2005 to 14.3% in 2011 (P < 0.001). The prevalence using eGFR decreased from 9.7% in 2005 to 8.6% in 2011 (P < 0.001). CONCLUSIONS Our data indicate that CKD prevalence and prevalence trends differ according to the CKD ascertainment method, highlighting the necessity for multiple sources of data to accurately estimate and track CKD prevalence.
Collapse
Affiliation(s)
- Emily B Schroeder
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; University of Colorado School of Medicine, Aurora, Colorado.
| | - J David Powers
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Patrick J O'Connor
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | | | - Stanley Xu
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Jay R Desai
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Leo S Morales
- Group Health Research Institute, Seattle, Washington
| | | | | | | | - Marsha A Raebel
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Melissa G Butler
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Jennifer Elston Lafata
- Department of Social and Behavioral Health, Virginia Commonwealth University, Richmond, Virginia; Henry Ford Health System, Detroit, Michigan
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | | | | | - John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
39
|
Penno G, Solini A, Zoppini G, Fondelli C, Trevisan R, Vedovato M, Gruden G, Lamacchia O, Pontiroli AE, Arosio M, Orsi E, Pugliese G. Hypertriglyceridemia Is Independently Associated with Renal, but Not Retinal Complications in Subjects with Type 2 Diabetes: A Cross-Sectional Analysis of the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study. PLoS One 2015; 10:e0125512. [PMID: 25942403 PMCID: PMC4420503 DOI: 10.1371/journal.pone.0125512] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 02/19/2015] [Indexed: 11/30/2022] Open
Abstract
Objective Atherogenic dyslipidemia seems to play a major role in microvascular complications and in residual microvascular risk after statin therapy, which reduces triglycerides up to 40%. We assessed whether raised TG levels are associated with an increased burden from microvascular complications in patients with type 2 diabetes. Methods Subjects from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study (n=15,773) were divided in 4 groups depending on whether they had plasma triglycerides below (NTG, 67.8%) or above (HTG, 32.2%) 1.7 mmol/L and were (42.4%) or not on (57.6%) statin therapy. Estimated GFR (eGFR) was calculated from serum creatinine, albuminuria was measured by immunonephelometry or immunoturbidimetry, and retinopathy was evaluated by fundus examination. Results HTG subjects, either with or without statin, had higher prevalence of albuminuria, reduced eGFR and chronic kidney disease (CKD), especially the albuminuric forms, but not of retinopathy, than NTG subjects. In contrast, cardiovascular disease and advanced DR were more prevalent in subjects on statin than in those not, independently of triglyceride levels. Logistic regression analysis confirmed that HTG, without or with statin, was independently associated with micro and macroalbuminuria, mildly to severely reduced eGFR, and all CKD phenotypes, but not with retinopathy. The adjusted odd ratios for CKD increased linearly for every 0.26 mmol/L increase (approximately one decile) in triglyceride levels. The increase was higher with increasing severity of albuminuria, eGFR loss and CKD phenotype as well as in subjects receiving than in those not receiving statin treatment. Conclusions Triglycerides are associated with CKD, but not retinopathy in subjects with type 2 diabetes, independently of statin treatment. These data point to a possible role of hypertriglyceridemia in the development of CKD, though it remains to be demonstrated that diabetic individuals might benefit from triglyceride reduction with statins and eventually with combination therapy with fibrates. Trial Registration www.ClinicalTrials.gov NCT00715481
Collapse
Affiliation(s)
- Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Anna Solini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giacomo Zoppini
- Division of Endocrinology and Metabolic Diseases, University of Verona, Verona, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Gabriella Gruden
- Department of Internal Medicine, University of Turin, Turin, Italy
| | - Olga Lamacchia
- Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Antonio E. Pontiroli
- Department of Medicine, Surgery and Odontoiatrics, San Paolo Hospital, University of Milan, Milan, Italy
| | - Maura Arosio
- Endocrinology Unit, San Giuseppe Hospital, University of Milan, Milan, Italy
| | - Emanuela Orsi
- Diabetes Unit, IRCCS “Cà Granda—Ospedale Maggiore Policlinico” Foundation, Milan, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, “La Sapienza” University, Rome, Italy
- * E-mail:
| | | |
Collapse
|
40
|
Abstract
Diabetic nephropathy (DN) is a major cause of morbidity and mortality in patients with both types of diabetes and the leading cause of end-stage renal disease (ESRD) worldwide. The classical, five-stage natural history of DN, after an initial phase of hyperfiltration, is characterized by a progressive increase of albuminuria from normoalbuminuria to proteinuria, followed by a decline of glomerular filtration rate (GFR). Accumulating evidence indicates that clinical course of DN has changed profoundly, likely as a consequence of changes in treatment. In fact, remission/regression of microalbuminuria is a common feature of both type 1 and 2 diabetes which far outweighs progression to proteinuria. Moreover, GFR loss has been shown to occur independently of albuminuria or even in the absence of it. Nonalbuminuric renal impairment probably represents a different pathway to loss of renal function, which might recognize different pathogenic mechanisms, prognostic implications, and possibly therapeutic measures, as compared with the albuminuric pathway. The nonalbuminuric phenotype might be related to macroangiopathy instead of microangiopathy and/or be the consequence of repeated and/or unresolved episodes of acute kidney injury, even of mild degree. Reduced GFR and albuminuria are both powerful risk factor for cardiovascular events, whereas albuminuria appears to predict death and progression to ESRD better than GFR loss. Finally, it is unclear whether reduced GFR and albuminuria warrant different interventions and whether GFR decline may also regress in response to treatment, as proteinuria does. Further epidemiological, pathologic, pathophysiological, and intervention studies are needed to clarify the distinctive features of nonalbuminuric renal impairment.
Collapse
Affiliation(s)
- Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University of Rome, Via di Grottarossa, 1035-1039, 00189, Rome, Italy,
| |
Collapse
|
41
|
Pugliese G, Solini A, Bonora E, Fondelli C, Orsi E, Nicolucci A, Penno G. Chronic kidney disease in type 2 diabetes: lessons from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study. Nutr Metab Cardiovasc Dis 2014; 24:815-822. [PMID: 24780515 DOI: 10.1016/j.numecd.2014.02.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 02/17/2014] [Accepted: 02/18/2014] [Indexed: 11/25/2022]
Abstract
The Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study is an ongoing observational survey that examines the role of estimated glomerular filtration rate (eGFR) as an independent predictor of cardiovascular and renal outcomes in 15,773 Italian subjects with type 2 diabetes. The analysis of data collected at the enrollment visit provided a picture of chronic kidney disease (CKD) and its association with other complications, risk factors for cardiovascular disease (CVD) and treatments in a large contemporary cohort. Main results of this analysis were that (a) non-albuminuric renal impairment is the predominant clinical phenotype in patients, particularly women, with reduced eGFR; (b) concordance between CKD and diabetic retinopathy is low, with only a minority of patients with renal dysfunction presenting with any or advanced retinal lesions; (c) the non-albuminuric form is associated with a significant prevalence of CVD, especially at the level of the coronary vascular bed; (d) CKD is associated with hemoglobin (Hb) A1c variability more than with average HbA1c, whereas retinopathy and CVD are not; (e) in elderly individuals with moderate-to-severe eGFR reduction, use of agents which are not recommended, such as sulphonylureas and metformin, is still frequent; and (f) though complications are generally more prevalent in men (except non-albuminuric renal impairment) women show a less favorable CVD risk profile and achieve therapeutic targets to a lesser extent than men, despite the fact that treatment intensity is not lower. These data update existing information on the natural history of CKD in patients with type 2 diabetes.
Collapse
Affiliation(s)
- G Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189 Rome, Italy.
| | - A Solini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - E Bonora
- Division of Endocrinology and Metabolic Diseases, University of Verona, Verona, Italy
| | - C Fondelli
- Diabetes Unit, Department of Internal Medicine, Endocrine and Metabolic Sciences and Biochemistry, University of Siena, Siena, Italy
| | - E Orsi
- Endocrinology and Diabetes Unit, Department of Medical Sciences, Fondazione IRCCS "Cà Granda - Ospedale Maggiore Policlinico", Milan, Italy
| | - A Nicolucci
- Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, S. Maria Imbaro, Chieti, Italy
| | - G Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| |
Collapse
|
42
|
Giorda CB, Nada E, Tartaglino B. Pharmacokinetics, safety, and efficacy of DPP-4 inhibitors and GLP-1 receptor agonists in patients with type 2 diabetes mellitus and renal or hepatic impairment. A systematic review of the literature. Endocrine 2014; 46:406-19. [PMID: 24510630 DOI: 10.1007/s12020-014-0179-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 01/16/2014] [Indexed: 12/14/2022]
Abstract
Renal or hepatic impairment, often encountered in patients with type 2 diabetes, influences the pharmacokinetics and bioavailability of antihyperglycemic agents. An emerging concern is whether pharmacotherapy with incretin-based agents, the most recent drug classes to be introduced for type 2 diabetes, can be safely used in patients with renal insufficiency or hepatic damage. This literature review examines the results of studies on these novel drug classes, with a view to provide the practitioner with a balanced, evidence-based position when considering incretin-based therapies in patients with type 2 diabetes and impaired kidney or liver function. All currently available dipeptidyl peptidase-4 (DPP-4) inhibitors appear to be appropriate pharmacotherapeutic choices in patients with declining renal function, with linagliptin affording the added advantage of not requiring dose adjustment or periodic monitoring of drug-related kidney function. In contrast, caution is warranted with the use of glucagon-like peptide-1 (GLP-1) receptor agonists in patients with moderate or severe renal impairment. The slightly wider evidence base for liraglutide than for exenatide or lixisenatide is not sufficient to support its use in severe renal impairment. What little evidence there is for incretin-based therapies in hepatic impairment has come from a few past hoc analysis of clinical trials, with most precautions and warnings reflecting the paucity of knowledge about incretin efficacy or safety in this condition.
Collapse
Affiliation(s)
- Carlo B Giorda
- Metabolism and Diabetes Unit, ASL TO5, Regione Piemonte, Chieri, Italy,
| | | | | |
Collapse
|
43
|
Viazzi F, Bonino B, Ratto E, De Cosmo S, Pontremoli R. Early renal abnormalities as an indicator of cardiovascular risk in type 2 diabetes. High Blood Press Cardiovasc Prev 2014; 21:257-60. [PMID: 25082469 DOI: 10.1007/s40292-014-0067-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 07/24/2014] [Indexed: 01/13/2023] Open
Abstract
Accurate assessment of cardiovascular (CV) risk is a prerequisite for devising effective therapeutic strategies in patients with type 2 diabetes (T2DM) as it allows to refine prognosis and treatment targets as well as the cost-benefit ratio for specific pharmacological interventions. The presence of subclinical vascular organ damage plays a well known role in determining overall risk and a wider use of low cost, easy to perform diagnostic tools to stratify CV risk is very much needed. Besides their well known prognostic value for progression to end stage renal disease (ESRD), subclinical renal abnormalities such as microalbuminuria and/or a slight reduction in estimation of glomerular filtration rate (eGFR), have been shown to be powerful, independent predictors of CV diseases in patients with T2DM. Through the combined evaluation of these two biomarkers of chronic kidney disease (CKD), clinicians can usefully and reliably get a perspective on global and CV outcome of their diabetic patients.
Collapse
Affiliation(s)
- Francesca Viazzi
- Università degli Studi and I.R.C.C.S. Azienda Ospedaliera Universitaria San Martino-IST, Viale Benedetto XV, 16125, Genoa, Italy
| | | | | | | | | |
Collapse
|
44
|
Schroeder EB, Goodrich GK, Newton KM, Schmittdiel JA, Raebel MA. Implications of different laboratory-based incident diabetic kidney disease definitions on comparative effectiveness studies. J Comp Eff Res 2014; 3:359-69. [DOI: 10.2217/cer.14.25] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: Comparative effectiveness studies using electronic health records (EHRs) often define chronic kidney disease (CKD) outcomes using laboratory-based definitions. Recommendations for defining CKD require multiple longitudinal measurements. The implications of applying these definitions to EHR data are poorly understood. Methods: Using a cohort of 36,025 individuals with diabetes from three health systems who initiated a new glucose-lowering medication, we compared concordance and CKD incidence rates and rate ratios for glucose-lowering medication classes for laboratory-based CKD definitions requiring one versus multiple abnormal tests. Results & conclusion: CKD incidence rates differed more than twofold based on the definition. Reassuring for CER, incidence rate ratios for glucose-lowering medication classes on risk of developing CKD were relatively unaffected by CKD definition.
Collapse
Affiliation(s)
- Emily B Schroeder
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO 80231, USA
- Department of Medicine, University of Colorado, Aurora, CO 80309, USA
| | - Glenn K Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO 80231, USA
| | | | - Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA
| | - Marsha A Raebel
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO 80231, USA
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of Colorado, Aurora, CO 80045, USA
| |
Collapse
|
45
|
Tahrani AA, Dubb K, Raymond NT, Begum S, Altaf QA, Sadiqi H, Piya MK, Stevens MJ. Cardiac autonomic neuropathy predicts renal function decline in patients with type 2 diabetes: a cohort study. Diabetologia 2014; 57:1249-56. [PMID: 24623102 DOI: 10.1007/s00125-014-3211-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 02/21/2014] [Indexed: 12/15/2022]
Abstract
AIMS/HYPOTHESIS The aim of this work was to assess the impact of cardiac autonomic neuropathy (CAN) on the development and progression of chronic kidney disease (CKD) in patients with type 2 diabetes. METHODS We conducted a cohort study in adults with type 2 diabetes. Patients with end-stage renal disease were excluded. CKD was defined as the presence of albuminuria (albumin/creatinine ratio GFR > 3.4 mg/mmol) or an estimated (eGFR) < 60 ml min(-1) 1.73 m(-2). CKD progression was based on repeated eGFR measurements and/or the development of albuminuria. CAN was assessed using heart rate variability. RESULTS Two hundred and four patients were included in the analysis. At baseline, the prevalence of CKD and CAN was 40% and 42%, respectively. Patients with CAN had lower eGFR and higher prevalence of albuminuria and CKD. Spectral analysis variables were independently associated with eGFR, albuminuria and CKD at baseline. After a follow-up of 2.5 years, eGFR declined to a greater extent in patients with CAN than in those without CAN (-9.0 ± 17.8% vs -3.3 ± 10.3%, p = 0.009). After adjustment for baseline eGFR and baseline differences, CAN remained an independent predictor of eGFR decline over the follow-up period (β = -3.5, p = 0.03). Spectral analysis variables were also independent predictors of eGFR decline. CONCLUSIONS/INTERPRETATION CAN was independently associated with CKD, albuminuria and eGFR in patients with type 2 diabetes. In addition, CAN was an independent predictor of the decline in eGFR over the follow-up period. CAN could be used to identify patients with type 2 diabetes who are at increased risk of rapid decline in eGFR, so that preventative therapies might be intensified.
Collapse
Affiliation(s)
- Abd A Tahrani
- Centre of Endocrinology, Diabetes and Metabolism, Institute of Biomedical Research, The Medical School, University of Birmingham, Birmingham, B15 2TT, UK,
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Pugliese G, Solini A, Bonora E, Orsi E, Zerbini G, Fondelli C, Gruden G, Cavalot F, Lamacchia O, Trevisan R, Vedovato M, Penno G. Distribution of cardiovascular disease and retinopathy in patients with type 2 diabetes according to different classification systems for chronic kidney disease: a cross-sectional analysis of the renal insufficiency and cardiovascular events (RIACE) Italian multicenter study. Cardiovasc Diabetol 2014; 13:59. [PMID: 24624891 PMCID: PMC4008155 DOI: 10.1186/1475-2840-13-59] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 02/18/2014] [Indexed: 12/30/2022] Open
Abstract
Background The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (NKF’s KDOQI) staging system for chronic kidney disease (CKD) is based primarily on estimated GFR (eGFR). This study aimed at assessing whether reclassification of subjects with type 2 diabetes using two recent classifications based on both eGFR and albuminuria, the Alberta Kidney Disease Network (AKDN) and the Kidney Disease: Improving Global Outcomes (KDIGO), provides a better definition of burden from cardiovascular disease (CVD) and diabetic retinopathy (DR) than the NKF’s KDOQI classification. Methods This is a cross-sectional analysis of patients with type 2 diabetes (n = 15,773) from the Renal Insufficiency And Cardiovascular Events Italian Multicenter Study, consecutively visiting 19 Diabetes Clinics throughout Italy in years 2007-2008. Exclusion criteria were dialysis or renal transplantation. CKD was defined based on eGFR, as calculated from serum creatinine by the simplified Modification of Diet in Renal Disease Study equation, and albuminuria, as measured by immunonephelometry or immunoturbidimetry. DR was assessed by dilated fundoscopy. Prevalent CVD, total and by vascular bed, was assessed from medical history by recording previous documented major acute events. Results Though prevalence of complications increased with increasing CKD severity with all three classifications, it differed significantly between NKF’s KDOQI stages and AKDN or KDIGO risk categories. The AKDN and KDIGO systems resulted in appropriate reclassification of uncomplicated patients in the lowest risk categories and a more graded independent association with CVD and DR than the NKF’s KDOQI classification. However, CVD, but not DR prevalence was higher in the lowest risk categories of the new classifications than in the lowest stages of the NKF’s KDOQI, due to the inclusion of subjects with reduced eGFR without albuminuria. CVD prevalence differed also among eGFR and albuminuria categories grouped into AKDN and KDIGO risk category 1 and moderate, respectively, and to a lesser extent into higher risk categories. Conclusions Though the new systems perform better than the NKF’s KDOQI in grading complications and identifying diabetic subjects without complications, they might underestimate CVD burden in patients assigned to lower risk categories and should be tested in large prospective studies. Trial registration ClinicalTrials.gov; NCT00715481
Collapse
Affiliation(s)
- Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189 Rome, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
De Cosmo S, Rossi MC, Pellegrini F, Lucisano G, Bacci S, Gentile S, Ceriello A, Russo G, Nicolucci A, Giorda C, Viazzi F, Pontremoli R. Kidney dysfunction and related cardiovascular risk factors among patients with type 2 diabetes. Nephrol Dial Transplant 2014; 29:657-62. [PMID: 24398892 DOI: 10.1093/ndt/gft506] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Kidney dysfunction is a strong predictor of end-stage renal disease and cardiovascular (CV) events. The main goal was to study the clinical correlates of diabetic kidney disease in a large cohort of patients with type 2 diabetes mellitus (T2DM) attending 236 Diabetes Clinics in Italy. METHODS Clinical data of 120 903 patients were extracted from electronic medical records by means of an ad hoc-developed software. Estimated glomerular filtration rate (GFR) and increased urinary albumin excretion were considered. Factors associated with the presence of albuminuria only, GFR < 60 mL/min/1.73 m(2) only or both conditions were evaluated through multivariate analysis. RESULTS Mean age of the patients was 66.6 ± 11.0 years, 58.1% were male and mean duration of diabetes was 11.1 ± 9.4 years. The frequency of albuminuria, low GFR and both albuminuria and low GFR was 36.0, 23.5 and 12.2%, respectively. Glycaemic control was related to albuminuria more than to low GFR, while systolic and pulse pressure showed a trend towards higher values in patients with normal kidney function compared with those with both albuminuria and low GFR. Multivariate logistic analysis showed that age and duration of disease influenced both features of kidney dysfunction. Male gender was associated with an increased risk of albuminuria. Higher systolic blood pressure levels were associated with albuminuria, with a 4% increased risk of simultaneously having albuminuria and low GFR for each 5 mmHg increase. CONCLUSIONS In this large cohort of patients with T2DM, reduced GFR and increased albuminuria showed, at least in part, different clinical correlates. A worse CV risk profile is associated with albuminuria more than with isolated low GFR.
Collapse
Affiliation(s)
- Salvatore De Cosmo
- Unit of Internal Medicine, Scientific Institute, San Giovanni Rotondo, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Tahrani AA, Ali A, Raymond NT, Begum S, Dubb K, Altaf QA, Piya MK, Barnett AH, Stevens MJ. Obstructive sleep apnea and diabetic nephropathy: a cohort study. Diabetes Care 2013; 36:3718-25. [PMID: 24062320 PMCID: PMC3816897 DOI: 10.2337/dc13-0450] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetic nephropathy (DN) is a leading cause of end-stage renal disease (ESRD). Obstructive sleep apnea (OSA) is common in type 2 diabetes and increases oxidative stress. Hence, OSA could promote the development and progression of DN. RESEARCH DESIGN AND METHODS This was a cohort study in adults with type 2 diabetes. Patients with known OSA or ESRD were excluded. DN was defined as the presence of albuminuria or an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. DN progression was based on eGFR measurements. OSA was defined as apnea hypopnea index (AHI) ≥5 events/h. Serum nitrotyrosine abundance (a marker of nitrosative stress) was measured by ELISA. RESULTS A total of 224 patients were included. OSA and DN prevalence was 64.3 and 40.2, respectively. DN prevalence was higher in patients with OSA (OSA+) compared with those without OSA (OSA-) (49.3% vs. 23.8%, P < 0.001). After adjustment, OSA (odds ratio 2.64 [95% CI 1.13-6.16], P = 0.02) remained independently associated with DN. After an average follow-up of 2.5 (0.7) years, eGFR decline was greater in OSA+ compared with OSA- patients (median -6.8% [interquartile range -16.1 to 2.2] vs. -1.6% [-7.7 to 5.3%], P = 0.002). After adjusting, both baseline OSA (B = -3.8, P = 0.044) and AHI (B = -4.6, P = 0.02) remained independent predictors of study-end eGFR. Baseline serum nitrotyrosine abundance (B = -0.24, P = 0.015) was an independent predictor of study-end eGFR after adjustment. CONCLUSIONS OSA is independently associated with DN in type 2 diabetes. eGFR declined faster in patients with OSA. Nitrosative stress may provide a pathogenetic link between OSA and DN. Interventional studies assessing the impact of OSA treatment on DN are needed.
Collapse
|
49
|
Penno G, Solini A, Bonora E, Fondelli C, Orsi E, Zerbini G, Trevisan R, Vedovato M, Gruden G, Laviola L, Nicolucci A, Pugliese G. Gender differences in cardiovascular disease risk factors, treatments and complications in patients with type 2 diabetes: the RIACE Italian multicentre study. J Intern Med 2013; 274:176-91. [PMID: 23565931 DOI: 10.1111/joim.12073] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Poorer control of risk factors for cardiovascular disease (CVD) has been reported in diabetic women, as compared with diabetic men. It has been proposed that this finding is due to gender disparities in treatment intensity. We investigated this hypothesis in a large contemporary cohort of subjects with type 2 diabetes. DESIGN Observational, cross-sectional study. SUBJECTS AND SETTING Consecutive patients with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicentre study (n = 15 773), attending 19 hospital-based diabetes clinics in 2007-2008. MAIN OUTCOME MEASURES Traditional CVD risk factors, macro- and microvascular complications and current glucose-, lipid- and blood pressure (BP)-lowering treatments were assessed. RESULTS Although CVD was more prevalent in men, women showed a less favourable CVD risk profile and worse performance in achieving treatment targets for haemoglobin A1c , LDL, HDL and non-HDL cholesterol, systolic blood pressure (BP) and in particular obesity [body mass index (BMI) and waist circumference], but not for triglycerides and diastolic BP. However, women were more frequently receiving pharmacological treatment for hypertension and to a lesser extent hyperglycaemia and dyslipidaemia than men, and female gender remained an independent predictor of unmet therapeutic targets after adjustment for confounders such as treatments, BMI, duration of diabetes and, except for the systolic BP goal, age. CONCLUSIONS In women with type 2 diabetes from the RIACE cohort, a more adverse CVD risk profile and a higher likelihood of failing treatment targets, compared with men, were not associated with treatment differences. This suggests that factors other than gender disparities in treatment intensity are responsible.
Collapse
Affiliation(s)
- G Penno
- Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Penno G, Solini A, Bonora E, Fondelli C, Orsi E, Zerbini G, Morano S, Cavalot F, Lamacchia O, Laviola L, Nicolucci A, Pugliese G. HbA1c variability as an independent correlate of nephropathy, but not retinopathy, in patients with type 2 diabetes: the Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicenter study. Diabetes Care 2013; 36:2301-10. [PMID: 23491522 PMCID: PMC3714498 DOI: 10.2337/dc12-2264] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the association of hemoglobin (Hb) A1c variability with microvascular complications in the large cohort of subjects with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study. RESEARCH DESIGN AND METHODS Serial (3-5) HbA1c values collected in a 2-year period before enrollment were available from 8,260 subjects from 9 centers (of 15,773 patients from 19 centers). HbA1c variability was measured as the intraindividual SD of 4.52 ± 0.76 values. Diabetic retinopathy (DR) was assessed by dilated funduscopy. Chronic kidney disease (CKD) was defined based on albuminuria, as measured by immunonephelometry or immunoturbidimetry, and estimated glomerular filtration rate (eGFR) was calculated from serum creatinine. RESULTS Median and interquartile range of average HbA1c (HbA1c-MEAN) and HbA1c-SD were 7.57% (6.86-8.38) and 0.46% (0.29-0.74), respectively. The highest prevalence of microalbuminuria, macroalbuminuria, reduced eGFR, albuminuric CKD phenotypes, and advanced DR was observed when both HbA1c parameters were above the median and the lowest when both were below the median. Logistic regression analyses showed that HbA1c-SD adds to HbA1c-MEAN as an independent correlate of microalbuminuria and stages 1-2 CKD and is an independent predictor of macroalbuminuria, reduced eGFR, and stages 3-5 albuminuric CKD, whereas HbA1c-MEAN is not. The opposite was found for DR, whereas neither HbA1c-MEAN nor HbA1c-SD affected nonalbuminuric CKD. CONCLUSIONS In patients with type 2 diabetes, HbA1c variability affects (albuminuric) CKD more than average HbA1c, whereas only the latter parameter affects DR, thus suggesting a variable effect of these measures on microvascular complications.
Collapse
Affiliation(s)
- Giuseppe Penno
- Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|