Risk factors for renal replacement therapy in the Early Treatment Diabetic Retinopathy Study (ETDRS), Early Treatment Diabetic Retinopathy Study Report No. 26

Strong Negative Association of non-HDL Cholesterol Goal Achievement With Incident CKD Among Adults With Diabetes

Context

The relative importance of the control of different metabolic risk factors for the prevention of chronic kidney disease among patients with diabetes in real life conditions is insufficiently understood.

Objective

We evaluated the effect of the achievement of glycated hemoglobin A_1c (HbA_1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDLc) or non-high-density lipoprotein cholesterol (non-HDLc) goals (ABC goals) on the development of incident chronic kidney disease (iCKD) among patients with diabetes.

Methods

In a nationwide registry of all individuals diagnosed with diabetes assisted by the health system in Colombia, we analyzed the association between baseline or sustained goal achievement and development of iCKD over a 4-year follow-up. iCKD was defined as a new occurrence of an estimated glomerular filtration rate less than 60 mL/min/1.73 m², hemodialysis, peritoneal dialysis, or kidney transplant.

Results

The study included 998 790 adults with diabetes (56% female, mean age 59). There were 125 626 cases of iCKD. After adjustment for multiple confounders, a baseline SBP less than 130 mm Hg (odds ratio [OR] 0.79 [0.78-0.80]) and a baseline HbA_1c less than 7.0% (OR 0.86 [0.85-0.87]) were negatively associated with iCKD. Sustained achievement showed stronger negative associations with iCKD than just baseline achievement. Considering each goal separately, sustained non-HDLc less than 130 mg/dL had the strongest negative association with iCKD (OR 0.67 [0.65-0.69]). Patients who maintained the triple ABC goal over the entire follow-up had 32% (29-34) lower odds of developing CKD, 38% (34-42) if they additionally kept a normal body mass index (BMI). Sustained ABC control including a normal BMI was more strongly associated with a lower incidence of CKD in patients of Black race (OR 0.72 vs 0.89; P for interaction = .002).

Conclusion

At the country level, sustained achievement of ABC goals and most especially non-HDLc were associated with substantial reductions in iCKD.

Bias or biology? Importance of model interpretation in machine learning studies from electronic health records

Objective

The rate of diabetic complication progression varies across individuals and understanding factors that alter the rate of complication progression may uncover new clinical interventions for personalized diabetes management.

Materials and Methods

We explore how various machine learning (ML) models and types of electronic health records (EHRs) can predict fast versus slow onset of neuropathy, nephropathy, ocular disease, or cardiovascular disease using only patient data collected prior to diabetes diagnosis.

Results

We find that optimized random forest models performed best to accurately predict the diagnosis of a diabetic complication, with the most effective model distinguishing between fast versus slow nephropathy (AUROC = 0.75). Using all data sets combined allowed for the highest model predictive performance, and social history or laboratory alone were most predictive. SHapley Additive exPlanations (SHAP) model interpretation allowed for exploration of predictors of fast and slow complication diagnosis, including underlying biases present in the EHR. Patients in the fast group had more medical visits, incurring a potential informed decision bias.

Discussion

Our study is unique in the realm of ML studies as it leverages SHAP as a starting point to explore patient markers not routinely used in diabetes monitoring. A mix of both bias and biological processes is likely present in influencing a model’s ability to distinguish between groups.

Conclusion

Overall, model interpretation is a critical step in evaluating validity of a user-intended endpoint for a model when using EHR data, and predictors affected by bias and those driven by biologic processes should be equally recognized.

Hypertriglyceridemia and Other Risk Factors of Chronic Kidney Disease in Type 2 Diabetes: A Hospital-Based Clinic Population in Greece

Aims/Introduction: Several reports indicate an increasing prevalence of chronic kidney disease (CKD) in type 2 diabetes mellitus (T2DM). Hyperglycemia and hypertension are the main risk factors for CKD development and progression. However, despite the achievement of recommended targets for blood glucose and blood pressure (BP), the residual risk of diabetic chronic kidney disease (DCKD) remains relatively high. The aim of this study is to examine dyslipidemia and other major risk factors to provide support for the prevention and treatment of DCKD. Materials and Methods: Participants are from the Redit-2-Diag study that examines 1759 subjects within a period of 6 months. DCKD severity is staged according to KDIGO criteria. Results: An increase in hemoglobin A_1c (1 unit) and systolic blood pressure (1 mm Hg) increases the probability of being classified into a higher CKD stage by 14% and 26%, respectively. Moreover, an increase of triglycerides by 88.5 mg/dL increases the risk of classification to a worse CKD stage by 24%. Conclusions: Elevated triglycerides, systolic blood pressure, and poor glycemic control increase the risk of CKD in T2DM and should be addressed in the treatment strategies.

Lower bile acids as an independent risk factor for renal outcomes in patients with type 2 diabetes mellitus and biopsy-proven diabetic kidney disease

AIMS

Abnormalities of glucolipid metabolism are critical mechanisms involved in the progression of diabetic kidney disease (DKD). Bile acids have an essential role in regulating glucolipid metabolism. This study investigated the clinicopathological characteristics of DKD patients with different bile acid levels and explored the relationship between bile acids and renal outcomes of DKD patients.

METHODS

We retrospectively reviewed and evaluated the histopathological features and clinical features of our cohort of 184 patients with type 2 diabetes mellitus and biopsy-proven DKD. Patients were divided into the lower bile acids group (≤2.8 mmol/L) and higher bile acids group (>2.8 mmol/L) based on the cutoff value of bile acids obtained using the time-dependent receiver-operating characteristic curve. Renal outcomes were defined as end-stage renal disease (ESRD). The influence of bile acids on renal outcomes and correlations between bile acids and clinicopathological indicators were evaluated.

RESULTS

Bile acids were positively correlated with age (r = 0.152; P = 0.040) and serum albumin (r = 0.148; P = 0.045) and negatively correlated with total cholesterol (r = -0.151; P = 0.041) and glomerular class (r = -0.164; P =0.027). During follow-up, 64 of 184 patients (34.78%) experienced progression to ESRD. Lower levels of proteinuria, serum albumin, and bile acids were independently associated with an increased risk of ESRD (hazard ratio, R=5.319; 95% confidence interval, 1.208-23.425).

CONCLUSIONS

Bile acids are an independent risk factor for adverse renal outcomes of DKD patients. The serum level of bile acids should be maintained at more than 2.8 mmol/L in DKD patients. Bile acid analogs or their downstream signaling pathway agonists may offer a promising strategy for treating DKD.

Oxidized LDL Is Associated with eGFR Decline in Proteinuric Diabetic Kidney Disease: A Cohort Study

Diabetic kidney disease (DKD) is a highly heterogenous disease, including the proteinuric and the nonproteinuric pattern. Oxidized low-density lipoprotein (ox-LDL) is progressively increased in DKD and causes direct damage to kidney tubular epithelial cells through a mechanism similar to that underlying the deleterious effect of lipid peroxides in the vascular endothelium. We aimed to examine the association between plasma ox-LDL cholesterol and clinical endpoints in DKD patients. Ninety-one patients with established proteinuric DKD and diabetic retinopathy were enrolled and prospectively followed for 10 years or the occurrence of death, or at least 30% decline in eGFR, or progression to end-stage kidney disease (ESKD) requiring renal replacement therapy (primary outcome). At the end of the study, both eGFR and proteinuria were reassessed. Secondary outcomes of the study were the percentage change in eGFR and proteinuria over time for each patient. At baseline, patients were divided into 2 groups according to the median ox-LDL value (i.e., below or equal and above 66.22 U/L). Both Kaplan-Meier curves (p = 0.001, log-rank test) and univariate Cox regression analysis showed that high ox-LDL was associated with the primary outcome (HR = 3.42, 95%CI = 1.55 − 7.56, p = 0.002). After adjustment for various well-known cofounders, multivariate Cox analysis showed that the association between increased circulating ox-LDL levels and the composite kidney endpoint remained significant (HR = 2.87, 95%CI = 1.14–7.20, p = 0.025). Regarding the secondary outcome of eGFR decline, the assessment of areas under the curves (AUC) showed that ox-LDL outperformed several cofounding factors (AUC 71%, 95%CI = 0.59 − 0.83, p = 0.001) and had better accuracy to predict deterioration of eGFR over time than baseline proteinuria (AUC 67%, 95%CI = 0.54 − 0.79, p = 0.014). Increased ox-LDL might be associated with disease progression in proteinuric DKD.

New insights into renal lipid dysmetabolism in diabetic kidney disease

Lipid dysmetabolism is one of the main features of diabetes mellitus and manifests by dyslipidemia as well as the ectopic accumulation of lipids in various tissues and organs, including the kidney. Research suggests that impaired cholesterol metabolism, increased lipid uptake or synthesis, increased fatty acid oxidation, lipid droplet accumulation and an imbalance in biologically active sphingolipids (such as ceramide, ceramide-1-phosphate and sphingosine-1-phosphate) contribute to the development of diabetic kidney disease (DKD). Currently, the literature suggests that both quality and quantity of lipids are associated with DKD and contribute to increased reactive oxygen species production, oxidative stress, inflammation, or cell death. Therefore, control of renal lipid dysmetabolism is a very important therapeutic goal, which needs to be archived. This article will review some of the recent advances leading to a better understanding of the mechanisms of dyslipidemia and the role of particular lipids and sphingolipids in DKD.

The association between dyslipidemia and the incidence of chronic kidney disease in the general Zhejiang population: a retrospective study

Background

According to the “lipid nephrotoxicity hypothesis”, there is now significant research being conducted in this area. By studying the role of hyperlipidemia in chronic kidney disease in the general Zhejiang population, we aimed to explore the correlation between changes in blood lipid levels and chronic kidney disease.

Methods

We collected and analyzed clinical data from ordinary residents who participated in the annual comprehensive physical examination with no overt kidney disease in Zhejiang Provincial People’s Hospital, China from January 2011 to December 2016. According to triglyceride, total cholesterol and low-density lipoprotein levels, participants were respectively divided into 4 groups. Statistical methods were used to evaluate the correlation between different blood lipid profiles and chronic kidney disease.

Results

Five thousand one hundred eighty-three participants were included in our study. During the six-year follow-up period, 227 participants (4.4%) developed chronic kidney disease. The odds ratio for incident chronic kidney disease was 3.14 (95%CI: 1.53–6.43) in Q3, 3.84 (95%CI: 1.90–7.76) in Q4 according to the total cholesterol group and 1.17 (95%CI: 1.04–1.32) in Q3, 1.40 (95%CI: 1.11–2.48) in Q4 according to the low-density lipoprotein group, respectively, after multivariable-adjusted analyses. According to the triglyceride grouping, the odds ratio for incident chronic kidney disease was 2.88 (95%CI: 1.29–6.43) in Q2, 2.92 (95%CI: 1.44–6.57) in Q3 and 3.08 (95%CI: 1.11–6.69) in Q4, after multivariable-adjusted analyses.

Conclusion

Increased triglycerides and high levels of total cholesterol and low-density lipoprotein were independently associated with an increased likelihood of estimated glomerular filtration rate (eGFR) decline and development of incident chronic kidney disease in the general Zhejiang population.

Anemia and Incident End-Stage Kidney Disease

Background

Chronic kidney disease (CKD) progression can be a cause and potentially a consequence of anemia. Previous studies suggesting that anemia is associated with CKD progression have not utilized methodologic approaches to address time-dependent confounding.

Methods

We evaluated the association of anemia (defined using World Health Organization criteria of hemoglobin <12 g/dL in women and <13 g/dL in men) with incident ESRD and all-cause death in individuals with CKD using data from the Chronic Renal Insufficiency Cohort Study. Marginal structural models were used to account for time-dependent confounding.

Results

Among 3919 participants, 1859 (47.4%) had anemia at baseline. Over median follow up of 7.8 years, we observed 1,010 ESRD events and 994 deaths. In multivariable analyses, individuals with anemia had higher risk for ESRD compared to those without (HR 1.62, 95% CI 1.24-2.11). In stratified analyses, the increased risk for incident ESRD with anemia was observed in males (HR 2.15, 95% CI: 1.53-3.02) but not females (HR 1.20, 95% CI 0.82-1.78. The association between anemia and ESRD was significant among all racial/ethnic groups except non-Hispanic blacks (non-Hispanic white, HR 2.16, 95% CI 1.53-3.06; Hispanic, HR 1.92, 1.04-3.51; others, HR 2.94; 95% CI 1.16-7.44; non-Hispanic black, HR 1.39; 95% CI 0.95-2.02). There was no association between anemia and all-cause death.

Conclusions

In this cohort, anemia was independently associated with increased risk for incident ESRD. Future work is needed to evaluate the mechanisms by which anemia leads to CKD progression as well as the impact of novel therapeutic agents to treat anemia.

Atherogenic dyslipidemia and diabetic nephropathy

Chronic kidney disease is associated with altered lipid metabolism and lipid accumulation. Although it is though that hyperlipemia is a consequence of kidney dysfunction, several lines of evidence support that hyperlipidemia may contribute to the onset and progression of kidney disease, also in diabetes. This review describes the results of recent observational studies supporting the concept that glucose is only partly responsible for kidney damage onset, while a cluster of factors, including hypertriglyceridemia and low HDL-cholesterol, could play a relevant role in inducing onset and progression of DKD. We also report the results of randomized clinical trials investigating in type 2 diabetic patients the role of drug improvement of hypertriglyceridemia on renal outcomes. Finally, we discuss putative mechanisms linking hyperlipidemia (i.e. hypertriglyceridemia or low HDL cholesterol) with kidney disease.

Specific impact of past and new major cardiovascular events on acute kidney injury and end-stage renal disease risks in diabetes: a dynamic view

BACKGROUND

Interconnections between major cardiovascular events (MCVEs) and renal events are recognized in diabetes, however, the specific impact of atrial fibrillation (AF), heart failure (HF) and acute coronary syndrome (ACS) on the risk of end-stage renal disease (ESRD) on top of established renal risk factors is unclear in type 2 diabetes mellitus.

METHODS

We conducted a retrospective study in 861 consecutive patients followed in a nephrology setting during the 2000-13 period.

RESULTS

The mean age was 70 ± 10 years, 65.1% were men and the estimated glomerular filtration rate (eGFR) was 42.4 ± 21.0 mL/min/1.73 m2. During follow-up (median 59 months), 194 patients reached ESRD. A history of AF, HF or ACS was associated with an increased risk of reduced baseline eGFR. In turn, reduced baseline eGFR resulted in a greater risk of new MCVE (especially HF) during follow-up. Finally, all new MCVEs were risk factors for subsequent acute kidney injury (AKI) {HF: hazard ratio [HR] 8.99 [95% confidence interval (CI) 7.06-11.4]; AF: HR 5.42 (3.91-7.52); ACS: HR 8.82 (6.24-12.5); all P < 0.0001} and ESRD [HF: HR 5.52 (95% CI 4.01-7.60), P < 0.0001; AF: HR 3.48 (2.30-5.21), P < 0.0001; ACS: HR 2.31 (1.43-3.73), P = 0.0006]. The AF- and HF-associated risks of ESRD were significant after adjustments on all renal risks of ESRD (gender, blood pressure, eGFR, albuminuria, renin-angiotensin blockers, retinopathy and AKI), but the association was less strong for ACS. Importantly, no association was noted between other major events such as stroke or infections and the risk of ESRD.

CONCLUSIONS

Past and new cardiovascular events (more HF and AF than ACS) have a strong, independent impact on the development of ESRD above and beyond established risk factors in diabetes.

Anemia and associated factors among type-2 diabetes mellitus patients attending public hospitals in Harari Region, Eastern Ethiopia

Background

Anemia is a common complication of diabetes mellitus, therefore having a major impact on the overall health and survival of diabetic patients. However, there is a paucity of evidence of anemia among diabetic patients in Ethiopia, particularly in Harari Region. Therefore, this study aimed to assess the magnitude of anemia and associated factors among Type 2 Diabetes Mellitus (T2DM) patients attending public hospitals in Harari Region, Eastern Ethiopia.

Methods

A hospital based cross-sectional study was conducted from February 25 to March 30, 2019. Probability proportion to size sampling, followed by simple random sampling, was utilized to select 374 T2DM patients. To collect the data, mixed methods were applied using questionnaires and checklist. Participants were tested for anemia based on World Health Organization (WHO) criteria. Data was double entered to EpiData version 3.1 and exported into Stata version 14.0 for statistical analysis. Bivariate and multivariate logistic regression models were fitted; Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were computed. Level of significance was declared at p-value less than 0.05.

Results

The study revealed 34.8% of the participants were anemic (CI: 28.7, 40.9). Being male (AOR = 2.92, CI: 1.65, 5.17), physical inactivity (AOR = 2.58, CI: 1.50, 4.44), having nephropathy (AOR = 2.43, CI: 1.41, 4.21), poor glycemic control (AOR = 1.98, CI: 1.17, 3.34), recent history of blood loss (AOR = 4.41, CI: 1.26, 15.44) and duration of diabetes for five years and greater(AOR = 1.72, CI: 1.01, 2.96)were all significantly associated with anemia.

Conclusions

Anemia was a major health problem among T2DM patients in the study area. Therefore, routine screening of anemia for all T2DM patients aiding in early identification and improved management of diabetes will lead to improved quality of life in this patient population.

Crosstalk Between Lipids and Mitochondria in Diabetic Kidney Disease

PURPOSE OF REVIEW

The goal of this review is to review the role that renal parenchymal lipid accumulation plays in contributing to diabetic kidney disease (DKD), specifically contributing to the mitochondrial dysfunction observed in glomerular renal cells in the context of DKD development and progression.

RECENT FINDINGS

Mitochondrial dysfunction has been observed in experimental and clinical DKD. Recently, Ayanga et al. demonstrate that podocyte-specific deletion of a protein involved in mitochondrial dynamics protects from DKD progression. Furthermore, our group has recently shown that ATP-binding cassette A1 (a protein involved in cholesterol and phospholipid efflux) is significantly reduced in clinical and experimental DKD and that genetic or pharmacological induction of ABCA1 is sufficient to protect from DKD. ABCA1 deficiency in podocytes leads to mitochondrial dysfunction observed with alterations of mitochondrial lipids, in particular, cardiolipin (a mitochondrial-specific phospholipid). However, through pharmacological reduction of cardiolipin peroxidation DKD progression is reverted. Lipid metabolism is significantly altered in the diabetic kidney and renders cellular components, such as the podocyte, susceptible to injury leading to worsened DKD progression. Dysfunction of the lipid metabolism pathway can also lead to mitochondrial dysfunction and mitochondrial lipid alteration. Future research aimed at targeting mitochondrial lipids content and function could prove to be beneficial for the treatment of DKD.

Characteristics of the Lipid Profile in Patients with Diabetes Mellitus and Chronic Kidney Disease

Background and aims Diabetes mellitus (DM) is one of the leading causes of end-stage chronic kidney disease (CKD). Patients with DM and CKD have a 10 or even 20 times higher cardiovascular risk (CVR) than the general population. Lipid metabolism disorders are more frequent in these patients, dyslipidemia being aggravated by the presence of hyperglycemia and insulin resistance. The main purpose of our study was to identify possible correlations between lipid profile parameters and altered renal function in patients with DM. We have also analyzed the correlations between lipid parameters, CKD, quality of glycemic control and CVR.

Material and method: The study was performed on 2732 patients with DM which received medical treatment and care at the Center for Diabetes Timisoara, for a 6-month period from March to October 2016, 1508 women (55.2%) and 1224 men (44.8%), mean age 63.7 ± 9.1 (33-78) years and mean diabetes duration 12.4 ± 6.8 (6-33) years. The study group included 312 patients (11.4%) with T1DM and 2420 patients (88.6%) with T2DM.

Results: The prevalence of CKD (GFR< 60 ml/min) was 12.5%. The levels of total cholesterol (TC), triglycerides (TG) and LDLc were significantly higher in the case of patients with DM and CKD (p<0.0001). Patients with CKD had twice the prevalence of ischemic heart disease and cerebrovascular disease when compared to patients without CKD. Peripheral artery disease was present in 16.9% of those with CKD and in 11% of those without CKD. Hypertension (HTN) was present in 91.8% of patients with CKD and in 67.1% of patients without CKD (GFR > 60 ml/min).

Conclusion: Analyzed data showed a strong correlation between CKD, dyslipidemia and CVR in patients with DM. Impaired renal function was strongly correlated with age, duration of DM and weight status of these patients.

Postmeal triglyceridemia and variability of HbA1c and postmeal glycemia were predictors of annual decline in estimated glomerular filtration rate in type 2 diabetic patients with different stages of nephropathy

BACKGROUND

This study examined associations of annual glycemic variability and postprandial dysmetabolism with annual decline in estimated glomerular filtration rate (eGFR) in type 2 diabetic patients with different stages of nephropathy.

METHODS

Intrapersonal mean and coefficient of variation (CV) of HbA1c, fasting and postmeal concentrations of plasma glucose (FPG and PMPG, respectively) and serum triglycerides (FTG and PMTG, respectively) during the first 12 months after enrollment were calculated in a cohort of 168 type 2 diabetic patients: 53 with optimal albumin/creatinine ratio (ACR < 10 mg/g), 62 with high normal ACR (10-29 mg/g) and 53 with elevated ACR (≧30 mg/g). Annual changes in eGFR were computed using 52 (median) creatinine measurements obtained over a median follow-up of 6.0 years. Multivariate linear regressions assessed the independent correlates of changes in eGFR.

RESULTS

Kidney function declined faster in patients with high normal and elevated ACR (-1.47 and -2.01 ml/min/1.73 m2/year, respectively) compared to patients with optimal ACR (0.08 ml/min/1.73 m2/year, p < 0.05). In patients with high normal ACR, age (standardized β、-0.30、p = 0.01), CV-HbA1c (standardized β、-0.66、p < 0.001) and CV-PMPG (standardized β、-0.27、p = 0.01) was associated with annual eGFR decline independently of mean HbA1c and PMPG, sex, BMI, waist circumference, diabetes duration and therapy, means and CVs of FPG and systolic blood pressure, baseline eGFR, log ACR and uses of anti-hypertensive medications (R2 = 0.47). In patients with elevated ACR, PMTG (standardized β、-0.408, p = 0.007) was associated with annual eGFR decline (R2 = 0.15).

CONCLUSIONS

Consistency of glycemic control and management of postprandial glycemia and lipidemia are important to preserve kidney function in type 2 diabetic patients.

Effect of losartan and spironolactone on triglyceride-rich lipoproteins in diabetic nephropathy

Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) can improve dyslipidemia in patients with diabetes and albuminuria. Whether combined ACEi+ARB or ACEi+mineralocorticoid receptor blockade improves dyslipidemia is not known. We hypothesized long-term administration of either losartan 100 mg or spironolactone 25 mg once daily added onto lisinopril 80 mg once daily would improve dyslipidemia in diabetic nephropathy (DN). We measured lipid levels, very-low-density (V), intermediate-density (I), low-density (LDL), high-density (HDL) lipoprotein, LDL particle size with their respective cholesterol (C) and apolipoprotein B levels (ApoB), and urine albumin/creatinine ratio (UACR) at 12-week interval during a 48-week randomized, double-blind placebo-controlled trial in 81 patients with DN. Plasma lipids and lipoprotein C were analyzed enzymatically and Apo B was determined chemically. Data were analyzed by mixed model repeated measures. ΔUACR differed among treatment arms (placebo −24.6%, los −38.2%, spiro −51.6%, p=0.02). No correlation existed between ΔUACR and ΔTG or any of the lipid or lipoprotein measurements. Compared with placebo losartan, but not spironolactone, decreased TG (−20.9% vs +34.3%, p<0.01), V+I C(−18.8% vs +21.3%, p<0.01), and V+I-ApoB (−13.2% vs +21%, p<0.01). There were no significant changes in body weight, HbA1c or other lipoprotein variables. We conclude losartan improves dyslipidemia in patients with DN. We speculate the mechanism improved clearance of VLDL and remnant lipoproteins.

A case-control study of prevalence of anemia among patients with type 2 diabetes

BACKGROUND

Anemia is defined as a reduction in the hemoglobin concentration of blood, which consequently reduces the oxygen-carrying capacity of red blood cells such that they are unable to meet the body's physiological needs. Several reports have indicated that anemia mostly occurs in patients with diabetes with renal insufficiency while limited studies have reported the incidence of anemia in people with diabetes prior to evidence of renal impairment. Other studies have also identified anemia as a risk factor for the need for renal replacement therapy in diabetes. Understanding the pathogenesis of anemia associated with diabetes may lead to the development of interventions to optimize outcomes in these patients. The aim of this study was therefore to determine the prevalence of anemia among patients with type 2 diabetes.

METHODS

A total of 100 (50 with type 2 diabetes and 50 controls) participants were recruited for our study. Participants' blood samples were analyzed for fasting blood glucose, full blood count and renal function tests among others. The prevalence of anemia was then determined statistically.

RESULTS

A high incidence of anemia was observed in the cases. Of the patients with diabetes, 84.8% had a hemoglobin concentration that was significantly less (males 11.16±1.83 and females 10.41±1.49) than the controls (males 14.25±1.78 and females 12.53±1.14). Renal insufficiency determined by serum creatinine level of >1.5 mg/dL, estimated glomerular filtration rate <60 ml/minute/1.73 m2, and erythropoietin levels was also observed to be high in the cases (54.0%; with mean creatinine concentration of 3.43±1.73 and erythropoietin 6.35±1.28 mIU/mL). A significantly increased fasting blood glucose, urea, sodium, potassium, and calcium ions were observed in the cases (7.99±1.30, 5.19±1.99, 140.90±6.98, 4.86±0.53 and 1.47±0.31 respectively) as compared to the controls (4.66±0.54, 3.56±2.11, 135.51±6.84, 4.40±0.58 and 1.28±0.26 respectively). Finally, a significant association between hemoglobin concentration and fasting blood glucose was also observed in the cases.

CONCLUSIONS

The findings suggest that a high incidence of anemia is likely to occur in patients with poorly controlled diabetes and in patients with diabetes and renal insufficiency.

Relationship between hepcidin and GDF15 in anemic patients with type 2 diabetes without overt renal impairment

AIMS

Despite the absence of overt renal impairment and decreased erythropoietin (EPO) levels, patients are usually anemic. Hepcidin, which is induced by inflammatory stimuli, plays an important role in anemia in chronic disease. Growth differentiation factor 15 (GDF15) is a putative anti-inflammatory cytokine that is elevated in type 2 diabetes (T2DM). Hence, we investigated the relationship between hepcidin and GDF15 in anemic T2DM patients without overt renal impairment.

METHODS

Among 1150 patients who visited Kyungpook National University Hospital for T2DM between June 2006 and June 2014, we selected 55 anemic patients without overt renal impairment (serum creatinine <1.5 mg/dL or estimated glomerular filtration rate >60 mL/min/1.73 m(2)) and other co-morbid diseases, including malignancy, thyroid disease, rheumatic arthritis, liver disease, iron-deficiency anemia and other endocrine disease. We measured anthropometric and metabolic parameters, as well as measured the serum iron, ferritin, interleukin-6 (IL-6), erythropoietin, hepcidin-25 and GDF15 levels.

RESULTS

Anemic T2DM patients without overt renal impairment presented a greater inflammatory state, with increased serum hsCRP, ESR and IL-6 levels compared with non-anemic T2DM patients. Both hepcidin and GDF15 levels were increased and showed a positive correlation in anemic T2DM patients.

CONCLUSION

In the absence of overt renal impairment, anemia in T2DM is associated with chronic inflammation, inducing elevation of hepcidin and GDF15 levels independently of the erythropoietin level.

Association between Helicobacter pylori infection and the subsequent risk of end-stage renal disease: a nationwide population-based cohort study

BACKGROUND & AIMS

The association between Helicobacter pylori infection and end-stage renal disease (ESRD) events remains unknown. We assessed the relationship between H. pylori infection requiring hospital admission and the subsequent risks of ESRD.

METHODS

This was a retrospective cohort study in which data from the National Health Insurance system of Taiwan was used. The H. pylori-infected cohort comprised 20,068 patients. Each participant was frequency-matched by age and sex with 4 individuals from the general population without H. pylori-infected. Cox proportional hazards regression analysis was used to estimate the influence of H. pylori infection on the risk of ESRD.

RESULTS

The overall incidence of ESRD was 3.72 times greater in the H. pylori-infected cohort than in the non-infected cohort (11.1 vs. 2.96 per 1000 person-years), with an adjusted HR of 2.58 [95% confidence interval (CI)=2.33-2.86]. The risk of ESRD markedly increased in patients with H. pylori infection combined with at least one of the following concomitant comorbidities: hypertension, diabetes, hyperlipidaemia and coronary artery disease.

CONCLUSIONS

This is currently the largest nation-based study in which the risk of ESRD in H. pylori-infected patients was examined. H. pylori infection was associated with a subsequent risk of ESRD. H. pylori-infected patients with concomitant chronic kidney disease (CKD) or cardiovascular disease (CVD) risk factors were at higher risk of ESRD than were those who had a single CKD or CVD risk factor.

The degree of retinopathy is equally predictive for renal and macrovascular outcomes in the ACCORD Trial

AIMS

Diabetic retinopathy (DR) is associated with a higher risk of renal and cardiovascular events. We sought to compare the risk for renal versus cardiovascular (CV) outcomes, stratified by retinopathy severity.

METHODS

ACCORD was a randomized trial of people with type 2 diabetes, at high-risk for CV disease. A subgroup (n=3,369 from 71 clinics) had stereoscopic fundus photographs graded centrally. Participants were stratified at baseline to moderate/severe DR or no/mild DR and were monitored for renal and CV outcomes at follow-up visits over 4 years. The composite renal outcome was composed of serum creatinine doubling, macroalbuminuria, or end-stage renal disease. The composite CV outcome was the ACCORD trial primary outcome. Competing risk techniques were used to estimate the relative risk (RR) of renal versus CV composite outcomes within each DR stratum.

RESULTS

The hazards ratio for doubling of serum creatinine and incident CV event in the moderate/severe DR versus no/mild DR strata were: 2.31 (95% CI: 1.25-4.26) and 1.98 (95% CI: 1.49-2.62), respectively. The RR of the two composite outcomes was highly similar in the no/mild DR stratum (adjusted RR at 4 years for CV versus renal events=0.96, 95% CI: 0.72-1.28) and the moderate/severe DR stratum (adjusted RR=0.92, 95% CI: 0.64-1.31).

CONCLUSIONS

Thus, in people with type 2 diabetes at high risk for cardiovascular disease, incident CV versus renal events was similar, irrespective of the severity of the DR. Further evaluation of the specificity of DR for microvascular versus macrovascular events in other populations is warranted.

A clinical study about contrast nephropathy: risk factors and the role of beta blockers

Objective:

There is still a group of patient that have unpredictable risk for the development of contrast nephropathy (CN). There is also an effort to find more effficient strategies to prevent CN. Carvedilol, metoprolol and nebivolol seem to have theoretical potentials for the prevention of CN. In this study, we aimed to investigate their effects on the prevention of CN. We also aimed to define the risk factors associated with the development of CN in our study group.

Methods:

In this prospective, cross-sectional study, the patients were divided into four groups according to whether they were taking 25 mg/day carvedilol (n:56), 5 mg/day nebivolol (n:60), 50 mg/day metoprolol (n:68) or none (n:63). We made analysis to determine the agents’ efficiency on the prevention of CN. We also performed multiple logistic regression analysis including all groups to define the risk factors associated with CN.

Results:

The incidents of CN were the lowest in the carvedilol group (4%) while the worst performance occurred in those taking metoprolol (10%). The difference between the groups in terms of the development of CN did not reach statistical significance (p>0.05). Multiple logistic regression analysis showed age (p=0.003), higher triglyceride levels (p=0.011) and family history of coronary artery disease (p=0.038) to be the predictors of CN.

Conclusion:

In this study, we didn’t find any relation between the development of CN and carvedilol, metoprolol or nebivolol usage. We found age, higher levels of triglyceride and family history of coronary artery disease to be risk factors for predicting CN.

Association between plasma triglycerides and high-density lipoprotein cholesterol and microvascular kidney disease and retinopathy in type 2 diabetes mellitus: a global case-control study in 13 countries

BACKGROUND

Microvascular renal and retinal diseases are common major complications of type 2 diabetes mellitus. The relation between plasma lipids and microvascular disease is not well established.

METHODS AND RESULTS

The case subjects were 2535 patients with type 2 diabetes mellitus with an average duration of 14 years, 1891 of whom had kidney disease and 1218 with retinopathy. The case subjects were matched for diabetes mellitus duration, age, sex, and low-density lipoprotein cholesterol to 3683 control subjects with type 2 diabetes mellitus who did not have kidney disease or retinopathy. The study was conducted in 24 sites in 13 countries. The primary analysis included kidney disease and retinopathy cases. Matched analysis was performed by use of site-specific conditional logistic regression in multivariable models that adjusted for hemoglobin A1c, hypertension, and statin treatment. Mean low-density lipoprotein cholesterol concentration was 2.3 mmol/L. The microvascular disease odds ratio increased by a factor of 1.16 (95% confidence interval, 1.11-1.22) for every 0.5 mmol/L (≈1 quintile) increase in triglycerides or decreased by a factor of 0.92 (0.88-0.96) for every 0.2 mmol/L (≈1 quintile) increase in high-density lipoprotein cholesterol. For kidney disease, the odds ratio increased by 1.23 (1.16-1.31) with triglycerides and decreased by 0.86 (0.82-0.91) with high-density lipoprotein cholesterol. Retinopathy was associated with triglycerides and high-density lipoprotein cholesterol in matched analysis but not significantly after additional adjustment.

CONCLUSIONS

Diabetic kidney disease is associated worldwide with higher levels of plasma triglycerides and lower levels of high-density lipoprotein cholesterol among patients with good control of low-density lipoprotein cholesterol. Retinopathy was less robustly associated with these lipids. These results strengthen the rationale for studying dyslipidemia treatment to prevent diabetic microvascular disease.

Dyslipidemia, kidney disease, and cardiovascular disease in diabetic patients

This article reviews the relationship between dyslipidemia, chronic kidney disease, and cardiovascular diseases in patients with diabetes. Diabetes mellitus is associated with complications in the cardiovascular and renal system, and is increasing in prevalence worldwide. Modification of the multifactorial risk factors, in particular dyslipidemia, has been suggested to reduce the rates of diabetes-related complications. Dyslipidemia in diabetes is a condition that includes hypertriglyceridemia, low high-density lipoprotein levels, and increased small and dense low-density lipoprotein particles. This condition is associated with higher cardiovascular risk and mortality in diabetic patients. Current treatment guidelines focus on lowering the low-density lipoprotein cholesterol level; multiple trials have confirmed the cardiovascular benefits of treatment with statins. Chronic kidney disease also contributes to dyslipidemia, and dyslipidemia in turn is related to the occurrence and progression of diabetic nephropathy. Different patterns of dyslipidemia are associated with different stages of diabetic nephropathy. Some trials have shown that treatment with statins not only decreased the risk of cardiovascular events, but also delayed the progression of diabetic nephropathy. However, studies using statins as the sole treatment of hyperlipidemia in patients on dialysis have not shown benefits with respect to cardiovascular risk. Diabetic patients with nephropathy have a higher risk of cardiovascular events than those without nephropathy. The degree of albuminuria and the reduction in estimated glomerular filtration rate are also correlated with the risk of cardiovascular events. Treatment with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers to reduce albuminuria in diabetic patients has been shown to decrease the risk of cardiovascular morbidity and mortality.

Factors related to nephrotic-range proteinuria in late-stage chronic kidney disease patients with diabetes mellitus

PURPOSE

Diabetic nephropathy and proteinuria are important risk factors for both end-stage renal disease and cardiovascular events. The present study aimed to identify the factors associated with nephrotic-range proteinuria in patients with advanced diabetic nephropathy.

METHODS

This cross-sectional study enrolled 386 diabetic patients with chronic kidney disease (CKD) stages 3-5, from our outpatient Department of Nephrology. Urinary protein-to-creatinine ratio was recorded. Additionally, other laboratory parameters, body mass index, blood pressure, comorbidities, and medications were also reviewed.

RESULTS

The mean age of the patients was 65.1 ± 11.6 years. Among patients with CKD stage 3 and 4, the odds ratio (OR) for nephrotic-range proteinuria in relation with systolic blood pressure significantly increased starting from 121 mmHg (OR 7.04 and 11.79 for systolic blood pressure of 121-140 and ≥141 mmHg, respectively, in comparison with systolic blood pressure below 121 mmHg). In addition, serum phosphorus ≥4.7 mg/dl was associated with significantly higher risk (OR 15.45) for severe proteinuria, compared with a phosphorus level ≤2.6 mg/dl. Finally, hypertriglyceridemia ≥241 mg/dl was also associated with higher OR for severe proteinuria, compared with a triglyceride level ≤200 mg/dl. Similar associations were found in patients with CKD stage 5.

CONCLUSIONS

Higher systolic blood pressure, serum phosphorus, and triglyceride levels are associated with nephrotic-range proteinuria in patients with diabetic nephropathy and CKD stage 3-5. Further studies should clarify whether a reduction in serum phosphorus would lead to a decrease in proteinuria in these patients.

Associations between hemoglobin concentrations and the clinical characteristics of patients with type 2 diabetes

BACKGROUND/AIMS

Many studies have demonstrated an association between hemoglobin levels and cardiovascular disease in diabetic patients. The aim of this study was to determine whether there is an association between hemoglobin concentrations and various clinical parameters, including metabolic factors, plasma C-peptide response after a meal tolerance test, and microvascular complications, in Korean patients with type 2 diabetes.

METHODS

In total, 337 male patients with type 2 diabetes were recruited. All subjects were subjected to a meal tolerance test and underwent assessment of hemoglobin levels, fasting and postprandial β-cell responsiveness, and microvascular complications.

RESULTS

Patients with lower hemoglobin concentrations had a longer duration of diabetes, a lower body mass index, and lower concentrations of total cholesterol, triglycerides, and low-density lipoprotein cholesterol. They also had lower levels of postprandial C-peptide, Δ C-peptide, and postprandial β-cell responsiveness. They had a higher prevalence of retinopathy and nephropathy. In multivariate analyses, there was a significant association between nephropathy and hemoglobin concentration. Also, hemoglobin concentrations were independently associated with Δ C-peptide levels and postprandial β-cell responsiveness.

CONCLUSIONS

Hemoglobin concentrations are associated with postprandial C-peptide responses and diabetic nephropathy in patients with type 2 diabetes.

Factors associated with diabetic retinopathy in chinese patients with type 2 diabetes mellitus

Objective. To investigate the risk factors of DR in Chinese T2DM patients. Methods. 2009 patients with T2DM were included in this cross-sectional study. All patients underwent eye examination, and the DR stage was defined by an ophthalmologist. Correlation analysis was performed to evaluate the relation between DR and clinical variables. Logistic regression models were used to assess risk for those factors associated with DR. Results. A total of 597 T2DM patients (29.7%) had DR, of which 548 (27.3%) were nonproliferative diabetic retinopathy and 49 (2.4%) were proliferative diabetic retinopathy. Positive correlations were found between DR and duration of diabetes, systolic blood pressure (SBP), diastolic blood pressure, glycated hemoglobin, glycated albumin, 24 hurinary albumin excretion, peripheral atherosclerosis (PA), diabetes nephropathy (DN), diabetic peripheral neuropathy, and anemia. Negative correlations were found between DR and C-peptide and glomerular filtration rate. Logistic regression analysis revealed that duration of diabetes, SBP, DN, anemia, PA, and C-peptide were each independent risk factors of DR. Conclusion. The duration of diabetes, SBP, DN, anemia, and PA are positively associated with DR in Chinese T2DM patients, while C-peptide is negatively associated with DR. Monitoring and evaluation of these related factors will likely contribute to the prevention and treatment of DR.

Obstructive sleep apnea and kidney disease: is there any direct link?

BACKGROUND

Obstructive sleep apnea (OSA) is a common and underrecognized disorder affecting at least 2% and 4% of women and men, respectively. Chronic kidney disease (CKD), on the other hand, affects around 13% of US adults. Both of these conditions share some risk factors such as age, obesity, and smoking and are associated with increased cardiovascular morbidity and mortality. By itself OSA may play a role in the development of arterial hypertension, metabolic syndrome, type 2 diabetes mellitus, and dyslipidemia with potential impact on CKD development and/or progression. But the data regarding OSA and CKD are relatively scant.

DISCUSSION

Moreover, several studies had shown possible harmful effects on kidney function independent from conventional risk factors. CKD is associated with excessive fluid volume, with potential shift during recumbency towards the neck area with increased upper airway resistance. Thus, OSA and CKD may be the results of each other and when present together may impose much greater cardiovascular risk than either disease alone.

Sex differences in the development of kidney disease in individuals with type 1 diabetes mellitus: a contemporary analysis

BACKGROUND

Kidney disease in patients with type 1 diabetes historically has been believed to be more prevalent in men. Because recent data do not reflect this pattern, we evaluated whether a sex difference persists.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

We used 18-year follow-up data from the Pittsburgh Epidemiology of Diabetes Complications Study (n = 788; baseline mean age, 27 years; diabetes duration, 19 years).

PREDICTOR OR FACTOR

Sex and diagnosis interval (1950-1964 or 1965-1980).

OUTCOMES

Cumulative incidences of macroalbuminuria (albumin excretion rate >200 μg/min) and end-stage renal disease (ESRD; kidney failure, dialysis, or transplant) were evaluated at 20, 25, and 30 years of diabetes duration. To address potential survival bias, death certificate information was included in determining ESRD for those who died before baseline (n = 145). Analyses were stratified by diagnosis year (1950-1964 or 1965-1980).

OTHER MEASUREMENTS

Kidney disease risk factor information was available.

RESULTS

A significant interaction was noted between sex and diagnosis cohort for ESRD incidence by 25 (P = 0.002) and 30 (P < 0.001) years' duration. Thus, within the 1950-1964 cohort (210 men and 180 women), ESRD incidence was higher in men compared with women by 25 (30.6% vs 18.0%, respectively) and 30 (43.4% vs 24.6%, respectively) years' duration of type 1 diabetes. However, in the 1965-1980 cohort (260 men and 283 women), the incidence was higher in women (7.6% vs 13.8% by 25 years [P = 0.04] and 13.7% vs 21.0% by 30 years' duration [P = 0.09] in men vs women, respectively). Results were similar for macroalbuminuria.

LIMITATIONS

Study participants were not followed up from the onset of diabetes; thus, risk-factor data from that period are lacking.

CONCLUSIONS

Our data suggest that the male excess of type 1 diabetic kidney disease cases observed in the earlier cohort has been eliminated in the younger cohort. The reason for this dramatic change presently is unclear, but should be addressed in subsequent studies.

Recent advances in the treatment of atherogenic dyslipidemia in type 2 diabetes mellitus

Despite best treatment efforts reducing low-density lipoprotein cholesterol, a substantial number of type 2 diabetes mellitus patients still experience progression of cardiovascular risk. Even with intensification of statin therapy, a substantial residual cardiovascular risk remains and atherogenic dyslipidemia is an important driver of this so-called residual risk. Besides statin therapy, new strategies evaluate the role of intensive combination lipid treatment for the entire type 2 diabetic population. The results from the ACCORD (Action to Control Cardiovascular Risk in Diabetes) Lipid trial suggest that there is a lipid-related modifiable component to cardiovascular residual risk in statin-treated type 2 diabetic patients, and that further research should address patients with triglycerides above 204 mg/dl and high-density lipoprotein cholesterol below 34 mg/dl. Based on their respective lipid-modifying activity, the combination of a fibrate and statin is a logical approach to improving achievement of lipid targets in statin-treated patients with a glomerular filtration rate of >60 ml/min/1.73 m(2) and with residual atherogenic dyslipidemia. The link between dyslipidemia treatment and diabetic retinopathy, nephropathy and neuropathy is an emerging new field and microvascular complications are targets for new treatments.

PPARalpha: an emerging therapeutic target in diabetic microvascular damage

The global pandemic of diabetes mellitus portends an alarming rise in the prevalence of microvascular complications, despite advanced therapies for hyperglycemia, hypertension and dyslipidemia. Peroxisome proliferator-activated receptor alpha (PPARalpha) is expressed in organs affected by diabetic microvascular disease (retina, kidney and nerves), and its expression is regulated specifically in these tissues. Experimental evidence suggests that PPARalpha activation attenuates or inhibits several mediators of vascular damage, including lipotoxicity, inflammation, reactive oxygen species generation, endothelial dysfunction, angiogenesis and thrombosis, and thus might influence intracellular signaling pathways that lead to microvascular complications. PPARalpha has emerged as a novel target to prevent microvascular disease, via both its lipid-related and lipid-unrelated actions. Despite strong experimental evidence of the potential benefits of PPARalpha agonists in the prevention of vascular damage, the evidence from clinical studies in patients with diabetes mellitus remains limited. Promising findings from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study on microvascular outcomes are countered by elevations in participants' homocysteine and creatinine levels that might potentially attenuate the benefits of PPARalpha activation. This Review focuses on the role of PPARalpha activation in diabetic microvascular disease and highlights the available experimental and clinical evidence from studies of PPARalpha agonists.

Risk markers of future microalbuminuria and hypertension based on clinical and morphological parameters in young type 1 diabetes patients

BACKGROUND

Nephropathy is a severe complication of type 1 diabetes and develops in 30% of patients. Currently, it is not possible to identify young patients at risk prior to the development of microalbuminuria (MA) and/or hypertension (HT).

OBJECTIVE

To study predictors of MA and/or HT in young normoalbuminuric (NA) patients with type 1 diabetes.

SUBJECTS AND METHODS

Forty-six NA and normotensive (NT) type 1 diabetes patients, regularly followed since onset with checks on metabolic control, kidney function, and MA, were investigated with kidney biopsies and 24-h ambulatory blood pressure measurements (ABPMs) after 10.6 yr of diabetes. The patients were followed another six and a half years with regard to the development of MA and HT.

RESULTS

Fifteen patients developed MA and/or HT during follow-up. The strongest risk markers were poor metabolic control after puberty, high day-time systolic blood pressure (BP), and increased BMT at 10 yr, which explained 62% of the outcome for MA and/or HT at 17 yr duration with 77% sensitivity and 65% specificity. The threshold values were long-term postpubertal HbA(1c) > 8.2%, day-time systolic BP > 130 mmHg, and BMT > 490 nm/1.73 m(2).

CONCLUSIONS

Normoalbuminuric and NT patients at risk of developing MA and HT could be identified and might benefit from an early start of antihypertensive therapy and improvement of metabolic control.

Effects of long-term fenofibrate treatment on markers of renal function in type 2 diabetes: the FIELD Helsinki substudy

OBJECTIVE

Although fenofibrate was associated with less progression of albuminuria in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study, it is unknown if it has any effect on renal function. We explored if there were changes in commonly available markers of renal function during fenofibrate treatment in the FIELD Helsinki cohort excluding statin users.

RESEARCH DESIGN AND METHODS

One hundred and seventy subjects with type 2 diabetes were randomly assigned to micronized fenofibrate (200 mg/day) or placebo for 5 years. In this substudy, we measured several markers of albumin excretion and renal function.

RESULTS

After intensified treatment, blood pressure and fasting glucose decreased in both groups while A1C remained at 7.2%. Plasma creatinine increased with fenofibrate while urine creatinine remained comparable between the groups, resulting in significant decreases in both creatinine clearance and estimated glomerular filtration rate (eGFR) by the Modification of Diet in Renal Disease (MDRD)-4 and Cockroft-Gault equations in the fenofibrate group. Cystatin C increased during fenofibrate treatment. Urinary albumin-to-creatinine ratio and diurnal urine protein remained unchanged, whereas overnight urinary albumin excretion rate showed minor decreases in both groups.

CONCLUSIONS

We report concomitant decreases in creatinine clearance and eGFR by fenofibrate. These changes complicate the clinical surveillance during fenofibrate treatment. We could not demonstrate the beneficial effects of fenofibrate on albumin excretion. A novel finding is the increase of cystatin C in type 2 diabetic patients during fenofibrate treatment. The clinical relevance of the changes needs to be assessed in a long-term outcome study of renal function.

Prediction of proliferative diabetic retinopathy with hemoglobin level

OBJECTIVE

To investigate the role of hemoglobin (HGB) level in predicting proliferative diabetic retinopathy (PDR).

METHODS

We assessed 426 individuals without PDR at baseline (213 men; 213 women) from the Pittsburgh Epidemiology of Diabetes Complications Study, an 18-year prospective cohort study of childhood-onset type 1 diabetes. Presence of PDR was determined by stereo fundus photography. Cox proportional hazards modeling with stepwise regression was used to determine the independent association of HGB level with PDR. Analyses were sex specific.

RESULTS

There were 206 events. Although the incidence of PDR did not vary by sex (48% in both men and women), in men, HGB exhibited a positive linear relationship with 18-year incidence of PDR (hazard ratio, 1.33; 95% confidence interval, 1.10-1.60; P = .003), while in women, HGB level exhibited a quadratic relationship with PDR (P < .001). After multivariable adjustment for univariately significant covariates, HGB level remained significantly predictive of PDR in both men (P = .004) and women (P = .04).

CONCLUSION

Higher HGB level predicts the incidence of PDR in type 1 diabetes mellitus, though the association varies by sex, being linear and positive in men and quadratic in women.

Exploration of anaemia as a progression factor in African Americans with cardiovascular disease

BACKGROUND

Despite the higher incidence of end-stage renal disease (ESRD) among African Americans, whites in the USA have a higher prevalence of chronic kidney disease. This may be due, in part, to faster progression to ESRD among African Americans. Anaemia is associated with a risk of kidney disease progression and is more prevalent among African Americans. The purpose of this study is to determine if anaemia is associated with progression to ESRD differently according to race.

METHODS

A retrospective cohort study of Cooperative Cardiovascular Project data for 87 693 Medicare beneficiaries >or=65 years old and ESRD free admitted to 4047 hospitals with acute myocardial infarction between February 1994 and June 1995 was conducted. Follow-up was collected through June 2004 for ESRD and mortality.

RESULTS

Among 87 693 patients, 7.0% were African Americans and 50.1% females. African Americans had a higher prevalence of anaemia than whites (40.2% versus 26.7%, respectively; P < 0.001). Lower haematocrit was associated with higher ESRD rates after adjustment, and the association of haematocrit with ESRD did not vary according to race (P = 0.19). This association was strongest at the lowest baseline kidney function (GFR <15) with hazard ratios increasing 7-fold as haematocrit decreased from >or= 42% to <28%.

CONCLUSIONS

In a nationally representative sample of patients with cardiovascular disease, anaemia was associated equally among African Americans and whites with an increased risk of ESRD.

Reducing lipids for CV protection in CKD patients-current evidence

Lipid parameters are altered in the earliest stages of primary kidney disease, some even when measured glomerular filtration rate (GFR) is still normal. The main problem is that routinely measured lipid parameters are deceivingly normal except low high-density lipoprotein (HDL) and moderately elevated triglycerides (TGs) (>150 mg per 100 ml). Behind this unimpressive spectrum, serious anomalies are hidden: increased very low-density lipoprotein (VLDL) and chylomicron remnants, accumulation of delipidated small dense low-density lipoprotein (LDL), post translational modification of lipoproteins, abnormal concentrations of Lp(a) and nonprotective HDL. A routine parameter with some predictive value is the concentration of non-HDL cholesterol. Several of these abnormal lipoprotein particles stimulate cellular free oxygen radical formation which in turn induce inflammation and impact on endothelial function.A bone of contention is the indication for treatment with statins in endstage renal disease. Poor survival is paradoxically predicted by low cholesterol. This appears to be the result of confounding by microinflammation. One controlled interventional study in hemodialysed type 2 diabetics, the 4-D study, failed to show a significant benefit on the primary cardiovascular endpoint. We discuss potential explanations for this 'negative' outcome and the implications for statin treatment.

Hemoglobin and overt nephropathy complications in type 1 diabetes

PURPOSE

Anemia tends to be more severe and occur earlier in individuals with diabetic nephropathy. We thus examined whether hemoglobin (HGB) relates to end-stage renal disease (ESRD), coronary artery disease (CAD), and all cause mortality in type 1 diabetes (T1D) subjects with overt nephropathy (ON).

METHODS

We prospectively followed up 174 individuals with childhood-onset T1D and ON (albumin excretion rate >200 microg/min in multiple urine samples) from the Pittsburgh Epidemiology of Diabetes Complications Study cohort for 12 years. One hundred forty persons had ON at baseline, whereas another 34 were followed up from their incidence of ON as determined by biennial examinations.

RESULTS

Baseline HGB inversely predicted ESRD (hazard ratio [HR] = 0.70, 0.61-0.80) and mortality (HR = 0.84, 0.72-0.98), but not CAD (HR = 0.91, 0.79-1.0). After adjustment for sex, diabetes duration, and other known risk factors, HGB remained significantly predictive of ESRD (HR = 0.72, 0.61-0.85), but not CAD (HR = 0.94, 0.80-1.10) or overall mortality (HR = 0.92, 0.77-1.10). However, in those who never progressed to ESRD, HGB was significantly predictive of mortality (HR = 0.59, 0.39-0.89). After including ESRD as a time-dependent, HGB was significantly predictive of overall mortality (HR = 0.75, 0.59-0.93). Gender-specific analyses, although limited by sample size, suggests similarity in the association between absolute HGB and ESRD in both genders, but differences for CAD and mortality.

CONCLUSION

Our data suggest that in T1D with ON, a higher HGB level is associated not only with reduced risk of ESRD, but also of mortality, particularly in those who do not develop ESRD. HGB, even in the clinically normal range, is able to predict long-term complications in those with T1D and ON.

Diabetic patients treated with dialysis: complications and quality of life

AIMS/HYPOTHESIS

The aim of this study was to describe the prevalence of complications, health-related quality of life (HRQOL) and the influence of beliefs about control over health in diabetic dialysis patients.

METHODS

Of 53 eligible diabetic patients on chronic dialysis during January 2004 in our clinic, 38 (76%) completed a kidney-specific (Kidney Disease Quality of Life) and a generic (SF-36) questionnaire and were characterised in terms of cardiovascular diseases and diabetic complications. Matched groups of non-diabetic dialysis patients (n = 40) and diabetic patients with a long duration of diabetes and normal kidney function (n = 38) served as controls. Generic HRQOL was compared with matched data from a survey on the Danish general population (n = 2248).

RESULTS

Micro- and macrovascular complications were significantly more frequent in diabetic dialysis patients than in diabetic patients without renal disease. Self-rated physical health was significantly worse (p < 0.01) in diabetic dialysis patients (35 +/- 9 [mean +/- SD]) compared with non-diabetic dialysis patients (41 +/- 10), diabetic patients with normal kidney function (45 +/- 12) and the matched general population (47 +/- 19). The diabetic dialysis patients had similar levels of kidney-specific quality of life and mental health compared with the control groups. Reduced physical health was predicted by the presence of end-stage renal disease, diabetes and short time spent in education. Among the diabetic patients, those who believed more on their own ability to control their diabetes and less on chance reported better mental health and were less likely to be on dialysis.

CONCLUSIONS/INTERPRETATIONS

Diabetic dialysis patients are characterised by a high prevalence of diabetic complications, reduced self-rated physical health but relatively good mental health.

Hyperlipidemia is associated with accelerated chronic kidney disease progression after lung transplantation

Hyperlipidemia is associated with faster progression of chronic kidney disease (CKD) in the general public. We sought to investigate this association after lung transplantation. Data was retrospectively collected on 230 lung recipients transplanted between January 1997 and December 2003. Estimated glomerular filtration rates (eGFR) and lipid levels were recorded at regular intervals posttransplant. Independent associations between lipid levels early posttransplant and pertinent renal endpoints were investigated. Baseline LDL was 110 +/- 35 mg/dL and remained unchanged at 6 months. A faster decline in eGFR was seen in those with 6 month LDLs > versus < the mean level of 110 mg/dL (p = 0.05). By 6 months posttransplant eGFRs were lower in the 6 month LDL > versus < 110 mg/dL group (53 +/- 23 vs. 62 +/- 29 mL/min/1.73 m2, p = 0.01), a difference that persisted at 60 months (39 +/- 24 vs. 73 +/- 57 mL/min/1.73 m2, p = 0.05). On univariate analysis, a 6 month LDL in the highest quartile, i.e. >140 mg/dL, predicted faster progression to CKD, defined as declining to an eGFR < 30 mL/min/1.73 m2 (HR 1.5, p = 0.01). This finding persisted in the multivariate Cox-proportional model (HR 1.4, p = 0.02). Hyperlipidemia predicts faster decline in renal function after lung transplant. Prospective trials are needed to confirm this finding.

Nutritional status in patients with diabetes and chronic kidney disease: a prospective study

BACKGROUND

A poor nutritional status reduces the life expectancy of diabetes patients undergoing hemodialysis.

OBJECTIVE

The study objective was to specify the nutritional outcome in patients with chronic kidney disease (CKD) and well-controlled diabetes.

DESIGN

Forty-five diabetes patients with CKD were enrolled in a cooperative-care program designed to control glucose, blood pressure, LDL cholesterol, and the albumin excretion rate (AER). Their glomerular filtration rate (GFR), body composition, serum albumin (SA), and resting energy expenditure were assessed and compared at baseline and 2 y later.

RESULTS

Thirty-five patients did not start dialysis. Their glycated hemoglobin, blood pressure, LDL cholesterol, and AER improved; their GFR declined slowly (-3.3 mL x min(-1) x 1.73 m(-2) x y(-1)). Their body mass index (BMI), lean body mass, and SA increased. The GFR decline was correlated negatively with the initial BMI (r = -0.37, P < 0.05) and positively with the initial GFR (r = 0.34, P < 0.05). Ten patients started hemodialysis: except for higher total body water (P < 0.05) and extracellular volume (P < 0.01), their initial nutritional status did not differ significantly from that of 10 patients with comparable baseline severe CKD but without dialysis. At the second evaluation, patients on hemodialysis lost lean body mass, and their SA was lower than that of the patients with severe CKD (P = 0.05); lean body mass was unchanged and SA was higher (P = 0.01) in the patients with severe CKD. No significant difference was detected for resting energy expenditure.

CONCLUSIONS

Nutritional status improved in CKD patients with well-controlled diabetes without dialysis, and it deteriorated in patients who started dialysis. A high initial BMI was associated with a slower decline in GFR.

Diabetes mellitus--overview

DM increases the risk of multiple complications including retinography, nephropathy, and atherosclerotic disease. Management strategies include management of the associated metabolic risk factors such has hyperglycemia, dyslipidemia, and hypertension. Additional management strategies include laser therapy for retinopathy and appropriate footwear to reduce the risk of lower extremity amputations.

Risk factors for renal dysfunction in type 2 diabetes: U.K. Prospective Diabetes Study 74

Not all patients with type 2 diabetes develop renal dysfunction. Identifying those at risk is problematic because even microalbuminuria, often used clinically as an indicator of future renal dysfunction, does not always precede worsening renal function. We sought to identify clinical risk factors at diagnosis of type 2 diabetes associated with later development of renal dysfunction. Of 5,102 U.K. Prospective Diabetes Study (UKPDS) participants, prospective analyses were undertaken in those without albuminuria (n = 4,031) or with normal plasma creatinine (n=5,032) at diagnosis. Stepwise proportional hazards multivariate regression was used to assess association of putative baseline risk factors with subsequent development of albuminuria (microalbuminuria or macroalbuminuria) or renal impairment (Cockcroft-Gault estimated creatinine clearance <60 ml/min or doubling of plasma creatinine). Over a median of 15 years of follow-up 1,544 (38%) of 4,031 patients developed albuminuria and 1,449 (29%) of 5,032 developed renal impairment. Of 4,006 patients with the requisite data for both outcomes, 1,534 (38%) developed albuminuria and 1,132 (28%) developed renal impairment. Of the latter, 575 (51%) did not have preceding albuminuria. Development of albuminuria or renal impairment was independently associated with increased baseline systolic blood pressure, urinary albumin, plasma creatinine, and Indian-Asian ethnicity. Additional independent risk factors for albuminuria were male sex, increased waist circumference, plasma triglycerides, LDL cholesterol, HbA(1c) (A1C), increased white cell count, ever having smoked, and previous retinopathy. Additional independent risk factors for renal impairment were female sex, decreased waist circumference, age, increased insulin sensitivity, and previous sensory neuropathy. Over a median of 15 years from diagnosis of type 2 diabetes, nearly 40% of UKPDS patients developed albuminuria and nearly 30% developed renal impairment. Distinct sets of risk factors are associated with the development of these two outcomes, consistent with the concept that they are not linked inexorably in type 2 diabetes.

Dyslipidemia and the progression of renal disease in chronic renal failure patients

Dyslipidemia is a common complication of progressive kidney disease and contributes to the high cardiovascular morbidity and mortality of chronic kidney disease (CKD) patients. Recent evidence also suggests a role for dyslipidemia in the development and progression of renal disease. Experimental studies have demonstrated that lipids may induce glomerular and tubulointerstitial injury, and that lipid-lowering treatments ameliorate renal injury. Various lipid abnormalities have been associated with the development and progression of renal disease in diabetic and nondiabetic patients. Population-based studies and studies of diabetic patients have reported associations of various lipid abnormalities with the development of renal disease. In patients with CKD, lipid abnormalities have also been associated with renal disease progression. Post hoc analyses of some large clinical trials on patients with vascular disease, diabetes, or dyslipidemia, and a meta-analysis of small, prospective, controlled studies on patients with CKD (diabetics and nondiabetics) suggest that statins may slow the progression of kidney disease. It is unclear whether the beneficial renal effects of statins are due to the reduction of serum cholesterol levels and/or their pleiotropic effects. There is also evidence for synergistic renoprotective effects between statins and renin-angiotensin system inhibitors. According to the results of post hoc analysis of several studies, treatment with fibrates does not seem to confer renoprotection, but evidence is scarce. In summary, there is growing evidence that lipid abnormalities may be a risk factor for renal disease, and that statins appear to confer a renoprotective effect.