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Natale P, Palmer SC, Navaneethan SD, Craig JC, Strippoli GF. Angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers for preventing the progression of diabetic kidney disease. Cochrane Database Syst Rev 2024; 4:CD006257. [PMID: 38682786 PMCID: PMC11057222 DOI: 10.1002/14651858.cd006257.pub2] [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] [Indexed: 05/01/2024]
Abstract
BACKGROUND Guidelines suggest that adults with diabetes and kidney disease receive treatment with angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). This is an update of a Cochrane review published in 2006. OBJECTIVES We compared the efficacy and safety of ACEi and ARB therapy (either as monotherapy or in combination) on cardiovascular and kidney outcomes in adults with diabetes and kidney disease. SEARCH METHODS We searched the Cochrane Kidney and Transplants Register of Studies to 17 March 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included studies evaluating ACEi or ARB alone or in combination, compared to each other, placebo or no treatment in people with diabetes and kidney disease. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS One hundred and nine studies (28,341 randomised participants) were eligible for inclusion. Overall, the risk of bias was high. Compared to placebo or no treatment, ACEi may make little or no difference to all-cause death (24 studies, 7413 participants: RR 0.91, 95% CI 0.73 to 1.15; I2 = 23%; low certainty) and with similar withdrawals from treatment (7 studies, 5306 participants: RR 1.03, 95% CI 0.90 to 1.19; I2 = 0%; low certainty). ACEi may prevent kidney failure (8 studies, 6643 participants: RR 0.61, 95% CI 0.39 to 0.94; I2 = 0%; low certainty). Compared to placebo or no treatment, ARB may make little or no difference to all-cause death (11 studies, 4260 participants: RR 0.99, 95% CI 0.85 to 1.16; I2 = 0%; low certainty). ARB have uncertain effects on withdrawal from treatment (3 studies, 721 participants: RR 0.85, 95% CI 0.58 to 1.26; I2 = 2%; low certainty) and cardiovascular death (6 studies, 878 participants: RR 3.36, 95% CI 0.93 to 12.07; low certainty). ARB may prevent kidney failure (3 studies, 3227 participants: RR 0.82, 95% CI 0.72 to 0.94; I2 = 0%; low certainty), doubling of serum creatinine (SCr) (4 studies, 3280 participants: RR 0.84, 95% CI 0.72 to 0.97; I2 = 32%; low certainty), and the progression from microalbuminuria to macroalbuminuria (5 studies, 815 participants: RR 0.44, 95% CI 0.23 to 0.85; I2 = 74%; low certainty). Compared to ACEi, ARB had uncertain effects on all-cause death (15 studies, 1739 participants: RR 1.13, 95% CI 0.68 to 1.88; I2 = 0%; low certainty), withdrawal from treatment (6 studies, 612 participants: RR 0.91, 95% CI 0.65 to 1.28; I2 = 0%; low certainty), cardiovascular death (13 studies, 1606 participants: RR 1.15, 95% CI 0.45 to 2.98; I2 = 0%; low certainty), kidney failure (3 studies, 837 participants: RR 0.56, 95% CI 0.29 to 1.07; I2 = 0%; low certainty), and doubling of SCr (2 studies, 767 participants: RR 0.88, 95% CI 0.52 to 1.48; I2 = 0%; low certainty). Compared to ACEi plus ARB, ACEi alone has uncertain effects on all-cause death (6 studies, 1166 participants: RR 1.08, 95% CI 0.49 to 2.40; I2 = 20%; low certainty), withdrawal from treatment (2 studies, 172 participants: RR 0.78, 95% CI 0.33 to 1.86; I2 = 0%; low certainty), cardiovascular death (4 studies, 994 participants: RR 3.02, 95% CI 0.61 to 14.85; low certainty), kidney failure (3 studies, 880 participants: RR 1.36, 95% CI 0.79 to 2.32; I2 = 0%; low certainty), and doubling of SCr (2 studies, 813 participants: RR 1.14, 95% CI 0.70 to 1.85; I2 = 0%; low certainty). Compared to ACEi plus ARB, ARB alone has uncertain effects on all-cause death (7 studies, 2607 participants: RR 1.02, 95% CI 0.76 to 1.37; I2 = 0%; low certainty), withdrawn from treatment (3 studies, 1615 participants: RR 0.81, 95% CI 0.53 to 1.24; I2 = 0%; low certainty), cardiovascular death (4 studies, 992 participants: RR 3.03, 95% CI 0.62 to 14.93; low certainty), kidney failure (4 studies, 2321 participants: RR 1.15, 95% CI 0.67 to 1.95; I2 = 29%; low certainty), and doubling of SCr (3 studies, 2252 participants: RR 1.18, 95% CI 0.85 to 1.64; I2 = 0%; low certainty). Comparative effects of different ACEi or ARB and low-dose versus high-dose ARB were rarely evaluated. No study compared different doses of ACEi. Adverse events of ACEi and ARB were rarely reported. AUTHORS' CONCLUSIONS ACEi or ARB may make little or no difference to all-cause and cardiovascular death compared to placebo or no treatment in people with diabetes and kidney disease but may prevent kidney failure. ARB may prevent the doubling of SCr and the progression from microalbuminuria to macroalbuminuria compared with a placebo or no treatment. Despite the international guidelines suggesting not combining ACEi and ARB treatment, the effects of ACEi or ARB monotherapy compared to dual therapy have not been adequately assessed. The limited data availability and the low quality of the included studies prevented the assessment of the benefits and harms of ACEi or ARB in people with diabetes and kidney disease. Low and very low certainty evidence indicates that it is possible that further studies might provide different results.
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Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | | | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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2
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Inker LA, Tighiouart H, Adingwupu OM, Ng DK, Estrella MM, Maahs D, Yang W, Froissart M, Mauer M, Kalil R, Torres V, de Borst M, Klintmalm G, Poggio ED, Seegmiller JC, Rossing P, Furth SL, Warady BA, Schwartz GJ, Velez R, Coresh J, Levey AS. Performance of GFR Estimating Equations in Young Adults. Am J Kidney Dis 2024; 83:272-276. [PMID: 37717845 PMCID: PMC11080956 DOI: 10.1053/j.ajkd.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Lesley A Inker
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Ogechi M Adingwupu
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Derek K Ng
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Michelle M Estrella
- Department of Medicine, Division of Nephrology, San Francisco VA Health Care System and University of California, San Francisco, California
| | - David Maahs
- Division of Endocrinology, Department of Pediatrics, and Stanford Diabetes Research Center, Stanford School of Medicine, Palo Alto, California
| | - Wei Yang
- Departments of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marc Froissart
- Clinical Trial Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Michael Mauer
- Divisions of Pediatric and Adult Nephrology, University of Minnesota, Minneapolis, Minnesota
| | - Roberto Kalil
- Department of Medicine, Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vicente Torres
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Martin de Borst
- Faculty of Medical Sciences, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jesse C Seegmiller
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Peter Rossing
- Steno Diabetes Center Copenhagen and the Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susan L Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, and Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - George J Schwartz
- Department of Pediatrics, Pediatric Nephrology, University of Rochester Medical Center, Rochester, New York
| | | | - Josef Coresh
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andrew S Levey
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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3
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Wang Y, Adingwupu OM, Shlipak MG, Doria A, Estrella MM, Froissart M, Gudnason V, Grubb A, Kalil R, Mauer M, Rossing P, Seegmiller J, Coresh J, Levey AS, Inker LA. Discordance Between Creatinine-Based and Cystatin C-Based Estimated GFR: Interpretation According to Performance Compared to Measured GFR. Kidney Med 2023; 5:100710. [PMID: 37753251 PMCID: PMC10518599 DOI: 10.1016/j.xkme.2023.100710] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Rationale & Objective Use of cystatin C in addition to creatinine to estimate glomerular filtration rate (estimated glomerular filtration rate based on cystatin C [eGFRcys] and estimated glomerular filtration rate based on creatinine [eGFRcr], respectively) is increasing. When eGFRcr and eGFRcys are discordant, it is not known which is more accurate, leading to uncertainty in clinical decision making. Study Design Cross-sectional analysis. Setting & Participants Four thousand fifty participants with measured glomerular filtration rate (mGFR) from 12 studies in North America and Europe. Exposures Serum creatinine and serum cystatin C. Outcomes Performance of creatinine-based and cystatin C-based glomerular filtration rate estimating equations compared to mGFR. Analytical Approach We evaluated the accuracy of eGFRcr, eGFRcys, and the combination (eGFRcr-cys) compared to mGFR according to the magnitude of the difference between eGFRcr and eGFRcys (eGFRdiff). We used CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equations to estimate glomerular filtration rate. eGFRdiff was defined as eGFRcys minus eGFRcr and categorized as less than -15, -15 to <15, and ≥15 mL/min/1.73 m2 (negative, concordant, and positive groups, respectively). We compared bias (median of mGFR minus eGFR) and the percentage of eGFR within 30% of mGFR. Results Thirty percent of participants had discordant eGFRdiff (21.0% and 9.6% negative and positive eGFRdiffs, respectively). In the concordant eGFRdiff group, all equations displayed similar accuracy. In the negative eGFRdiff groups, eGFRcr had a large overestimation of mGFR (-13.4 [-14.5 to -12.2] mL/min/1.73 m2) and eGFRcys had a large underestimation (9.9 [9.1-11.2] mL/min/1.73m2), with opposite results in the positive eGFRdiff group. In both negative and positive eGFRdiff groups, eGFRcr-cys was more accurate than either eGFRcr or eGFRcys. These results were largely consistent across age, sex, race, and body mass index. Limitations Few participants with major comorbid conditions. Conclusions Discordant eGFRcr and eGFRcys are common. eGFR using the combination of creatinine and cystatin C provides the most accurate estimates among persons with discordant eGFRcr or eGFRcys.
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Affiliation(s)
- Yeli Wang
- Department of Nutrition, Harvard University T.H. Chan School of Public Health, Boston, MA
| | | | - Michael G. Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affair Medical Center and University of California, San Francisco, CA
| | - Alessandro Doria
- Section on Genetics & Epidemiology, Joslin Diabetes Center, and the Department of Medicine, Harvard Medical School, Boston, MA
| | - Michelle M. Estrella
- Division of Nephrology, Department of Medicine, San Francisco VA Health Care System and University of California, San Francisco, CA
| | - Marc Froissart
- Clinical Trial Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Vilmundur Gudnason
- Faculty of Medicine, University of Iceland, Reykjavik, and the Icelandic Heart Association, Kopavogur, Iceland
| | - Anders Grubb
- Department of Clinical Chemistry and Pharmacology, Institute of Laboratory Medicine, Lund University, Sweden
| | - Roberto Kalil
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore MD
| | - Michael Mauer
- Divisions of Pediatric and Adult Nephrology, University of Minnesota, Minneapolis, MN
| | - Peter Rossing
- Steno Diabetes Center Copenhagen and the Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesse Seegmiller
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Josef Coresh
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, MD
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Rossing P, Caramori ML, Chan JC, Heerspink HJ, Hurst C, Khunti K, Liew A, Michos ED, Navaneethan SD, Olowu WA, Sadusky T, Tandon N, Tuttle KR, Wanner C, Wilkens KG, Zoungas S, de Boer IH. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int 2022; 102:S1-S127. [PMID: 36272764 DOI: 10.1016/j.kint.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 02/07/2023]
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Hashemi SA, Azad A, Erfani A, Shahriarirad R, Azarpira N. Promising results of captopril in improving knee arthrofibrosis and cartilage status: an animal model study. J Exp Orthop 2022; 9:72. [PMID: 35900609 PMCID: PMC9334488 DOI: 10.1186/s40634-022-00516-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/21/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Several cytokines and growth factors start and progress the destruction process of joint hyaline cartilage and fibrosis formation. Captopril is classified as an Angiotensin-converting enzyme inhibitor in which several studies revealed that captopril significantly decreases fibrosis formation in some organs like the liver, heart, and kidney. This study aimed to evaluate the use of captopril in reducing the possibility of arthrofibrosis and osteoarthritis in an animal model. METHOD In this in-vivo animal model study, the anterior cruciate ligament of 24 rabbits was transected to induce osteoarthritis and arthrofibrosis. The control group contained 11 rabbits and the second group consisted of 13 rabbits. The second group was treated with 10 mg/ kilogram/day captopril through a nasogastric tube. The control group was treated with normal saline in the same way. Cartilage damage and osteoarthritis were evaluated by Osteoarthritis Research Society International (OARSI) scoring system. After 30 days, animals were sacrificed, and arthrofibrosis and cartilage damage were evaluated microscopically and macroscopically. RESULTS According to macroscopic and microscopic evaluation, captopril dramatically reduced arthrofibrosis formation based on visual scoring and the Masson trichrome staining system. Cartilage damage was lower in the intervention group compared to the control group. CONCLUSIONS Captopril is an angiotensin-converting enzyme inhibitor that demonstrated to significantly decreases the possibility of arthrofibrosis. Although the beneficial preventive effect of captopril on osteoarthritis was not proved statistically, better results may be obtained if the route of administration or drug dosage is changed.
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Affiliation(s)
- Seyed Ali Hashemi
- Research Center for Bone and Joint Diseases, Department of Orthopedic Surgery, Chamran Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Azad
- Research Center for Bone and Joint Diseases, Department of Orthopedic Surgery, Chamran Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirhossein Erfani
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.,Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Shahriarirad
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. .,Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Negar Azarpira
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Nanomedicine and Nanobiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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6
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Wang SW, Chang SY, Hsieh CM. Measurement and modeling of solubility of gliclazide (hypoglycemic drug) and captopril (antihypertension drug) in supercritical carbon dioxide. J Supercrit Fluids 2021. [DOI: 10.1016/j.supflu.2021.105244] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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7
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Inker LA, Couture SJ, Tighiouart H, Abraham AG, Beck GJ, Feldman HI, Greene T, Gudnason V, Karger AB, Eckfeldt JH, Kasiske BL, Mauer M, Navis G, Poggio ED, Rossing P, Shlipak MG, Levey AS. A New Panel-Estimated GFR, Including β 2-Microglobulin and β-Trace Protein and Not Including Race, Developed in a Diverse Population. Am J Kidney Dis 2021; 77:673-683.e1. [PMID: 33301877 PMCID: PMC8102017 DOI: 10.1053/j.ajkd.2020.11.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
Abstract
RATIONALE AND OBJECTIVE Glomerular filtration rate (GFR) estimation based on creatinine and cystatin C (eGFRcr-cys) is more accurate than estimated GFR (eGFR) based on creatinine or cystatin C alone (eGFRcr or eGFRcys, respectively), but the inclusion of creatinine in eGFRcr-cys requires specification of a person's race. β2-Microglobulin (B2M) and β-trace protein (BTP) are alternative filtration markers that appear to be less influenced by race than creatinine is. STUDY DESIGN Study of diagnostic test accuracy. SETTING AND PARTICIPANTS Development in a pooled population of 7 studies with 5,017 participants with and without chronic kidney disease. External validation in a pooled population of 7 other studies with 2,245 participants. TESTS COMPARED Panel eGFR using B2M and BTP in addition to cystatin C (3-marker panel) or creatinine and cystatin C (4-marker panel) with and without age and sex or race. OUTCOMES GFR measured as the urinary clearance of iothalamate, plasma clearance of iohexol, or plasma clearance of [51Cr]EDTA. RESULTS Mean measured GFRs were 58.1 and 83.2 mL/min/1.73 m2, and the proportions of Black participants were 38.6% and 24.0%, in the development and validation populations, respectively. In development, addition of age and sex improved the performance of all equations compared with equations without age and sex, but addition of race did not further improve the performance. In validation, the 4-marker panels were more accurate than the 3-marker panels (P < 0.001). The 3-marker panel without race was more accurate than eGFRcys (percentage of estimates greater than 30% different from measured GFR [1 - P30] of 15.6% vs 17.4%; P = 0.01), and the 4-marker panel without race was as accurate as eGFRcr-cys (1 - P30 of 8.6% vs 9.4%; P = 0.2). Results were generally consistent across subgroups. LIMITATIONS No representation of participants with severe comorbid illness and from geographic areas outside of North America and Europe. CONCLUSIONS The 4-marker panel eGFR is as accurate as eGFRcr-cys without requiring specification of race. A more accurate race-free eGFR could be an important advance.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA.
| | - Sara J Couture
- Division of Nephrology, Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA; Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Alison G Abraham
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Harold I Feldman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Tom Greene
- Department of Internal Medicine, University of Utah Health, Salt Lake City, UT
| | - Vilmundur Gudnason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Icelandic Heart Association, Kopavogur, Iceland
| | - Amy B Karger
- Departments of Laboratory Medicine and Pathology, University of Minnesota; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - John H Eckfeldt
- Departments of Laboratory Medicine and Pathology, University of Minnesota; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Bertram L Kasiske
- University of Minnesota; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Michael Mauer
- Medicine, University of Minnesota; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Gerjan Navis
- Faculty of Medical Sciences, University Medical Center Groningen, Groningen, The Netherlands
| | - Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Peter Rossing
- Steno Diabetes Center Copenhagen and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, CA
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
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Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW, Tomson CR, Mann JF. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int 2021; 99:S1-S87. [PMID: 33637192 DOI: 10.1016/j.kint.2020.11.003] [Citation(s) in RCA: 380] [Impact Index Per Article: 126.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
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9
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de Boer IH, Caramori ML, Chan JC, Heerspink HJ, Hurst C, Khunti K, Liew A, Michos ED, Navaneethan SD, Olowu WA, Sadusky T, Tandon N, Tuttle KR, Wanner C, Wilkens KG, Zoungas S, Rossing P. KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int 2020; 98:S1-S115. [PMID: 32998798 DOI: 10.1016/j.kint.2020.06.019] [Citation(s) in RCA: 525] [Impact Index Per Article: 131.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 12/13/2022]
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Abstract
Purpose of Review Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are commonly used anti-hypertensive medications in a number of clinical settings. They are often used interchangeably, but we pose the provocative question as to whether they should be. We review the literature to evaluate for any differences in efficacy between the two classes in order to determine if the greater side effects associated with angiotensin-converting enzyme inhibitors are offset by any advantageous effects on outcomes to warrant their use over angiotensin receptor blockers. Recent Findings In many clinical scenarios, the data supports similar efficacy between ACE inhibitors and ARBs, while in a minority of others, there are murky signals from previous trials that suggest ACE inhibitors may be better. However, when reviewing the literature in its entirety, and taking into account recently published pooled analysis and head to head trials, it is reasonable to conclude that ACE inhibitors and ARBs have similar efficacy. This is in contrast to data on adverse effects, which consistently favors the use of ARBs. Summary From the available data, it is reasonable to conclude that ACE inhibitors and ARBs have equal efficacy yet unequal adverse effects. It is in this context that we take the provocative stance that ACE inhibitors should not be used to treat hypertension.
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11
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Novel field amplification for sensitive colorimetric detection of microalbuminuria on a paper-based analytical device. Anal Chim Acta 2019; 1080:146-152. [DOI: 10.1016/j.aca.2019.06.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 01/08/2023]
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12
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Ebadi Z, Moradi N, Kazemi Fard T, Balochnejadmojarrad T, Chamani E, Fadaei R, Fallah S. Captopril and Spironolactone Can Attenuate Diabetic Nephropathy in Wistar Rats by Targeting microRNA-192 and microRNA-29a/b/c. DNA Cell Biol 2019; 38:1134-1142. [PMID: 31433203 DOI: 10.1089/dna.2019.4732] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Diabetes mellitus is a complicated metabolic disease characterized by hyperglycemia. Diabetic nephropathy (DN) is a progressive kidney disease, which results in mortality in diabetic patients. The present study was designed to investigate the effect of applying spironolactone (S), captopril (C), and their combination (S+C) on some renal performance indices and microRNAs' (miRNAs) expression. A total of 35 two-month-old male Wistar rats were provided for the study. Intraperitoneal injection of freshly dissolved streptozotocin (60 mg/kg) in cold citrate buffer was used to induce diabetes. Blood samples were examined through calorimetry to assess serum concentrations of glucose, blood urea nitrogen (BUN), and creatinine. To measure the microalbuminuria and transforming growth factor-β (TGF-β) levels and to evaluate the miRNAs expression levels of the kidney tissue, the ELISA method and the real-time PCR were used. The obtained results serve as in vivo evidence for the positive relationship between miR-192 and TGF-β levels in the DN rats. A significant increase and decrease were found for miR-29a/b/c and the miR-192 expression of DN after treatment with S, C, and S+C. TGF-β levels and microalbuminuria of diabetic rats also increased. The results obtained from this research study suggest that S, C, and S + C can improve DN by targeting miR-192 and miR-29 family and changing their expression. These findings suggest that miR-192 and miRs-29a/b/c can be potential targets for DN remediation.
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Affiliation(s)
- Zahra Ebadi
- Department of Biochemistry, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nariman Moradi
- Department of Clinical Biochemistry, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran.,Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Toktam Kazemi Fard
- Department of Biochemistry, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Elham Chamani
- Cardiovascular Diseases Research Center, Department of Biochemistry, Birjand University of Medical Sciences, Birjand, Iran
| | - Reza Fadaei
- Sleep Disorder Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Soudabeh Fallah
- Department of Biochemistry, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
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13
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Chiang JL, Maahs DM, Garvey KC, Hood KK, Laffel LM, Weinzimer SA, Wolfsdorf JI, Schatz D. Type 1 Diabetes in Children and Adolescents: A Position Statement by the American Diabetes Association. Diabetes Care 2018; 41:2026-2044. [PMID: 30093549 PMCID: PMC6105320 DOI: 10.2337/dci18-0023] [Citation(s) in RCA: 237] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Jane L Chiang
- McKinsey & Company and Diasome Pharmaceuticals, Inc., Palo Alto, CA
| | - David M Maahs
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Katharine C Garvey
- Division of Endocrinology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Korey K Hood
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Stuart A Weinzimer
- Pediatric Endocrinology & Diabetes, Yale School of Medicine, New Haven, CT
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Desmond Schatz
- Division of Endocrinology, Department of Pediatrics, University of Florida, Gainesville, FL
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14
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Michelsen MM, Rask AB, Suhrs E, Raft KF, Høst N, Prescott E. Effect of ACE-inhibition on coronary microvascular function and symptoms in normotensive women with microvascular angina: A randomized placebo-controlled trial. PLoS One 2018; 13:e0196962. [PMID: 29883497 PMCID: PMC5993253 DOI: 10.1371/journal.pone.0196962] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 04/23/2018] [Indexed: 12/13/2022] Open
Abstract
Objective Studies have suggested a beneficial effect of angiotensin-converting enzyme (ACE) inhibition. To explore whether the ACE inhibitor ramipril has a direct effect on the microvasculature beyond the blood pressure (BP) lowering effect, we investigated whether ramipril improved coronary microvascular function in normotensive women with coronary microvascular dysfunction (CMD). Methods We included 63 normotensive women with angina, no epicardial stenosis>50% and CMD defined as a coronary flow velocity reserve (CFVR)<2.2 assessed by adenosine stress-echocardiography in a randomized double-blinded, superiority trial with 1:1 allocation to placebo or ramipril (maximum dose 10 mg depending on blood pressure) for 24±6 weeks. Primary outcome was CFVR. Secondary outcomes were left ventricular systolic and diastolic function and symptoms evaluated by Seattle Angina Questionnaire (clinicaltrials.gov, NCT02525081). Results Follow-up was available on 55 patients. BP remained unchanged during treatment in both groups. CFVR improved in both the ramipril (p = 0.004) and placebo group (p = 0.026) with no difference between groups (p = 0.63). Symptoms improved in both groups with no significant between-group differences. No changes were detected in parameters of systolic and diastolic function. No serious adverse reactions were reported. Conclusions In normotensive women with angina and CMD, treatment with ramipril had no significant effect on CFVR or symptoms compared with placebo. The effect of ACE inhibition previously reported may be mediated by blood pressure reduction.
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Affiliation(s)
- Marie Mide Michelsen
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anna Bay Rask
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Elena Suhrs
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Nis Høst
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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15
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16
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Haymann JP, Hammoudi N, Stankovic Stojanovic K, Galacteros F, Habibi A, Avellino V, Bartolucci P, Benzerara Y, Arlet JB, Djebbar M, Letavernier E, Grateau G, Tabibzadeh N, Girshovich A, Chaignon M, Girot R, Levy P, Lionnet F. Renin-angiotensin system blockade promotes a cardio-renal protection in albuminuric homozygous sickle cell patients. Br J Haematol 2017; 179:820-828. [DOI: 10.1111/bjh.14969] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/25/2017] [Indexed: 01/26/2023]
Affiliation(s)
- Jean-Philippe Haymann
- Service d'Explorations Fonctionnelles Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
- Sorbonne Universites UPMC Univ Paris 06; Paris France
- Institut National de la Sante et de la Recherche Medicale; UMR-S 1155; Paris France
| | - Nadjib Hammoudi
- Service de Cardiologie; Hôpital de la Pitie Salpetrière; Assistance Publique-Hopitaux de Paris; Paris France
- Institute of Cardiometabolism and Nutrition (ICAN); Paris France
| | | | - Frederic Galacteros
- Centre for Sickle Cell Disease; Hôpital Mondor; Assistance Publique-Hopitaux de Paris; Paris France
| | - Anoosha Habibi
- Centre for Sickle Cell Disease; Hôpital Mondor; Assistance Publique-Hopitaux de Paris; Paris France
| | - Virginie Avellino
- Centre for Sickle Cell Disease; Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
| | - Pablo Bartolucci
- Centre for Sickle Cell Disease; Hôpital Mondor; Assistance Publique-Hopitaux de Paris; Paris France
| | - Yahia Benzerara
- Service d'Explorations Fonctionnelles Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
| | - Jean-Benoit Arlet
- Centre for Sickle Cell Disease; Hôpital Européen Georges Pompidou; Assistance Publique-Hopitaux de Paris; Paris France
| | - Morad Djebbar
- Service d'Explorations Fonctionnelles Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
| | - Emmanuel Letavernier
- Service d'Explorations Fonctionnelles Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
- Sorbonne Universites UPMC Univ Paris 06; Paris France
- Institut National de la Sante et de la Recherche Medicale; UMR-S 1155; Paris France
| | - Gilles Grateau
- Centre for Sickle Cell Disease; Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
| | - Nathalie Tabibzadeh
- Service d'Explorations Fonctionnelles Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
| | - Alexei Girshovich
- Service d'Explorations Fonctionnelles Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
| | - Michel Chaignon
- Service d'Explorations Fonctionnelles Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
| | - Robert Girot
- Centre for Sickle Cell Disease; Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
| | - Pierre Levy
- Public Health Department; Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
| | - Francois Lionnet
- Centre for Sickle Cell Disease; Hôpital Tenon; Assistance Publique-Hopitaux de Paris; Paris France
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17
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Kim Y, Jeon JY, Kim EY, Lim CH, Jang HB, Kim MG. Pharmacokinetics and Safety of DW1029M, a Botanical Drug for the Treatment of Diabetic Nephropathy, Following Single Doses in Healthy Subjects. Clin Pharmacol Drug Dev 2017; 6:499-507. [PMID: 28301092 DOI: 10.1002/cpdd.343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 01/18/2017] [Indexed: 11/07/2022]
Abstract
DW1029M is a botanical extract of Morus albalinne root bark and Puerariae radix that is used for the treatment of diabetic nephropathy. This study evaluated the safety and pharmacokinetics of DW1029M following its administration in healthy Korean subjects. We conducted a randomized, open-label, single-dose, crossover phase 1 clinical study. During each period, subjects received 300, 600, or 1200 mg oral doses of DW1029M. Plasma concentrations of puerarin, daidzin, and daidzein were analyzed using a liquid chromatography-tandem mass spectrometry. Six healthy male subjects completed the study. The maximum concentration of the drug in the plasma (Cmax ) and area under the plasma drug concentration-time curve to the last measurable concentration (AUClast ) for puerarin, daidzin, and daidzein were assessed after oral administration of DW1029M. No serious adverse events or clinically or statistically significant adverse events associated with any of the drug levels were observed. The results of the measurement of vital signs, electrocardiogram, laboratory tests, and physical examinations indicated that no clinically significant changes occurred during this study. The DW1029M tablet was safe and well tolerated over a single dose range of 300-1200 mg. This pharmacokinetic study of a botanical drug may aid in the development of DW1029M.
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Affiliation(s)
- Yunjeong Kim
- Center for Clinical Pharmacology and Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Ji-Young Jeon
- Center for Clinical Pharmacology and Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Eun-Young Kim
- Center for Clinical Pharmacology and Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Cheol-Hee Lim
- Department of Pharmacology, College of Medicine, Chung-ang University, Seoul, Republic of Korea.,Dongwha Pharmaceuticals Project Team, Seoul, Republic of Korea
| | - Hwan Bong Jang
- Dongwha Pharmaceuticals Project Team, Seoul, Republic of Korea
| | - Min-Gul Kim
- Center for Clinical Pharmacology and Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Republic of Korea.,Department of Pharmacology, School of Medicine, Chonbuk National University, Jeonju, Republic of Korea
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18
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Mathiesen ER. Pregnancy Outcomes in Women With Diabetes-Lessons Learned From Clinical Research: The 2015 Norbert Freinkel Award Lecture. Diabetes Care 2016; 39:2111-2117. [PMID: 27879355 DOI: 10.2337/dc16-1647] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Among women with diabetes, the worst pregnancy outcome is seen in the subgroup of women with diabetic nephropathy. Development of severe preeclampsia that leads to early preterm delivery is frequent. Predictors and pathophysiological mechanisms for the development of preeclampsia among women with diabetes and observational studies that support antihypertension treatment for pregnant women with microalbuminuria or diabetic nephropathy preventing preeclampsia and early preterm delivery are presented here. Obtaining and maintaining strict glycemic control before and during pregnancy is paramount to prevent preterm delivery. The cornerstones of diabetes management are appropriate diet and insulin, although the risk of severe hypoglycemia always needs to be taken into account when tailoring a diabetes treatment plan. Pathophysiological mechanisms of the increased risk of hypoglycemia during pregnancy are explored, and studies evaluating the use of insulin analogs, insulin pumps, and continuous glucose monitoring to improve pregnancy outcomes and to reduce the risk of severe hypoglycemia in pregnant women with type 1 diabetes are reported. In addition to strict glycemic control, other factors involved in fetal overgrowth are explored, and restricting maternal gestational weight gain is a promising treatment area. The optimal carbohydrate content of the diet is discussed. In summary, the lessons learned from this clinical research are that glycemic control, gestational weight gain, and antihypertension treatment all are of importance for improving pregnancy outcomes in pregnant women with preexisting diabetes. An example of how to use app technology to share the recent evidence-based clinical recommendations for women with diabetes who are pregnant or planning pregnancy is given.
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Affiliation(s)
- Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes and Faculty of Health and Medical Sciences, Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Ringholm L, Damm JA, Vestgaard M, Damm P, Mathiesen ER. Diabetic Nephropathy in Women With Preexisting Diabetes: From Pregnancy Planning to Breastfeeding. Curr Diab Rep 2016; 16:12. [PMID: 26803648 DOI: 10.1007/s11892-015-0705-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In women with preexisting diabetes and nephropathy or microalbuminuria, it is important to deliver careful preconception counselling to assess the risk for the mother and the foetus, for optimizing glycaemic status and to adjust medical treatment. If serum creatinine is normal in early pregnancy, kidney function is often preserved during pregnancy, but complications such as severe preeclampsia and preterm delivery are still common. Perinatal mortality is now comparable with that in women with diabetes and normal kidney function. Besides strict glycaemic control before and during pregnancy, early and intensive antihypertensive treatment is important to optimize pregnancy outcomes. Methyldopa, labetalol, nifedipine and diltiazem are considered safe, whereas angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers should be stopped before or at confirmation of pregnancy. Supplementation with folic acid in early pregnancy and low-dose aspirin from 10 to 12 weeks reduces the risk of adverse pregnancy outcomes. During breastfeeding, several ACE inhibitors are considered safe.
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Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Steno Diabetes Center, Niels Steensens Vej 2, 2820, Gentofte, Denmark.
| | - Julie Agner Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark.
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark.
- Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark.
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20
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Eboh C, Chowdhury TA. Management of diabetic renal disease. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:154. [PMID: 26244141 DOI: 10.3978/j.issn.2305-5839.2015.06.25] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 06/26/2015] [Indexed: 12/15/2022]
Abstract
Diabetic nephropathy is the leading cause of end stage renal failure (ESRF) worldwide, representing over 50% of patients on renal replacement therapy in some parts of the world. The condition is common in people with type 1 and type 2 diabetes, although the incidence appears to be declining, especially in type 1 diabetes. More than 1 in 3 people with type 2 diabetes have impaired kidney function. Advances in our understanding of the pathogenesis and natural history of the condition have enabled us to consider earlier therapy aimed at renal preservation and reduction in cardiovascular morbidity. Microalbuminuria is now established as the earliest risk marker for nephropathy in type 1 diabetes and cardiovascular disease in type 2 diabetes. This review examines the current concepts in the pathogenesis and management of diabetic nephropathy.
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Affiliation(s)
- Cecil Eboh
- Department of Diabetes and Metabolism, the Royal London Hospital, London, UK
| | - Tahseen A Chowdhury
- Department of Diabetes and Metabolism, the Royal London Hospital, London, UK
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22
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Krolewski AS, Gohda T, Niewczas MA. Progressive renal decline as the major feature of diabetic nephropathy in type 1 diabetes. Clin Exp Nephrol 2014; 18:571-83. [PMID: 24218296 PMCID: PMC4018428 DOI: 10.1007/s10157-013-0900-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 10/21/2013] [Indexed: 01/15/2023]
Abstract
Despite almost universal implementation of renoprotective therapies over the past 25 years, the risk of end-stage renal disease (ESRD) in type 1 diabetes (T1D) is not decreasing, and ESRD remains the major cause of excess morbidity and premature mortality [1]. Such a state of affairs prompts a call to action. In this review we re-evaluated the proteinuria-centric model of diabetic nephropathy and showed its deficiencies. On the basis of extensive studies that we have been conducting on the patients attending the Joslin Clinic, we propose that progressive renal decline, not abnormalities in urinary albumin excretion, should be considered as the major feature of disease processes leading to ESRD in T1D. The etiology of diabetic nephropathy should be reconsidered in light of our new findings so our perspective can be broadened regarding new therapeutic targets available for interrupting the progressive renal decline in T1D. Reduction in the loss of glomerular filtration rate, not reduction of albumin excretion rate, should become the measure for evaluating the effectiveness of new therapeutic interventions. We need new accurate methods for early diagnosis of patients at risk of progressive renal decline or, better still, for detecting in advance which patients will have rapid, moderate or minimal rate of progression to ESRD.
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Affiliation(s)
- Andrzej S Krolewski
- Section on Genetics and Epidemiology, Research Division of Joslin Diabetes Center, One Joslin Place, Boston, MA, 02215, USA,
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23
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Damm JA, Asbjörnsdóttir B, Callesen NF, Mathiesen JM, Ringholm L, Pedersen BW, Mathiesen ER. Diabetic nephropathy and microalbuminuria in pregnant women with type 1 and type 2 diabetes: prevalence, antihypertensive strategy, and pregnancy outcome. Diabetes Care 2013; 36:3489-94. [PMID: 24009298 PMCID: PMC3816914 DOI: 10.2337/dc13-1031] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [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 evaluate the prevalence of diabetic nephropathy and microalbuminuria in pregnant women with type 2 diabetes in comparison with type 1 diabetes and to describe pregnancy outcomes in these women following the same antihypertensive protocol. RESEARCH DESIGN AND METHODS Among 220 women with type 2 diabetes and 445 women with type 1 diabetes giving birth from 2007-2012, 41 women had diabetic nephropathy (albumin-creatinine ratio ≥300 mg/g) or microalbuminuria (albumin-creatinine ratio 30-299 mg/g) in early pregnancy. Antihypertensive therapy was initiated if blood pressure ≥135/85 mmHg or albumin-creatinine ratio ≥300 mg/g. RESULTS The prevalence of diabetic nephropathy was 2.3% (5 of 220) in women with type 2 diabetes and 2.5% (11 of 445) in women with type 1 diabetes (P = 1.00). The figures for microalbuminuria were 4.5 (10 of 220) vs. 3.4% (15 of 445) (P = 0.39). Baseline glycemic control was comparable between women with type 2 diabetes (n = 15) and type 1 diabetes (n = 26). Blood pressure at baseline was median 128 (range 100-164)/81 (68-91) vs. 132 (100-176)/80 (63-100) mmHg (not significant) and antihypertensive therapy in type 2 versus type 1 diabetes was used in 0 and 62%, respectively, at baseline, increasing to 33 and 96%, respectively, in late pregnancy. Pregnancy outcome was comparable regardless type of diabetes; gestational age at delivery: 259 days (221-276) vs. 257 (184-271) (P = 0.19); birth weight 3,304 g (1,278-3,914) vs. 2,850 (370-4,180) (P = 0.67). CONCLUSIONS The prevalence of diabetic nephropathy and microalbuminuria in early pregnancy was similar in type 2 and type 1 diabetes. Antihypertensive therapy was used more frequently in type 1 diabetes. Pregnancy outcome was comparable regardless type of diabetes.
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Yoneda H, Ueta K, Nagasaki M, Arakawa K. Involvement of heparan sulfate in the renoprotective effects of imidapril, an angiotensin-converting enzyme inhibitor, in diabetic db/db mice. J Recept Signal Transduct Res 2013; 34:21-5. [PMID: 24094140 DOI: 10.3109/10799893.2013.845788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We investigated the renoprotective effects of imidapril hydrochloride ((-)-(4 S)-3-[(2 S)-2-[[(1 S)-1-ethoxycarbonyl-3-phenylpropyl] amino] propionyl]-1-methyl-2-oxoimidazolidine-4-carboxylic acid hydrochloride, imidapril), an angiotensin-converting enzyme inhibitor, in a diabetic animal model. We used BKS.Cg-+Lepr(db)/+Lepr(db) (db/db) mice, a genetic animal model of obese type 2 diabetes. Diabetic db/db mice suffered from glomerular hyperfiltration, albuminuria and hypoalbuminemia. Oral administration of 5 mg/kg/day of imidapril for 3 weeks suppressed renal hyperfiltration, reduced albuminuria and normalized hypoalbuminemia. Imidapril did not influence body weights, blood pressure or blood glucose concentrations in db/db mice. Urinary excretion of heparan sulfate (HS) in non-treated 11-week-old db/db mice was significantly lower than that in age-matched non-diabetic db/+m mice. HS is a component of HS proteoglycans, which are present in glomerular basement membranes and glycocalyx of cell surfaces. Reduced urinary HS excretion indicated glomerular HS loss in db/db mice. Imidapril increased urinary excretion of HS to concentrations observed in db/+m mice, indicating that imidapril prevented the loss of renal HS. These results suggest that imidapril ameliorates renal hyperfiltration and loss of renal contents of HS. Improvement of filtration function and maintenance of HS, which is an important structural component of glomeruli, may contribute to renoprotective effects of imidapril.
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Affiliation(s)
- Hikaru Yoneda
- Pharmacology Research Laboratories II, Mitsubishi Tanabe Pharma Corporation , Kawagishi, Toda-shi, Saitama , Japan
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25
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McFarlane P, Gilbert RE, MacCallum L, Senior P. La néphropathie chronique en présence de diabète. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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26
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Maahs DM, Caramori ML, Cherney DZ, Galecki AT, Gao C, Jalal D, Perkins BA, Pop-Busui R, Rossing P, Mauer M, Doria A. Uric acid lowering to prevent kidney function loss in diabetes: the preventing early renal function loss (PERL) allopurinol study. Curr Diab Rep 2013; 13:550-9. [PMID: 23649945 PMCID: PMC3703487 DOI: 10.1007/s11892-013-0381-0] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Diabetic kidney disease causes significant morbidity and mortality among people with type 1 diabetes (T1D). Intensive glucose and blood pressure control have thus far failed to adequately curb this problem and therefore a major need for novel treatment approaches exists. Multiple observations link serum uric acid levels to kidney disease development and progression in diabetes and strongly argue that uric acid lowering should be tested as one such novel intervention. A pilot of such a trial, using allopurinol, is currently being conducted by the Preventing Early Renal Function Loss (PERL) Consortium. Although the PERL trial targets T1D individuals at highest risk of kidney function decline, the use of allopurinol as a renoprotective agent may also be relevant to a larger segment of the population with diabetes. As allopurinol is inexpensive and safe, it could be cost-effective even for relatively low-risk patients, pending the completion of appropriate trials at earlier stages.
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Affiliation(s)
- David M. Maahs
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO
| | - M. Luiza Caramori
- Departments of Pediatrics and Medicine, University of Minnesota, Minneapolis, MN
| | - David Z.I. Cherney
- Department of Medicine and Division of Nephrology, University of Toronto, Toronto, ON
| | - Andrzej T. Galecki
- Division of Geriatrics/Institute of Gerontology, Medical School, and Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Chuanyun Gao
- Joslin Clinic, Joslin Diabetes Center, Boston, MA
| | - Diana Jalal
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO
| | - Bruce A. Perkins
- Department of Medicine and Division of Endocrinology, University of Toronto, Toronto, ON
| | - Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI
| | - Peter Rossing
- Steno Diabetes Center, Gentofte, Denmark
- HEALTH, University of Aarhus, Aarhus, Denmark
- NNF CBMR University of Copenhagen, Copenhagen, Denmark
| | - Michael Mauer
- Departments of Pediatrics and Medicine, University of Minnesota, Minneapolis, MN
| | - Alessandro Doria
- Research Division, Joslin Diabetes Center, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
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Abstract
Progressive renal dysfunction is a major complication of type 1 diabetes. Studying relationships between evolution of diabetic nephropathy lesions and renal functional alterations (structural-functional relationships) helps to better understand the natural history of diabetic nephropathy. The focus of this review is our current understanding of the interplay between morphologic changes of diabetic nephropathy and glomerular filtration rate (GFR) loss. These morphologic changes often may not progress in parallel to each other or to the decline in GFR or increase in albumin excretion rate (AER). Quantitative measures of renal (mainly glomerular) structural changes can predict a substantially larger fraction of AER variability compared with that of GFR, especially using linear correlation analyses. However, nonlinear models better fit the structural-functional relationships across a wide range of GFRs and AERs. Currently, there are insufficient longitudinal data to show which structural changes predict the slope of GFR decline in type 1 diabetic patients. Based on cross-sectional studies, however, such a predictor would be about 10% more robust in patients whose GFR was 45 mL/min/1.73 m(2) or greater if comprised of a composite of glomerular, tubular, and interstitial parameters versus glomerular changes alone. For a slowly progressive disease, such as diabetic nephropathy, in which, especially in the earlier stages, it takes a long time for GFR to decline substantially, such predictors are much needed and, if sufficiently precise, could potentially serve as a surrogate of renal functional decline in clinical trials.
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Affiliation(s)
- Behzad Najafian
- Department of Pathology, University of Washington, Seattle, WA, USA
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29
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Vivian E, Mannebach C. Therapeutic approaches to slowing the progression of diabetic nephropathy - is less best? Drugs Context 2013; 2013:212249. [PMID: 24432038 PMCID: PMC3884747 DOI: 10.7573/dic.212249] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 01/28/2013] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors are known to reduce proteinuria and have been the first-line agents in the management of diabetic nephropathy for the past 20 years. This review covers recent studies that compare the benefit of additional blockage of the renin-angiotensin-aldosterone system through combination therapy with an ACE inhibitor and ARB, or a direct renin inhibitor (DRI), to monotherapy. DESIGN Primary and review articles that addressed the pathophysiology, diagnosis, and therapeutic options for attenuating the progression of diabetic nephropathy were retrieved through a MEDLINE search (January 1990 to December 2012) and the bibliographies of identified articles were reviewed. English language sources were searched using the following search terms: diabetes mellitus, nephropathy, proteinuria, ACE inhibitors, ARBs, and DRIs. SETTING Randomized, placebo-controlled, short- and long-term studies published in peer-reviewed journals that were determined to be methodologically sound, with appropriate statistical analysis of the results, were selected for inclusion in this review. PARTICIPANTS Adult (≥18 years) patients with diabetic nephropathy. MEASUREMENTS Serum creatinine level was used to estimate glomerular filtration rate (GFR). GFR was calculated using the four-variable Modification of Diet in Renal Disease formula. The urine albumin-to-creatinine ratio was measured at baseline and at the conclusion of each study. A value between 3.4 mg/mmol and below 33.9 mg/mmol was defined as microalbuminuria. A value of 33.9 mg/mmol or more (approximately 300 mg/g creatinine) was defined as macroalbuminuria. RESULTS ACE inhibitors and ARBs are now the mainstay of treatment for diabetic nephropathy. However, combination therapy with an ACE inhibitor and an ARB, or DRI, has not been found to be more effective than monotherapy with an ACE inhibitor or ARB, and may increase the risk of hyperkalemia or acute kidney injury. CONCLUSION Both ACE inhibitors and ARBs remain the first-line agents in attenuating the progression of diabetic nephropathy; however, recent studies suggest that combining an ACE inhibitor with an ARB, or combining a DRI with an ACE inhibitor or ARB, may increase adverse events without clinical benefits to offset them.
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Affiliation(s)
- Eva Vivian
- University of Wisconsin-Madison, School of Pharmacy, Madison, USA
| | - Chelsea Mannebach
- Idaho State University Affiliate Faculty, Boise Veterans Affairs Medical Center, Boise, USA
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Pandya KG, Budhram R, Clark G, Lau-Cam CA. Comparative Evaluation of Taurine and Thiotaurine as Protectants Against Diabetes-Induced Nephropathy in a Rat Model. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 775:371-94. [DOI: 10.1007/978-1-4614-6130-2_29] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Inoue N, Hidaka S, Miura N, Yamada K, Fukahori M, Maruyama M, Kawahara S, Ohta K, Muguruma M. Effects of Liver Hydrolysate on the Blood Glucose in Metabolic Syndrome Model Rats (SHR/NDmcr-cp). YAKUGAKU ZASSHI 2013; 133:117-23. [DOI: 10.1248/yakushi.y110185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Naonori Inoue
- Interdisciplinary Graduate School of Agriculture and Engineering, University of Miyazaki
- Consumer Healthcare Laboratories, Central Research Laboratories, Zeria Pharmaceutical Co., Ltd
| | - Shuji Hidaka
- Laboratory of Food Science and Nutrition, Department of Biochemistry and Applied Biosciences, Faculty of Agriculture, University of Miyazaki
| | - Naoyoshi Miura
- Consumer Healthcare Laboratories, Central Research Laboratories, Zeria Pharmaceutical Co., Ltd
| | - Kotaro Yamada
- Consumer Healthcare Products Development, Zeria Pharmaceutical Co., Ltd
| | - Masahiro Fukahori
- Consumer Healthcare Products Development, Zeria Pharmaceutical Co., Ltd
| | - Masugi Maruyama
- Department of Applied Physiology, Faculty of Medicine, University of Miyazaki
| | - Satoshi Kawahara
- Interdisciplinary Graduate School of Agriculture and Engineering, University of Miyazaki
- Laboratory of Food Science and Nutrition, Department of Biochemistry and Applied Biosciences, Faculty of Agriculture, University of Miyazaki
| | - Kazuyoshi Ohta
- Interdisciplinary Graduate School of Agriculture and Engineering, University of Miyazaki
- Laboratory of Food Science and Nutrition, Department of Biochemistry and Applied Biosciences, Faculty of Agriculture, University of Miyazaki
| | - Michio Muguruma
- Interdisciplinary Graduate School of Agriculture and Engineering, University of Miyazaki
- Laboratory of Food Science and Nutrition, Department of Biochemistry and Applied Biosciences, Faculty of Agriculture, University of Miyazaki
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Mathiesen ER, Ringholm L, Feldt-Rasmussen B, Clausen P, Damm P. Obstetric nephrology: pregnancy in women with diabetic nephropathy--the role of antihypertensive treatment. Clin J Am Soc Nephrol 2012; 7:2081-8. [PMID: 22917698 DOI: 10.2215/cjn.00920112] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This review highlights factors of importance for the clinical care of pregnant women with pregestational diabetes and microalbuminuria or diabetic nephropathy with particular focus on the role of intensive antihypertensive treatment during pregnancy. Most information in the literature comes from women with type 1 diabetes and diabetic nephropathy, but this is probably also valid for women with type 2 diabetes. Careful counseling of women with diabetic nephropathy before pregnancy with estimation of the risk for the mother and fetus is important. Pregnancy does not result in worsening of kidney function in women with diabetic nephropathy and normal serum creatinine, but pregnancy complications such as pre-eclampsia and preterm delivery are common. Intensive metabolic control before and during pregnancy, low-dose aspirin from 12 gestational weeks onward, and intensive antihypertensive treatment are important. Methyldopa, labetalol, and nifedipine are regarded safe in pregnancy, whereas angiotensin converting enzyme inhibitors, AngII antagonists, or statins should be paused before pregnancy. Case series and pathophysiological studies support the use of a stringent goal for BP and albumin excretion in pregnant women with diabetic nephropathy. Screening for diabetic retinopathy before and during pregnancy is mandatory and laser treatment should be performed if indicated. Pregnancy outcome in women with diabetic nephropathy has improved considerably with a take-home-baby rate of approximately 95%. Further research on the benefits and risks of intensive antihypertensive treatment in this population is needed.
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Affiliation(s)
- Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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VandenBerg P. Dr. David Cherney, Canadian Diabetes Association-KRESCENT Joint New InvestigatorAwardee. Can J Diabetes 2011. [DOI: 10.1016/s1499-2671(11)51002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Stevens LA, Claybon MA, Schmid CH, Chen J, Horio M, Imai E, Nelson RG, Van Deventer M, Wang HY, Zuo L, Zhang YL, Levey AS. Evaluation of the Chronic Kidney Disease Epidemiology Collaboration equation for estimating the glomerular filtration rate in multiple ethnicities. Kidney Int 2010; 79:555-62. [PMID: 21107446 DOI: 10.1038/ki.2010.462] [Citation(s) in RCA: 377] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
An equation from the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) provides more accurate estimates of the glomerular filtration rate (eGFR) than that from the modification of diet in renal disease (MDRD) Study, although both include a two-level variable for race (Black and White and other). Since creatinine generation differs among ethnic groups, it is possible that a multilevel ethnic variable would allow more accurate estimates across all groups. To evaluate this, we developed an equation to calculate eGFR that includes a four-level race variable (Black, Asian, Native American and Hispanic, and White and other) using a database of 8254 patients pooled from 10 studies. This equation was then validated in 4014 patients using 17 additional studies from the United States and Europe (validation database), and in 1022 patients from China (675), Japan (248), and South Africa (99). Coefficients for the Black, Asian, and Native American and Hispanic groups resulted in 15, 5, and 1% higher levels of eGFR, respectively, compared with the White and other group. In the validation database, the two-level race equation had minimal bias in Black, Native American and Hispanic, and White and other cohorts. The four-level ethnicity equation significantly improved bias in Asians of the validation data set and in Chinese. Both equations had a large bias in Japanese and South African patients. Thus, heterogeneity in performance among the ethnic and geographic groups precludes use of the four-level race equation. The CKD-EPI two-level race equation can be used in the United States and Europe across a wide range of ethnicity.
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Affiliation(s)
- Lesley A Stevens
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts 02111, USA.
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Abstract
The mechanisms that drive the development of diabetic nephropathy remain undetermined. Only 30-40% of patients with diabetes mellitus develop overt nephropathy, which suggests that other contributing factors besides the diabetic state are required for the progression of diabetic nephropathy. Endothelial dysfunction is associated with human diabetic nephropathy and retinopathy, and advanced diabetic glomerulopathy often exhibits thrombotic microangiopathy, including glomerular capillary microaneurysms and mesangiolysis, which are typical manifestations of endothelial dysfunction in the glomerulus. Likewise, diabetic mice with severe endothelial dysfunction owing to deficiency of endothelial nitric oxide synthase develop progressive nephropathy and retinopathy similar to the advanced lesions observed in humans with diabetes mellitus. Additionally, inhibitors of the renin-angiotensin system fail to be renoprotective in some individuals with diabetic nephropathy (due in part to aldosterone breakthrough) and in some mouse models of the disease. In this Review, we discuss the clinical and experimental evidence that supports a role for endothelial nitric oxide deficiency and subsequent endothelial dysfunction in the progression of diabetic nephropathy and retinopathy. If endothelial dysfunction is the key factor required for diabetic nephropathy, then agents that improve endothelial function or raise intraglomerular nitric oxide level could be beneficial in the treatment of diabetic nephropathy.
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Lemley KV. When to initiate ACEI/ARB therapy in patients with type 1 and 2 diabetes. Pediatr Nephrol 2010; 25:2021-34. [PMID: 20352458 DOI: 10.1007/s00467-010-1498-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Revised: 02/08/2010] [Accepted: 02/16/2010] [Indexed: 10/19/2022]
Abstract
Angiotensin converting enzyme inhibitors (ACEI) and angiotensin 2 receptor blockers (ARB) have become a mainstay of adjunctive therapy for the prevention and amelioration of diabetic nephropathy. Although ACEI were shown over 20 years ago to slow the rate of loss of renal function in diabetic subjects with decreased renal function, the question of how early in the course of diabetes to introduce them remains unresolved. Recent studies suggest that very early initiation of ACEI/ARB therapy may not have demonstrable beneficial effects even over a period of years.
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Affiliation(s)
- Kevin V Lemley
- Division of Nephrology, MS#40, Childrens Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA.
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Stevens LA, Schmid CH, Greene T, Zhang YL, Beck GJ, Froissart M, Hamm LL, Lewis JB, Mauer M, Navis GJ, Steffes MW, Eggers PW, Coresh J, Levey AS. Comparative performance of the CKD Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal Disease (MDRD) Study equations for estimating GFR levels above 60 mL/min/1.73 m2. Am J Kidney Dis 2010; 56:486-95. [PMID: 20557989 DOI: 10.1053/j.ajkd.2010.03.026] [Citation(s) in RCA: 442] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Accepted: 03/16/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Modification of Diet in Renal Disease (MDRD) Study equation underestimates measured glomerular filtration rate (GFR) at levels>60 mL/min/1.73 m2, with variable accuracy among subgroups; consequently, estimated GFR (eGFR)>or=60 mL/min/1.73 m2 is not reported by clinical laboratories. Here, performance of a more accurate GFR-estimating equation, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, is reported by level of GFR and clinical characteristics. STUDY DESIGN Test of diagnostic accuracy. SETTING & PARTICIPANTS Pooled data set of 3,896 people from 16 studies with measured GFR (not used for the development of either equation). Subgroups were defined by eGFR, age, sex, race, diabetes, prior solid-organ transplant, and body mass index. INDEX TESTS eGFR from the CKD-EPI and MDRD Study equations and standardized serum creatinine. REFERENCE TEST Measured GFR using urinary or plasma clearance of exogenous filtration markers. RESULTS Mean measured GFR was 68+/-36 (SD) mL/min/1.73 m2. For eGFR<30 mL/min/1.73 m2, both equations have similar bias (median difference compared with measured GFR). For eGFR of 30-59 mL/min/1.73 m2, bias was decreased from 4.9 to 2.1 mL/min/1.73 m2 (57% improvement). For eGFR of 60-89 mL/min/1.73 m2, bias was decreased from 11.9 to 4.2 mL/min/1.73 m2 (61% improvement). For eGFR of 90-119 mL/min/1.73 m2, bias was decreased from 10.0 to 1.9 mL/min/1.73 m2 (75% improvement). Similar or improved performance was noted for most subgroups with eGFR<90 mL/min/1.73 m2, other than body mass index<20 kg/m2, with greater variation noted for some subgroups with eGFR>or=90 mL/min/1.73 m2. LIMITATIONS Limited number of elderly people and racial and ethnic minorities with measured GFR. CONCLUSIONS The CKD-EPI equation is more accurate than the MDRD Study equation overall and across most subgroups. In contrast to the MDRD Study equation, eGFR>or=60 mL/min/1.73 m2 can be reported using the CKD-EPI equation.
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Bacic A, Kogika MM, Barbaro KC, Iuamoto CS, Simões DMN, Santoro ML. Evaluation of albuminuria and its relationship with blood pressure in dogs with chronic kidney disease. Vet Clin Pathol 2010; 39:203-9. [DOI: 10.1111/j.1939-165x.2009.00207.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Abstract
Diabetes is the most common cause of end-stage renal disease in industrialized countries. This article describes the structural changes in early diabetic nephropathy and the relationship with renal functional parameters, blood pressure, and albumin excretion. The detrimental influence of sustained hyperglycemia and/or glycemic fluctuations on renal structural change has been well documented. Tight glycemic control is paramount to preventing the development, and even the regression, of renal lesions. As much of the renal injury from diabetes occurs in clinical silence before symptoms or laboratory findings of renal injury are evident, finding early markers of risk is imperative so that nephropathy can be prevented. Currently, the only clinical surrogate marker of diabetic renal injury available is microalbuminuria. However, given the reports of regression of microalbuminuria back to normoalbuminuria, the reliability of this tool as an indicator of risk has been questioned. The need for alternative, noninvasive surrogate markers is described in this report.
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Affiliation(s)
- Julia M Steinke
- Division of Pediatric Nephrology, Dialysis and Transplantation, Helen Devos Children's Hospital and Clinics, , Grand Rapids, MI 49503, USA.
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Stevens LA, Schmid CH, Zhang YL, Coresh J, Manzi J, Landis R, Bakoush O, Contreras G, Genuth S, Klintmalm GB, Poggio E, Rossing P, Rule AD, Weir MR, Kusek J, Greene T, Levey AS. Development and validation of GFR-estimating equations using diabetes, transplant and weight. Nephrol Dial Transplant 2009; 25:449-57. [PMID: 19793928 DOI: 10.1093/ndt/gfp510] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND We have reported a new equation (CKD-EPI equation) that reduces bias and improves accuracy for GFR estimation compared to the MDRD study equation while using the same four basic predictor variables: creatinine, age, sex and race. Here, we describe the development and validation of this equation as well as other equations that incorporate diabetes, transplant and weight as additional predictor variables. METHODS Linear regression was used to relate log-measured GFR (mGFR) to sex, race, diabetes, transplant, weight, various transformations of creatinine and age with and without interactions. Equations were developed in a pooled database of 10 studies [2/3 (N = 5504) for development and 1/3 (N = 2750) for internal validation], and final model selection occurred in 16 additional studies [external validation (N = 3896)]. RESULTS The mean mGFR was 68, 67 and 68 ml/min/ 1.73 m(2) in the development, internal validation and external validation datasets, respectively. In external validation, an equation that included a linear age term and spline terms in creatinine to account for a reduction in the magnitude of the slope at low serum creatinine values exhibited the best performance (bias = 2.5, RMSE = 0.250) among models using the four basic predictor variables. Addition of terms for diabetes and transplant did not improve performance. Equations with weight showed a small improvement in the subgroup with BMI <20 kg/m(2). CONCLUSIONS The CKD-EPI equation, based on creatinine, age, sex and race, has been validated and is more accurate than the MDRD study equation. The addition of weight, diabetes and transplant does not significantly improve equation performance.
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Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, Feldman HI, Kusek JW, Eggers P, Van Lente F, Greene T, Coresh J. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009. [PMID: 19414839 DOI: 10.7326/0003-4819-150-9-200905050-0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Equations to estimate glomerular filtration rate (GFR) are routinely used to assess kidney function. Current equations have limited precision and systematically underestimate measured GFR at higher values. OBJECTIVE To develop a new estimating equation for GFR: the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. DESIGN Cross-sectional analysis with separate pooled data sets for equation development and validation and a representative sample of the U.S. population for prevalence estimates. SETTING Research studies and clinical populations ("studies") with measured GFR and NHANES (National Health and Nutrition Examination Survey), 1999 to 2006. PARTICIPANTS 8254 participants in 10 studies (equation development data set) and 3896 participants in 16 studies (validation data set). Prevalence estimates were based on 16,032 participants in NHANES. MEASUREMENTS GFR, measured as the clearance of exogenous filtration markers (iothalamate in the development data set; iothalamate and other markers in the validation data set), and linear regression to estimate the logarithm of measured GFR from standardized creatinine levels, sex, race, and age. RESULTS In the validation data set, the CKD-EPI equation performed better than the Modification of Diet in Renal Disease Study equation, especially at higher GFR (P < 0.001 for all subsequent comparisons), with less bias (median difference between measured and estimated GFR, 2.5 vs. 5.5 mL/min per 1.73 m(2)), improved precision (interquartile range [IQR] of the differences, 16.6 vs. 18.3 mL/min per 1.73 m(2)), and greater accuracy (percentage of estimated GFR within 30% of measured GFR, 84.1% vs. 80.6%). In NHANES, the median estimated GFR was 94.5 mL/min per 1.73 m(2) (IQR, 79.7 to 108.1) vs. 85.0 (IQR, 72.9 to 98.5) mL/min per 1.73 m(2), and the prevalence of chronic kidney disease was 11.5% (95% CI, 10.6% to 12.4%) versus 13.1% (CI, 12.1% to 14.0%). LIMITATION The sample contained a limited number of elderly people and racial and ethnic minorities with measured GFR. CONCLUSION The CKD-EPI creatinine equation is more accurate than the Modification of Diet in Renal Disease Study equation and could replace it for routine clinical use. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.
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Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, Feldman HI, Kusek JW, Eggers P, Van Lente F, Greene T, Coresh J. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150:604-12. [PMID: 19414839 PMCID: PMC2763564 DOI: 10.7326/0003-4819-150-9-200905050-00006] [Citation(s) in RCA: 17966] [Impact Index Per Article: 1197.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Equations to estimate glomerular filtration rate (GFR) are routinely used to assess kidney function. Current equations have limited precision and systematically underestimate measured GFR at higher values. OBJECTIVE To develop a new estimating equation for GFR: the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. DESIGN Cross-sectional analysis with separate pooled data sets for equation development and validation and a representative sample of the U.S. population for prevalence estimates. SETTING Research studies and clinical populations ("studies") with measured GFR and NHANES (National Health and Nutrition Examination Survey), 1999 to 2006. PARTICIPANTS 8254 participants in 10 studies (equation development data set) and 3896 participants in 16 studies (validation data set). Prevalence estimates were based on 16,032 participants in NHANES. MEASUREMENTS GFR, measured as the clearance of exogenous filtration markers (iothalamate in the development data set; iothalamate and other markers in the validation data set), and linear regression to estimate the logarithm of measured GFR from standardized creatinine levels, sex, race, and age. RESULTS In the validation data set, the CKD-EPI equation performed better than the Modification of Diet in Renal Disease Study equation, especially at higher GFR (P < 0.001 for all subsequent comparisons), with less bias (median difference between measured and estimated GFR, 2.5 vs. 5.5 mL/min per 1.73 m(2)), improved precision (interquartile range [IQR] of the differences, 16.6 vs. 18.3 mL/min per 1.73 m(2)), and greater accuracy (percentage of estimated GFR within 30% of measured GFR, 84.1% vs. 80.6%). In NHANES, the median estimated GFR was 94.5 mL/min per 1.73 m(2) (IQR, 79.7 to 108.1) vs. 85.0 (IQR, 72.9 to 98.5) mL/min per 1.73 m(2), and the prevalence of chronic kidney disease was 11.5% (95% CI, 10.6% to 12.4%) versus 13.1% (CI, 12.1% to 14.0%). LIMITATION The sample contained a limited number of elderly people and racial and ethnic minorities with measured GFR. CONCLUSION The CKD-EPI creatinine equation is more accurate than the Modification of Diet in Renal Disease Study equation and could replace it for routine clinical use. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.
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Kim SK, Jung KH, Lee BC. Protective Effect of Tanshinone IIA on the Early Stage of Experimental Diabetic Nephropathy. Biol Pharm Bull 2009; 32:220-4. [DOI: 10.1248/bpb.32.220] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Su Kang Kim
- Kohwang Medical Research Institute, Kyung Hee University
| | - Kyung-Hee Jung
- Kohwang Medical Research Institute, Kyung Hee University
| | - Byung-Cheol Lee
- Department of Internal Medicine, College of Oriental Medicine, Kyung Hee University
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Abstract
Early renal insufficiency (ERI), defined as a calculated or measured glomerular filtration rate (GFR) between 30 and 60 mL/min per 1.73 m2, is present in more than 10% of the adult Australian population. This pernicious condition is frequently unrecognised, progressive and accompanied by multiple associated comorbidities, including hypertension, renal osteodystrophy, anaemia, sleep apnoea, cardiovascular disease, hyperparathyroidism and malnutrition. Several treatments have been suggested to retard GFR decline in ERI, including blood pressure reduction, angiotensin-converting enzyme inhibition, angiotensin receptor antagonism, calcium channel blockade, cholesterol reduction, smoking cessation, erythropoietin therapy, dietary protein restriction, intensive glycaemic control and early intensive multidisciplinary patient education within a renal unit. In addition, specific interventions have been reported to be renoprotective in atherosclerotic renal artery stenosis, diabetic nephropathy, lupus nephritis and certain forms of primary glomerulonephritis. The present paper reviews the available published randomised controlled clinical trials and meta-analyses supporting (or refuting) a role for each of these therapeutic manoeuvres.
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Affiliation(s)
- D W Johnson
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Queensland 4102, Australia.
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Renin–angiotensin system blockade in diabetic nephropathy. Diabetes Metab Syndr 2008. [DOI: 10.1016/j.dsx.2008.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Perrin NESS, Jaremko GA, Berg UB. The effects of candesartan on diabetes glomerulopathy: a double-blind, placebo-controlled trial. Pediatr Nephrol 2008; 23:947-54. [PMID: 18270751 DOI: 10.1007/s00467-008-0745-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Revised: 12/21/2007] [Accepted: 12/28/2007] [Indexed: 12/17/2022]
Abstract
Our objective was to study the effects of candesartan on diabetic glomerulopathy in young normoalbuminuric and normotensive patients with type 1 diabetes in a double-blind, placebo-controlled trial. In 13 patients aged 24 years at baseline, we evaluated blood pressure, kidney biopsies and kidney function tests at baseline and after 5 years of treatment. Kidney biopsies were examined with light and electron microscopy, glomerular filtration rate and effective renal plasma flow determined with inulin and para-aminohippuric acid clearances. Two patients in the placebo group needed antihypertensive treatment because they developed microalbuminuria and/or hypertension, but no patient in the candesartan group did. A significant reduction in mesangial matrix volume and mesangial volume occurred in the candesartan group, although changes in morphological parameters were similar between groups. Office blood pressure was significantly lower in the candesartan group at follow-up than in the placebo group. Deterioration in morphological parameters observed in earlier studies of our patients did not become worse during treatment with candesartan or placebo. The effects of candesartan, with reduction in morphological parameters and lowering of blood pressure, might influence future treatment of glomerulopathy in type 1 diabetes patients.
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Affiliation(s)
- Nina E S S Perrin
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, B57, Children's Hospital, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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Schjoedt KJ, Hansen HP, Tarnow L, Rossing P, Parving HH. Long-term prevention of diabetic nephropathy: an audit. Diabetologia 2008; 51:956-61. [PMID: 18385971 DOI: 10.1007/s00125-008-0990-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Accepted: 02/12/2008] [Indexed: 10/22/2022]
Abstract
AIMS/HYPOTHESIS In type 1 diabetic patients with microalbuminuria not receiving antihypertensive treatment, an increase in urinary AER (UAER) of 6-14%/year and a risk of developing diabetic nephropathy (DN) of 3-30%/year have been reported. We audited the long-term effect of blocking the renin-angiotensin-aldosterone system (RAAS) with an ACE inhibitor (ACEI) or angiotensin II receptor blocker (ARB) in microalbuminuric type 1 diabetic patients on progression of microalbuminuria and development of DN. METHODS All patients with type 1 diabetes and persistent microalbuminuria (30-300 mg/24 h) were identified (n=227) in 1995 at Steno Diabetes Center and followed for 11 years. Development of DN was defined as a UAER of >300 mg/24 h in two of three consecutive urine samples. RESULTS Age and duration of diabetes at baseline (mean+/-SD) were 46+/-15 and 28+/-13 years, respectively. During follow-up 14 patients emigrated and 58 (26%) died. Over the same period 79% were treated with an ACEI or ARB. There was a mean decline in UAER of 4%/year. Sixty-five patients (29%) progressed to overt DN, corresponding to 3.1%/year. However, 29 of them regressed to normo- or microalbuminuria on intensified antihypertensive treatment. Glycaemic control and blood pressure remained nearly unchanged. CONCLUSIONS/INTERPRETATION In our outpatient clinic, the implementation of RAAS-blocking treatment in type 1 diabetic patients with microalbuminuria successfully reduced long-term progression to overt DN to a rate similar to those previously reported in randomised, double-blind intervention trials of shorter duration using RAAS blockade.
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Affiliation(s)
- K J Schjoedt
- Steno Diabetes Center, Niels Steensens Vej 1, 2820 Gentofte, Denmark.
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Franek E, Fliser D, Ritz E. Section Review: Cardiovascular & Renal: Angiotensin converting enzyme inhibitors and nephroprotection. Expert Opin Investig Drugs 2008. [DOI: 10.1517/13543784.4.11.1139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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