Statin initiation and risk of incident kidney disease in patients with diabetes

Association between lipid-lowering drug targets and the risk of cystic kidney disease: a drug-target Mendelian randomization analysis

BACKGROUND

Evidence regarding the causal relationship between lipid-lowering drugs and cystic kidney disease, including polycystic kidney disease (PKD), was limited. This study aimed to evaluate the causal relationship between lipid phenotypes mediated by lipid-lowering drug targets-3-hydroxy-3-methyl glutaryl coenzyme A reductase (HMGCR), proprotein convertase subtilisin/kexin type-9 (PCSK9), and Niemann-Pick C1-like 1 (NPC1L1)-and the risk of cystic kidney disease and PKD.

METHODS

Genetic variants encoding lipid-lowering drug targets-HMGCR, PCSK9, and NPC1L1-from published genome-wide association study (GWAS) statistics were collected to perform drug target Mendelian randomization (MR) analysis. Summary statistics for the GWAS of cystic kidney disease and PKD were obtained from the FinnGen consortium and the European Bioinformatics Institute. Inverse variance weighting (IVW) was used as the primary MR analysis method, with sensitivity analyses conducted to ensure the robustness of the results.

RESULTS

Increased gene expression of HMGCR was associated with an elevated risk of cystic kidney disease (IVW-MR: odds ratio [OR] = 3.05, 95% confidence interval [CI] = 1.19-7.84, p = 0.02) and PKD (IVW-MR: OR = 2.13, 95% CI = 1.01-4.46; p = 0.045). There was no evidence of causal effects of PCSK9 and NPC1L1 targets on cystic kidney disease and PKD. Cochran's Q test, MR-PRESSO, and MR-Egger intercept tests showed no heterogeneity or horizontal pleiotropy among the instrumental variables.

CONCLUSIONS

This study supported that increased HMGCR expression was associated with an increased risk of cystic kidney disease and PKD, suggesting potential benefits of statin therapy for cystic kidney disease and PKD. Further research is necessary to elucidate specific mechanisms and potential therapeutic applications of HMGCR inhibitors.

Prognosis of non-albuminuric patients with the cardiovascular-kidney-metabolic syndrome

Background

Cardiovascular-kidney-metabolic (CKM) syndrome affects a significant portion of the general population. Urinary albumin-to-creatinine ratio (UACR) is an important indicator of kidney injury. While some studies have indicated associations between UACR within the normal range and mortality outcomes, it remains uncertain whether traditionally normal UACR could help to distinguish the prognosis of CKM patients.

Methods

This cohort study included patients with CKM syndrome at stages 2 and 3 and traditionally normal UACR from the China Renal Data System (CRDS) and UK Biobank (UKB) databases. UACR was treated as a continuous variable and categorized into low-normal and high-normal. The associations were initially assessed in the CRDS database and subsequently validated in the UKB database. Multivariable Cox proportional hazards regression was employed to estimate the associations with UACR. Additionally, subgroup analyses and sensitivity analyses were conducted to enhance the robustness of the results.

Results

The study encompassed a total of 14 602 patients from the CRDS database and 82 694 patients from the UKB database. Near-linear associations were identified between continuous UACR levels and progression to CKM stage 4, as well as all-cause mortality. When compared with the low-normal UACR group, individuals with high-normal UACR exhibited an elevated risk of progression to CKM stage 4 (HR 1.133, 95% CI 1.026-1.250) and increased all-cause mortality (HR 2.321, 95% CI 1.679-3.208) within the CRDS database. These associations were further corroborated in the UKB database. Consistent findings were also observed through subgroup analyses and sensitivity analyses.

Conclusions

The findings indicate that elevated UACR levels within the normal range are significantly associated with poor prognosis among CKM patients at stages 2 and 3. These results underscore the critical role of UACR in identifying high-risk populations, particularly among individuals with metabolic disorders. This information may prove valuable for monitoring and implementing risk intervention strategies for CKM patients.

Causal Association Between Cholesterol-Lowering Drugs and Diabetic Microvascular Complications: A Drug-Target Mendelian Randomization Study

Background: It remains unclear whether cholesterol-lowering therapy can reduce the incidence of microvascular complications in patients with diabetes. We aim to explore the potential causal relationship between three common types of cholesterol-lowering drugs and diabetic microvascular complications through drug-target Mendelian randomization (MR) study, laying the groundwork for the development of new medications. Methods: In this study, we collected single nucleotide polymorphisms (SNPs) associated with HMGCR (3-hydroxy-3-methylglutaryl-CoA reductase) inhibitors, PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors, and NPC1L1 (Niemann-Pick C1-Like 1) inhibitors from published genome-wide association study statistics. Subsequently, drug-target MR analyses were performed to investigate the effects of these inhibitors on low-density lipoprotein cholesterol (LDL-C) level-mediated microvascular complications in diabetes mellitus. Coronary atherosclerosis as a positive control. Primary outcomes included diabetic nephropathy, diabetic retinopathy, and diabetic neuropathy from the FinnGen Consortium. Results: The MR analysis revealed significant associations between HMGCR inhibition and increased risks of diabetic nephropathy (OR [95%confidence interval (CI)] = 1.88 [1.50, 2.36], p = 5.55 × 10-8), retinopathy (OR [95%CI] = 1.86 [1.54, 2.24], p = 6.28 × 10-11), and neuropathy (OR [95%CI] = 2.63 [1.84, 3.75], p = 1.14 × 10-7) using the inverse variance weighted method. PCSK9 inhibitors have been associated with an increased risk of diabetic nephropathy (OR [95%CI] = 1.30 [1.07, 1.58], p = 0.009) and diabetic neuropathy (OR [95%CI] = 1.40 [1.15, 1.72], p = 0.001); NPC1L1 inhibitors significantly reduce the incidence of diabetic retinopathy (OR [95%CI] = 0.48 [0.28, 0.85], p = 0.01). The coronary heart disease as positive control. Conclusions: The findings show that HMGCR inhibitors and PCSK9 inhibitors may significantly increase the risk of diabetic microvascular complications. However, NPC1L1 inhibitors may provide protection against diabetic retinopathy.

Dipeptidyl Peptidase 4 Inhibitors vs Metformin for New-onset Dementia: A Propensity Score-matched Cohort Study

BACKGROUND

Hypoglycemic pharmacotherapy interventions for alleviating the risk of dementia remain controversial, particularly regarding dipeptidyl peptidase 4 (DPP4) inhibitors vs metformin. Our objective was to investigate whether the initiation of DPP4 inhibitors, as opposed to metformin, was linked to a reduced risk of dementia.

METHODS

We included individuals with type 2 diabetes over 40 years old who were new users of DPP4 inhibitors or metformin in the Chinese Renal Disease Data System database between 2009 and 2020. The study employed Kaplan-Meier and Cox regression for survival analysis and the Fine and Gray model for the competing risk of death.

RESULTS

Following a 1:1 propensity score matching, the analysis included 3626 DPP4 inhibitor new users and an equal number of metformin new users. After adjusting for potential confounders, the utilization of DPP4 inhibitors was associated with a decreased risk of all-cause dementia compared to metformin [hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.45-0.89]. Subgroup analysis revealed that the utilization of DPP4 inhibitors was associated with a reduced incidence of dementia in individuals who initiated drug therapy at the age of 60 years or older (HR 0.69, 95% CI 0.48-0.98), those without baseline macrovascular complications (HR 0.62, 95% CI 0.41-0.96), and those without baseline microvascular complications (HR 0.67, 95% CI 0.47-0.98).

CONCLUSION

In this real-world study, we found that DPP4 inhibitors presented an association with a lower risk of dementia in individuals with type 2 diabetes than metformin, particularly in older people and those without diabetes-related comorbidities.

High-Density Lipoprotein in Patients with Diabetic Kidney Disease: Friend or Foe?

High-density lipoprotein (HDL) exhibits multiple metabolic protective functions, such as facilitating cellular cholesterol efflux, antioxidant, anti-inflammatory, anti-apoptotic and anti-thrombotic properties, showing antidiabetic and renoprotective potential. Diabetic kidney disease (DKD) is considered to be associated with high-density lipoprotein cholesterol (HDL-C). The hyperglycemic environment, non-enzymatic glycosylation, carbamylation, oxidative stress and systemic inflammation can cause changes in the quantity and quality of HDL, resulting in reduced HDL levels and abnormal function. Dysfunctional HDL can also have a negative impact on pancreatic β cells and kidney cells, leading to the progression of DKD. Based on these findings, new HDL-related DKD risk predictors have gradually been proposed. Interventions aiming to improve HDL levels and function, such as infusion of recombinant HDL (rHDL) or lipid-poor apolipoprotein A-I (apoA-I), can significantly improve glycemic control and also show renal protective effects. However, recent studies have revealed a U-shaped relationship between HDL-C levels and DKD, and the loss of protective properties of high levels of HDL may be related to changes in composition and the deposition of dysfunctional particles that exacerbate damage. Further research is needed to fully elucidate the complex role of HDL in DKD. Given the important role of HDL in metabolic health, developing HDL-based therapies that augment HDL function, rather than simply increasing its level, is a critical step in managing the development and progression of DKD.

Acute kidney injury is associated with liver-related outcomes in patients with hepatitis B virus infection: a retrospective cohort study

BACKGROUND

The effects of acute kidney injury (AKI) on liver-related outcomes in patients with hepatitis B virus (HBV) infection remain unclear. The study aimed to evaluate the association between AKI with liver-related mortality and complications in patients with HBV infection.

METHODS

The multicenter, retrospective cohort study included Chinese adults with HBV infection from 24 regional central hospitals between January 2000 and December 2022. AKI was defined as a ≥ 26.5 μmol/l increase in serum creatinine concentration within 48 h, or a ≥ 50% increase over the baseline within 7 days. The primary outcome was post-discharge liver-related mortality, while the secondary outcome was a composite of new-onset liver cirrhosis and hepatocellular carcinoma. Cox proportional hazard model was employed for analyses.

RESULTS

Of the 86,204 inpatients with HBV infection and without liver cancer or cirrhosis at baseline, 4407(5.1%) patients experienced AKI. During a mean follow-up of 4.6 ± 2.4 years, 334 (0.4%) patients died of liver-related events. After adjustment, AKI during hospitalization was significantly associated with a higher risk of liver-related mortality after discharge (adjusted hazard ratio (HR), 1.78; 95% confidence intervals (CI), 1.26-2.51, P = 0.001), especially in those with severe AKI. Similarly, AKI was associated with a higher risk of cirrhosis or new-onset hepatocellular carcinoma (adjusted HR, 1.33; 95%CI, 1.10-1.60, P = 0.004). The association between AKI and liver-related outcomes remained consistent across different subgroups.

CONCLUSIONS

AKI during hospitalization was associated with substantial increased risk of liver-related mortality and incident liver-related complication. Our findings highlight the importance of monitoring AKI in patients with HBV infection for tailoring personalized treatments.

Characteristics of patients with undiagnosed stage 3 chronic kidney disease: results from an observational study (REVEAL-CKD) in China

Background

Early diagnosis of chronic kidney disease (CKD) is crucial for timely intervention to delay disease progression and improve patient outcomes. However, data for clinical characteristics of Chinese patients with undiagnosed, early-stage CKD are lacking.

Methods

REVEAL-CKD is a multinational, observational study using real-world data in selected countries to describe factors associated with undiagnosed stage 3 CKD, time to diagnosis, and CKD management post diagnosis. We analysed patient data from 20 hospitals in the China Renal Data System. Adult patients with two consecutive estimated glomerular filtration rate (eGFR) measurements indicating stage 3 CKD (30-<60 ml/min/1.73 m2) recorded >90-730 days apart from 2015 to 2020 were eligible.

Findings

Among 35,222 eligible patients, 25,214 (71.6%) were undiagnosed (lacked a CKD diagnostic code before and up to six months post-second-qualifying-eGFR). Only 2344 (9.3%) undiagnosed patients eventually received a delayed diagnosis, whose median time to diagnosis was 18.1 (95% CI: 17.6-18.8) months. Age ≥65 years, being female, stage 3A CKD, and the absence of nephrology visit and comorbidities (diabetes, established cardiovascular disease, heart failure, hypertension, or chronic nephritic syndrome) were associated with undiagnosed CKD (P < 0.001). Among the diagnosed patients, the proportion receiving ≥1 prescription of guideline-recommended medications (e.g. renin-angiotensin system inhibitors) increased and their eGFR decline attenuated post-diagnosis.

Interpretation

The high proportion of undiagnosed, early-stage CKD, and delayed diagnosis are concerning. The improved prescription patterns and the attenuation of eGFR decline post-diagnosis demonstrate the importance of early diagnosis and timely intervention in CKD patients.

Funding

AstraZeneca China.

Identify unmet needs in diabetes care in Shandong, China: a secondary analysis of a cross-sectional study using cascade of care framework

BACKGROUND

The continuum management of diabetes remains under-evaluated in China. This study aimed to estimate the proportions of diabetes adults at each stage of the cascade of care framework in Shandong, China.

METHODS

We conducted a secondary analysis using the 2018 China Adult Chronic Disease and Nutrition Surveillance (CACDNS) data in Shandong. This nationwide cross-sectional survey was conducted between September and November 2018, investigating the major chronic diseases among Chinese adults through interviews, physical examinations, and laboratory tests. We employed the cascade model to examine the proportion of diabetes adults, including both type 1 and type 2, from diabetes screening, diagnosis, pharmaceutical and non-pharmaceutical treatments, to single and comprehensive management targets, and quantified the attrition between each stage. Diabetes screening was defined as participants reported to have ever received a blood glucose test. Diabetes diagnosis was defined as: 1) fasting plasma glucose (FPG) ≥ 126 mg/dL, or 2) 2-h oral glucose tolerance test (2 h-OGTT) ≥ 200 mg/dL, or 3) hemoglobin A1c (HbA1c) ≥ 6.5%, or 4) self-reported diabetes. Diabetes management targets included: 1) single glycemic target of personalized HbA1c level, 2) comprehensive ABC targets of personalized HbA1c level, blood pressure (BP) < 140/80 mm Hg, and low-density lipoprotein cholesterol (LDL-c) level < 2.6 mmol/L, 3) lifestyle target of not currently smoking. The estimated proportion was calculated through self-reported diabetes status and FPG, 2h-OGTT and HbA1c. The number of diabetes cases in Shandong was extrapolated using the 2018 provincial census data for adults aged 18 years and above (N = 80.6 million). The cascade of diabetes care was further examined by age, sex, and Basic Public Health Service (BPHS) enrollment.

RESULTS

This secondary analysis included 8,462 individuals (47.8% males, median age: 49.0), among whom 12.4% had diabetes (self-reported: 4.2%, newly diagnosed: 8.2%) and 41.1% had prediabetes. In 2018, an estimated 9.2 million adults in Shandong had diabetes, with 6.4 million (69.6%) receiving diabetes screening but 6.2 million (67.7%) remaining unaware of their conditions. Among self-reported diabetes adults, 2.7 million (86.4%) and 2.8 million (89.6%) received pharmaceutical and non-pharmaceutical treatment, respectively. Of those with treatments, 1.2 million (58.2%) met personalized glycemic target. A rapid decline, however, was observed in BP (31.1%) and LDL-c (39.3%) control among diabetes patients with multimorbidity (≥ 2 diseases). Ultimately, 0.1 million self-reported diabetes adults (3.8%) achieved the ABC targets. BPHS Enrollment slightly improved comprehensive management with ABC targets.

CONCLUSIONS

A significant unmet need exists for diabetes adults from screening to management, particularly the comprehensive management of glycemia, BP and LDL-c levels among those with multimorbidity. Tailored strategies and appropriate allocation of healthcare resource is needed to addressing gaps in care continuum and reduce long-term disease burden.

Mendelian randomization analysis reveals causal factors behind diabetic nephropathy: evidence, opportunities, and challenges

Diabetic nephropathy (DN), as the most serious minor vascular complication of diabetes, imposes a significant socioeconomic and medical cost around the world, and its prevention and treatment are a major challenge in the current medical community. Observational studies and randomized controlled trials have revealed protective and risk factors for some DN. However, the conclusions of these researches may be influenced by several types of confounding. Mendelian randomization is a new epidemiological method mainly used to infer the causal relationship between exposure and outcome. Many Mendelian randomization studies have found potential causal relationships between DN and some diseases and lifestyle habits, thus providing valuable data for future mechanistic studies as well as the development and implementation of clinical prevention strategies. As a result, the purpose of this review is to evaluate the published Mendelian randomization study of DN, using the bibliometric research method, analyze the current research status and hot spots, and further summarize the genetic evidence about the potential protection of DN and risk factors to provide new inspiration for the etiology of DN and as a reference for clinical intervention.

Inflammation-based scores predict chronic kidney disease progression in patients with chronic kidney disease and chronic heart failure

BACKGROUND

Inflammation is associated with adverse outcomes of chronic kidney disease (CKD) or chronic heart failure (CHF), but few large data exist. We aimed to explore the clinical associations, and prognostic consequences of inflammation-based scores in patients with CKD and CHF.

METHODS

This work was a retrospective cohort study. Glasgow Prognostic Score (GPS), modified Glasgow Prognostic Score (mGPS), Prognostic Nutritional Index (PNI) and Prognostic Index (PI), were used to explore its relationship with CKD progression in patients with CKD stage 1-3b and CHF from the China Renal Data System (CRDS). The composite end point of this study was CKD progression which was defined as eGFR reduction of 40% or progression to end stage renal disease (ESRD).

RESULTS

Of 8491 patients were enrolled. Kaplan-Meier curve showed that compared to the lower inflammation-based scores, the increased scores have a higher rate of CKD progression, whether in GPS, mGPS, PNI or PI (log-rank test, p < 0.001). After considering competing risk events, multivariable Cox hazards analysis revealed that GPS and PNI scores were significantly related to CKD progression [GPS: hazard ratio (HR) 1.40, 95% confidence interval (CI) 1.11-1.76, p = 0.005; PNI: HR 1.54, 95% CI 1.25-1.89, p < 0.001]. PNI showed acceptable prognostic value (C-index = 0.757, 95% CI 0.734-0.78) compared to GPS, mGPS and PI. In subgroup analysis, PNI was consistently related to CKD progression in patients with or without hypertension, DM, MI, VDH and CVD (P for interaction > 0.05).

CONCLUSIONS

Inflammation-based scores, especially PNI may be a useful clinical biomarker for CKD progression in CKD with CHF patients.

Comparative Effectiveness and Safety of Atorvastatin Versus Rosuvastatin : A Multi-database Cohort Study

BACKGROUND

Rosuvastatin and atorvastatin are the most widely prescribed moderate- to high-intensity statins. However, evidence on their efficacy and safety during actual use is limited.

OBJECTIVE

To compare the real-world effectiveness and safety of rosuvastatin and atorvastatin.

DESIGN

Active comparator cohort study using target trial emulation.

SETTING

The China Renal Data System (CRDS) and UK Biobank (UKB) databases.

PARTICIPANTS

Adults newly prescribed rosuvastatin or atorvastatin.

MEASUREMENTS

The primary outcome was all-cause mortality. Cox proportional hazards regressions were used after 1:1 multilevel propensity score matching.

RESULTS

Among the 285 680 eligible participants in both databases, 6-year all-cause mortality was lower for rosuvastatin than for atorvastatin (2.57 vs. 2.83 per 100 person-years in the CRDS database and 0.66 vs. 0.90 per 100 person-years in the UKB database), with differences in cumulative incidence of -1.03% (95% CI, -1.44% to -0.46%) in the CRDS database and -1.38% (CI, -2.50% to -0.21%) in the UKB database. For secondary outcomes in both databases, rosuvastatin conferred lower risks for major adverse cardiovascular events and major adverse liver outcomes. In the UKB database, the risk for development of type 2 diabetes mellitus was higher with rosuvastatin, and the 2 medications carried similar risks for development of chronic kidney disease and other statin-related adverse effects.

LIMITATION

Possible residual confounding.

CONCLUSION

This study found differences in risks for some important outcomes associated with rosuvastatin and atorvastatin. The differences were relatively small, and many did not meet traditional standards for statistical significance. Further research is needed to understand whether these findings can be used with confidence in clinical practice.

PRIMARY FUNDING SOURCE

National Key R&D Program of China and National Natural Science Foundation of China.

Cardiovascular effectiveness of newer glucose-lowering agents, with and without baseline lipid-lowering therapy in type 2 diabetes: A systematic meta-analysis of cardiovascular outcome trials and real-world evidence

BACKGROUND

Whether the cardiovascular treatment benefits of sodium-glucose co-transporter 2 inhibitors (SGLT-2is) and glucagon-like peptide 1 receptor agonists (GLP-1RAs) differ by baseline use of statins/lipid lowering therapy is unclear. This systematic review and meta-analysis investigated whether baseline statin use (users vs non-users) influences the cardiovascular and kidney benefits of SGLT-2is and GLP-1RAs in patients with type 2 diabetes (T2D).

METHODS

We identified relevant cardiovascular outcome trials (CVOTs) and observational cohort studies from MEDLINE, Embase, the Cochrane Library, and bibliographic searches up to March 2024. The analysis pooled study-specific hazard ratios (HRs) with 95 % confidence intervals (CIs) for outcomes, categorized by baseline statin use status. We also assessed the interactions between these medications and baseline statin use by calculating and pooling the ratio of HRs (RHRs) within each trial.

RESULTS

Twenty-five articles (13 articles comprising 6 unique CVOTs and 12 articles comprising 9 unique cohort studies) were eligible. In CVOTs of SGLT-2is, the HRs (95 % CIs) of MACE; composite of CVD death or hospitalisation for heart failure; stroke; and kidney events in statin users were 0.90 (0.82-1.00), 0.78 (0.60-1.02), 1.00 (0.77-1.31), and 0.60 (0.53-0.69), respectively. The corresponding estimates were similar in non-statin users. In CVOTs of GLP-1RAs, the HRs (95 % CIs) for MACE in statin and non-statin users were 0.81 (0.73-0.90) and 0.92 (0.77-1.11), respectively. In observational cohort studies, SGLT-2is similarly reduced the risk of several cardiovascular and kidney outcomes in both statin and non-statin users. The estimated RHRs and p-values for interaction indicated that baseline statin use status did not significantly modify the cardio-kidney benefits of SGLT-2is and GLP-1RAs.

CONCLUSIONS

Aggregate analyses of intervention and real-world evidence show that SGLT-2is and GLP-1RAs provide comparable cardio-kidney benefits in patients with T2D, regardless of baseline statin use status. PROSPERO Registration: CRD42024498939.

The association between serum complement 4 and relapse of primary membranous nephropathy: a multicenter retrospective cohort study

Background

Relapse after initial remission reduces renal survival in patients with primary membranous nephropathy (PMN). In this study, we aim to identify risk factors of relapse in PMN and construct a model to identify patients at high risk of relapse early.

Methods

We conducted a multi-center retrospective study using the China Renal Data System database, which includes data from 24 urban academic centers across China. A prediction model based on the Cox proportional hazards model was derived in the derivation group and validated in the validation group.

Result

515 patients with biopsy-proven PMN achieving initial remission were enrolled. 32.62% of patients subsequently relapsed during a median of 6.08 months. Lower serum albumin (Alb) (per 1 g/L decrease, hazard ratio [HR] =1.48, 95% confidence interval [CI] 1.29-1.78, p < 0.001), lower estimated glomerular filtration rate (eGFR) (per 10 mL/min/1.73m2 decrease, HR =1.14, 95% CI 0.97-1.49, p < 0.001), higher serum complement 4 (C4) (per 0.1 g/L increase, HR =1.89, 95% CI 1.32-3.22, p = 0.012), partial remission (PR) (HR =2.28, 95%CI 1.74-4.04, p < 0.001), and treatment with calcineurin inhibitors (CINs) (HR =1.33, 95%CI 1.04-1.64, p < 0.001) at the time of remission were risk factors for relapse. C-statistic, time-dependent areas under the receiver operating characteristic curve, and calibration plots confirmed that the model had excellent discrimination and calibration in predicting PMN relapse. The anti-phospholipase A2 receptor antibody (aPLA2Rab) titers and pathologic features did not substantially improve the model.

Conclusion

Our study confirms the well-known low Alb and eGFR, PR, and treatment of CNIs at the time of remission as risk factors for PMN relapse, but aPLA2Rab and pathologic features may not predict relapse. In addition, it is the first study to show serum C4 is associated with PMN relapse. We suggest that complement-targeted therapies may be a potential therapy to prevent PMN relapse.

Association of serum 25-hydroxyvitamin D with cardiovascular mortality and kidney outcome in patients with early stages of CKD

PURPOSE

While serum 25-hydroxyvitamin D (25[OH]D) deficiency is prevalent in chronic kidney disease (CKD), the effects of 25(OH)D deficiency on cardiovascular mortality and kidney outcomes in patients with early-stage CKD remain incompletely understood.

METHODS

This multicenter retrospective cohort study included adult patients with stages 1-3 CKD from 19 medical centers across China between January 2000 and May 2021. The primary outcome was cardiovascular mortality. The secondary study outcome included CKD progression (defined as a sustained > 40% eGFR decrease from baseline or progress to end-stage kidney disease), and annual percentage change of eGFR.

RESULTS

Of 9229 adults with stages 1-3 CKD, 27.0% and 38.9% had severe (< 10 ng/mL) and moderate (10 to < 20 ng/mL) serum 25(OH)D deficiency, respectively. Compared with patients having 25(OH)D ≥ 20 ng/mL, a significantly higher risk of cardiovascular mortality (hazard ratio [HR] 1.90, 95% CI 1.37-2.63), CKD progression (HR 2.20, 95% CI 1.68-2.88), and a steeper annual decline in eGFR (estimate - 7.87%; 95% CI - 10.24% to - 5.51% per year) was found in those with serum 25(OH)D < 10 ng/mL. Similar results were obtained in subgroups and by sensitivity analyses.

CONCLUSIONS

25(OH)D deficiency is associated with increased risks of cardiovascular mortality and CKD progression in patients with early-stage CKD. Studies are needed to determine whether early intervention for 25(OH)D deficiency could improve the prognosis of patients with early-stage CKD.

N-terminal pro-B-type natriuretic peptide, eGFR, and progression of kidney disease in chronic kidney disease patients without heart failure

Background

Cardiorenal syndrome highlights the bidirectional relationship between kidney and heart dysfunction. N-terminal pro-B-type natriuretic peptide (NT-proBNP), which is the gold standard biomarker in heart failure (HF), may be an important biomarker for chronic kidney disease (CKD) progression. However, NT-proBNP is negatively related with estimated glomerular filtration rate (eGFR). In this study, we investigated the association of NT-proBNP, eGFR, and progression of kidney disease in CKD patients without HF.

Methods

This multicentric retrospective cohort study recruited 23 860 CKD patients without HF, who had at least one NT-proBNP record from China Renal Data System database. Linear regression model evaluated the relationship between eGFR and NT-proBNP. Cox regression analysis assessed the association between NT-proBNP and CKD progression. Sensitivity analysis examined the robustness of the main findings.

Results

This study involved 23 860 CKD patients without HF, distributed across different CKD stages: 10 526 in stages G1-2, 4665 in G3a, 3702 in G3b, 2704 in G4, and 2263 in G5. NT-proBNP was negatively correlated with eGFR, particularly in stages 4-5 CKD. A 15-unit decrease in eGFR was associated with increases in log (NT-proBNP) levels by 1.04-fold, 1.27-fold, 1.29-fold, 1.80-fold, and 3.50-fold for stages 1-2, 3a, 3b, 4, and 5, respectively. After excluding patients who developed CKD progression within 1 year, the Cox regression analysis revealed that the relationship between NT-proBNP and CKD progression was not significant in stages 4 and 5. However, for stages 1-3, each standard deviation increase in log (NT-proBNP) was associated with a 26%, 36%, and 28% higher risk of CKD progression, with P interaction ≤.001. The hazard ratios were 1.26 (95% confidence intervals (CI), 1.18 to 1.35), 1.36 (95% CI, 1.22 to 1.51), and 1.28 (95% CI, 1.14 to 1.43) for stages 1-2, stage 3a, and stage 3b, respectively.

Conclusions

Despite its strong inverse association with eGFR, NT-proBNP was positively associated with the risk of progression of kidney disease in CKD patients with stages 1-3 without HF. Future studies should investigate the effectiveness of NT-proBNP as a predictive biomarker for the progression of kidney disease across diverse racial groups and healthcare settings.

Enhancing the human health and lifespan: a targeted strategy emphasizing statins

There has been substantial research interest in finding activities/agents that slow the onset and reduce the severity of numerous age-related diseases/conditions. This assessment indicates that the most studied agent intended to promote health in human population investigations for a broad spectrum of diseases are the statins, with large-scale epidemiological studies addressing numerous health endpoints. The key findings are that statin treatment consistently reduces the occurrence and attenuates the course of numerous non-communicable and contagious pathologies and numerous types of cancer with high mortality rates by about 20-50%. That one agent could affect such a broad based and consistently positive trends in epidemiological studies is unexpected and impressive, along with consistent cell and animal model research. Underlying mechanisms have been proposed that significantly contribute to the spectrum of salutary effects of statins, especially the capacity to activate Nrf2 showing hormetic dose responses in multiple organs and cell types, due to its bioavailability and broad tissue distribution. The widespread use of statins, which has the capacity to enhance human health span, should be considered for experimental exploration as a novel public health strategy that includes practical approaches for reduction of the most common adverse effects of this class of drugs including myalgia/myopathy and transaminitis.

Research hotspots and future trends in lipid metabolism in chronic kidney disease: a bibliometric and visualization analysis from 2004 to 2023

Background

Disorders of lipid metabolism play a key role in the initiation and progression of chronic kidney disease (CKD). Recently, research on lipid metabolism in CKD has rapidly increased worldwide. However, comprehensive bibliometric analyses in this field are lacking. Therefore, this study aimed to evaluate publications in the field of lipid metabolism in CKD over the past 20 years based on bibliometric analysis methods to understand the important achievements, popular research topics, and emerging thematic trends.

Methods

Literature on lipid metabolism in CKD, published between 2004 and 2023, was retrieved from the Web of Science Core Collection. The VOSviewer (v.1.6.19), CiteSpace (v.6.3 R1), R language (v.4.3.2), and Bibliometrix (v.4.1.4) packages (https://www.bibliometrix.org) were used for the bibliometric analysis and visualization. Annual output, author, country, institution, journal, cited literature, co-cited literature, and keywords were also included. The citation frequency and H-index were used to evaluate quality and influence.

Results

In total, 1,285 publications in the field of lipid metabolism in CKD were identified in this study. A total of 7,615 authors from 1,885 institutions in 69 countries and regions published articles in 466 journals. Among them, China was the most productive (368 articles), and the United States had the most citations (17,880 times) and the highest H-index (75). Vaziri Nosratola D, Levi Moshe, Fornoni Alessia, Zhao Yingyong, and Merscher Sandra emerged as core authors. Levi Moshe (2,247 times) and Vaziri Nosratola D (1,969 times) were also authors of the top two most cited publications. The International Journal of Molecular Sciences and Kidney International are the most published and cited journals in this field, respectively. Cardiovascular disease (CVD) and diabetic kidney disease (DKD) have attracted significant attention in the field of lipid metabolism. Oxidative stress, inflammation, insulin resistance, autophagy, and cell death are the key research topics in this field.

Conclusion

Through bibliometric analysis, the current status and global trends in lipid metabolism in CKD were demonstrated. CVD and DKD are closely associated with the lipid metabolism of patients with CKD. Future studies should focus on effective CKD treatments using lipid-lowering targets.

A non-linear association between low-density lipoprotein cholesterol and the risk of diabetic kidney disease in patients with type 2 diabetes in China

Objective

To explore the intrinsic relationship between low-density lipoprotein cholesterol (LDL-C) and diabetic kidney disease (DKD) in patients with type 2 diabetes (T2D) in China.

Methods

This cross-sectional study included 1,313 patients with type 2 diabetes treated at the Affiliated Jinhua Hospital of Zhejiang University School of Medicine, located in Jinhua, China. The data were combined from two periods, 2017 and 2020-2021. Participants were categorized into groups with and without DKD. The relationship between LDL-C levels and DKD was evaluated employing logistics regression analysis and restricted cubic spline (RCS) curves.

Results

Generally, there was no statistical difference in LDL-C levels between DKD and non-DKD groups, however, a significantly non-linear relationship (Pnon-linear = 0.011) was observed between LDL-C levels and DKD prevalence after adjusting for confounding factors according to the RCS analysis. Two optimal cut-points of 2.97 and 3.61 mmol/L were selected out using random forest algorithm. With the middle LDL-C concentration (2.97-3.61 mmol/L) as the reference, the odds ratios for low (<2.97 mmol/L) and high (>3.61 mmol/L) concentrations were 1.45 (1.08-1.96) and 1.47 (1.01-2.15) respectively, after adjusting for confounding factors in the multivariate analyses. Notably, this association was more pronounced among female participants in the subgroup analyses.

Conclusion

A non-linear association was observed between LDL-C levels and the risk of DKD in patients with T2D in China. LDL-C levels below 2.97 mmol/L may elevate the risk of DKD, particularly in female patients with T2D.

Genetic association analyses highlight apolipoprotein B as a determinant of chronic kidney disease in patients with type 2 diabetes

BACKGROUND

Blood lipid levels were associated with chronic kidney disease (CKD) in patients with type 2 diabetes (T2D), but the genetic basis and causal nature remain unclear.

OBJECTIVE

This study aimed to investigate the relationships of lipids and their fractions with CKD in patients with T2D.

METHODS

Our prospective analysis involved 8,607 White participants with T2D but no CKD at baseline from the UK Biobank. Five common lipid traits were included as exposures. Weighted genetic risk scores (GRSs) for these lipid traits were developed. The causal associations between lipid traits, as well as lipid fractions, and CKD were explored using linear or nonlinear Mendelian randomization (MR). The 10-year predicted probabilities of CKD were evaluated via integrating MR and Cox models.

RESULTS

Higher GRS of apolipoprotein B (ApoB) was associated with an increased CKD risk (hazard ratio (HR) [95% confidence interval (CI)]:1.07[1.02,1.13] per SD; P = 0.008) after adjusting for potential confounders. Linear MR indicated a positive association between genetically predicted ApoB levels and CKD (HR [95% CI]:1.53 [1.12,2.09]; P = 0.008), but no evidence of associations was found between other lipid traits and CKD in T2D. Regarding 12 ApoB- containing lipid fractions, a significant causal association was found between medium very-low-density lipoprotein particles and CKD (HR[95% CI]:1.16[1.02,1.32];P = 0.020). Nonlinear MR did not support nonlinearity in these causal associations. The 10-year probability curve showed that ApoB level was positively associated with the risk of CKD in patients with T2D.

CONCLUSION

Lower ApoB levels were causally associated with a reduced risk of CKD in patients with T2D, positioning ApoB as a potential therapeutic target for CKD prevention in this population.

Renin-angiotensin system inhibitors and risk of hepatocellular carcinoma among patients with hepatitis B virus infection

BACKGROUND

Hepatitis B virus (HBV) infection is a common cause of liver-related morbidity and mortality. Evidence suggests that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) decrease liver fibrosis, an intermediate step between liver injury and hepatocellular carcinoma (HCC). Our aim was to investigate the association between the use of ACEIs and ARBs on incident HCC and liver-related mortality among patients with HBV infection.

METHODS

We conducted a population-based study on a new-user cohort of patients seen at 24 hospitals across China. We included adult patients with HBV infection who started ACEIs or ARBs (ACEIs/ARBs), or calcium channel blockers or thiazide diuretics (CCBs/THZs) from January 2012 to December 2022. The primary outcome was incident HCC; secondary outcomes were liver-related mortality and new-onset cirrhosis. We used propensity score matching and Cox proportional hazards regression to estimate the hazard ratio (HR) and 95% confidence intervals (CIs) of study outcomes.

RESULTS

Among 32 692 eligible patients (median age 58 [interquartile range (IQR) 48-68] yr, and 18 804 male [57.5%]), we matched 9946 pairs of patients starting ACEIs/ARBs or CCBs/THZs. During a mean follow-up of 2.3 years, the incidence rate of HCC per 1000 person-years was 4.11 and 5.94 among patients who started ACEIs/ARBs and CCBs/THZs, respectively, in the matched cohort. Use of ACEIs/ARBs was associated with lower risks of incident HCC (HR 0.66, 95% CI 0.50-0.86), liver-related mortality (HR 0.77, 95% CI 0.64-0.93), and new-onset cirrhosis (HR 0.81, 95% CI 0.70-0.94).

INTERPRETATION

In this cohort of patients with HBV infection, new users of ACEIs/ARBs had a lower risk of incident HCC, liver-related mortality, and new-onset cirrhosis than new users of CCBs/THZs.

Inverse association between serum chloride levels and the risk of atrial fibrillation in chronic kidney disease patients

Background

Electrolyte abnormalities are common symptoms of chronic kidney disease (CKD), but previous studies have mainly focussed on serum potassium and sodium levels. Chloride is an important biomarker for the prognosis of various diseases. However, the relationship between serum chloride levels and atrial fibrillation (AF) in CKD patients is unclear.

Objective

In this study, we sought to determine the association between serum chloride homeostasis and AF in CKD patients.

Methods

In this retrospective cohort study, we included patients who met the diagnostic criteria for CKD in China between 2000 and 2021. Competing risk regression for AF was performed. The associations of the baseline serum chloride concentration with heart failure (HF) and stroke incidence were also calculated by competing risk regression. The association of baseline serum chloride levels with all-cause death was determined by a Cox regression model.

Results

The study cohort comprised 20 550 participants. During a median follow-up of 350 days (interquartile range, 123-730 days), 211 of the 20 550 CKD patients developed AF. After multivariable adjustment, every decrease in the standard deviation of serum chloride (5.02 mmol/l) was associated with a high risk for AF [sub-hazard ratio (sHR) 0.78, 95% confidence interval (CI) 0.65-0.94, P = .008]. These results were also consistent with those of the stratified and sensitivity analyses. According to the fully adjusted models, the serum chloride concentration was also associated with a high risk for incident HF (sHR 0.85, 95% CI 0.80-0.91, P < .001), a high risk for incident stroke (sHR 0.87, 95% CI 0.81-0.94, P < .001), and a high risk for all-cause death [hazard ratio (HR) 0.82, 95% CI 0.73-0.91, P < .001].

Conclusion

In this CKD population, serum chloride levels were independently and inversely associated with the incidence of AF. Lower serum chloride levels were also associated with an increased risk of incident HF, stroke, and all-cause death.

Effects of genetically proxied statins on diabetic nephropathy and retinopathy: a Mendelian randomization study

There is no reliable causal evidence for the effect of statins on diabetic nephropathy (DN) and diabetic retinopathy (DR), and the results of previous observational studies are contradictory. Genetic variants linked to low-density lipoprotein cholesterol (LDL-C) from a UK biobank genome-wide association study and located within a 100kb window around HMGCR were used to proxy statins, comparing with PCSK9 inhibitors (control). DN and DR genome-wide association study summary statistics were obtained from the FinnGen study. Secondary MR analyses and NHANES cross-sectional data were used for validation. Drug-target Mendelian randomization (MR) was applied to investigate the association between the genetically proxied inhibition of HMGCR and PCSK9 with DN and DR, p < 0.0125 was considered significant after Bonferroni Correction. To triangulate the findings, genetic variants of whole blood-derived targets gene expression (cis-eQTL) and plasma-derived protein (cis-pQTL) levels were used to perform secondary MR analyses and data from the National Health and Nutrition Examination Survey were used for cross-sectional analysis. Genetically proxied inhibition of HMGCR was associated with higher risks of DN and DR (DN: OR = 1.79, p = 0.01; DR: OR = 1.41, p = 0.004), while no such association was found for PCSK9. Secondary MR analyses confirmed these associations. Cross-sectional analysis revealed a positive link between statin use and DR incidence (OR = 1.26, p = 0.03) and a significant negative association with glomerular filtration rate (Beta = - 1.9, p = 0.03). This study provides genetic evidence that genetically proxied inhibition of HMGCR is associated with increased risks of DN/DR, and this effect may not be attributed to their LDL-C-lowering properties. For patients with diabetic dyslipidemia, PCSK9 inhibitors may be a preferable alternative.

A pharmacovigilance study of chronic kidney disease in diabetes mellitus patients with statin treatment by using the US Food and Drug Administration adverse event reporting system

Background

Statins were regarded as a main medication for managing hypercholesterolemia. Administration of statin therapy could reduce the incidence of cardiovascular disease in individuals diagnosed with type 2 diabetes mellitus (DM), which was recognized by multipal clinical guidelines. But previous studies had conflicting results on whether the long-term use of statins could benefit the renal function in diabetic patients.

Aim

To evaluate the association between statin treatment and Chronic Kidney Disease in DM patients.

Methods

This is a retrospective disproportionality analysis and cohort study based on real-world data. All DM cases reported in US Food and Drug Administration adverse event reporting system (FAERS) between the first quarter of 2004 and the fourth quarter of 2022 were included. Disproportionality analyses were conducted by estimating the reporting odds ratio (ROR) and the information component (IC). We further compared the CKD odds ratio (OR) between the statins group and the other primary suspected drug group among the included diabetes mellitus cases.

Results

We finally included 593647 DM cases from FAERS, 5113 (5.31%) CKD cases in the statins group and 8810 (1.77%) CKD cases in the control group. Data analysis showed that the statins group showed a significant CKD signal (ROR: 3.11, 95% CI: 3.00-3.22; IC: 1.18, 95% CI: 1.07-1.29). In case group with two or more statins treatment history, the CKD signal was even stronger (ROR: 19.56, 95% CI: 18.10-21.13; IC: 3.70, 95% CI:3.44-3.93) compared with cases with one statin treatment history.

Conclusion

The impact of statin therapy on the progression of renal disease in individuals diagnosed with type 2 diabetes mellitus (DM) remains inconclusive. After data mining on the current FAERS dataset, we discovered significant signals between statin treatment and CKD in diabetic patients. Furthermore, the incidence rate of CKD was higher among DM patients who used statins compared to those who did not.

Association between urate-lowering therapy initiation and all-cause mortality in patients with type 2 diabetes and asymptomatic hyperuricemia

AIMS

To assess the relationships between urate-lowering therapy (ULT) initiation with all-cause mortality in patients with asymptomatic hyperuricemia and Type 2 Diabetes (T2D).

METHODS

This nationwide retrospective cohort study involved patients with T2D and asymptomatic hyperuricemia from 19 academic hospitals across China between 2000 and 2021. The primary exposure was ULT initiation, including allopurinol, febuxostat, or benzbromarone. The primary outcome was all-cause mortality. The secondary outcomes were cardiovascular (CV) and non-CV mortality. Propensity score matching was employed to create a 1:2 matched cohort with balanced likelihood of ULT initiation. Associations between ULT initiation with all-cause and CV mortality were assessed in the matched cohort.

RESULTS

Among 42 507 patients, 5028 initiated ULT and 37 479 did not. In the matched cohort, comprising 4871 ULT initiators and 9047 noninitiators, ULT initiation was significantly associated with reduced risk of all-cause mortality (hazard ratio [HR] 0.77; 95% confidence interval [CI], 0.71-0.84), CV mortality (HR 0.86; 95% CI, 0.76-0.97), and non-CV mortality (HR 0.72; 95% CI, 0.64-0.80) over an average 3.0 years of follow-up. Among the ULT initiators, post-treatment SUA levels of 360-420 μmol/L was related to a significantly lower risk for all-cause mortality compared to levels >420 μmol/L (HR 0.74; 95% CI, 0.59-0.94) while levels ≤360 μmol/L did not (HR, 0.96; 95% CI, 0.81-1.14), suggesting a U-shaped relationship.

CONCLUSIONS

Initiating ULT was associated with a significant reduction in all-cause mortality in patients with T2D and asymptomatic hyperuricemia. Notably, maintaining post-treatment SUA concentrations within 360-420 μmol/L could potentially enhance this reduced mortality.

Glycaemic control and macrovascular and microvascular outcomes: A systematic review and meta-analysis of trials investigating intensive glucose-lowering strategies in people with type 2 diabetes

AIM

We aimed to determine the macrovascular and microvascular outcomes of intensive versus standard glucose-lowering strategies in type 2 diabetes (T2D) and investigate the relationships between these outcomes and trial arm glycated haemoglobin (HbA1c) reduction.

MATERIALS AND METHODS

In this systematic review and meta-analysis, we identified relevant trials from MEDLINE, Embase, the Cochrane Library, and bibliographies up to August 2023. Macrovascular and microvascular outcomes, along with safety outcomes, were evaluated. Pooled study-specific hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated, and meta-regression was employed to analyse the relationships between outcomes and HbA1c reduction.

RESULTS

We included 11 unique RCTs involving 51 469 patients with T2D (intensive therapy, N = 26 691; standard therapy, N = 24 778). Intensive versus standard therapy reduced the risk of non-fatal myocardial infarction (MI) (HR 0.84; 95% CI 0.75-0.94) with no difference in the risk of major adverse cardiovascular events (HR 0.97; 95% CI 0.92-1.03) and other adverse cardiovascular outcomes. Intensive versus standard therapy reduced the risk of retinopathy (HR 0.85; 0.78-0.93), nephropathy (HR 0.71; 0.58-0.87) and composite microvascular outcomes (HR 0.88; 0.77-1.00). Meta-regression analyses showed modest evidence of inverse linear relationships between HbA1c reduction and the outcomes of major adverse cardiovascular events, non-fatal MI, stroke and retinopathy, but these were not statistically significant.

CONCLUSIONS

In people with T2D, intensive glucose control was associated with a reduced risk of non-fatal MI and several microvascular outcomes, particularly retinopathy and nephropathy. The lack of an effect of intensive glucose-lowering on most macrovascular outcomes calls for a more comprehensive approach to managing cardiovascular risk factors alongside glycaemic control.

Associations between Different Antivirals and Hospital-Acquired Acute Kidney Injury in Adults with Herpes Zoster

Key Points

Among intravenous antivirals, acyclovir was associated with the highest risk of hospital-acquired AKI, followed by penciclovir/ganciclovir and foscarnet. The risk of hospital-acquired AKI was dose dependent for intravenous nucleoside analogs.

Background

To examine the association of use of different antivirals with hospital-acquired AKI among Chinese adults with herpes zoster.

Methods

This study selected 3273 adult patients who received antiviral therapy for herpes zoster during hospitalization from the China Renal Data System. We identified and staged AKI using patient-level serum creatinine data according to the Kidney Disease Improving Global Outcomes criteria. We compared the relative risks of hospital-acquired AKI among patients treated with different antivirals using Cox proportional hazards models.

Results

Among 3273 patients, 1480 (45%), 681 (21%), 489 (15%), and 623 (19%) were treated with acyclovir/valacyclovir, ganciclovir, penciclovir/famciclovir, and foscarnet, respectively. During the follow-up period, a total of 111 cases of hospital-acquired AKI occurred, predominantly classified as AKI stage 1. The cumulative incidences of hospital-acquired AKI were 5%, 3%, 3%, and 1% in the patients receiving acyclovir/valacyclovir, ganciclovir, penciclovir/famciclovir, and foscarnet, respectively. Compared with acyclovir/valacyclovir, penciclovir/famciclovir/ganciclovir and foscarnet were associated with a lower risk of hospital-acquired AKI, with an adjusted hazard ratio of 0.59 (95% confidence interval [CI], 0.37 to 0.94) and 0.27 (95% CI, 0.11 to 0.63), respectively. Compared with intravenous acyclovir, intravenous penciclovir/ganciclovir and foscarnet were associated with a lower risk of hospital-acquired AKI with an adjusted hazard ratio of 0.53 (95% CI, 0.29 to 0.98) and 0.31 (95% CI, 0.12 to 0.76), respectively. The associations were consistent across various subgroups and sensitivity analyses.

Conclusions

Among antiviral therapies for herpes zoster, we found different risks of hospital-acquired AKI among the patients receiving different antivirals, in particular, those administered intravenously. Among intravenous antivirals, acyclovir was associated with the highest risk of hospital-acquired AKI, followed by penciclovir/ganciclovir and foscarnet. Confirmation studies with large samples from other populations are warranted.

Associations between remnant cholesterol levels and mortality in patients with diabetes

BACKGROUND

Dyslipidemia is frequently present in patients with diabetes. The associations of remnant cholesterol and mortality remains unclear in patients with diabetes.

AIM

To explore the associations of remnant cholesterol with all-cause and cardiovascular mortality in patients with diabetes.

METHODS

This prospective cohort study included 4740 patients with diabetes who participated in the National Health and Nutrition Examination Survey from 1999 through 2018. Remnant cholesterol was used as the exposure variable, and all-cause and cardiovascular mortality were considered outcome events. Outcome data were obtained from the National Death Index, and all participants were followed from the interview date until death or December 31, 2019. Multivariate proportional Cox regression models were used to explore the associations between exposure and outcomes, in which remnant cholesterol was modeled as both a categorical and a continuous variable. Restricted cubic splines (RCSs) were calculated to assess the nonlinearity of associations. Subgroup (stratified by sex, age, body mass index, and duration of diabetes) and a series of sensitivity analyses were performed to evaluate the robustness of the associations.

RESULTS

During a median follow-up duration of 83 months, 1370 all-cause deaths and 389 cardiovascular deaths were documented. Patients with remnant cholesterol levels in the third quartile had a reduced risk of all-cause mortality [hazard ratio (HR) 95% confidence interval (CI): 0.66 (0.52-0.85)]; however, when remnant cholesterol was modeled as a continuous variable, it was associated with increased risks of all-cause [HR (95%CI): 1.12 (1.02-1.21) per SD] and cardiovascular [HR (95%CI): 1.16 (1.01-1.32), per SD] mortality. The RCS demonstrated nonlinear associations of remnant cholesterol with all-cause and cardiovascular mortality. Subgroup and sensitivity analyses did not reveal significant differences from the above results.

CONCLUSION

In patients with diabetes, higher remnant cholesterol was associated with increased risks of all-cause and cardiovascular mortality, and diabetes patients with slightly higher remnant cholesterol (0.68-1.04 mmol/L) had a lower risk of all-cause mortality.

Roles of Sirt1 and its modulators in diabetic microangiopathy: A review

Diabetic vascular complications include diabetic macroangiopathy and diabetic microangiopathy. Diabetic microangiopathy is characterised by impaired microvascular endothelial function, basement membrane thickening, and microthrombosis, which may promote renal, ocular, cardiac, and peripheral system damage in diabetic patients. Therefore, new preventive and therapeutic strategies are urgently required. Sirt1, a member of the nicotinamide adenine dinucleotide-dependent histone deacetylase class III family, regulates different organ growth and development, oxidative stress, mitochondrial function, metabolism, inflammation, and aging. Sirt1 is downregulated in vascular injury and microangiopathy. Moreover, its expression and distribution in different organs correlate with age and play critical regulatory roles in oxidative stress and inflammation. This review introduces the background of diabetic microangiopathy and the main functions of Sirt1. Then, the relationship between Sirt1 and different diabetic microangiopathies and the regulatory roles mediated by different cells are described. Finally, we summarize the modulators that target Sirt1 to ameliorate diabetic microangiopathy as an essential preventive and therapeutic measure for diabetic microangiopathy. In conclusion, targeting Sirt1 may be a new therapeutic strategy for diabetic microangiopathy.

Change in Liver Fibrosis Associates with Progress of Diabetic Nephropathy in Patients with Nonalcoholic Fatty Liver Disease

Diabetic nephropathy (DN) is a major complication of diabetes. Nonalcoholic fatty liver disease (NAFLD) is common in diabetes, and liver fibrosis is a prognostic risk factor for NAFLD. The interaction between DN and liver fibrosis in NAFLD remains unclear. In 189 patients with DN and NAFLD who received an education course about diabetic nephropathy, liver fibrosis was evaluated using the fibrosis-4 (FIB-4) index. The association between the outcome of DN and changes in liver fibrosis was examined. The FIB-4 index was maintained at the baseline level in patients with improved DN, while it was increased in other patients. The ΔFIB-4 index was positively correlated with changes in albuminuria and proteinuria (ρ = 0.22, p = 0.004). In a multivariate analysis, changes in albuminuria and proteinuria were associated with the ΔFIB-4 index (p = 0.002). Patients with a progressive FIB-4 index category from baseline to 5 years showed a lower event-free survival rate after 5 years than patients with an improved FIB-4 index category (p = 0.037). The outcome of DN is associated with changes in liver fibrosis in patients with diabetes, NAFLD and DN. Developing a preventive and therapeutic approach for these conditions is required.