Increased Risk of Incident Chronic Kidney Disease, Cardiovascular Disease, and Mortality in Patients With Diabetes With Comorbid Depression

An update on chronic complications of diabetes mellitus: from molecular mechanisms to therapeutic strategies with a focus on metabolic memory

Diabetes mellitus, a chronic metabolic disease, often leads to numerous chronic complications, significantly contributing to global morbidity and mortality rates. High glucose levels trigger epigenetic modifications linked to pathophysiological processes like inflammation, immunity, oxidative stress, mitochondrial dysfunction, senescence and various kinds of cell death. Despite glycemic control, transient hyperglycemia can persistently harm organs, tissues, and cells, a latent effect termed "metabolic memory" that contributes to chronic diabetic complications. Understanding metabolic memory's mechanisms could offer a new approach to mitigating these complications. However, key molecules and networks underlying metabolic memory remain incompletely understood. This review traces the history of metabolic memory research, highlights its key features, discusses recent molecules involved in its mechanisms, and summarizes confirmed and potential therapeutic compounds. Additionally, we outline in vitro and in vivo models of metabolic memory. We hope this work will inform future research on metabolic memory's regulatory mechanisms and facilitate the development of effective therapeutic compounds to prevent diabetic complications.

The association between triglyceride-glucose index and related parameters and risk of cardiovascular disease in American adults under different glucose metabolic states

BACKGROUND

Cardiovascular disease (CVD) encompasses an array of cardiac and vascular disorders, posing a significant threat to global health. It remains unclear whether there exists an association between triglyceride-glucose index (TyG) and its derived indices and the incidence of cardiovascular disease, and in particular, the strength of the association in populations with different glucose metabolisms is not known.

METHODS

Data extracted from the National Health and Nutrition Examination Survey (NHANES) covering the period from 1999 to 2020, involving a cohort of 14,545 participants, were leveraged for the analysis. Statistical assessments were executed utilizing R software, employing multivariable logistic regression models to scrutinize the correlation between TyG and its associated parameters with the incidence of cardiovascular disease across diverse glucose metabolism categories. Interaction analyses and restricted cubic splines were applied to evaluate potential heterogeneity in associations and investigate the link between TyG and its derivatives with the occurrence of cardiovascular disease. Furthermore, receiver operating characteristic curves were constructed to evaluate the extent of variability in the predictive performance of TyG and its derived parameters for cardiovascular disease across distinct glucose metabolic statuses.

RESULTS

This study found that TyG and its related parameters were differentially associated with the occurrence of cardiovascular disease in different glucose metabolic states. Curvilinear correlations were found between TyG in the IFG population and TyG-WC, TyG-BMI, and TyG-WHtR in the impaired glucose tolerance (IGT) population with the occurrence of cardiovascular disease. In addition, the introduction of TyG and its derived parameters into the classical Framingham cardiovascular risk model improved the predictive performance in different glucose metabolism populations. Among them, the introduction of TyG-WHtR in the normal glucose tolerance (NGT), impaired fasting glucose (IFG), IFG & IGT and diabetes groups and TyG in the IGT group maximized the predictive power.

CONCLUSIONS

The findings provide new insights into the relationship between the TyG index and its derived parameters in different glucose metabolic states and the risk of cardiovascular disease, offering important reference value for future clinical practice and research. The study highlights the potential for improved risk stratification and prevention strategies based on TyG and its derived parameters.

Prevalence of Adult Type 2 Diabetes Mellitus and Related Complications in Alberta, Canada: A Retrospective, Observational Study Using Administrative Data

OBJECTIVES

Type 2 diabetes mellitus (T2DM) is a prevalent chronic disease and a leading cause of morbidity/mortality in Canada. We evaluated the burden of T2DM in Alberta, Canada, by estimating the 5-year period prevalence of T2DM and rates of comorbidities and complications/conditions after T2DM.

METHODS

We conducted a population-based, retrospective study linking administrative health databases. Individuals with T2DM (≥18 years of age) were identified between 2008-2009 and 2018-2019 using a published algorithm, with follow-up data to March 2020. The 5-year period prevalence was estimated for 2014-2015 to 2018-2019. Individuals with newly identified T2DM, ascertained between 2010-2011 and 2017-2018 with a lookback period between 2008-2009 and 2009-2010 and a minimum 1 year of follow-up data, were evaluated for subsequent cardiovascular, diabetic, renal, and other complication/condition frequencies (%) and rates (per 100 person-years). Complications/conditions were stratified by atherosclerotic cardiovascular disease (ASCVD) status at index and age.

RESULTS

The 5-year period prevalence of T2DM was 11,051 per 100,000 persons, with the highest prevalence in men 65 to <75 years of age. There were 195,102 individuals included in the cohort (mean age 56.7±14.7 years). The most frequently reported complications/conditions (rates per 100 person-years) were acute infection (23.10, 95% confidence interval [CI] 23.00 to 23.30), hypertension (17.30, 95% CI 16.80 to 17.70), and dyslipidemia (12.20, 95% CI 11.90 to 12.40). Individuals who had an ASCVD event/procedure and those ≥75 years of age had higher rates of complications/conditions.

CONCLUSIONS

We found that over half of the individuals had hypertension or infection after T2DM. Also, those with ASCVD had higher rates of complications/conditions. Strategies to mitigate complications/conditions after T2DM are required to reduce the burden of this disease on individuals and health-care systems.

Depressive Symptoms Associated with Peripheral Artery Disease and Predicting Mortality in Type 2 Diabetes

This retrospective cohort study aimed to assess the mortality risk in patients with type 2 diabetes mellitus (DM) by screening for depressive symptoms and peripheral artery disease (PAD). We enrolled patients aged ≥60 years who had undergone assessments of both the ankle-brachial index (ABI) and the five-item Geriatric Depression Scale (GDS-5). PAD and depression were defined as ABI ≤ 0.90 and GDS-5 ≥ 1, respectively. The primary endpoint was total mortality. In 1673 enrolled patients, the prevalence of PAD was higher in those with depression than in those without depression (8.9% vs. 5.7%, p = 0.021). After a median follow-up of 56.6 months (interquartile range: 47.0-62.3 months), a total of 168 (10.0%) deaths occurred. The patients in the depression and PAD subgroup had the highest hazard ratio of mortality, followed by the PAD without depression subgroup and the depression without PAD subgroup (2.209, 95%CI: 1.158-4.217; 1.958, 95%CI: 1.060-3.618; and 1.576, 95%CI: 1.131-2.196; respectively) in comparison to the patients without depression and PAD after adjustment for associated factors. In conclusion, a combination of depression and PAD predicted the highest mortality risk. Screening for depression and PAD is recommended in patients aged ≥60 years with type 2 DM.

Depression and Medication Beliefs in African Americans with Diabetes

Medication non-adherence impacts health significantly in African Americans with diabetes. We performed a retrospective data analysis on 56 patients who presented to the emergency departments of two hospitals in Philadelphia, PA, USA. Demographic data, medical history, and point-of-care hemoglobin A1c were collected at baseline. Using Spearman rank correlations, we examined whether depressive symptoms measured with the Patient Health Questionnaire-9 (PHQ-9) were associated with diabetes health beliefs, which were assessed with the Diabetes Health Belief Scale (DHBS). PHQ-9 scores were significantly correlated with DHBS's Perceived Side Effects scores [r(56) = 0.474, p < 0.01] and Perceived Barriers scores [r(56) = 0.337, p < 0.05]. These findings suggest that negative health beliefs may play a role in the relationship between depression and low medication adherence. Treatment of diabetes in middle-aged and older African American individuals should address both depression and negative health beliefs on side effects and perceived barriers.

Clinical insights into the cross-link between mood disorders and type 2 diabetes: A review of longitudinal studies and Mendelian randomisation analyses

Mood disorders and type 2 diabetes mellitus (T2DM) are prevalent conditions that often co-occur. We reviewed the available evidence from longitudinal and Mendelian randomisation (MR) studies on the relationship between major depressive disorder (MDD), bipolar disorder and T2DM. The clinical implications of this comorbidity on the course of either condition and the impact of antidepressants, mood stabilisers, and antidiabetic drugs were examined. Consistent evidence indicates a bidirectional association between mood disorders and T2DM. T2DM leads to more severe depression, whereas depression is associated with more complications and higher mortality in T2DM. MR studies demonstrated a causal effect of MDD on T2DM in Europeans, while a suggestive causal association in the opposite direction was found in East Asians. Antidepressants, but not lithium, were associated with a higher T2DM risk in the long-term, but confounders cannot be excluded. Some oral antidiabetics, such as pioglitazone and liraglutide, may be effective on depressive and cognitive symptoms. Studies in multi-ethnic populations, with a more careful assessment of confounders and appropriate power, would be important.

All-trans retinoic acid inhibits oxidative stress via ACE2/Ang (1-7)/MasR pathway in renal tubular epithelial cells stimulated with high glucose

The aim of this study was to investigate the effects of all-trans retinoic acid (atRA) on oxidative stress in renal tubular epithelial cells induced by high glucose (HG) and its potential mechanism. We investigated the effects of atRA in HG-induced renal epithelial cell line HK-2. Seven groups were designed for this experiment: negative control, mannitol, high-glucose (HG), HG combined with a low concentration of atRA, HG combined with a middle concentration of atRA, HG combined with a high concentration of atRA, and HG combined with captopril. After 48 h of incubation, oxidative stress factor expression in the supernatant was detected by enzyme-linked immunosorbent assay. Reactive oxygen species and cell apoptosis expression were assessed by flow cytometry. NADPH oxidase, fibrosis factor, and angiotensin-converting enzyme 2/angiotensin (1-7)/mas receptor (ACE2/Ang (1-7)/MasR) pathway-related protein expressions were determined by western blot analysis. The expressions of oxidative stress factors, NADPH oxidase components, and fibrosis factors were significantly higher after HG treatment. Apoptosis of HK2 cells in the HG group was also significantly higher. AtRA could reverse the above abnormal changes in a concentration-dependent manner. HG significantly promoted the expression of ACE, Ang II, and Ang II type 1 receptor (AT1R), whereas it inhibited the expression of ACE2, Ang (1-7), and MasR. With the elevation of concentration, atRA could gradually suppress the expression of ACE, Ang II, and AT1R, but facilitate ACE2, Ang (1-7), and MasR. These results were statistically significant. AtRA could significantly inhibit oxidative stress and apoptosis of renal tubular epithelial cells induced by HG. The mechanism may inhibit the ACE/Ang II/AT1R pathway and/or activate ACE2/Ang (1-7)/MasR pathway.

The Hidden Burden-Exploring Depression Risk in Patients with Diabetic Nephropathy: A Systematic Review and Meta-Analysis

INTRODUCTION

Diabetic nephropathy is a common complication among patients with diabetes mellitus, and it has been linked to a higher risk of depression. However, the magnitude of this association remains unclear. This study aimed to systematically review and meta-analyse the risk of depression in patients with diabetic nephropathy compared to diabetes patients without nephropathy.

METHODS

We conducted a systematic literature review, searching multiple databases from January 1964 to March 2023, and included randomized controlled trials, non-randomized controlled trials, and observational studies. We assessed the risk of bias using the Newcastle Ottawa scale for observational studies. The statistical analysis was performed using STATA version 14.2, and pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated. A total of 60 studies were included.

RESULTS

The pooled OR for the risk of depression among patients with diabetic nephropathy was 1.78 (95% CI 1.56-2.04; I² = 83%; n = 56), indicating a significantly higher risk compared to diabetes patients without nephropathy (p < 0.001). Pooling the effect size across these studies showed that the pooled OR was 1.15 (95% CI 1.14-1.16; I² = 88%; n = 32). Subgroup analyses based on the type of diabetes and study region revealed no significant differences in the pooled estimates.

CONCLUSION

This study demonstrates that patients with diabetic nephropathy have a significantly higher risk of depression compared to diabetes patients without nephropathy. These findings highlight the importance of assessing and addressing the mental health of patients with diabetic nephropathy as part of their overall healthcare management.

Association between antidepressant use and liver fibrosis in patients with type 2 diabetes: a population based study

BACKGROUND

The prevalence of liver fibrosis among diabetic patients is increasing rapidly. Our study aims at exploring the relationship between antidepressant use and liver fibrosis in diabetic patients.

METHODS

We conducted this cross-sectional study through the cycle of National Health and Nutrition Examination Survey (NHANES) 2017-2018. The study population were consisted of patients with type 2 diabetes and reliable vibration-controlled transient elastography (VCTE) results. The presence of liver fibrosis and steatosis were assessed by the median values of liver stiffness measurement (LSM) and controlled attenuation parameter (CAP), respectively. Antidepressants included selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin and norepinephrine reuptake inhibitors (SNRIs) and serotonin antagonists and reuptake inhibitors (SARIs). Patients with evidence of viral hepatitis and significant alcohol consumption were excluded. Logistic regression analysis was performed to evaluate the association between antidepressant use and both steatosis and significant (≥ F3) liver fibrosis after adjustment for potential confounders.

RESULTS

Our study population consisted of 340 women and 414 men, of whom 87 women(61.3%) and 55(38.7%) men received antidepressants. The most commonly used antidepressants were SSNIs(48.6%), SNRIs(22.5%) and TCAs(12.7%), followed by SARIs(10.6%) and other antidepressants(5.6%). 165 participants had significant liver fibrosis by VCTE, with a weighted overall prevalence of 24%(95% CI 19.2-29.5). In addition, 510 patients had evidence of hepatic steatosis by VCTE with a weighted overall prevalence of 75.4%(95% CI 69.2-80.7). After adjusting confounders, no significant association was observed between antidepressant use and significant liver fibrosis or cirrhosis.

CONCLUSIONS

In conclusion, in this cross-sectional study, we found that antidepressant drugs was not associated with liver fibrosis and cirrhosis in patients with type 2 diabetes in a nationwide population.

Defining measures of kidney function in observational studies using routine health care data: methodological and reporting considerations

The availability of electronic health records and access to a large number of routine measurements of serum creatinine and urinary albumin enhance the possibilities for epidemiologic research in kidney disease. However, the frequency of health care use and laboratory testing is determined by health status and indication, imposing certain challenges when identifying patients with kidney injury or disease, when using markers of kidney function as covariates, or when evaluating kidney outcomes. Depending on the specific research question, this may influence the interpretation, generalizability, and/or validity of study results. This review illustrates the heterogeneity of working definitions of kidney disease in the scientific literature and discusses advantages and limitations of the most commonly used approaches using 3 examples. We summarize ways to identify and overcome possible biases and conclude by proposing a framework for reporting definitions of exposures and outcomes in studies of kidney disease using routinely collected health care data.

Bidirectional association between depression and diabetic nephropathy by meta-analysis

BACKGROUND

Studies suggested that the association between depression and diabetic nephropathy may be bi-directional, but this hypothesis remains investigating. In this meta-analysis, the bi-directional relationship between depression and diabetic nephropathy was investigated.

METHODS

A search for the publications on depression and diabetic nephropathy in the databases of PubMed, Web of science, and Embase from the earliest available to August 2022 was conducted. Two sets of pooled risk estimates were calculated using random effects models: diabetic nephropathy predicting depression and depression predicting diabetic nephropathy. Cross-sectional studies were assessed using Agency for Healthcare Research and Quality (AHRQ), cohort and case-control studies were assessed using Newcastle-Ottawa Scale (NOS).

RESULT

Of the 974,121 patients in 30 clinical studies, 24 studies met eligibility for diabetic nephropathy predicting onset of depression, representing 28,438 incident cases. The other 6 studies met criteria for depression predicting onset of diabetic nephropathy, representing 945,683 incident cases. The pooled odds ratio (OR) of diabetic nephropathy predicting depression was 1.46 (95% CI 1.27-1.67). The OR of depression predicting diabetic nephropathy was 1.22 (95% CI 1.13-1.31).

CONCLUSION

This meta-analysis shows that the relationship between depression and diabetic nephropathy may be bidirectional. Diabetic nephropathy may be a predictor of depression, and depression may also be an indicator of diabetic nephropathy. The mechanisms underlying the bidirectional relationship need to be further investigated and interventions of the comorbidity of depression and diabetic nephropathy need be studied in clinical practice.

Solid lipid nanoparticles: a promising tool for insulin delivery

INTRODUCTION

Insulin plays a critical role in metabolism modulation including carbohydrate, lipid, and protein metabolism. There is room to improve insulin delivery but optimizing the best carrier remains challenging. Traditional and conventional approaches for insulin delivery do not emulate the normal fate of insulin release in the body. Despite extensive research attempts to overcome this and other challenges, the goal of achieving optimal insulin delivery that emulates the natural system remains unresolved.

AREAS COVERED

Solid Lipid Nanoparticles (SLNs) may provide a solution, because they are nontoxic, biocompatible, and straightforward to formulate thus providing a promising platform for achieving targeted and controlled delivery of various therapeutic agents. This review aims to provide an overview on the suitability and application of SLNs for insulin delivery. A special emphasis is placed on the biopharmaceutical aspects of insulin loaded SLNs which have not been explored in detail to date.

EXPERT OPINION

SLNs have proven to be safe and versatile drug delivery systems suitable for insulin delivery and capable of improving the efficacy and pharmacokinetic profile of encapsulated insulin. There is still some work to be done to fully explore SLNs' true potential as drug delivery and specifically insulin delivery vehicles suitable for clinical use.

Individualized prediction of chronic kidney disease for the elderly in longevity areas in China: Machine learning approaches

Background

Chronic kidney disease (CKD) has become a major public health problem worldwide and has caused a huge social and economic burden, especially in developing countries. No previous study has used machine learning (ML) methods combined with longitudinal data to predict the risk of CKD development in 2 years amongst the elderly in China.

Methods

This study was based on the panel data of 925 elderly individuals in the 2012 baseline survey and 2014 follow-up survey of the Healthy Aging and Biomarkers Cohort Study (HABCS) database. Six ML models, logistic regression (LR), lasso regression, random forests (RF), gradient-boosted decision tree (GBDT), support vector machine (SVM), and deep neural network (DNN), were developed to predict the probability of CKD amongst the elderly in 2 years (the year of 2014). The decision curve analysis (DCA) provided a range of threshold probability of the outcome and the net benefit of each ML model.

Results

Amongst the 925 elderly in the HABCS 2014 survey, 289 (18.8%) had CKD. Compared with the other models, LR, lasso regression, RF, GBDT, and DNN had no statistical significance of the area under the receiver operating curve (AUC) value (>0.7), and SVM exhibited the lowest predictive performance (AUC = 0.633, p-value = 0.057). DNN had the highest positive predictive value (PPV) (0.328), whereas LR had the lowest (0.287). DCA results indicated that within the threshold ranges of ~0-0.03 and 0.37-0.40, the net benefit of GBDT was the largest. Within the threshold ranges of ~0.03-0.10 and 0.26-0.30, the net benefit of RF was the largest. Age was the most important predictor variable in the RF and GBDT models. Blood urea nitrogen, serum albumin, uric acid, body mass index (BMI), marital status, activities of daily living (ADL)/instrumental activities of daily living (IADL) and gender were crucial in predicting CKD in the elderly.

Conclusion

The ML model could successfully capture the linear and nonlinear relationships of risk factors for CKD in the elderly. The decision support system based on the predictive model in this research can help medical staff detect and intervene in the health of the elderly early.

The Geriatric Depression Scale Predicts Glycemic Control in Older Adult with Type 2 Diabetes Mellitus: A Longitudinal Study

The presence of comorbid depression and diabetes is associated with worse glycemic control, higher complication and greater mortality risk than expected by each condition alone. The association between various levels of severity of depressive symptoms and glycemic control over time among type 2 diabetic older patients was unclear. This study aimed to investigate a longitudinal association between depression and HbA1c among type 2 diabetic older patients. Type 2 diabetes patients aged 60 years and above with normal cognition were recruited from the outpatient department from 1 June 2020 to 1 July 2021. The Thai Geriatric Depression Scale (TGDS) and HbA1c were assessed at five time points (baseline and every 12 weeks) for 1 year. A linear mixed effect model was used. Of the 161 enrolled participants, 146 completed the study. At baseline, 14% were susceptible to depression or having depression (TGDS score 6 and above), and there was a significant correlation between HbA1c and depression (r = 0.26, p ≤ 0.01). The longitudinal analysis indicated that TGDS was a significant predictor of HbA1c in the next visit, and the relationship was J-shaped. A TGDS below 5 was associated with decreasing HbA1c in the next visit, but the association became positive at a TGDS score at 5 or higher. The presence of significant symptoms of depression was associated with glycemic control in the next 3-month interval OPD visit event, although major depressive disorder has not yet been established.

Association Between Dietary Fiber Intake and Risk of Depression in Patients With or Without Type 2 Diabetes

BACKGROUND

Depression and type 2 diabetes (T2D) are both serious public health problems, with morbidity and mortality in people increasing year by year, resulting in a heavy economic burden. A correlation between dietary fiber and both has been reported. Nevertheless, few data are available concerning dietary fiber and the risk of depression with or without T2D, which deserve further attention.

MATERIALS AND METHODS

We assessed the relationship between dietary fiber intake and risk of depression with or without T2D in the 2007-2014 National Health and Nutrition Examination Survey (NHANES) population. A 24-h dietary review was used to assess fiber intake. The Patient Health Questionnaire-9 was used to assess depression. Stability of the results was assessed using restricted cubic spline models and logistic regression, as well as sensitivity analyses.

RESULTS

A total of 17,866 adults aged 20 years and older with a mean age of 49.3 ± 17.7 years were included in this study, of whom 49.5% were male. After adjusting for covariates, the association of dietary fiber intake with the risk of depression appeared to differ between non-T2D group and T2D group (OR, 0.987; 95% CI, 0.979-0.995 vs. OR, 1.003; 95% CI, 0.988-1.017). Furthermore, when dietary fiber was converted to a categorical variable, there was evidence of interaction between T2D status and fiber intake on decreasing the prevalence of depression (P-value for interaction = 0.015). Sensitivity analysis showed stable results.

CONCLUSION

Our findings indicated that whether a patient has T2D may affect the relationship between dietary fiber intake and the risk of depression, which still needs to be confirmed by further randomized controlled trials.

Relationships Between Metabolic Body Composition Status and Rapid Kidney Function Decline in a Community-Based Population: A Prospective Observational Study

Obesity and metabolic syndrome are strong risk factors for incident chronic kidney disease (CKD). However, the predictive accuracy of metabolic body composition status (MBCS), which combines the status of obesity and metabolic syndrome, for rapid kidney function decline (RKFD) is unclear. The aim of this study was to investigate the relationship between MBCS and RKFD in a healthy population in a prospective community-based cohort study. In the current study, we followed changes in renal function in 731 people residing in northern Taiwan for 5 years. The participants were divided into four groups according to their MBCS, including metabolically healthy normal weight (MHNW), metabolically healthy overweight (MHOW), metabolically unhealthy normal weight (MUNW), and metabolically unhealthy overweight (MUOW). We evaluated traditional risk factors for CKD and metabolic profiles. The primary outcome was RKFD, which was defined as a 15% decline in estimated glomerular filtration rate (eGFR) within the first 4 years, and a reduction in eGFR which did not improve in the 5th year. During the study period, a total of 731 participants were enrolled. The incidence of RKFD was 17.1% (125/731). Multiple Cox logistic regression hazard analysis revealed that age, cerebrovascular accident, eGFR, urine albumin-to-creatinine ratio, use of painkillers, depressive mood, MUNW and MUOW were independent predictors of RKFD. After adjusting for age, sex, eGFR and total cholesterol, the participants with MUNW and MUOW had higher hazard ratios (HRs) for RKFD [HR: 2.19, 95% confidence interval (CI): 1.22–3.95 for MUNW; HR: 1.86, 95% CI: 1.21–2.87 for MUOW] than those with MHNW. Similar results were also observed in subgroup analysis of those aged above 65 years. On the basis of the results of this study, we conclude that MBCS was independently associated with RKFD, especially in the older adults. On the basis of our results, we suggest that MUNW and MUOW should be considered as risk factors for RKFD.

COVID-19 and kidney disease: insights from epidemiology to inform clinical practice

Over the course of the COVID-19 pandemic, numerous studies have aimed to address the challenges faced by patients with kidney disease and their caregivers. These studies addressed areas of concern such as the high infection and mortality risk of patients on in-centre haemodialysis and transplant recipients. However, the ability to draw meaningful conclusions from these studies has in some instances been challenging, owing to barriers in aspects of usual care, data limitations and problematic methodological practices. In many settings, access to SARS-CoV-2 testing differed substantially between patient groups, whereas the incidence of SARS-CoV-2 infection varied over time and place because of differences in viral prevalence, targeted public health policies and vaccination rates. The absence of baseline kidney function data posed problems in the classification of chronic kidney disease and acute kidney injury in some studies, potentially compromising the generalizability of findings. Study findings also require attentive appraisal in terms of the effects of confounding, collider bias and chance. As this pandemic continues and in the future, the implementation of sustainable and integrated research infrastructure is needed in settings across the world to minimize infection transmission and both prevent and plan for the short-term and long-term complications of infectious diseases. Registries can support the real-world evaluation of vaccines and therapies in patients with advanced kidney disease while enabling monitoring of rare complications.

Patients with kidney disease are at particular risk of the adverse outcomes of COVID-19. Throughout the pandemic, epidemiological studies have been performed to inform clinical care; however, these studies have faced a number of methodological challenges. This Review discusses current understanding of the effects of COVID-19 on patients with kidney disease and some of the major obstacles encountered when conducting epidemiological research in a pandemic setting.

Patients who are receiving in-centre dialysis have a higher risk of exposure to SARS-CoV-2 than members of the general population, owing to their limited ability to isolate.

Studies have found a dose–response of increasing risk of mortality from COVID-19 with decreasing kidney function, with particularly high mortality seen in people with kidney failure and those on kidney replacement therapy.

Evidence of how infection risk can be mitigated in patients with chronic kidney disease is often of poor quality due to the many challenges of conducting epidemiological research in fragmented health-care settings.

Observational studies of associations between risk factors, such as chronic kidney disease or transplantation, and outcomes, such as COVID-19-related mortality, can be distorted as a result of collider bias, and thus care must be taken in study design and evaluation.

Recognizing the challenges that affect epidemiological studies in pandemic settings together with information on local health contexts enables rigorous assessment of study quality; adequate reporting of aspects relevant to local care availability enables readers to identify studies that contribute robust findings to the literature.

To confront the challenges wrought by future pandemics, a sustainable and integrated global infrastructure is needed to identify evidence-based approaches to minimize infection transmission and adverse outcomes.

Depressive symptoms among older adults with diabetes mellitus: a cross-sectional study

BACKGROUND

Diabetes mellitus is a chronic disease with long-term consequences that is often associated with depressive symptoms. This relationship predicts increased morbidity and mortality rates, leading to serious health consequences.

OBJECTIVE

To identify the prevalence and health factors associated with depressive symptoms among older adults with diabetes mellitus.

DESIGN AND SETTING

An observational cross-sectional study was conducted among 236 older adults in the Basic Healthcare Units of Jequié, Brazil.

METHODS

A survey containing sociodemographic, behavioral, and health conditions was used as a data collection instrument, in addition to the Geriatric Depression Scale. The main inclusion criterion was older adults diagnosed with diabetes mellitus. To identify the risk factors associated with depressive symptoms among older adults with diabetes mellitus, logistic regression analysis was conducted for calculating the odds ratio (OR), and a 95% confidence interval (CI) was considered statistically significant.

RESULTS

The prevalence of depressive symptoms was 24.2% among older adults with diabetes, corroborating the Brazilian average of 30%. The final multivariate analysis model for the risk of depressive symptoms showed a significant association with diabetes complications [OR = 2.50, 95% CI 1.318-4.74)] and osteoporosis [OR = 2.75, 95% CI 1.285-5.891)].

CONCLUSION

A high prevalence of depressive symptoms was observed among older adults with diabetes. Critically examining older adults with diabetes mellitus is necessary, and screening for depressive symptoms is highly recommended, especially for those with complications resulting from diabetes mellitus and musculoskeletal comorbidities, such as osteoporosis, as it seems to be associated with depressive symptoms.

Persistent Depressive Symptoms and the Changes in Serum Cystatin C Levels in the Elderly: A Longitudinal Cohort Study

BACKGROUND

The burden of depression in the elderly is increasing worldwide with global aging. However, there is still a lack of research on the relationship between depressive symptoms and the progression of renal function. Our aim is to evaluate the longitudinal association between baseline depressive symptoms and the changes in serum cystatin C levels over 10 years' follow-up period.

METHODS

We used longitudinal data from the Health and Retirement Study (HRS), an existing community based nationally representative aging cohort study which enrolled individuals over age 50 in the USA. Depressive symptoms were determined using an eight-item version of the Center for Epidemiologic Studies Depression Scale (CESD) at wave 7 (2004) and wave 8 (2006). Persistent depressive symptoms were defined as both CESD scores measured at waves 7 and 8 were ≥3; episodic depressive symptoms were defined as CESD scores ≥3 at wave 7 or wave 8. A linear mixed model was used to evaluate the correlation between baseline depressive symptoms and future changes in cystatin C levels.

RESULTS

The mean age of the 7,642 participants was 63.8 ± 10.8 years, and 60.9% were women. Among the participants, 1,240 (16.2%) had episodic depressive symptoms and 778 (10.2%) had persistent depressive symptoms. Compared with participants with no depressive symptoms at both waves, a significant increase in serum cystatin C levels was found among those with persistent depressive symptoms.

CONCLUSIONS

Our results showed that baseline persistent depressive symptoms were significantly associated with an increased rate of serum cystatin C levels. The level of serum cystatin C should be monitored in the elderly with persistent depressive symptoms.

Effect of depression on progression to end-stage renal disease or pre-end-stage renal disease death in advanced diabetic nephropathy: A prospective cohort study of the Diabetes Study from the Center of Tokyo Women's Medical University

AIMS/INTRODUCTION

This study aimed to determine the effect of depression on the progression to end-stage renal disease (ESRD) and pre-ESRD death in patients with advanced diabetic nephropathy.

MATERIALS AND METHODS

This single-center prospective cohort study enrolled Japanese patients with type 2 diabetes and advanced diabetic nephropathy. The total Patient Health Questionnaire-9 score was used to evaluate depression at baseline and classified patients into: no, mild and severe depression groups. The outcomes were ESRD, defined as initiation of renal replacement therapy, and pre-ESRD death. The relationship between the severity of depression and these outcomes was analyzed using a competing risks model, defining each outcome as the competing risk of the other outcome.

RESULTS

Of the 486 patients with a mean estimated glomerular filtration rate of 37.1 ± 21.1 mL/min/1.73 m2 , 345 were men. During the median follow up of 4.4 years, 164 patients progressed to ESRD and 50 died. The cumulative incidence function of ESRD was significantly higher in the severe depression group (Gray's test, P = 0.003). The ESRD risk increased by 12.4% and 45.1% in patients with mild and severe depression, respectively, compared with those without depression, although these differences did not reach statistical significance in the multivariate subdistribution hazard model (P = 0.450 and 0.161, respectively). The cumulative incidence of death was similar for the study groups.

CONCLUSION

Depression potentially has a weak impact on progression to ESRD, however, the presence of comorbidities might have the possibility to reduce the effect of depression on the renal outcome in patients with advanced diabetic nephropathy.

Comorbid Chronic Physical Illnesses in Type 1 Diabetes Adolescents: Personal, Caregiver, and Family Functioning

Having diabetes and comorbid chronic physical illnesses (CCPIs) suggests a higher risk for depression and lower health-related quality of life and treatment adherence. Caring for these patients is often overwhelming. Although CCPIs affect youths with type 1 diabetes (T1D), no study has examined the psychosocial or health-related impact of CCPIs in this population. We examined individual, caregiver, and family functioning differences among T1D adolescents with (G1; n = 25) and without (G2; n = 26) CCPIs. Participants were 51 youth (aged 12-17 years) enrolled in a depression treatment study. We administered diagnostic interviews and rating scales to assess each domain of interest. Using MANOVA, followed by individual univariate analyses, and Chi-square tests, we compared groups in continuous and categorical variables, respectively. MANOVA results were significant, F(4, 46) = 2.62, p = .047. Participants from G1 obtained lower global functioning scores compared to G2. Caregivers whose offspring had CCPIs were more depressed and reported higher burden but lower family functioning scores than their counterparts did. A higher percent of youths with CCPIs needed reminders about insulin use and met the criteria for major depression, but a lower proportion had access to insulin pumps. Taking care of youths from G1 was associated with a lifetime history of depressive disorder or suicidality. Our findings support the existence of individual, caregiver, and family functioning differences between T1D adolescents with vs. without CCPIs. Psychosocial interventions should consider the incremental burden that CCPIs may pose over these youth and their families.

The Association of Posttraumatic Stress Disorder With Longitudinal Change in Glomerular Filtration Rate in World Trade Center Responders

OBJECTIVE

High levels of psychological distress increase the risk of a wide range of medical diseases. In this study, we investigated the association between posttraumatic stress disorder (PTSD) and kidney disease.

METHODS

World Trade Center (WTC) responders were included if they had two or more measures of estimated glomerular filtration rate (eGFR). The PTSD Checklist (PCL) was used to define no PTSD (PCL < 40), "mild" PTSD (40 ≤ PCL <50), and "severe" PTSD (PCL ≥50). Subtypes of PTSD by symptom clusters were analyzed. Multinomial logistic regression was used to estimate the association of PTSD with two GFR change outcomes (decline or increase) compared with the stable GFR outcome.

RESULTS

In 2266 participants, the mean age was 53.1 years, 8.2% were female, and 89.1% were White. Individuals with PTSD (n = 373; 16.5%) did not differ in mean baseline GFR from individuals without PTSD (89.73 versus 90.56 mL min-1 1.73 m-2; p = .29). During a 2.01-year mean follow-up, a mean GFR decline of -1.51 mL min-1 1.73 m-2 per year was noted. In multivariable-adjusted models, PTSD was associated with GFR decline (adjusted relative risk [aRR] = 1.74 [1.32-2.30], p < .001) compared with stable GFR, with "hyperarousal" symptoms showing the strongest association (aRR =2.11 [1.40-3.19]; p < .001). Dose-response effects were evident when comparing mild with severe PTSD and comparing PTSD with versus without depression. PTSD was also associated with GFR rise (aRR = 1.47 [1.10-1.97], p < .009). The association between PTSD and GFR change was stronger in participants older than 50 years.

CONCLUSIONS

PTSD may be a novel risk factor for exaggerated longitudinal GFR change in young, healthy adults. These findings need to be validated in other cohorts.

Incidence of end-stage renal disease and risk factors for progression of renal dysfunction in Japanese patients with type 2 diabetes: the Fukuoka Diabetes Registry

BACKGROUND

Epidemiological data regarding diabetic kidney disease are accumulated insufficiently in Japan. We prospectively investigated the incidence of end-stage renal disease (ESRD) and risk factors for progression of renal dysfunction in Japanese patients with type 2 diabetes.

METHODS

4904 participants with type 2 diabetes (mean age 65 years, mean estimated glomerular filtration rate (eGFR) 75 mL/min/1.73 m², proportion of eGFR  < 60 mL/min/1.73 m² 21%) were investigated for the progression to ESRD requiring dialysis in multicenter outpatients registry for 5 years. Risk factors for progression of renal dysfunction (≥ 30% decline in eGFR from the baseline and annual eGFR decline rates) were evaluated.

RESULTS

The incidence rates of ESRD and all-cause mortality were 4.1/1000 person-years and 12.3/1000 person-years, respectively, and increased according to stages of chronic kidney disease (eGFR  < 30 mL/min/1.73 m², incidence of ESRD 176.6/1000 person-years, all-cause mortality 57.4/1000 person-years). Incidence of  ≥ 30% decline in eGFR from the baseline was 16.4% at 5 years, and the mean annual decline rate was -1.84 mL/min/1.73 m²/year. The progression of renal dysfunction was significantly associated with older age, poor glycemic control, blood pressure, albuminuria, eGFR, previous cardiovascular disease, lifestyle factors (body mass index, reduced intake of dietary fiber, increased intake of sodium, no regular exercise), and depressive symptoms.

CONCLUSIONS

This prospective study has emphasized the importance of multifactorial interventions on risk factors to suppress the high incidence of ESRD in Japanese patients with type 2 diabetes.

Estimating the joint effect of diabetes and subsequent depressive symptoms on mortality among older latinos

PURPOSE

Diabetes and depression are risk factors for cardiovascular disease, but the evidence about their interaction effect on long-term health outcomes among Latinos is lacking. We aimed to investigate the joint association of diabetes and subsequent depressive symptoms with mortality among older Latinos, an understudied racial/ethnic group with high prevalence of diabetes.

METHODS

This study included 1,495 adults from the Sacramento Area Latino Study on Aging. We employed Cox proportional-hazards models to estimate the adjusted hazard ratios [aHRs] for cardiovascular and all-cause mortality according to diabetes status at enrollment and depressive symptoms a year after the enrollment. We used marginal structural models to adjust for time-varying confounders.

RESULTS

The mean age (standard deviation) of participants was 70 (6.6) years. Over follow-up (median 7.7 years), diabetes and depressive symptoms were individually associated with increased risk of cardiovascular mortality (diabetes, aHR[95% CI]=2.13[1.60-2.84]; depressive symptoms, aHR[95% CI]=1.62[1.09-2.39]) and all-cause mortality (diabetes, aHR[95% CI]=1.92[1.53-2.41]; depressive symptoms, aHR[95% CI]=1.41[1.02-1.94]). After adjusting for time-varying confounders, we found a multiplicative interaction between diabetes and subsequent depressive symptoms for cardiovascular mortality (aHR[95% CI]=2.94[1.07-8.39]), but not all-cause mortality (aHR[95% CI]=1.80[0.81-4.35]).

CONCLUSIONS

Using a longitudinal cohort of community-dwelling older Latinos, we found that diabetes and subsequent depressive symptoms were jointly associated with increased risk of cardiovascular mortality.

Serum albumin and albuminuria predict the progression of chronic kidney disease in patients with newly diagnosed type 2 diabetes: a retrospective study

Background

Diabetes-related kidney disease is associated with end-stage renal disease and a high mortality rate. However, data on risk factors associated with kidney disease in patients with newly diagnosed type 2 diabetes mellitus (DM) remains insufficient. The aim of the present study was to identify the risk factors significantly associated with chronic kidney disease progression in patients with newly diagnosed type 2 DM.

Methods

We reviewed a total of 254 consecutive patients who were newly diagnosed with type 2 diabetes at Nanjing First Hospital from January to December 2014. They were observed for two years, and baseline and biochemical variables were used to identify significant predictors of kidney failure progression. Kidney failure progression was defined as a ≥ 30% increase in serum creatine level.

Results

The mean age of patients was 58.96 years, 37.4% were women, and 57.1% had hypertension. Kidney function progressed in 40 patients (15.75%). Multivariable logistic regression analyses showed that serum albumin (p = 0.015) and microalbuminuria (p < 0.001) were associated with kidney failure progression in patients with newly diagnosed type 2 DM. Those with lower estimated glomerular filtration rate (eGFR; 30–60 ml/min/1.73 m²) at baseline had lower serum albumin levels compared to those of patients with higher eGFR. The albuminuria levels were higher in patients with lower eGFR than in those with eGFR ≥ 90 ml/min/1.73 m². Receiver operating characteristic curve analysis showed that the area under the curve was 0.754 (95% CI [0.670–0. 0.837]).

Conclusions

The overall rate of chronic kidney disease progression is relatively high, and low serum albumin and high albuminuria levels are associated with kidney failure progression in newly diagnosed diabetic patients.

Association between the level of adherence to dietary guidelines and depression among Korean patients with type 2 diabetes mellitus

OBJECTIVE

This study aimed to examine the cross-sectional association between adherence to dietary guidelines for type 2 diabetes mellitus (T2DM) and depression.

METHODS

A total of 3457 patients with T2DM were included. Dietary information was obtained using 24-h recall, and adherence to dietary guidelines was estimated using the Korean Diabetes Association-Korean Ministry of Health and Welfare index. Depression was evaluated using a questionnaire. Participants who had responded "yes" to any of the three questions related to diagnosis, current condition, and treatment were defined as depression. Multivariable logistic regression analysis was used to examine the association between adherence to dietary guidelines and depression.

RESULTS

T2DM patients with a lower score on adherence to dietary guidelines were more likely to report depression than those with a higher score (Odds ratios (OR): 0.51, 95% Confidence Interval (CI): 0.30-0.87). Patients with poor adherence to moderate calorie consumption (OR: 1.65, 95% CI: 1.07-2.52) and regular meal patterns (OR: 1.69, 95% CI: 1.15-2.50) were more likely to report depression. However, patients with poor adherence to low sodium intake were less likely to report depression (OR: 0.60, 95% CI: 0.40-0.88), and no association was observed between moderate carbohydrate consumption, sufficient vegetable/seaweed consumption, and moderate alcohol consumption and depression.

CONCLUSION

Good adherence to dietary guidelines was closely associated with a lower prevalence of depression among individuals with type 2 diabetes, but the specific guidelines were inconsistent. Systematic and continuous nutrition education for individuals with T2DM is necessary to improve their mental health outcomes.

Causal Effects of Positive Affect, Life Satisfaction, Depressive Symptoms, and Neuroticism on Kidney Function: A Mendelian Randomization Study

BACKGROUND

Further investigation of the causal effects of psychologic wellbeing on kidney function is warranted.

METHODS

In this Mendelian randomization (MR) study, genetic instruments for positive affect, life satisfaction, depressive symptoms, and neuroticism were introduced from a previous genome-wide association study meta-analysis of European individuals. Summary-level MR was performed using the CKDGen data of European ancestry (n=567,460), and additional allele score-based MR was performed in the individual-level data of White British UK Biobank participants (n=321,024).

RESULTS

In summary-level MR with the CKDGen data, depressive symptoms were a significant causative factor for kidney function impairment (CKD OR, 1.45; 95% confidence interval, 1.07 to 1.96; eGFR change [%] beta -2.18; 95% confidence interval, -3.61 to -0.72) and pleiotropy-robust sensitivity analysis results supported the causal estimates. A genetic predisposition for positive affect was significantly associated with better kidney function (CKD OR, 0.69; 95% confidence interval, 0.52 to 0.91), eGFR change [%] beta 1.50; 95% confidence interval, 0.09 to 2.93) and sensitivity MR analysis results supported the finding for CKD outcome, but was nonsignificant for eGFR. Life satisfaction and neuroticism exposures showed nonsignificant causal estimates. In the UK Biobank with covariate-adjusted allele score MR analysis, allele scores for positive affect and life satisfaction were causally associated with reduced risk of CKD and higher eGFR. In contrast, neuroticism allele score was associated with increased risk of CKD and lower eGFR, and depressive symptoms allele score was associated with lower eGFR, but showed nonsignificant association with CKD.

CONCLUSIONS

Health care providers in the nephrology field should be aware of the causal linkage between psychologic wellbeing and kidney function.

Meta-analysis of studies on depression prevalence among diabetes mellitus patients in Africa

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion or insulin action. It can be caused by the consumption of carbohydrate meals or medication side effects. Depression as a comorbid condition in an individual with diabetes is accountable for increased disability, mortality, and significant health problem in patients. As a continent, Africa does not have an overall estimation of depression prevalence among diabetes mellitus patients at a regional level. Consequently, this study's purpose was to use the meta-analysis method to summarize estimates of extant studies that have reported depression prevalence among patients with diabetes mellitus in Africa. The literature search method was executed to classify studies with reported depression prevalence with evidently designed inclusion and exclusion criteria. In total, 20 studies from sundry screened articles were appropriate for ultimate inclusion in the meta-analysis. Since substantial heterogeneity was expected, a random-effects meta-analysis was carried out using the number of cases with a total sample size to estimate the prevalence of diabetes mellitus at a regional level. The residual amount of heterogeneity was found to be high according to the statistics of τ² = 0.06; I² = 99.10%, chi-square = 2184.85, degree of freedom = 19 and P =< 0.001. The pooled depression prevalence was 40% within a 95% confidence interval of 29%–51%. The meta-regression analysis result showed that none of the included moderators contributed to the heterogeneity of studies. The result of effect size estimates against its standard error showed publication bias with a P-value of 0.001. The meta-analysis findings of this study have indicated that depression prevalence in Africa is still high. Reporting on numerous risk factors like socio-demographic characteristics were not possible in this study because of a lack of completeness in the included articles. Consequently, screening diabetes patients for comorbid depression with its associated risk factors is highly recommended.

Risk of Typical Diabetes-Associated Complications in Different Clusters of Diabetic Patients: Analysis of Nine Risk Factors

Objectives: Diabetic patients are often diagnosed with several comorbidities. The aim of the present study was to investigate the relationship between different combinations of risk factors and complications in diabetic patients. Research design and methods: We used a longitudinal, population-wide dataset of patients with hospital diagnoses and identified all patients (n = 195,575) receiving a diagnosis of diabetes in the observation period from 2003–2014. We defined nine ICD-10-codes as risk factors and 16 ICD-10 codes as complications. Using a computational algorithm, cohort patients were assigned to clusters based on the risk factors they were diagnosed with. The clusters were defined so that the patients assigned to them developed similar complications. Complication risk was quantified in terms of relative risk (RR) compared with healthy control patients. Results: We identified five clusters associated with an increased risk of complications. A combined diagnosis of arterial hypertension (aHTN) and dyslipidemia was shared by all clusters and expressed a baseline of increased risk. Additional diagnosis of (1) smoking, (2) depression, (3) liver disease, or (4) obesity made up the other four clusters and further increased the risk of complications. Cluster 9 (aHTN, dyslipidemia and depression) represented diabetic patients at high risk of angina pectoris “AP” (RR: 7.35, CI: 6.74–8.01), kidney disease (RR: 3.18, CI: 3.04–3.32), polyneuropathy (RR: 4.80, CI: 4.23–5.45), and stroke (RR: 4.32, CI: 3.95–4.71), whereas cluster 10 (aHTN, dyslipidemia and smoking) identified patients with the highest risk of AP (RR: 10.10, CI: 9.28–10.98), atherosclerosis (RR: 4.07, CI: 3.84–4.31), and loss of extremities (RR: 4.21, CI: 1.5–11.84) compared to the controls. Conclusions: A comorbidity of aHTN and dyslipidemia was shown to be associated with diabetic complications across all risk-clusters. This effect was amplified by a combination with either depression, smoking, obesity, or non-specific liver disease.

Prostaglandin E2 induced cardiac hypertrophy through EP2 receptor-dependent activation of β-catenin in 5/6 nephrectomy rats

Aims

Prostaglandin E₂ (PGE2) is involved in the development of cardiac hypertrophy. However, whether PGE2 regulates the chronic kidney disease‐associated cardiac hypertrophy and the tentative mechanism remains to be elucidated.

Methods and results

We explored the effect of PGE2 receptor inhibitors on cardiac hypertrophy in vitro and in a 5/6 nephrectomy (5/6NT) rat model using quantitative reverse transcription polymerase chain reaction, western blotting, enzyme‐linked immunosorbent assay, immunohistochemical staining, and immunofluorescence staining assays. The result showed that EP2 and EP4 receptors were both up‐regulated in the PGE2‐treated cardiomyocyte cells. PGE2 treatment enhanced active β‐catenin (non‐phosphorylated) signalling through mediating EP2 and EP4 receptors. Interestingly, inhibition of EP2 receptor suppressed PGE2‐induced cardiomyocyte hypertrophy and cardiac fibrosis‐related proteins in vitro. In the 5/6NT rat model, the increased secretion PGE2 was identified in the 5/6NT rat model for 2 weeks (P = 0.0251). EP2 receptor inhibitor administration significantly improved the cardiac function and fibrosis in 5/6NT rats.

Conclusions

Our study demonstrated that inhibition of EP2 receptor could improve PGE2‐induced cardiac hypertrophy in 5/6NT rats. The exploration of these mechanisms may contribute to the optimization of therapy in chronic kidney disease accompanied cardiac hypertrophy in clinic.

Art Therapy Alleviates the Levels of Depression and Blood Glucose in Diabetic Patients: A Systematic Review and Meta-Analysis

Objective: To systematically analyze the effects of art therapy on the levels of depression, anxiety, blood glucose, and glycated hemoglobin in diabetic patients.

Methods: We searched Cochrane Library, PubMed, Embase, and ClinicalTrials.gov databases from inception to January 24, 2021. The language of publication was limited to English. Randomized controlled trials (RCTs) that used art therapy to improve mental disorders in diabetic patients were involved. After selection of eligible studies, data were extracted, including the first author's full-name, year of publication, the first author's country of residence, number of intervention and control groups, the mean age of participants, method of intervention, duration of follow-up, and outcome measures. Assessment of quality of the included studies and data extraction were independently carried out by two researchers. RevMan 5.3 software was used to perform statistical analysis.

Results: A total of 396 samples from five studies were included, and the eligible studies were RCTs with a parallel design. Methods of art therapy included music therapy and painting therapy. The results showed that compared with the control group, art therapy could positively affect the levels of depression [standardized mean difference (SMD), −1.36; 95% confidence interval (CI), (−1.63, −1.09); P < 0.00001] and blood glucose in diabetic patients [mean difference (MD), −0.90; 95% CI, (−1.03, −0.77); P < 0.0001], while it had no influence on the levels of anxiety [SMD, −0.31; 95% CI, (−0.93, 0.31); P = 0.32] and glycated hemoglobin [MD, 0.22; 95% CI, (−0.02, 0.46); P = 0.07].

Conclusion: Art therapy may have significant effects on the levels of depression and blood glucose for diabetic patients.

Stress Related Disorders and the Risk of Kidney Disease

INTRODUCTION

Stress related disorders (SRDs, i.e., psychiatric disorders induced by significant life stressors) increase vulnerability to health problems. Whether SRDs associate with risk of acute kidney injury (AKI) and chronic kidney disease (CKD) is unknown.

METHODS

A population-matched cohort study in Sweden included 30,998 patients receiving a SRDs diagnosis and 116,677 unexposed patients matched by age, sex and estimated glomerular filtration rates (eGFR). The primary outcome was CKD progression, defined as a sustained relative decline in eGFR of more than 40% or commencement of kidney replacement therapy. The secondary outcome was AKI, defined by death or hospitalization attributed to AKI or rapid creatinine changes (increase ≥ 0.3 mg/d over 48 hours or 1.5x over 7 days). Cox models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

During a medium follow-up of 3.2 years, compared to the unexposed, patients with SRDs (median age 45 years, 71% women), were at increased risk of CKD progression (HR 1.23, 95% CI 1.10-1.37) and AKI (HR 1.22, 95% CI 1.04-1.42). While the HR of CKD progression remained similarly elevated during the entire follow-up period, the association with AKI was only observed during the first year after SRDs diagnosis. Results were consistent in stratified analyses, when only considering AKI-hospitalizations/death, and when disregarding eGFR measurements close to index date.

CONCLUSIONS

A diagnosis of SRDs is associated with subsequent risk of AKI and CKD progression. While studies should confirm this observation and characterize underlying mechanisms, close monitoring of kidney function following SRDs diagnosis may be indicated.

The cumulative impact of social determinants of health factors on mortality in adults with diabetes and chronic kidney disease

BACKGROUND

A growing body of evidence supports the potential role of social determinants of health on health outcomes. However, few studies have examined the cumulative effect of social determinants of health on health outcomes in adults with chronic kidney disease (CKD) with or without diabetes. This study examined the cumulative impact of social determinants of health on mortality in U.S. adults with CKD and diabetes.

METHODS

We analyzed data from National Health and Nutrition Examination Surveys (2005-2014) for 1376 adults age 20 and older (representing 7,579,967 U.S. adults) with CKD and diabetes. The primary outcome was all-cause mortality. CKD was based on estimated glomerular filtration rate and albuminuria. Diabetes was based on self-report or Hemoglobin A1c of ≥6.5%. Social determinants of health measures included family income to poverty ratio level, depression based on PHQ-9 score and food insecurity based on Food Security Survey Module. A dichotomous social determinant measure (absence vs presence of ≥1 adverse social determinants) and a cumulative social determinant score ranging from 0 to 3 was constructed based on all three measures. Cox proportional models were used to estimate the association between social determinants of health factors and mortality while controlling for covariates.

RESULTS

Cumulative and dichotomous social determinants of health score were significantly associated with mortality after adjusting for demographics, lifestyle variables, glycemic control and comorbidities (HR = 1.41, 95%CI 1.18-1.68 and HR = 1.41, 95%CI 1.08-1.84, respectively). When investigating social determinants of health variables separately, after adjusting for covariates, depression (HR = 1.52, 95%CI 1.10-1.83) was significantly and independently associated with mortality, however, poverty and food insecurity were not statistically significant.

CONCLUSIONS

Specific social determinants of health factors such as depression increase mortality in adults with chronic kidney disease and diabetes. Our findings suggest that interventions are needed to address adverse determinants of health in this population.

Association of suicide with short-term exposure to air pollution at different lag times: A systematic review and meta-analysis

BACKGROUND

Suicide is a major public health problem, with some environmental risk factors.

OBJECTIVES

This meta-analysis study explored the association between short-term exposure to air pollution and suicide mortality, with an emphasis on different lag times.

METHODS

A systematic search was used to find relevant studies in databases including Scopus, Web of Knowledge, Pubmed, and Embase published up to 19 May 2020. The inclusion criteria included case-crossover or time-series studies assessing the association of criteria air pollutants with suicide mortality at different Lag Days of 0-7 (LD0 to LD7) and Cumulative Lags of 1-7 days (CL1 to CL7). Odds ratios (OR) were calculated with 95% confidence intervals (CI).

RESULTS

Of 1436 retrieved articles, 11 were eligible for data extraction, representing data on 283,550 suicides published between 2010 and 2019. The odds of suicide death increase with each 10 μg/m³ increase in the mean concentrations of NO₂ at CL1 (1.013: 1.006-1.021), CL2 (1.028: 1.003-1.053), CL3 (1.035: 1.001-1.070), and LD2 (1.011: 1.001-1.022), SO₂ at CL1 (1.024: 1.014-1.034), CL2 (1.030: 1.012-1.048), CL3 (1.029: 1.009-1.049), and CL4 (1.027: 1.005-1.049), O₃ at CL6 (1.008: 1.000-1.016), PM₁₀ at CL1 (1.004: 1.000-1.008), and PM_2.5 at CL1 (1.017: 1.003-1.031). Besides, the odds of suicide death increases with each 0.5 mg/m³ increase in the mean concentration of CO at LD6 (1.005: 1.000-1.011). However, it decreased with increased O₃ exposure at LD3 (0.997: 0.994-1.000).

CONCLUSION

The study supports a positive association between air pollution and suicide mortality. No immediate risk was elucidated but the possible effects seem to be exerted cumulatively.

Changes Induced by Mind-Body Intervention Including Epigenetic Marks and Its Effects on Diabetes

Studies have evidenced that epigenetic marks associated with type 2 diabetes (T2D) can be inherited from parents or acquired through fetal and early-life events, as well as through lifelong environments or lifestyles, which can increase the risk of diabetes in adulthood. However, epigenetic modifications are reversible, and can be altered through proper intervention, thus mitigating the risk factors of T2D. Mind-body intervention (MBI) refers to interventions like meditation, yoga, and qigong, which deal with both physical and mental well-being. MBI not only induces psychological changes, such as alleviation of depression, anxiety, and stress, but also physiological changes like parasympathetic activation, lower cortisol secretion, reduced inflammation, and aging rate delay, which are all risk factors for T2D. Notably, MBI has been reported to reduce blood glucose in patients with T2D. Herein, based on recent findings, we review the effects of MBI on diabetes and the mechanisms involved, including epigenetic modifications.

The quest for cardiovascular disease risk prediction models in patients with nondialysis chronic kidney disease

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of death in patients with chronic kidney disease (CKD). However, traditional CVD risk prediction equations do not work well in patients with CKD, and inclusion of kidney disease metrics such as albuminuria and estimated glomerular filtration rate have a modest to no benefit in improving prediction.

RECENT FINDINGS

As CKD progresses, the strength of traditional CVD risk factors in predicting clinical outcomes weakens. A pooled cohort equation used for CVD risk prediction is a useful tool for guiding clinicians on management of patients with CVD risk, but these equations do not calibrate well in patients with CKD, although a number of studies have developed modifications of the traditional equations to improve risk prediction. The reason for the poor calibration may be related to the fact that as CKD progresses, associations of traditional risk factors such as BMI, lipids and blood pressure with CVD outcomes are attenuated or reverse, and other risk factors may become more important.

SUMMARY

Large national cohorts such as the US Veteran cohort with many patients with evolving CKD may be useful resources for the developing CVD prediction models; however, additional considerations are needed for the unique composition of patients receiving care in these healthcare systems, including those with multiple comorbidities, as well as mental health issues, homelessness, posttraumatic stress disorders, frailty, malnutrition and polypharmacy. Machine learning over conventional risk prediction models may be better suited to handle the complexity needed for these CVD prediction models.

Depression Is Associated With Progression of Diabetic Nephropathy in Type 1 Diabetes

OBJECTIVE

To investigate the relationship between depression and diabetic nephropathy progression in type 1 diabetes.

RESEARCH DESIGN AND METHODS

Data from 3,730 participants without end-stage renal disease (ESRD) at baseline, participating in the Finnish Diabetic Nephropathy Study, were included. Depression was assessed in three ways. Depression diagnoses were obtained from the Finnish Care Register for Health Care. Antidepressant agent purchase data were obtained from the Drug Prescription Register. Symptoms of depression were assessed using the Beck Depression Inventory (BDI). Based on their urinary albumin excretion rate (AER), participants were classified as those with normal AER, microalbuminuria, and macroalbuminuria. Progression from normal AER to microalbuminuria, macroalbuminuria, or ESRD; from microalbuminuria to macroalbuminuria or ESRD; or from macroalbuminuria to ESRD, during the follow-up period, was investigated.

RESULTS

Over a mean follow-up period of 9.6 years, renal status deteriorated in 18.4% of the participants. Diagnosed depression and antidepressant purchases before baseline were associated with 53% and 32% increased risk of diabetic nephropathy progression, respectively. Diagnosed depression assessed during follow-up remained associated with increased risk of disease progression (32%). BDI-derived symptoms of depression showed no association with the progression, but the total number of antidepressant purchases modestly reduced the risk (hazard ratio 0.989 [95% CI 0.982-0.997]), P = 0.008). With the sample divided based on median age, the observations followed those seen in the whole group. However, symptoms of depression additionally predicted progression in those age ≤36.5 years.

CONCLUSIONS

Diagnosed depression and antidepressant purchases are associated with the progression of diabetic nephropathy in type 1 diabetes. Whether successful treatment of depression reduces the risk needs to be determined.

The Risk Threshold for Hemoglobin A1c Associated With Albuminuria: A Population-Based Study in China

BACKGROUND

Diabetic kidney disease (DKD) is a kind of common microvascular complication of diabetes. This study aims to explore the possible links between blood sugar level and albuminuria, providing the exact cut point of the "risk threshold" for blood glucose with DKD.

METHODS

The relationship between blood glucose and albuminuria was modeled using linear and logistic regression in the REACTION study cohorts (N= 8932). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by logistic regression model. Two-slope linear regression was used to simulate associations between blood glucose and ACR.

RESULTS

We found that the increase in ACR was accompanied by increased HbA1c, with a turning point at 5.5%. The positive correlation remained highly significant (P<0.001) when adjusted for age, sex, marital status, education, smoking status, drinking status, BMI, waistline, SBP and DBP. In subgroup analyses including gender, obesity, hypertension, and smoking habits, the relationship was significant and stable.

CONCLUSIONS

We determined a risk threshold for HbA1c associated with albuminuria in a Chinese population over the age of 40. HbA1c ≥ 5.5% was positively and independently associated with ACR. These results suggest the necessity of early blood glucose control and renal function screening for DKD in at-risk populations.

Depression and cardiovascular disease events among patients with type 2 diabetes: A systematic review and meta-analysis with bias analysis

AIMS

To provide updated systematic and quantitative summary of the association between depression and the risk of CVD events among individuals with type 2 diabetes. We also aimed to examine the sensitivity of the association to uncontrolled confounding.

METHODS

Data sources included Medline, Embase, and PsycInfo through September 2019. Two independent reviewers selected cohort studies that evaluated the association between depression and fatal or non-fatal CVD events among individuals with type 2 diabetes. Bias analysis was performed using the bias formula approach.

RESULTS

Of 2527 citations screened, 17 eligible studies with a total of 1,033,131 participants were identified. Based on random-effects meta-analysis, depression was associated with higher risks of non-fatal CVD events (relative risk 1.35, 95% confidence interval [CI] 1.20 to 1.53) and fatal CVD event (relative risk 1.47, 95% CI 1.21 to 1.77). Bias analysis indicated that unmeasured confounders alone may not explain the observed association between depression and CVD events among individuals with type 2 diabetes.

CONCLUSIONS

Depression was associated with a higher risk of non-fatal and fatal CVD events among individuals with type 2 diabetes. Our findings provide updated and robust evidence about the association between depression and CVD events among individuals with type 2 diabetes.

Evolution in geriatric syndromes and association with survival over 5 years in the GERODIAB cohort of older French diabetic patients

PURPOSE

Although one in three patients with diabetes in Western countries is over 70 years-old, geriatric syndromes and their relationship with survival remain seldom studied. The present aim of the GERODIAB study was to examine the evolution of geriatric disorders and their relationship with survival in older type 2 patients with diabetes with initial sufficient autonomy.

METHODS

We performed a prospective, observational study over 5 years in patients with diabetes aged 70 years or above. A total of 987 consecutive type 2 patients with diabetes (mean age 77 years, range 70-94 years, 65.2% were 75 years and above, 52.1% women) were included from 56 French diabetic centres. Individual characteristics, diabetes parameters and geriatric parameters (autonomy, nutrition, cognitive alteration, depression, orthostatic hypotension, falls) were annually recorded. Survival was analysed using the Kaplan-Meier method and proportional hazards regression models.

RESULTS

Institutional living, impaired activity and difficulties in instrumental daily activity, cognitive disorders, malnutrition, depression, orthostatic hypotension and hypoglycaemia strongly increased during the follow-up. Institutional living, impaired activity and difficulties in instrumental daily activity, cognitive disorders and hypoglycaemia were strongly associated with reduced survival, but not falls. In hazard ratio models, living in an institution (HR = 2.39; CI = 1.77-3.24; p < 0.0001) and impaired Activity of Daily Living scale score were the most significant and independent predictors of death (HR = 1.59; CI = 1.19-2.13; p = 0.0016), associated with HbA1c ≥ 70 mmol/mol (HR = 1.62; CI = 1.12-2.36; p = 0.011).

CONCLUSION

Our findings show the considerable alteration of geriatric parameters and their relationship with decreased survival after a 5-year follow-up in type 2 patients with diabetes, independent of HbA1c and age. They, therefore, confirm the prognostic interest of using yearly geriatric markers in older diabetic patient management, especially the ADL, IADL and MMSE scales. Taking into account these prognostic parameters should contribute to target appropriate HbA1c goals.

TRIAL REGISTRATION

Registered at clinicaltrials.gov (21/01/2011): NCT01282060.

Elevated depressive symptoms and risk of all-cause and cardiovascular mortality among adults with and without diabetes: The REasons for Geographic And Racial Differences in Stroke (REGARDS) study

AIMS

To examine the association of elevated depressive symptoms with all-cause and cardiovascular disease (CVD) mortality and determine whether these associations differ for those with and without diabetes.

METHODS

We included 22,807 black and white men and women aged 45-98 years at baseline (2003-2007) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Elevated depressive symptoms were defined as a score ≥ 4 on the 4-item Centers for Epidemiologic Studies of Depression Scale. Participants were classified as having diabetes, prediabetes, or no prediabetes/diabetes based on glucose levels and diabetes medication use. All-cause mortality events were available through 2018 and adjudicated CVD mortality events were available through 2015.

RESULTS

During follow-up, there were 5383 all-cause deaths, of which 1585 were adjudicated CVD deaths. The mean survival time was lower for participants with elevated depressive symptoms than those without elevated depressive symptoms for those with diabetes, prediabetes, and no prediabetes/diabetes. In multivariable adjusted models, elevated depressive symptoms increased the risk of all-cause mortality for those with diabetes (HR = 1.15; 95% CI = 1.00-1.32), prediabetes (HR = 1.56; 95% CI = 1.28-1.91), and neither prediabetes/diabetes (HR = 1.34; 95% CI = 1.19-1.50) (p for interaction = 0.0342). Findings were similar for CVD mortality.

CONCLUSION

Elevated depressive symptoms increased the risk of all-cause and CVD mortality among individuals with and without diabetes, with a stronger magnitude of association observed among those with prediabetes. This underscores the need for assessing depressive symptoms across the glycemic spectrum, including those with prediabetes.

Effect of music intervention on mental health in patients with diabetes mellitus: protocol for a systematic review and meta-analysis of randomizsed controlled trials

INTRODUCTION

About 463 million adults aged 20-79 have diabetes globally. Mental disorders often exist in patients with diabetes as comorbidities, which can lead to aggravation of the diseases, increased difficulties in treatment, as well as elevated mortality rates. Music intervention has been applied in the treatment of comorbidities for 12 years now, but there are still no recommendations due to the lack of evidence. Thus, a meta-analysis is necessary to evaluate the effect of music intervention in treating mental disorders of patients with diabetes.

METHODS AND ANALYSIS

We will search the following nine online electronic databases from their inception until March 2020: PubMed, Web of Science, Embase, EBSCO, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang Database, Chinese Scientific Journal Database (VIP) and Chinese Biomedical and Medical Database. We also plan to search other relevant resources, including grey literature and the reference lists of relevant publications. Only randomised controlled trials of music intervention to treat depression or anxiety in patients with diabetes will be involved. The primary outcomes include the depression score and anxiety score measured on certain scales, and the secondary outcome is safety. Data extraction will be independently implemented by two researchers. The risk of bias will be evaluated through the Cochrane Collaboration's Risk of Bias tool. Eventually, all the data will be analysed via the Review Manager V.5.3 software.

ETHICS AND DISSEMINATION

This meta-analysis will provide information about applying music intervention to treat depression or anxiety in patients with diabetes. No ethical approval is required because this meta-analysis is based on published data. The results of this systematic review will be published in a peer-reviewed journal.PROSPERO registration numberCRD42019146439.

Association between Depression and Renal Hyperfiltration in a General Chinese Population

BACKGROUND

Depression is prevalent in patients with all stages of CKD and is associated with adverse outcome. Abnormally elevated GFR, or hyperfiltration, may play a crucial role in the initiation and progression of CKD. However, the association between depression and hyperfiltration is not known. The aim of this study is to investigate the relationship between depression and hyperfiltration.

METHODS

This was an observational cross-sectional study. A total of 3,716 volunteers (1,303 males and 2,413 females) aged 40-75 years without CKD from a community in China were included for the study. Depressive symptoms and the presence of a minor or major depressive episode were assessed with the 9-item Patient Health Questionnaire (PHQ-9) and Diagnostic and Statistical Manual of Mental Disorders (4th edition)-based structured interview, respectively.

RESULTS

The mean age of the participants in the present study was 53.8 ± 9.0 years. 115 participants had clinically relevant depression, and 122 participants had a minor or major depressive episode. In a multivariable logistic regression analysis adjusted for potential confounders, the association between clinically relevant depression and renal hyperfiltration remained significant in men but not in women. As compared with men without depression (PHQ <5) or depressive episodes, those with clinically relevant depression (PHQ ≥10) had a significantly higher risk of renal hyperfiltration. The fully adjusted OR (95% CI) was 4.81 (1.62-14.30, p = 0.005), those with a major depressive episode had a higher risk of renal hyperfiltration (OR 7.45; 95% CI 2.04-27.21, p = 0.002).

CONCLUSION

Depressive symptoms and major depressive episodes are associated with renal hyperfiltration in middle-aged and elderly Chinese men without CKD. Future studies are needed to verify and clarify the role of depression in the development of abnormally high eGFR and CKD.

Factors associated with the onset of major depressive disorder in adults with type 2 diabetes living in 12 different countries: results from the INTERPRET-DD prospective study

AIMS

To examine the factors that are associated with changes in depression in people with type 2 diabetes living in 12 different countries.

METHODS

People with type 2 diabetes treated in out-patient settings aged 18-65 years underwent a psychiatric assessment to diagnose major depressive disorder (MDD) at baseline and follow-up. At both time points, participants completed the Patient Health Questionnaire (PHQ-9), the WHO five-item Well-being scale (WHO-5) and the Problem Areas in Diabetes (PAID) scale which measures diabetes-related distress. A composite stress score (CSS) (the occurrence of stressful life events and their reported degree of 'upset') between baseline and follow-up was calculated. Demographic data and medical record information were collected. Separate regression analyses were conducted with MDD and PHQ-9 scores as the dependent variables.

RESULTS

In total, there were 7.4% (120) incident cases of MDD with 81.5% (1317) continuing to remain free of a diagnosis of MDD. Univariate analyses demonstrated that those with MDD were more likely to be female, less likely to be physically active, more likely to have diabetes complications at baseline and have higher CSS. Mean scores for the WHO-5, PAID and PHQ-9 were poorer in those with incident MDD compared with those who had never had a diagnosis of MDD. Regression analyses demonstrated that higher PHQ-9, lower WHO-5 scores and greater CSS were significant predictors of incident MDD. Significant predictors of PHQ-9 were baseline PHQ-9 score, WHO-5, PAID and CSS.

CONCLUSION

This study demonstrates the importance of psychosocial factors in addition to physiological variables in the development of depressive symptoms and incident MDD in people with type 2 diabetes. Stressful life events, depressive symptoms and diabetes-related distress all play a significant role which has implications for practice. A more holistic approach to care, which recognises the interplay of these psychosocial factors, may help to mitigate their impact on diabetes self-management as well as MDD, thus early screening and treatment for symptoms is recommended.

Incidence and Associations of Chronic Kidney Disease in Community Participants With Diabetes: A 5-Year Prospective Analysis of the EXTEND45 Study

OBJECTIVE

To determine the incidence of and factors associated with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² in people with diabetes.

RESEARCH DESIGN AND METHODS

We identified people with diabetes in the EXamining ouTcomEs in chroNic Disease in the 45 and Up Study (EXTEND45), a population-based cohort study (2006-2014) that linked the Sax Institute's 45 and Up Study cohort to community laboratory and administrative data in New South Wales, Australia. The study outcome was the first eGFR measurement <60 mL/min/1.73 m² recorded during the follow-up period. Participants with eGFR < 60 mL/min/1.73 m² at baseline were excluded. We used Poisson regression to estimate the incidence of eGFR <60 mL/min/1.73 m² and multivariable Cox regression to examine factors associated with the study outcome.

RESULTS

Of 9,313 participants with diabetes, 2,106 (22.6%) developed incident eGFR <60 mL/min/1.73 m² over a median follow-up time of 5.7 years (interquartile range, 3.0-5.9 years). The eGFR <60 mL/min/1.73 m² incidence rate per 100 person-years was 6.0 (95% CI 5.7-6.3) overall, 1.5 (1.3-1.9) in participants aged 45-54 years, 3.7 (3.4-4.0) for 55-64 year olds, 7.6 (7.1-8.1) for 65-74 year olds, 15.0 (13.0-16.0) for 75-84 year olds, and 26.0 (22.0-32.0) for those aged 85 years and over. In a fully adjusted multivariable model incidence was independently associated with age (hazard ratio 1.23 per 5-year increase; 95% CI 1.19-1.26), geography (outer regional and remote versus major city: 1.36; 1.17-1.58), obesity (obese class III versus normal: 1.44; 1.16-1.80), and the presence of hypertension (1.52; 1.33-1.73), coronary heart disease (1.13; 1.02-1.24), cancer (1.30; 1.14-1.50), and depression/anxiety (1.14; 1.01-1.27).

CONCLUSIONS

In participants with diabetes, the incidence of an eGFR <60 mL/min/1.73 m² was high. Older age, remoteness of residence, and the presence of various comorbid conditions were associated with higher incidence.

Longitudinal associations between depression and diabetes complications: a systematic review and meta-analysis

To conduct a systematic review and meta-analysis of longitudinal studies assessing the bi-directional association between depression and diabetes macrovascular and microvascular complications. Embase, Medline and PsycINFO databases were searched from inception through 27 November 2017. A total of 4592 abstracts were screened for eligibility. Meta-analyses used multilevel random/mixed-effects models. Quality was assessed using the Newcastle-Ottawa scale. Twenty-two studies were included in the systematic review. Sixteen studies examined the relationship between baseline depression and incident diabetes complications, of which nine studies involving over one million participants were suitable for meta-analysis. Depression was associated with an increased risk of incident macrovascular (HR = 1.38; 95% CI: 1.30-1.47) and microvascular disease (HR = 1.33; 95% CI: 1.25-1.41). Six studies examined the association between baseline diabetes complications and subsequent depression, of which two studies involving over 230 000 participants were suitable for meta-analysis. The results showed that diabetes complications increased the risk of incident depressive disorder (HR = 1.14; 95% CI: 1.07-1.21). The quality analysis showed increased risk of bias notably in the representativeness of selected cohorts and ascertainment of exposure and outcome. Depression in people with diabetes is associated with an increased risk of incident macrovascular and microvascular complications. The relationship between depression and diabetes complications appears bi-directional. However, the risk of developing diabetes complications in depressed people is higher than the risk of developing depression in people with diabetes complications. The underlying mechanisms warrant further research.

Depressive Symptoms and All-Cause Mortality in Older American Indians with Type 2 Diabetes Mellitus

OBJECTIVES

American Indians experience disproportionately high rates of poor mental health and type 2 diabetes mellitus (T2DM). We examined the association between depressive symptoms and all-cause mortality in older American Indians with T2DM.

DESIGN

We used the Native Elder Care Study survey data from community-dwelling American Indians aged 55 years or older, linked to data extracted from participants' electronic health records. We focused on those who had an International Classification of Diseases-Ninth Revision diagnosis of T2DM in their electronic health records.

SETTING

The study was conducted with a federally-recognized tribe with approximately 16,000 enrolled members, most of whom reside on or near tribally-owned lands that span several rural counties.

PARTICIPANTS

Participants were among the Native Elder Care Study participants with a final analytic sample of 222.

MEASUREMENTS

We measured depressive symptoms with the Centers for Epidemiologic Studies-Depression (CES-D) scale. We used Cox proportional hazard models to examine the association between depressive symptoms and all-cause mortality in the final analytic sample of 222 subjects.

RESULTS

Survival curves revealed that individuals in the third and fourth CES-D scale categories had higher mortality than those in the first and second categories. Mortality risk was significantly higher for participants with CES-D scale scores in the third highest compared with the lowest category (hazard ratio = 2.07; 95% confidence interval = 1.07-4.04), after adjustment for demographic characteristics, health behaviors, obesity, and prevalent T2DM complications. Analyses with the CES-D scale as a continuous variable also showed a positive association with mortality.

CONCLUSION

The impact of mental health on older American Indians with T2DM is often overlooked, yet it is vital to clinical and public health practice. Our findings underscore the importance of addressing the mental health needs of this population, particularly because depression in older patients is often undetected or inadequately treated. J Am Geriatr Soc 67:1940-1945, 2019.

Pharmacotherapeutic strategies for managing comorbid depression and diabetes

Introduction: The increasing prevalence of comorbid depression and diabetes exerts a heavy burden on global health. Co-occurrence of depression and diabetes is common, affecting 14% to 35.8% of patients with diabetes, leading to a higher mortality and morbidity rate, more micro- and macro-vascular diseases and more cognitive decline. Areas covered: In this paper, the authors address various areas from epidemiology, the association between depression and diabetes, treatment strategies and future directions based on the currently available literature to provide novel insight into the pharmacotherapeutic management of comorbid depression and diabetes. Expert opinion: Pharmacotherapy can help patients with comorbid depression and diabetes by relieving depressive symptoms and improving glycemic control. When combined with psychological therapy, as a collaborative care effort, pharmacological therapy based on selective serotonin reuptake inhibitors (SSRIs) is recommended for comorbid depression with diabetes. Furthermore, studies with larger sample sizes that can help to define different subtypes of diabetes and severity of depression are needed so that clinicians can draw up a precise and applicable management guidelines for the personalized therapy of these diseases.