Abnormal albuminuria as a predictor of mortality and renal impairment in Chinese patients with NIDDM

Evaluation of the efficacy of Abelmoschus manihot (L.) on diabetic nephropathy by analyzing biomarkers in the glomeruli and proximal and distal convoluted tubules of the kidneys

Introduction: As a traditional Chinese medicine, Abelmoschus manihot (L.) in the form of Huangkui (HK) capsule has been used as a medication for kidney diseases, including diabetic nephropathy (DN), in China. The most significant effect of HK capsule treatment in kidney diseases is the reduction of albuminuria and proteinuria. To evaluate the efficacy of HK capsule in the regression of DN, in the current study, we analyzed the biomarkers in the glomerulus and proximal and distal convoluted tubules in the kidneys of db/db mice, the animal model for type 2 diabetes and DN. Methods: Huangkui capsules (0.84 g/kg/d) or vehicle were administered daily via oral gavage for 4 weeks in db/db mice. Urinary albumin-to-creatinine ratio and blood glucose levels were measured during the whole experimental period. Five biomarkers in the glomerulus and proximal and distal convoluted tubules in the kidneys were selected, namely, col4a3, slc5a2, slc34a1, slc12a3, and slc4a1, and their activities at mRNA and protein levels before and after HK capsule treatment were analyzed by real-time RT-PCR and immunohistochemistry. Result and discussion: After HK capsule treatment for 4 weeks, the urinary albumin-to-creatinine ratio in db/db mice was found to be significantly decreased. The activities of col4a3, slc5a2, slc34a1, slc12a3, and slc4a1 in the kidneys were upregulated in db/db mice prior to the treatment but downregulated after HK capsule treatment. Further analyses of the fields of whole kidney tissue sections demonstrated that the number of nephrons in the kidneys of db/db mice with HK capsule treatment was higher than that in the kidneys of db/db mice without HK capsule treatment. Thereby, the current study provides experimental evidence confirming the medical efficacy of A. manihot in the reduction of albuminuria and proteinuria, suggesting that A. manihot may have pharmacological efficacy in the regression of the development of type 2 diabetes-DN.

Therapeutic inertia in proteinuria management among type 2 diabetes (T2DM) patients in primary care settings: prevalence and associated risk factors

BACKGROUND

Therapeutic inertia (TI), defined as physicians' failure to increase therapy when treatment goals are unmet, is an impediment to chronic disease management. This study aimed to identify the prevalence of TI in proteinuria management among T2DM patients managed in primary care settings and to explore possible associating factors.

METHODS

This was a cross-sectional study. T2DM patients with proteinuria (either microalbuminuria or macroalbuminuria) and had been followed up in 7 public primary care clinics of the Hospital Authority of Hong Kong from 1 Jan, 2014 to 31 Dec, 2015 were included. The prevalence of TI in proteinuria management and its association with patients' demographic and clinical parameters and the working profile of the attending doctors were explored. Student's t test and analysis of variance were used for analyzing continuous variables and Chi square test was used for categorical data. Multivariate stepwise logistic regression was used to determine the association between TI and the significant variables from patients' and doctors' characteristics.

RESULTS

Among the 22,644 T2DM patients identified in the case register, 5163 (26.4%) patients were found to have proteinuria. Among the sampled 385 T2DM patients with proteinuria, TI was identified in 155 cases, with a prevalence rate of 40.3%. Male doctor, doctor with longer duration of clinical practice and have never received any form of Family Medicine training were found to have a higher TI. Patients with microalbuminuria range and lower systolic and diastolic blood pressure (BP) were also found to have higher TI. Logistic regression study revealed that patients' systolic BP level and microalbuminuria range of proteinuria were negatively associated with the presence of TI, whereas doctor's year of clinical practice being over 20 years and patients being treated with submaximal dose of medication were positively associated with the presence of TI.

CONCLUSIONS

TI is commonly present in proteinuria management among T2DM patients, with a prevalence of 40.3% in primary care. Systolic BP and microalbuminuria range of urine ACR were negatively associated with the presence of TI, whereas submaximal ACEI/ARB dose and doctors practicing over 20 years were positively associated with the presence of TI. Further studies exploring the strategies to combat TI are needed to improve the clinical outcome of T2DM patients.

Development of a predictive risk model for all-cause mortality in patients with diabetes in Hong Kong

INTRODUCTION

Patients with diabetes mellitus are risk of premature death. In this study, we developed a machine learning-driven predictive risk model for all-cause mortality among patients with type 2 diabetes mellitus using multiparametric approach with data from different domains.

RESEARCH DESIGN AND METHODS

This study used territory-wide data of patients with type 2 diabetes attending public hospitals or their associated ambulatory/outpatient facilities in Hong Kong between January 1, 2009 and December 31, 2009. The primary outcome is all-cause mortality. The association of risk variables and all-cause mortality was assessed using Cox proportional hazards models. Machine and deep learning approaches were used to improve overall survival prediction and were evaluated with fivefold cross validation method.

RESULTS

A total of 273 678 patients (mean age: 65.4±12.7 years, male: 48.2%, median follow-up: 142 (IQR=106-142) months) were included, with 91 155 deaths occurring on follow-up (33.3%; annualized mortality rate: 3.4%/year; 2.7 million patient-years). Multivariate Cox regression found the following significant predictors of all-cause mortality: age, male gender, baseline comorbidities, anemia, mean values of neutrophil-to-lymphocyte ratio, high-density lipoprotein-cholesterol, total cholesterol, triglyceride, HbA1c and fasting blood glucose (FBG), measures of variability of both HbA1c and FBG. The above parameters were incorporated into a score-based predictive risk model that had a c-statistic of 0.73 (95% CI 0.66 to 0.77), which was improved to 0.86 (0.81 to 0.90) and 0.87 (0.84 to 0.91) using random survival forests and deep survival learning models, respectively.

CONCLUSIONS

A multiparametric model incorporating variables from different domains predicted all-cause mortality accurately in type 2 diabetes mellitus. The predictive and modeling capabilities of machine/deep learning survival analysis achieved more accurate predictions.

Urine albumin dipstick independently predicts cardiovascular and renal outcomes among rural Thai population: a 14-year retrospective cohort study

Background

Albuminuria is an established risk marker for both cardiovascular and renal outcomes. In this study, we expected to use portable and inexpensive test strips to detect urine albumin level for risk stratification in cardiovascular and renal outcomes among rural Thai community.

Objective

To evaluate the relationship between urine albumin dipstick and cardiovascular and renal complications in rural Thai population.

Methods

We conducted a retrospective study in 635 rural Thai adults who tested urine albuminuria by using commercial urine albumin dipstick and the Micral-albumin test II strips at baseline. The subjects were divided into normoalbuminuria (albumin < 20 mg/L), microalbuminuria (albumin 20–200 mg/L), or macroalbuminuria (Urine dipstick at least 1+ or albumin > 200 mg/L). We collected data on the incidences of primary composite outcomes including cardiovascular or renal morbidity and mortality. Incident density and cox regression were analyzed to evaluate the association between albuminuria status and primary composite outcome.

Results

During an average 14-year follow-up, 102 primary composite events occurred including 59 (13.1%), 32 (20.6%) and 11 (39.3%) among 452, 155, and 28 subjects with normoalbuminuria, microalbuminuria, and macroalbuminuria, respectively. Incident densities of primary composite outcome were elevated continually according to the degree of albuminuria (9.36, 17.11 and 38.12 per 1000 person-years). Compared with the subjects without albuminuria, subjects with microalbuminuria and macroalbuminuria at baseline had higher risk for primary composite outcome in univariate model. After multivariate analysis was performed, the effect of macroalbuminuria was only persisted with 3.13-fold risk (adjusted HR 3.13; 95% CI 1.40–6.96, P= 0.005).

Conclusion

Albuminuria from semi-quantitative methods is an important factor predicting cardiovascular and renal risk among subjects in Thai rural population. Our findings support to also incorporating urine albumin dipstick into assessments of cardiovascular risk in the general population.

From Hong Kong Diabetes Register to JADE Program to RAMP-DM for Data-Driven Actions

In 1995, the Hong Kong Diabetes Register (HKDR) was established by a doctor-nurse team at a university-affiliated, publicly funded, hospital-based diabetes center using a structured protocol for gathering data to stratify risk, triage care, empower patients, and individualize treatment. This research-driven quality improvement program has motivated the introduction of a territory-wide diabetes risk assessment and management program provided by 18 hospital-based diabetes centers since 2000. By linking the data-rich HKDR to the territory-wide electronic medical record, risk equations were developed and validated to predict clinical outcomes. In 2007, the HKDR protocol was digitalized to establish the web-based Joint Asia Diabetes Evaluation (JADE) Program complete with risk levels and algorithms for issuance of personalized reports to reduce clinical inertia and empower self-management. Through this technologically assisted, integrated diabetes care program, we have generated big data to track secular trends, identify unmet needs, and verify interventions in a naturalistic environment. In 2009, the JADE Program was adapted to form the Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) in the publicly funded primary care clinics, which reduced all major events by 30-60% in patients without complications. Meanwhile, a JADE-assisted assessment and empowerment program provided by a university-affiliated, self-funded, nurse-coordinated diabetes center, aimed at complementing medical care in the community, also reduced all major events by 30-50% in patients with different risk levels. By combining universal health coverage, public-private partnerships, and data-driven integrated care, the Hong Kong experience provides a possible solution than can be adapted elsewhere to make quality diabetes care accessible, affordable, and sustainable.

Cardiovascular events in patients with over 10 years history of type 2 diabetes mellitus

BACKGROUND

Diabetes is one of the concerns of today's public health and patients with type 2 diabetes are at increased risk of death due to cardiovascular diseases. The aim of this study was to evaluate the prevalence of cardiovascular diseases in patients with over 10 years history of type 2 diabetes mellitus referred to the Sanandaj Diabetes Clinic.

METHODS

In this study, 400 patients with type 2 diabetes who had over 10 years history of diabetes were selected and the required information was prepared based on taking their history and files. Finally data were analyzed using T-test, Chi-square and Fisher test methods.

RESULTS

In this the mean duration of diabetes was 14.59 ± 4.07 years. 95.25% of patients had dyslipidemia. The frequency of history of cardiovascular events was 78.25%. 12.25% of patients had a history of ischemic heart disease and 82.75% had a history of high blood pressure. There was a significant relationship between the incidence of cardiovascular events with hypertension, HDL level and family history of early cardiovascular disease (p < 0.05).

CONCLUSION

The high risk of cardiovascular events in diabetic patients it strongly emphasizes the need for quick and serious approaches to prevent cardiovascular events in diabetic patients.

Correlation Between Different Stages of Diabetic Nephropathy and Neuropathy in Patients with T2DM: A Cross-Sectional Controlled Study

INTRODUCTION

Early detection of diabetic peripheral neuropathy (DPN) is critical in patients with type 2 diabetes mellitus (T2DM) due to the lack of targeted therapy for DPN. We have investigated the relationship between different stages of diabetic nephropathy and DPN in an attempt to elucidate whether albuminuria can be used as an early warning signal of DPN progression.

METHODS

A total of 217 T2DM patients who met the inclusion criteria were recruited from the Department of Endocrinology, Nanfang Hospital between January 2016 and June 2016. These patients were placed in groups based on urinary albumin excretion rate (UAER) and estimated glomerular filtration rate. Nerve conduction studies, the Semmes-Weinstein monofilament test (SWMT) and the vibration perception threshold (VPT) test were conducted. Multiple linear regression analysis, multivariate logistic regression and receiver-operating characteristic (ROC) analysis were performed to investigate the relationship between different stages of diabetic nephropathy and DPN in these patients.

RESULTS

Significant differences were observed in the conduction velocity (CV) and amplitude of sensory/motor nerve potential among the T2DM patients at different stages of diabetic nephropathy (all p  < 0.05). The UAER and duration of diabetes were found to be independent factors associated with the mean CV and amplitude of sensory/motor nerve potential (all p  < 0.05). A disease duration of > 10 years (p  = 0.025) and a higher total cholesterol value (p  = 0.024) were found to be significantly associated with abnormal SWMT results. A UAER of > 300 mg/24 h (p  = 0.007) and a diastolic blood pressure of > 100 mmHg (p  = 0.042) were associated with a higher risk for abnormal VPT. A UAER  of > 300 mg/24 h (p  < 0.001) and a disease duration of > 10 years (p  = 0.02) were observed to be significantly correlated with DPN. The ROC analysis showed that the optimal cutoff values of UAER and duration as indicators of DPN were 90.5 mg/24 h and 9.5 years, respectively (both p  < 0.001).

CONCLUSIONS

The results suggest that diabetic nephropathy is closely associated with the development of DPN in T2DM patients and that UAER and disease duration can be used as warning indicators of DPN progression.

CHINESE CLINICAL TRIALS REGISTER NUMBER

ChiCTR-ROC-16007701.

Glycated Hemoglobin, Albuminuria and Surrogate Markers of Macrovascular Disease in Adults Without Diabetes: The Guangzhou Biobank Cohort Study, Cardiovascular Disease Subcohort

OBJECTIVES

To explore the clinical utility of glycated hemoglobin (A1C) levels as an early marker of albuminuria, macrovascular disease and subclinical cardiovascular disease in comparison to fasting and postprandial glucose levels in a well-characterized Chinese population with no history of diabetes.

METHODS

The study population consisted of 1223 individuals who were enrolled in the Guangzhou Biobank Cohort Study, Cardiovascular Disease Subcohort, and who had undergone oral glucose tolerance tests. The associations between each glycemic measure and albuminuria, carotid intima-media thickness (CIMT) and CIMT-based presence of carotid plaques and aortic arch calcification were assessed by chest radiographs.

RESULTS

The overall prevalence of albuminuria, carotid plaque and any aortic arch calcification was 20.6%, 22.8% and 25.8%, respectively. All 3 glycemia indices were significantly associated with albuminuria, but only 1 (fasting glucose) was associated with carotid plaques. No significant difference was detected among them in the area under the curve for albuminuria (chi-square test; p=0.84), carotid plaques (p=0.28) or calcifications (p=0.29). In sensitivity analysis, adjusted for age and sex, the above findings remained unchanged.

CONCLUSIONS

Although there was evidence suggesting differential associations, the performance of the glycemic indices was similar, and their association with macrovascular disease and albuminuria was modest.

Transplantation of human fetal pancreatic progenitor cells ameliorates renal injury in streptozotocin-induced diabetic nephropathy

Background

Diabetic nephropathy (DN) is a severe complication of diabetes mellitus (DM). Pancreas or islet transplantation has been reported to prevent the development of DN lesions and ameliorate or reverse existing glomerular lesions in animal models. Shortage of pancreas donor is a severe problem. Islets derived from stem cells may offer a potential solution to this problem.

Objective

To evaluate the effect of stem cell-derived islet transplantation on DN in a rat model of streptozotocin-induced DM.

Methods

Pancreatic progenitor cells were isolated from aborted fetuses of 8 weeks of gestation. And islets were prepared by suspension culture after a differentiation of progenitor cells in medium containing glucagon-like peptide-1 (Glp-1) and nicotinamide. Then islets were transplanted into the liver of diabetic rats via portal vein. Blood glucose, urinary volume, 24 h urinary protein and urinary albumin were measured once biweekly for 16 weeks. Graft survival was evaluated by monitoring human C-peptide level in rat sera and by immunohistochemical staining for human mitochondrial antigen and human C-peptide in liver tissue. The effect of progenitor-derived islets on filtration membrane was examined by electron microscopy and real-time polymerase chain reaction (PCR). Immunohistochemical staining, real-time PCR and western blot were employed for detecting fibronectin, protein kinase C beta (PKCβ), protein kinase A (PKA), inducible nitric oxide synthase (iNOS) and superoxide dismutase (SOD).

Results

Islet-like clusters derived from 8th gestational-week human fetal pancreatic progenitors survived in rat liver. And elevated serum level of human C-peptide was detected. Blood glucose, 24 h urinary protein and urinary albumin were lower in progenitor cell group than those in DN or insulin treatment group. Glomerular basement membrane thickness and fibronectin accumulation decreased significantly while podocytes improved morphologically in progenitor cell group. Furthermore, receptor of advanced glycation end products and PKCβ became down-regulated whereas PKA up-regulated by progenitor cell-derived islets. And iNOS rose while SOD declined.

Conclusions

DN may be reversed by transplantation of human fetal pancreatic progenitor cell-derived islets. And fetal pancreatic progenitor cells offer potential resources for cell replacement therapy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-017-1253-1) contains supplementary material, which is available to authorized users.

Managing diabetes in Asia: overcoming obstacles and the role of DPP-IV inhibitors

Asia bears the world's greatest burden of type 2 diabetes (T2DM) and prevalence is increasing rapidly. Compared to other races, Asians develop T2DM younger, at a lower degree of obesity, suffer longer from its complications and die earlier. Curbing this epidemic requires an integrated, risk-based, and multidisciplinary approach. Inadequately managed T2DM has macrovascular and microvascular sequelae, Asians with T2DM being particularly susceptible to diabetic nephropathy. Earlier and more intensive monitoring and management of risk factors are required, especially for patients with, or at risk of, renal impairment. Particular challenges of T2DM management in Asia include: lack of access to specialist healthcare, insufficient clinical evaluation and delayed diagnosis. As in Caucasians, conventional treatment modalities are limited by deteriorating glycaemic control with disease progression and there is an unmet need for efficacious, safe, cost-effective and convenient pharmacotherapies for treating different stages of T2DM and preventing its complications, particularly in high-risk patients. There is a trend towards increasing use of DPP-IV inhibitors, which are no less efficacious and safe in Asians than Caucasians and may have some advantages over existing oral antidiabetic agents, particularly for certain high-risk groups. Such agents may play a significant future role in the management of T2DM.

The Complexity of Vascular and Non-Vascular Complications of Diabetes: The Hong Kong Diabetes Registry

Diabetes is a complex disease characterized by chronic hyperglycemia and multiple phenotypes. In 1995, we used a doctor-nurse-clerk team and structured protocol to establish the Hong Kong Diabetes Registry in a quality improvement program. By 2009, we had accrued 2616 clinical events in 9588 Chinese type 2 diabetic patients with a follow-up duration of 6 years. The detailed phenotypes at enrollment and follow-up medications have allowed us to develop a series of risk equations to predict multiple endpoints with high sensitivity and specificity. In this prospective database, we were able to validate findings from clinical trials in real practice, confirm close links between cardiovascular and renal disease, and demonstrate the emerging importance of cancer as a leading cause of death. In addition to serving as a tool for risk stratification and quality assurance, ongoing data analysis of the registry also reveals secular changes in disease patterns and identifies unmet needs.

Urinary biomarkers involved in type 2 diabetes: a review

Diabetes mellitus is one of the most challenging health concerns of the 21st century. With at least 30% of the diabetic population remaining undiagnosed, effective and early diagnosis is of critical concern. Development of a diagnostic test, more convenient and reliable than those currently used, would therefore be highly beneficial. Urine as a diagnostic medium allows for non-invasive detection of biomarkers, including some associated with type 2 diabetes and its complications. This review provides a synopsis of those urinary biomarkers that potentially may provide a basis for the development of improved diagnostic tests. Three main pathways for the sourcing of potential makers are identified: kidney damage, oxidative stress and low-grade inflammation including atherosclerosis/vascular damage. This review briefly presents each pathway and some of the most relevant urinary biomarkers that may be used to monitor the development or progression of diabetes and its complications. In particular, biomarkers of renal dysfunction such as transferrin, type IV collagen and N-acetyl-beta-D-glucosaminidase might prove to be more sensitive than urinary albumin, the current gold standard, in the detection of incipient nephropathy and risk assessment of cardiovascular disease. Inflammatory markers including orosomucoid, tumour necrosis factor-alpha, transforming growth factor-beta, vascular endothelial growth factor and monocyte chemoattractant protein-1, as well as oxidative stress markers such as 8-hydroxy-2'deoxyguanosine may also be useful biomarkers for diagnosis or monitoring of diabetic complications, particularly kidney disease. However, the sensitivity of these markers compared with albumin requires further investigation.

Proteinuria as a surrogate outcome in CKD: report of a scientific workshop sponsored by the National Kidney Foundation and the US Food and Drug Administration

Changes in proteinuria have been suggested as a surrogate outcome for kidney disease progression to facilitate the conduct of clinical trials. This report summarizes a workshop sponsored by the National Kidney Foundation and US Food and Drug Administration (FDA) with the following goals: (1) to evaluate the strengths and limitations of criteria for assessment of proteinuria as a potential surrogate end point for clinical trials in chronic kidney disease (CKD), (2) to explore the strengths and limitations of available data for proteinuria as a potential surrogate end point, and (3) to delineate what more needs to be done to evaluate proteinuria as a potential surrogate end point. We review the importance of proteinuria in CKD, including the conceptual model for CKD, measurement of proteinuria and albuminuria, and epidemiological characteristics of albuminuria in the United States. We discuss surrogate end points in clinical trials of drug therapy, including criteria for drug approval, the definition of a surrogate end point, and criteria for evaluation of surrogacy based on biological plausibility, epidemiological characteristics, and clinical trials. Next, the report summarizes data for proteinuria as a potential surrogate outcome in 3 broad clinical areas: early diabetic kidney disease, nephrotic syndrome, and diseases with mild to moderate proteinuria. We conclude with a synthesis of data and recommendations for further research. At the present time, there appears to be sufficient evidence to recommend changes in proteinuria as a surrogate for kidney disease progression in only selected circumstances. Further research is needed to define additional contexts in which changes in proteinuria can be expected to predict treatment effect. We recommend collaboration among many groups, including academia, industry, the FDA, and the National Institutes of Health, to share data from past and future studies.

In a population-based cohort of diabetes patients, men and women had similar risks for all-cause mortality

OBJECTIVES

To compare death rates of diabetic men and women relative to the general population and to identify sex-specific risk factors for all-cause mortality.

STUDY DESIGN AND SETTINGS

In the current historical prospective cohort study, standardized mortality ratios (SMRs) were calculated for 19,657 men and women with diabetes in a large Israeli health care organization compared to the mortality in the general population from 1999 to 2003. In addition, sex-specific survival analyses were performed for men and women separately using baseline data obtained between 1995 and 1999.

RESULTS

During the study follow-up (90,899 person-years), 2,924 deaths were identified. The SMR for diabetic women (1.40; 95% confidence interval [CI]: 1.33, 1.47) was significantly (P<0.01) higher than for diabetic men (1.20; 95% CI: 1.14, 1.26). Age, glycated hemoglobin, serum creatinine, low-density lipoprotein, high-density lipoprotein, dialysis, use of angiotensin-converting enzyme inhibitors, and insulin were similarly associated with mortality in both sexes. Residing in the south of Israel was related with higher risk among men but with decreased risk among women.

CONCLUSIONS

The study indicates that diabetes seems to eliminate the relative protection against death usually seen in women. It also suggests that most risk factors are comparable between the sexes, underlining the importance of similarly intensive disease management in diabetic women and in diabetic men.

End-stage renal disease risk equations for Hong Kong Chinese patients with type 2 diabetes: Hong Kong Diabetes Registry

AIMS/HYPOTHESIS

The objective of the study was to investigate risk factors and develop risk equations for end-stage renal disease (ESRD) in Chinese patients with type 2 diabetes.

SUBJECTS AND METHODS

A prospective cohort of 4,438 patients with type 2 diabetes mellitus and without ESRD (median observation period 2.9 years, interquartile range 1.6-4.1 years) was included in the analysis. The end-point (ESRD) was defined by: (1) death due to diabetes with renal manifestations or renal failure; (2) hospitalisation due to renal failure; (3) estimated GFR (eGFR) <15 ml min(-1) 1.73 m(-2). Cox proportional hazards regression was used to develop risk equations. The data were randomly and evenly divided into the training data for development of the risk equations and the test data for validation. The validation was performed using the area under the receiver operating characteristic curve (aROC), which takes into account follow-up time and censoring.

RESULTS

During the observation period, 159 patients or 12.45 per 1,000 person-years (95% CI 10.52-14.37 per 1,000 person-years) developed ESRD. Known duration of diabetes, systolic blood pressure, log(10) total cholesterol:HDL cholesterol ratio and retinopathy were significant predictors of ESRD. After further adjusting for eGFR, log(10) spot albumin:creatinine ratio (ACR) and haematocrit, only eGFR, haematocrit and log(10) ACR remained as independent predictors of ESRD. The risk equation derived from these three independent predictors had good discrimination, with an aROC of 0.97.

CONCLUSIONS/INTERPRETATION

Estimated GFR, haematocrit and ACR were independent predictors of ESRD and the derived risk equation performed well in Chinese patients with type 2 diabetes.

Renin angiotensin aldosterone system blockade and renal disease in patients with type 2 diabetes: a subanalysis of Japanese patients from the RENAAL study

BACKGROUND

The Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) study has previously shown losartan to confer significant benefits to patients with type 2 diabetes and nephropathy. The original study of 1513 patients included 96 Japanese patients; the present study is a post-hoc analysis of the effects of losartan in this Japanese subpopulation.

METHODS

This double-blind, randomized study compared losartan (50 to 100 mg once daily) with placebo. The study medication was taken in addition to conventional antihypertensive treatment, and the mean follow-up period for the Japanese patients was 2.8 years. The primary endpoint was the composite of doubling of serum creatinine, endstage renal disease, or death. Secondary endpoints included changes in proteinuria levels. Safety was also evaluated.

RESULTS

The primary composite endpoint was reached in fewer Japanese patients receiving losartan than placebo (50.0% versus 65.4%, respectively). The treatment effects of losartan were more robust when data were corrected for differences in proteinuria at baseline--a significant relative risk reduction of 45% with losartan (P=0.0397) was apparent. Treatment benefit exceeded that attributable to blood pressure changes alone. Levels of proteinuria were reduced with losartan compared with placebo, with an overall losartan treatment effect of 37.8% (P<0.001). Overall, losartan was similarly well tolerated in both the Japanese patients and the total population.

CONCLUSIONS

In Japanese patients with type 2 diabetes and nephropathy, losartan offers renal protection and is generally well tolerated.

Vascular defect beyond the endothelium in type II diabetic patients with overt nephropathy and moderate renal insufficiency

There is a paucity of data on the effects of overt nephropathy and moderate renal impairment on endothelial function in diabetic patients. A total of 26 type II diabetic (DM) patients with nephropathy (DMN+) (mean +/- s.d. age: 63.7 +/- 6.3 years), 32 diabetic patients without nephropathy (DMN-) (59.4 +/- 10.1 years), and 52 non-diabetic subjects (54.9 +/- 8.2 years) were recruited. High-resolution ultrasound scan was used to measure carotid intima media thickness (IMT) and flow-mediated dilation (FMD) of the brachial artery. Endothelium-independent dilation was determined by maximal vascular dilation after sublingual nitroglycerine (glyceryl trinitrate (GTN)-induced dilation). The mean carotid IMT increased progressively from non-DM to DMN- to DMN+ groups (0.74 +/- 0.23 vs 0.80 +/- 0.25 vs 1.03 +/- 0.38 mm; P=0.001 for trend) whereas FMD- (4.3 +/- 2.5 vs 3.9 +/- 1.7 vs 1.9 +/- 2.0%, P<0.001 for trend) and GTN-induced dilation (14.7 +/- 4.0 vs 14.5 +/- 3.9 vs 10.3 +/- 3.2%; P<0.001 for trend) declined in an opposite manner. On multivariate analysis, age (beta=0.257, P=0.009), glomerular filtration rate (beta=-0.364, P<0.001), and smoking (beta=0.25, P=0.013) were independently associated with carotid IMT (F=15.76, R(2)=0.340, P<0.001). After adjustment for baseline brachial arterial diameter, history of smoking (beta=-0.039, P<0.001), fasting plasma glucose (beta=-0.033, P=0.002), and total cholesterol (beta=-0.023, P=0.024) were independently associated with vessel diameter after FMD (F=2446.5, R(2)=0.992, P<0.001); whereas age (beta=-0.069, P=0.001) and urinary albumin excretion (beta=-0.048, P=0.018) were independently associated with vessel diameter after GTN (F=851.6, R(2)=0.967, P<0.001). Type II diabetic patients with overt nephropathy and moderate renal impairment had both structural and functional vascular abnormalities beyond the endothelium.

Fibrinogen and AER are major independent predictors of 11-year cardiovascular mortality in type 2 diabetes: the Casale Monferrato Study

AIMS/HYPOTHESIS

Fibrinogen and elevated AER increase cardiovascular mortality, but few data are available in the type 2 diabetic population. We have conducted an 11-year follow-up study of the Casale Monferrato cohort to assess: (1) the long-term predictive role of AER independently of conventional risk factors; (2) the shape of its relationship with cardiovascular mortality; and (3) whether fibrinogen has a predictive effect independent of the increased cardiovascular risk associated with nephropathy.

METHODS

During the follow-up period (1991-2001) a population-based cohort of 1,565 patients was regularly examined, and measurements of HbA1c were centralised. Multivariate Cox proportional hazards modelling was employed to assess the role of fibrinogen and AER as predictors of all-cause and cardiovascular mortality, independently of baseline variables and individual cumulative average values of HbA1c during follow-up.

RESULTS

In 10,890.2 person-years of observations, 685 deaths were identified, giving an all-cause mortality rate of 63.4 per 1,000 person-years (95% CI 58.8-68.3). In Cox regression analyses, the strongest predictor of cardiovascular mortality was macroalbuminuria (relative risk 2.18, 95% CI 1.62-2.94), which was mainly associated with a high risk of short-term mortality. No increased risk was evident until the upper microalbuminuric range of AER values. Plasma fibrinogen was also a major independent predictor, and its role was not modified by AER, or by the exclusion of subjects developing chronic renal failure or diabetic nephropathy during follow-up.

CONCLUSIONS/INTERPRETATION

The results indicate that: (1) AER is the main independent predictor of 11-year cardiovascular mortality; (2) this effect is mainly evident in the upper range of microalbuminuria and in macroalbuminuria; and (3) fibrinogen has an independent effect on cardiovascular mortality, but no synergistic effect with AER, suggesting that both endothelial dysfunction and chronic inflammation are involved in the excess cardiovascular mortality of type 2 diabetic patients.

Triglyceride predicts cardiovascular mortality and its relationship with glycaemia and obesity in Chinese type 2 diabetic patients

BACKGROUND

To examine the lipid profile in Chinese type 2 diabetic patients and their relationship with anthropometric parameters, glycaemic control and cardiovascular mortality.

METHODS

A consecutive cohort of 562 newly referred patients with type 2 diabetes to a hospital-based diabetes centre were examined in 1996. Subjects treated with lipid lowering drugs at the time of referral were excluded. A total of 517 subjects were followed up over a mean (+/-SD) period of 4.6 +/- 0.9 years. Glycated haemoglobin (HbA1c), fasting insulin and lipid profile and anthropometric parameters were documented at the time of recruitment. Cardiovascular mortality, mainly due to coronary heart disease and stroke, was ascertained using death registry and review of hospital case notes in 2001.

RESULT

Of the 517 subjects (mean age of 54.0 +/- 14.0 years), 42.6% were men. In this cohort, 63.3% of subjects were either overweight (BMI > or = 23 kg/m2) or obese (BMI > or = 25 kg/m2) using Asian criteria. The mean (+/-SD) total cholesterol (TC), LDL-Cholesterol (LDL-C), HDL-Cholesterol (HDL-C) and geometric mean (x// antilog SD) of triglycerides (TG) were 5.6 +/- 1.3 mmol/L, 3.6 +/- 1.1 mmol/L, 1.3 +/- 0.3 mmol/L and 1.46x//1.90 mmol/L respectively. TC and LDL-C correlated positively with HbA1c, HDL-C negatively with BMI and WC (waist circumference), while TG positively with HbA1c, BMI, WC and HOMA (insulin resistance estimated using the homeostasis model assessment). During the 4.6 years follow-up period, there were 61 deaths giving a total mortality rate of 11.4%, of which 15 (25%) were because of cardiovascular events. Apart from age and disease duration, logarithm of TG was significantly associated with increased risk of cardiovascular mortality (p = 0.049, relative risk = 2.97, 95% CI 1.00-8.77).

CONCLUSIONS

Chinese type 2 diabetic patients had a lower prevalence of obesity, lower TG and higher HDL-C than Caucasian patients. Despite the low incidence of cardiovascular death, TG, which was closely associated with obesity indexes, was significantly associated with cardiovascular death in these patients.

Associations of mortality and diabetes complications in patients with type 1 and type 2 diabetes: early treatment diabetic retinopathy study report no. 27

OBJECTIVE

Diabetes is a leading cause of morbidity and mortality. The purpose of this study is to assess the associations between diabetes complications and mortality in the Early Treatment Diabetic Retinopathy Study (ETDRS).

RESEARCH DESIGN AND METHODS

We examined demographic, clinical, and laboratory characteristics of the 3,711 subjects enrolled in the ETDRS, a randomized controlled clinical trial designed to evaluate the role of laser photocoagulation and aspirin therapy for diabetic retinopathy. The outcome assessed was all-cause mortality. Multivariable Cox proportional hazards regression was used to assess associations between diabetes complications and mortality for type 1 and type 2 diabetes separately.

RESULTS

The 5-year estimates of all-cause mortality were 5.5 and 18.9% for patients with type 1 and type 2 diabetes, respectively. In patients with type 1 diabetes, amputation (hazard ratio [HR] 5.08 [95% CI 2.06-12.54]) and poor visual acuity (1.74 [1.10-2.75]) remained significantly associated with mortality, after adjusting for other diabetes complications and baseline characteristics. In patients with type 2 diabetes, macrovascular disease and worsening levels of nephropathy, neuropathy, retinopathy, and visual acuity are associated with progressively increasing risks of mortality, after controlling for other baseline risk factors.

CONCLUSIONS

Amputation is the strongest predictor for mortality in patients with type 1 diabetes. All complications independently predict mortality in patients with type 2 diabetes. There is an increased risk for mortality as the degree of each complication worsens. Additional studies are needed to investigate the effectiveness of tertiary prevention to decrease mortality in these patients.

Renal damage in patients with Type 2 diabetes: a strong predictor of mortality

AIMS

(i) To compare mortality rates in a cohort of Type 2 diabetic patients with those of the general population; (ii) to assess the prognostic role of pre-existing chronic conditions; (iii) to evaluate the impact of different severity of renal damage on mortality.

METHODS

All 3892 patients with Type 2 diabetes attending our Diabetic Clinic during 1995 and alive on 1 January 1996 were identified and followed for 4.5 years. Information on vital status (100% complete) and causes of death (98.5% complete) for 599 deceased subjects was derived from death certificates.

RESULTS

In comparison with the general population, standardized mortality ratios (x 100) were: 125 (95% confidence interval 104-148) in patients aged < 75 and 85 (75-95) in patients > or = 75 years. Cardiovascular diseases and diabetes were responsible for most of the excess deaths. In a Cox-proportional hazard model, renal damage was a powerful predictor of death (hazard ratio = 2.39; 95% confidence intervals = 2.00-2.85). The severity of renal damage was associated with increasing hazard ratios for death from all-cause mortality and from specific causes (especially coronary artery disease, other cardiovascular causes and diabetes) after multiple adjustments. Other significant predictors of death were: greater age, glycated haemoglobin, smoking, lower body mass index, pre-existing coronary and peripheral artery disease and known co-morbidity (cirrhosis and cancer).

CONCLUSIONS

Renal damage of any severity is significantly associated with subsequent mortality from all causes and from cardiovascular diseases. These associations are not confounded by pre-existing co-morbidity or coronary diseases.

Albuminuria is a marker of increasing intracranial and extracranial vascular involvement in Type 2 diabetic Chinese patients

AIMS/HYPOTHESIS

Albuminuria has been reported to be a marker of cardiovascular risk factors and disease morbidity and mortality, but its relationship with intracerebral atherosclerotic disease is less clear. The aim of this study was to investigate the association between albuminuria and intracranial and extracranial vascular involvement in Chinese Type 2 diabetic patients.

METHODS

The anthropometric and fasting biochemical measurements of 966 Type 2 diabetic patients with normoalbuminuria (55.6%), microalbuminuria (27.7%) or macroalbuminuria (16.7%) were compared. The prevalence of microvascular and macrovascular disease and middle cerebral artery (MCA) stenosis, measured by transcranial Doppler ultrasound, were also compared between the groups.

RESULTS

Albuminuria was closely associated with a range of adverse parameters, including high BP, dyslipidaemia, smoking and adiposity (all p<0.01). The prevalence of microvascular disease (retinopathy p<0.001) and macrovascular disease (peripheral vascular disease p=0.012, myocardial infarction, p=0.004, MCA stenosis p<0.001) increased significantly with increasing levels of albuminuria. Albuminuria was also found to be an independent predictor of microvascular and macrovascular disease.

CONCLUSIONS/INTERPRETATION

Albuminuria was an independent predictor of increasing levels of vascular risk factors and microvascular and macrovascular disease in this group of Type 2 diabetic patients, and a possible role for albuminuria as a marker of intracranial cerebrovascular disease should be further investigated.

The renoprotective effects of structured care in a clinical trial setting in type 2 diabetic patients with nephropathy

BACKGROUND

The RENAAL Study has confirmed the renoprotective effects of Losartan in type 2 diabetes. In this subgroup analysis from the RENAAL Study, we hypothesized that the intensive care received by patients in a clinical trial setting also reduced the rate of decline in renal function through optimization of all risk factors.

METHODS

We compared the rate of deterioration in renal function, expressed as the regression coefficient of the monthly serum creatinine (SeCr) reciprocal (beta-1/Cr) in 55 Chinese type 2 diabetic patients before and after entry into the RENAAL Study.

RESULTS

Of the 55 patients, 44 had at least three out-patient SeCr measurements both before (2.9+/-2.4 years) and after (3.3+/-0.8 years) entry into the study for evaluation. In the Losartan group (n = 24), the median beta-1/Cr fell from -11.4 x 10(-5) l micro mol(-1) month(-1) before entry into the trial to -4.7 x 10(-5) l micro mol(-1) month(-1) following entry (P = 0.001). The respective figures were -9.1 x 10(-5) and -5.0 x 10(-5) l micro mol(-1) month(-1) (P = 0.01) in the placebo group (n = 20). A decrease in beta-1/Cr was observed in 21 (87.5%) and 14 (70.0%) patients in the Losartan and placebo groups, respectively. Spot urinary albumin-to-creatinine ratio was reduced by 56% (P = 0.001) in the Losartan group but the change was not significant in the placebo group. At the end of the study, patients in both groups had lower blood pressure and better lipid control. The frequency of patient visits to doctors and nurses were doubled.

CONCLUSIONS

The rate of renal function decline was significantly reduced in the majority of patients allocated to either Losartan or placebo following entry into the RENAAL study. These results suggest that in patients with diabetic nephropathy, implementation of a structured care protocol in a clinical trial setting facilities intensive treatment of risk factors confering renoprotective effects in addition to those resulting from Losartan treatment.

Renin angiotensin aldosterone system blockade and renal disease in patients with type 2 diabetes. An Asian perspective from the RENAAL Study

OBJECTIVE

Asia is predicted to have the largest population of patients with diabetes who are at high risk for renal disease. In the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) study, approximately 17% of patients were Asians. In this subgroup analysis, we examined the characteristics, response, and adherence to treatment of the Asian population, as well as their baseline predictors of risk of renal end points.

RESEARCH DESIGN AND METHODS

A total of 252 Asian patients were enrolled in the RENAAL study, which compared losartan (50 mg titrated to 100 mg) to placebo in addition to conventional antihypertensive medications in type 2 diabetic patients with nephropathy. Mean follow-up was 3.2 years. The effect of losartan therapy on renal and cardiovascular outcomes was examined, and baseline predictors of risk were determined using a Cox proportional hazards model with prespecified baseline covariates.

RESULTS

Losartan reduced the risk of the primary composite end point composed of a doubling of serum creatinine, end-stage renal disease, or all-cause mortality in Asian patients by 35% (P = 0.02). No difference between losartan and placebo was observed for the cardiovascular composite outcomes. Losartan reduced the level of proteinuria by 47% (P < 0.001) and rate of decrease in renal function by 31% (0.0074). Discontinuations were lower in the losartan-treated patients. The strongest baseline predictors of risk of renal end points were proteinuria (hazard ratio 1.42, P < 0.0001) and low Hb (0.81, P < 0.0001).

CONCLUSIONS

In this subgroup analysis of the RENAAL study, losartan conferred significant renal benefits and was well tolerated in Asian patients with type 2 diabetes and clinical nephropathy. Baseline proteinuria and low Hb were strong predictors of risk of renal outcomes.

Genetic variants of hepatocyte nuclear factor-1beta in Chinese young-onset diabetic patients with nephropathy

In Hong Kong, the prevalence of diabetes is estimated to be 2% in the young population. In the diabetic population, 30% of patients have diagnosis before the age of 40 years. Besides, 30% of young diabetic patients have varying degrees of albuminuria. Mutations in the gene encoding the hepatocyte nuclear factor (HNF)-1beta are associated with a subtype of maturity-onset diabetes of the young (MODY 5) characterized by urogenital abnormalities. We examined 74 unrelated Chinese subjects with young-onset diabetes complicated by nephropathy for variants in this gene. The HNF-1beta gene was screened by direct sequencing and the functional properties of wild-type and mutant proteins were analyzed by transactivation analysis.A novel variant in exon 3 (E260D) was found in one patient. Extended family analysis revealed four other siblings carrying this variant. One subject had diabetes and another had impaired glucose tolerance. Another sibling had microalbuminuria but normal glucose tolerance. Transfection studies showed insignificant differences in transactivation ability between wild-type and mutated HNF-1beta. A silent polymorphism Q378Q was identified in another unrelated subject. These results suggest genetic variants in HNF-1beta are not a common cause of young-onset diabetes or diabetic nephropathy in Chinese, but may modify disease manifestation and progression. Other potential candidate genes should be looked for to account for the high prevalence of young-onset diabetes and nephropathy in this population.

Lessons learned from young-onset diabetes in China

The prevalence of young-onset diabetes is rapidly rising in China. Young-onset diabetes is etiologically and phenotypically heterogeneous. Thirty percent to 50% of these patients have insulin secretory failure owing to autoimmune or monogenic or other yet to be identified forms of diabetes. Others have a strong family history of diabetes and exhibit features of the metabolic syndrome. Management of these young patients poses major diagnostic and therapeutic challenges, which require a multidisciplinary and holistic approach to ensure that these subjects are identified early and managed appropriately. Understanding the molecular basis of diabetes in these subjects may also eventually lead to improvement in diagnosis, classification, and treatment.

Animal versus plant protein meals in individuals with type 2 diabetes and microalbuminuria: effects on renal, glycemic, and lipid parameters

OBJECTIVE

To determine, for individuals with type 2 diabetes and microalbuminuria, the effects of 6 weeks of meals containing plant-based protein (PP) versus meals with predominantly animal-based protein (AP) on renal function and secondarily on glycemia, lipid levels, and blood pressure.

RESEARCH DESIGN AND METHODS

In a randomized crossover trial, we compared 6 weeks of meals containing only PP with meals containing primarily AP (60% animal, 40% plant) in 17 subjects with type 2 diabetes and microalbuminuria treated with diet and/or oral antidiabetic agents. Protein content was equivalent to the average American diet, and calories provided weight maintenance. Nutrients were equivalent between the two diets. Meals were prepared and packaged by a metabolic kitchen staff and were sent home weekly. At the beginning and end of each 6-week period, subjects were studied for 36 h on a metabolic unit.

RESULTS

There were no significant differences between diets for glomerular filtration rate, renal plasma flow, albumin excretion rate, total cholesterol, HDL cholesterol, triglyceride area under the curve (AUC), glucose and insulin AUC, HbA(1c,) blood pressure, or serum amino acids. For both diets, at the end of the treatment periods as compared with baseline, total cholesterol was significantly lower (PP and AP: from 4.75 to 4.34 mmol/l, P < 0.01), HbA(1c) had significantly improved (PP: from 8.1 to 7.5%, P < 0.01; AP: from 7.9 to 7.4%, P < 0.01), and diastolic blood pressure was significantly lower (PP: from 83 to 80 mmHg, P < 0.02; AP: from 82 to 78, P < 0.02).

CONCLUSIONS

There is no clear advantage for the recommendation of diets containing only PP rather than diets containing protein that is primarily animal-based for individuals with type 2 diabetes and microalbuminuria. There are, however, potential lipid, glycemic, and blood pressure benefits for following a carefully constructed, weight-maintaining, healthy diet, regardless of protein source.

Diabetes mellitus--a special medical challenge from a Chinese perspective

As we enter the new millennium, Asia is being hit by an epidemic of diabetes and its related diseases. The rising prevalence of young onset diabetes which is closely associated with obesity and genetic factors as well as the increased propensity to develop kidney disease are special challenges in the management of Chinese diabetic patients. Although diabetic patients have earlier mortality and increased risks for micro and macrovascular complications, there is strong evidence that these devastating complications can be largely prevented by patient education, periodic assessments and use of appropriate therapeutic agents to optimize metabolic control and improve cardiovascular risk factors. However, a multidisciplinary approach is often required to deliver these complex disease management protocols. Hence, it is not surprising that large scale studies often revealed substandard diabetes management in both the hospital and community settings. This is often due to a combination of factors such as non-adherence to recommended guidelines both by patients and doctors as well as the 'non-urgent' and 'silent nature' of diabetes and its complications. To minimize the impacts of diabetes on quality of life, society productivity and utilization of health care resources, concerted efforts between health care professionals and public bodies are urgently needed to increase awareness, improve standards of care and develop better diagnostics and treatment modalities.

Prevalence of and risk factors for erectile dysfunction in Hong Kong diabetic patients

AIM

To estimate the prevalence of erectile dysfunction (ED) in Chinese diabetic men and to identify its risk factors, we carried out a cross-sectional survey of 500 Chinese diabetic men attending a community hospital diabetic clinic in Hong Kong.

METHODS

Patients were interviewed and asked to report on their experience of ED as defined in the National Institutes of Health Consensus Conference 1993. Diabetic complications and patient clinical data were obtained from patients' medical records.

RESULTS

Of the 486 patients studied, the prevalence of ED was 63.6% (95% confidence interval 59.3-67.9%). The prevalence of ED increased with age, from 33.3% to 73.8% for diabetic men aged between 21 and 80 years (P = 0.001). Severity of ED also increased with age. Among diabetic men with ED, there was no report of complete ED for diabetic men aged 40 years and below, whereas the proportion of patients with complete ED increased from 7.4% to 71.1% between the ages of 41 and 80 years. ED occurred early in the course of the disease, with a prevalence increasing from 56.0% in men with diabetes mellitus (DM) for < 5 years to 72.0% in those with DM for > 20 years (P = 0.038). Duration of DM was also associated with severity; the proportion of patients with complete ED increased from 30.8% for those with DM for < 5 years to 72.2% for those with DM for > or = 20 years (P < 0.001). Using logistic regression analysis, DM duration, diabetic complications including retinopathy, abnormal albuminuria and sensory neuropathy, and higher level of education were associated with a higher risk of ED. By polychotomous logistic regression, age was the only factor found to be associated with the severity of ED, after adjusting for other variables.

CONCLUSIONS

Chinese diabetic patients have a prevalence of self-reported ED that appears to be higher than that of Western populations. This may be due to cultural differences and the association of abnormal albuminuria and hypertension.

Predictors of mortality from type 2 diabetes mellitus in Canterbury, New Zealand; a ten-year cohort study

The aim was to establish mortality rates in a cohort of subjects with type 2 diabetes mellitus over 10 years in Canterbury, New Zealand (NZ) and to determine baseline prognostic factors. Subjects (447) with type 2 diabetes (208 male, 239 female; age range 30-82 years, median 62 years; of predominantly European origin) were characterised in a clinic survey in 1989. Individual status (dead or alive) at June 1 1999 (10 year follow-up) was ascertained. Mortality rates were compared with the general NZ population and the relative risk (RR) of baseline prognostic factors evaluated with Cox's proportional hazards model. At 10 years, 232 subjects were confirmed as alive and 187 as dead - only 28 were untraceable. Ten year survival was 55% (95% CI: 50-60) for the cohort, compared with 70% (95% CI: 65-75) at 6 years. Factors assessed at baseline (1989), that were independently prognostic of total mortality, included age (RR 2.0, 95% CI: 1.6-2.5), pre-existing coronary artery disease (CAD; RR 1.7, 95% CI: 1.2-2.4) and albuminuria (RR 1.58, 95% CI: 1.1-2.3). Glycated haemoglobin was not a significant predictor of total mortality, although was a predictor of CAD mortality in those subjects free of CAD in 1989 (RR 1.6, 95% CI: 1.1-2.3). In the latter subset, independent prognostic factors for CAD mortality also included age (RR 2.5, 95% CI: 1.7-3.8), hypertension (RR 1.9, 95% CI: 1.0-3.7), peripheral vascular disease (RR 2.4, 95% CI: 1.3-4.5) and smoking (RR 2.6, 95% CI: 1.2-5.8). Increased mortality in type 2 diabetic subjects is therefore attributable to multiple risk factors. Improved outcomes will depend on interventions targeted at glycaemic and all other remediable factors.

Long-term effects of angiotensin-converting enzyme inhibition and metabolic control in hypertensive type 2 diabetic patients

Long-term effects of angiotensin-converting enzyme inhibition and metabolic control in hypertensive type 2 diabetic patients.

BACKGROUND

In hypertensive type 2 diabetic patients, treatment with angiotensin-converting enzyme (ACE) inhibitors is associated with a lower incidence of cardiovascular events than those treated with calcium channel-blocking agents. However, the long-term renal effects of ACE inhibitors in these patients remain inconclusive. In 1989, we commenced a placebo-controlled, double-blind, randomized study to examine the anti-albuminuric effects of enalapril versus nifedipine (slow release) in 102 hypertensive, type 2 diabetic patients. These patients have been followed up for a mean trial duration of 5.5 +/- 2.2 years. We examined the determinants, including the effect of ACE inhibition on clinical outcomes in these patients.

METHODS

After a six-week placebo-controlled, run-in period, 52 patients were randomized double-blind to receive nifedipine (slow release) and 50 patients to receive enalapril. After the one-year analysis, which confirmed the superior anti-albuminuric effects of enalapril (-54%) over nifedipine (+11%), all patients were continued on their previously assigned treatment with informed consent. They were subdivided into normoalbuminuric (N = 43), microalbuminuric (N = 34), and macroalbuminuric (N = 25) groups based on two of three 24-hour urinary albumin excretion (UAE) measurements during the run-in period. Renal function was shown by the 24-hour UAE, creatinine clearance (CCr), and the regression coefficient of the yearly plasma creatinine reciprocal (beta-1/Cr). Clinical endpoints were defined as death, cardiovascular events, and/or renal events (need for renal replacement therapy or doubling of baseline plasma creatinine).

RESULTS

In the whole group, patients treated with enalapril were more likely to revert to being normoalbuminuric (23.8 vs. 15.4%), and fewer of them developed macroalbuminuria (19.1 vs. 30.8%) compared with the nifedipine-treated patients (P < 0.05). In the microalbuminuric group, treatment with enalapril (N = 21) was associated with a 13.0% (P < 0.01) reduction in 24-hour UAE compared with a 17.3% increase in the nifedipine group (N = 13). In the macroalbuminuric patients, enalapril treatment (N = 11) was associated with stabilization compared with a decline in renal function in the nifedipine group, as shown by the beta-1/Cr (0.65 +/- 4.29 vs. -1.93 +/- 2.35 1/micromol x 10-3, P < 0.05) after adjustment for baseline values. Compared with the normoalbuminuric and microalbuminuric patients, those with macroalbuminuria had the lowest mean CCr (75.5 +/- 24.1 vs. 63.5 +/- 21.3 vs. 41.9 +/- 18.5 mL/min, P < 0.001) and the highest frequency of clinical events (4.7 vs. 5.9 vs. 52%, P < 0. 001). On multivariate analysis, beta-1/Cr (R2 = 0.195, P < 0.001) was independently associated with baseline HbA1c (beta = -0.285, P = 0.004), whereas clinical outcomes (R2 = 0.176, P < 0.001) were independently related to the mean low-density lipoprotein cholesterol (beta = 2.426, P = 0.018), high-density lipoprotein cholesterol (beta = -8.797, P = 0.03), baseline UAE (beta = 0.002, P = 0.04), and mean CCr during treatment (beta = -0.211, P = 0.006).

CONCLUSION

In this prospective cohort analysis involving 102 hypertensive, type 2 diabetic patients with varying degrees of albuminuria followed up for a mean duration of five years, we observed the importance of good metabolic and blood pressure control on the progression of albuminuria and renal function. Treatment with enalapril was associated with a greater reduction in albuminuria than with nifedipine in the entire patient group, and especially in those with microalbuminuria. In the macroalbuminuric patients, the rate of deterioration in renal function was also attenuated by treatment with enalapril.

Albuminuria and other risk factors for mortality in patients with non-insulin-dependent diabetes mellitus aged under 65 years: a population-based prospective 5-year study

The overall 5-year mortality of non-insulin-dependent diabetes mellitus (NIDDM) patients aged under 65 years and associated risk factors were examined with a population-based study in a primary care setting. At the baseline, diabetic patients were asked of existing coronary heart disease (CHD) and hypertension, and checked for body mass index (BMI), glycemic control, lipid values and overnight albuminuria. Of 381 identified NIDDM patients, 252 (66%) participated in the study. The median age was 58 (range 36-64) years, BMI 30.5 (S.D. 5.5) kg/m2 and glycosylated hemoglobin A1c 8.7 (S.D. 2.0)%. Overall 5-year mortality was 8.3%. Factors associated with mortality were male gender, low high-density lipoprotein cholesterol, initial CHD and albuminuria > or = 20 microg/min. In Cox regression analysis, combination of CHD and albuminuria had the highest relative risk for mortality (RR = 3.43, 95% CI 1.63-7.19, P = 0.001), adjusted for gender and age. Albuminuria was associated with CHD only in male NIDDM patients. In primary health care, physicians should be aware that combination of CHD and (micro)albuminuria is a major predictor of mortality in NIDDM patients.

Causes of death and associated factors among patients with non-insulin-dependent diabetes mellitus in Taipei, Taiwan

A cohort of 766 patients with non-insulin-dependent diabetes mellitus (NIDDM) from a general teaching hospital in Taipei, Taiwan were followed prospectively to assess survival experience and associated risk factors. Data were abstracted from the medical records and additional information was obtained from patients or their closest relatives using a structured questionnaire. Date and cause of death were determined from death certificates. Standardized mortality ratios were calculated by the direct method. Chi2-Square test and Cox's proportional hazard analysis were used to control for potential confounders. During a median follow-up of 3.5 years (range 1 month to 4.6 years), 131 deaths occurred. Of these, 29.8% were due to cardiopulmonary disease (ICD 401-429), 13.0% due to cerebrovascular disease (ICD 430-438), 13.0% due to acute diabetes metabolic complications (250.1, 250.2), and 11.4% due to nephropathy (580-589). Adjusted for age, people with NIDDM had 2.2 (95% CI 1.6-2.9) times the risk of death than members of the general population, and cause-specific standardized mortality ratios were: CPD 4.6, nephropathy 8.8, cerebrovascular disease 1.9, and neoplasm 0.7. Age, fasting plasma glucose, hypertension, and proteinuria were positively and independently associated with all-cause mortality (P < 0.05 for each). Thus, NIDDM patients have higher mortality rates than the general population in Taiwan, and age, fasting plasma glucose, hypertension, and proteinuria are associated with this excess risk. Proper application of available interventions may control these factors with a consequent reduction in mortality. Particular attention is needed to prevent deaths from the acute metabolic complications of diabetes.

Relationship between blood glucose level and mortality in type 2 diabetes mellitus: a systematic review

AIM

To review the relationship between blood glucose level and mortality in patients with Type 2 diabetes mellitus (DM) as reported in the literature.

METHODS

Literature search using Medline Search: January 1966 - April 1998.

KEYWORDS

Diabetes, Non Insulin Dependent, Mortality. Inclusion criteria for papers were: Type 2 DM; follow-up for at least 3 years; glucose or glycated haemoglobin (HbA1c) was used as parameter; published in the form of an article. Additionally all references in the selected articles that dealt with the relationship between blood glucose level and mortality in Type 2 DM were included in the search.

RESULTS

Twenty-seven eligible articles were found. Twenty-three of them showed a positive association: measures of elevated blood glucose concentrations were associated with higher mortality; in 15 out of 23 studies the positive association was statistically significant, in two only for postprandial blood glucose. One study found a nonsignificant negative relationship in a very old population.

CONCLUSION

In the literature there is a positive, but rather weak, association between the measures of blood glucose control and the risk of dying of patients with Type 2 DM. In the six larger studies (more than 100 deceased patients) that used a continuous categorization of glycaemia, the Risk ratio per unit varies from 1.03 to 1.12.

Microalbuminuria is not associated with cardiovascular death in Japanese NIDDM

To evaluate whether the presence of microalbuminuria can predict cardiovascular death in Japanese subjects with non-insulin-dependent diabetes mellitus (NIDDM), we investigated 297 Japanese NIDDM patients with Albustix-negative urine. Patients were divided into two groups, normoalbuminuric (n = 201) and microalbuminuric (n = 96) and followed until death or the end of 1994 (the mean follow-up period was 6.4 years). During the follow-up period, 28 deaths (14 normoalbuminuric and 14 microalbuminuric patients) were confirmed and only 10 deaths were attributed to cardiovascular disease (6 normoalbuminuric and 4 microalbuminuric patients). Although the age- and sex-adjusted mortality rate from all-causes in the microalbuminuric group was significantly higher than that in the normoalbuminuric group (13.5 vs. 8.2 per 1000 person-years: P < 0.05), the mortality rate from cardiovascular disease was not significantly different between two groups (3.4 vs. 3.3 per 1000 person-years). On age-adjusted Cox proportional hazards analysis. HbA1c and triglyceride were independent risk factors in mortality from cardiovascular disease, while microalbuminuria was not associated with cardiovascular death. These results indicate that, unlike Caucasians, the presence of microalbuminuria can not predict cardiovascular death in Japanese subjects with NIDDM.