Association of Normal and Mutated APOL1 G2 Rs60910145 alleles with SCD, Body Mass Index, and Renal Function Biomarkers and Indices

PURPOSE OF THE STUDY

The current study aimed to detect the frequency of normal and mutated APOL1 alleles in sickle cell disease (SCD) patients and test their relation with Microalbuminuria, Creatinine, Urea, Glomerular Filtration Rate (GFR), and Body Mass Index (BMI).

PATIENTS AND METHODS

The study included 156 SCD subjects. Serum Creatinine (mg/dl) and Urea (mg/dl) as well as Microalbuminuria (mg/l) level were measured by using Biosystems kit (Biosystems, Barcelona, Spain) and Mindary BA88A semi-automated biochemistry analyzer. Glomerular filtration rate and body mass index were calculated by equations. Blood DNA extraction was achieved by using the modified G-DEX™IIb Genomic DNA Extraction Kit protocol. The PCR was done for the detection of the APOL1 G2 rs60910145 alleles by using allele-specific PCR and primers.

RESULTS

The CC allele was more frequent in study cases (66.7%) than TT allele. The frequency of a mutated allele (CC) was insignificantly higher in males (67.8%) than in females (65.2%) and in rural (70.9%) than urban areas. It is also higher in Shankhab compared to other tribes and subjects 26-37 years compared to other, P˃0.05. Interstingly, the subjects who carry the CC allele showed a significantly higher level of Microalbuminuria, Creatinine, BMI, and Urea compared to those carry TT allele. Moreover, GFR is also higher in subjects who carry CC than TT allele but it is not significant.

CONCULSION

Altogether, the study findings highlighted the link of normal and mutated APOL1 G2 rs60910145 alleles with SCD and displayed the significant value of mutated APOL1 allele in the prediction of early nephropathy in SCD patients.

Sympathetic skin response for early detection of type 2 diabetic peripheral neuropathy and nephropathy

BACKGROUND

Diabetic peripheral neuropathy (DPN) and diabetic nephropathy (DN) are common complications of type 2 diabetes mellitus (T2DM). Although nerve conduction studies (NCS) and sympathetic skin response (SSR) can detect DPN, the more sensitive method for early diagnosis remains unclear. Furthermore, whether DPN can be used as a predictor for diabetic nephropathy needs clarification.

METHODS

We evaluated nerve conduction studies, sympathetic skin response, and the diabetic nephropathy indicator microalbuminuria (MAU) in 192 patients with type 2 diabetes mellitus and 50 healthy controls.

RESULTS

Patients with type 2 diabetes mellitus showed a lower sensory nerve conduction velocity (SCV), sensory active nerve potential (SNAP), motor nerve conduction velocity (MCV), and compound motor action potential (CMAP) than the controls on NCS. Abnormal rates for nerve conduction studies and sympathetic skin response were 75.0% and 83.3%, respectively, in patients with type 2 diabetes mellitus. Interestingly, 54.2% of patients with normal nerve conduction studies had an abnormal sympathetic skin response. Moreover, we found a positive correlation between sympathetic skin response and microalbuminuria for the first time. The abnormal rate of microalbuminuria was 53.8%, lower than that of abnormal nerve conduction studies or sympathetic skin response patients.

CONCLUSION

Sympathetic skin response is a more sensitive method than nerve conduction studies for the early diagnosis of diabetic peripheral neuropathy. Abnormal sympathetic skin response might serve as an indicator for early diabetic nephropathy. Additionally, diabetic peripheral neuropathy may occur earlier than diabetic nephropathy in the development of type 2 diabetes mellitus.

Positive association between circulating Caveolin-1 and microalbuminuria in overt diabetes mellitus in pregnancy

AIMS

Mounting evidence has shown that caveolin-1 plays a pathological role in the progression of albuminuria. Our study aimed to provide clinical evidence showing whether circulating caveolin-1 levels were associated with microalbuminuria (MAU) in women with overt diabetes mellitus in pregnancy (ODMIP).

METHODS

A total of 150 pregnant women were enrolled in different groups, including 40 women with ODMIP and MAU (ODMIP + MAU), 40 women with ODMIP, and 70 women without ODMIP (Non-ODMIP). Plasma caveolin-1 levels were determined by ELISA. The presence of caveolin-1 in the human umbilical vein vascular wall was evaluated by immunohistochemical and western blot analysis, respectively. Albumin transcytosis across endothelial cells was measured using an established nonradioactive in vitro approach.

RESULTS

Significantly increased levels of plasma caveolin-1 were detected in ODMIP + MAU women. The Pearson's correlation analysis revealed a positive correlation between plasma caveolin-1 levels and Hemoglobin A1c (HbA1c %) as well as with MAU in the ODMIP + MAU group. Simultaneously, experimental knockdown or overexpression of caveolin-1 significantly decreased or increased the level of albumin transcytosis across both human and mouse glomerular endothelial cells (GECs), respectively.

CONCLUSIONS

Our data showed a positive association between plasma caveolin-1 levels and microalbuminuria in ODMIP + MAU.

Urine ACR uptake in patients with a diagnosis of type 1 and 2 diabetes mellitus in a primary care setting: A cross sectional study

BACKGROUND AND OBJECTIVES

A recent change in the diabetes Quality and Outcomes Framework (QOF) retired the mandatory testing of urinary ACR. We designed a study demonstrates the impact of this change in a primary healthcare setting. This is relevant as a significant proportion of the NHS budget is spent on managing microvascular and macrovascular complications that result from type 1 and 2 Diabetes mellitus.

METHODS

Our cross-sectional study collected testing data for 482 patients in a primary care setting. Based on the results seen from the first set of data collection, an intervention was offered to the clinicians by way of clinical presentation that emphasised and refreshed the knowledge of the latest NICE guidelines on urine ACR collection. Subsequently, a second set of data collection was conducted to assess the success, if any, of changes implemented based on the intervention made RESULTS: Our study demonstrates the drastic decrease in uptake of ACR testing in the primary care setting that took place following the change in the diabetes QOF.

CONCLUSION

The study highlights the need for the reintroduction of such a QOF measure to enable regular monitoring of early signs of nephropathy, thereby allow the timely commencement treatment as deemed appropriate. Furthermore, detecting the development of such complications in diabetic patients, in a timely manner, has the potential to reduce the financial footprint associated with treating the complications resulting from this condition.

Effects of Aliskiren Monotherapy versus Amlodipine Monotherapy in Hypertensive Patients with Obesity or Type 2 Diabetes Mellitus

INTRODUCTION

Renin-angiotensin system inhibitors have been reported to exert protective effects against organ damage and failure; however, the impact of the direct renin inhibitor as monotherapy has not been assessed. Here, we investigated the effects of 24-week monotherapy with aliskiren compared to amlodipine in hypertensive patients with type 2 diabetes or obesity.

METHODS

In this randomized intervention study, 62 adult hypertensive patients with visceral obesity (defined as a body mass index [BMI] greater than 25 kg/m2 and a visceral adipose tissue area [VFA] greater than 100 cm2) or type 2 diabetes mellitus (age 57 ± 13, 65% men, BMI 28.8 ± 4.8 kg/m2, VFA 134.8 ± 47.0 cm2, blood pressure 141 ± 16/86 ± 13 mm Hg) were randomized to receive 24-week treatment with aliskiren (max. 300 mg) or amlodipine (max. 10 mg). The primary outcome was the change in VFA at 24 weeks post-treatment.

RESULTS

Change in VFA did not differ significantly from baseline in either group. Systolic blood pressure significantly decreased at 12 weeks (-10 mm Hg, p = 0.001) and 24 weeks (-10 mm Hg, p = 0.001) in the amlodipine group and at 24 weeks (-11 mm Hg, p = 0.001) in the aliskiren group. Diastolic blood pressure significantly decreased at 24 weeks (-6 mm Hg, p = 0.009) only in the amlodipine group. Although the estimated glomerular filtration rates did not significantly change in either group, the logarithm of urinary albumin excretion significantly decreased at 24 weeks only in the aliskiren group (-0.60, p < 0.001). The 24-week changes in the urinary albumin excretion significantly correlated with the changes in the plasma renin activity in the aliskiren group (r = 0.51, p = 0.008).

CONCLUSION

Aliskiren monotherapy did not show any superiority to amlodipine monotherapy on VFA, estimated glomerular filtration rates, or urinary albumin excretion in obese or type 2 diabetic hypertensive patients.

Central diastolic blood pressure, plasma aldosterone and uric acid are associated with microalbuminuria in essential hypertension: a case-control study

OBJECTIVE

To study the development of microalbuminuria (MAU) in essential hypertension (EHT), we investigated the association of MAU with central blood pressure (CBP), direct renin concentration (DRC), plasma aldosterone (PA), and uric acid (UA).

METHOD

We determined 24 h-urinary albumin excretion (24 h-UAE) in patients with EHT who were hospitalized at TEDA International Cardiovascular Hospital from June 2020 to May 2022. We defined MAU as 24 h-UAE in the range of 30 mg/24 h to 300 mg/24 h. Univariate and multivariate analyses were conducted to determine the associations of MAU with CBP, DRC, PA, and UA in EHT, considering demographic and clinical information. We also plotted receiver operating characteristic curves (ROCs) for predicting MAU using these results.

RESULTS

More than a quarter of patients (26.5%, 107/404, 95% CI: 22.2-31.1%) were diagnosed with MAU in EHT. A higher body mass index (BMI), longer duration of hypertension, and higher severity were associated with MAU. Also, nearly 10% more creatinine levels were recorded in the MAU group than in the control group (69.5 ± 18.7 µmol/L vs. 64.8 ± 12.5 µmol/L, P = 0.004). The increase was also observed for PA (15.5, 9.7-20.6 ng/dL vs. 12.3, 9.0-17.3 ng/dL, P = 0.024) and UA (419.8 ± 105.6 µmol/L vs. 375.1 ± 89.5 µmol/L, P < 0.001) in the MAU group compared to that in the control group. Several variables were associated with MAU, including central diastolic blood pressure (CDBP) (OR = 1.017, 95% CI: 1.002-1.032, P = 0.027), PA (OR = 1.043, 95% CI: 1.009-1.078, P = 0.012) and UA (OR = 1.005, 95% CI: 1.002-1.008, P < 0.001). For MAU prediction, the area under the curve (AUC) was 0.709 (95% CI: 0.662-0.753; P < 0.001) when CDBP, PA, and UA were used in combination, and the optimal probability of the cut-off value was 0.337.

CONCLUSION

We found that CDBP, PA, and UA, used for MAU prediction, might be associated with its development during EHT.

Do not forget the kidney in graves' disease

PURPOSE

To investigate the prevalence of microalbuminuria and factors associated with microalbuminuria in Graves' Disease (GD).

METHODS

This cross-sectional and single-center study included 99 patients with GD and 47 healthy controls (HC). Exclusion criteria such as active infection, uncontrolled diabetes, and chronic kidney disease were applied to the participants. The participants' clinical findings, comorbidities, drug use, laboratory tests, and thyroid antibody levels were recorded. Spot urine samples were collected and stored at - 80 ℃ to analyze the presence of microalbuminuria.

RESULTS

The prevalence of microalbuminuria in patients with GD was 12.1%. The median microalbumin/creatinine ratio in spot urine (UACR) in patients with GD (9.49 mg/g [5.09-18.10]) was higher than in the HC group (7.99 mg/g [3.48-12.88], p = 0.033). UACR was correlated with thyroid-stimulating hormone receptor antibody (TRAb), thyroid-stimulating hormone (TSH), and free triiodothyronine (FT3) levels (p = 0.020, p = 0.006, p = 0.009 respectively). In the regression analysis, only the relationship between TRAb level and UACR remained (p = 0.040).

CONCLUSION

This study demonstrates an increased prevalence of microalbuminuria in patients with GD. There was a significant correlation between microalbuminuria and TRAb level in patients with GD. This relationship suggests that one of the underlying mechanisms of microalbuminuria seen in patients with GD may be autoimmunity.

Microalbuminuria and mortality in individuals with coronary heart disease: A meta-analysis of a prospective study

AIM

Microalbuminuria has been elevated as an outcome predictor in cardiovascular medicine. However, due to the small number of studies investigating the association of microalbuminuria and mortality in the coronary heart disease (CHD) population, the prognosis value of microalbuminuria in CHD remains under debate. The objective of this meta-analysis was to investigate the relationship between microalbuminuria and mortality in individuals with CHD.

METHOD

A comprehensive literature search was performed using Pubmed, EuroPMC, Science Direct, and Google Scholar from 2000 to September 2022. Only prospective studies investigating microalbuminuria and mortality in CHD patients were selected. The pooled effect estimate was reported as risk ratio (RR).

RESULTS

5176 patients from eight prospective observational studies were included in this meta-analysis. Individuals with CHD have a greater overall risk of all-cause mortality (ACM) [rR = 2.07 (95% CI = 1.70-2.44); p = 0.0003; I2 = 0.0%] as well as cardiovascular mortality (CVM) [rR = 3.23 (95% CI = 2.06-4.39), p < 0.0001; I2 = 0.0%]. Subgroup analysis based on follow-up duration and a subset of CHD patients were similarly associated with an increased risk of ACM.

CONCLUSION

This meta-analysis indicates that microalbuminuria is associated with a higher risk of mortality in individuals with CHD. Microalbuminuria can serve as a predictor of poor outcomes in CHD patients.

Trajectories of renal biomarkers and new-onset heart failure in the general population: Findings from the PREVEND study

AIMS

Renal dysfunction is one of the most critical risk factors for developing heart failure (HF). However, the association between repeated measures of renal function and incident HF remains unclear. Therefore, this study investigated the longitudinal trajectories of urinary albumin excretion (UAE) and serum creatinine and their association with new-onset HF and all-cause mortality.

METHODS AND RESULTS

Using group-based trajectory analysis, we estimated trajectories of UAE and serum creatinine in 6881 participants from the Prevention of Renal and Vascular End-stage Disease (PREVEND) study and their association with new-onset HF and all-cause death during the 11-years of follow-up. Most participants had stable low UAE or serum creatinine. Participants with persistently higher UAE or serum creatinine were older, more often men, and more often had comorbidities, such as diabetes, a previous myocardial infarction or dyslipidaemia. Participants with persistently high UAE had a higher risk of new-onset HF or all-cause mortality, whereas stable serum creatinine trajectories showed a linear association for new-onset HF and no association with all-cause mortality.

CONCLUSION

Our population-based study identified different but often stable longitudinal patterns of UAE and serum creatinine. Patients with persistently worse renal function, such as higher UAE or serum creatinine, were at a higher risk of HF or mortality.

Early diabetic kidney disease: Focus on the glycocalyx

The incidence of diabetic kidney disease (DKD) is sharply increasing worldwide. Microalbuminuria is the primary clinical marker used to identify DKD, and its initiating step in diabetes is glomerular endothelial cell dysfunction, particularly glycocalyx impairment. The glycocalyx found on the surface of glomerular endothelial cells, is a dynamic hydrated layer structure composed of pro-teoglycans, glycoproteins, and some adsorbed soluble components. It reinforces the negative charge barrier, transduces the shear stress, and mediates the interaction of blood corpuscles and podocytes with endothelial cells. In the high-glucose environment of diabetes, excessive reactive oxygen species and proinflammatory cytokines can damage the endothelial glycocalyx (EG) both directly and indirectly, which induces the production of microalbuminuria. Further research is required to elucidate the role of the podocyte glycocalyx, which may, together with endothelial cells, form a line of defense against albumin filtration. Interestingly, recent research has confirmed that the negative charge barrier function of the glycocalyx found in the glomerular basement membrane and its repulsion effect on albumin is limited. Therefore, to improve the early diagnosis and treatment of DKD, the potential mechanisms of EG degradation must be analyzed and more responsive and controllable targets must be explored. The content of this review will provide insights for future research.

Postprandial glucagon-like peptide 1 secretion is associated with urinary albumin excretion in newly diagnosed type 2 diabetes patients

BACKGROUND

Microalbuminuria is an early and informative marker of diabetic nephropathy. Our study found that microalbuminuria developed in patients with newly diagnosed type 2 diabetes mellitus (T2DM).

AIM

To investigate the association between glucagon-like peptide 1 (GLP-1) and microalbuminuria in newly diagnosed T2DM patients.

METHODS

In total, 760 patients were recruited for this cross-sectional study. The GLP-1 levels during a standard meal test and urinary albumin-creatinine ratio (UACR) were determined.

RESULTS

Patients with microalbuminuria exhibited lower GLP-1 levels at 30 min and 120 min during a standard meal test than patients with normal albuminuria (30 min GLP-1, 16.7 ± 13.3 pmol vs 19.9 ± 15.6 pmol, P = 0.007; 120 min GLP-1, 16.0 ± 14.1 pmol vs 18.4 ± 13.8 pmol, P = 0.037). The corresponding area under the curve for active GLP-1 (AUCGLP-1) was also lower in microalbuminuria patients (2257, 1585 to 3506 vs 2896, 1763 to 4726, pmol × min, P = 0.003). Postprandial GLP-1 levels at 30 min and 120 min and AUCGLP-1 were negatively correlated with the UACR (r = 0.159, r = 0.132, r = 0.206, respectively, P < 0.001). The prevalence of microalbuminuria in patients with newly diagnosed T2DM was 21.7%, which decreased with increasing quartiles of AUCGLP-1 levels (27.4%, 25.3%, 18.9% and 15.8%). After logistic regression analysis adjusted for sex, age, hemoglobin A1c, body mass index, systolic blood pressure, estimated glomerular filtration rate, homeostasis model assessment of insulin resistance, AUC_glucose and AUC_glucagon, patients in quartile 4 of the AUCGLP-1 presented a lower risk of microalbuminuria compared with the patients in quartile 1 (odds ratio = 0.547, 95% confidence interval: 0.325-0.920, P = 0.01). A consistent association was also found between 30 min GLP-1 or 120 min GLP-1 and microalbuminuria.

CONCLUSION

Postprandial GLP-1 levels were independently associated with microalbuminuria in newly diagnosed Chinese T2DM patients.

(*ABC is an acronym for Adria, Bassano, Conegliano, and Padova Hospitals)

BACKGROUND

Microalbuminuria is associated with adverse outcomes in acute coronary syndrome (ACS) patients.

METHODS

To evaluate the very long-term association between Microalbuminuria and the overall mortality and causes of death in this clinical setting, we prospectively studied 579 unselected ACS patients admitted to three hospitals. The baseline albumin-to-creatinine ratio (ACR) was measured on days 1, 3, and 7 in 24-h urine samples. Patients were followed for 22 years or until death.

RESULTS

Virtually all patients completed follow-up; 449(78%) had died: 41% due to non-sudden cardiac death (non-SCD), 19% sudden cardiac death (SCD), 40% due to non-cardiac (non-CD) death. Using unadjusted Cox regression analysis, ACR was a significant predictor of all-cause mortality (hazard ratio [HR] 1.26;95%confidence interval [CI] 1.22-1.31; p˂0.0001) and the three causes of death (HR 1.40;95%CI 1.32-1.48; p˂0.0001), (HR 1.22;95%CI 1.12-1.32; p˂0.0001) and (HR 1.16;95%CI 1.09-1.23; p˂0.0001) for non-SCD, SCD and non-CD respectively. Using a fully adjusted model, ACR was a significant independent predictor of all-cause mortality (HR 1.12; 95%CI 1.08-1.16; p˂0.0001) and only non-SCD (HR 1.21; 95%CI 1.14-1.29; p˂0.0001). There was a positive interaction between ACR level and history of AMI (HR 1.15; 95%CI 1.03-1.29; p = 0.01) and the presence of heart failure at admission (HR 1.11; 95%CI 1.01-1.24; p = 0.04), and negative interaction with higher than median LVEF (HR 0.89; 95%CI 0.80-0.99; p = 0.03) for all-cause mortality at the multivariable level.

CONCLUSION

Based on the present analysis, baseline urinary albumin excretion during ACS is a strong independent predictor of the very long-term mortality risk, chiefly due to non-sudden cardiac death.

Evaluation of Apelin-13 levels in patients with diabetic nephropathy

PURPOSE

There is no clear information about the level of Apelin-13 in patients with diabetic nephropathy (DN). In this study, we investigated whether there is a relationship between Apelin-13 level and the severity of the disease in patients with DN.

METHODS

In our case-control study, we included patients who applied to the endocrinology outpatient clinic in 2019. Patients without a history of diabetes were determined as the healthy group (group 1). The patients were divided into 4 groups according to their microalbumin and creatinine levels. Venous blood samples were obtained from all patients for routine laboratory parameters and Apelin-13 levels. Homeostatic Model Assessment-Insulin Resistance (HOMA-IR) for insulin resistance was calculated using the formula: plasma glucose X insulin level/405.

RESULTS

Albumin was found to be significantly lower in group 5 (p = 0.032), hemoglobin A1c, microalbumin/creatinine and HOMA-IR values were found to be significantly lower in group 1 (p < 0.001 for each). Apelin-13 level was found to be significantly higher in group 4 and group 5 (p < 0.001). A negative correlation was found between Apelin-13 and GFR (r = - 0.286, p = 0.003). A positive correlation was found between Apelin-13 and HOMA-IR (r = 0.309, p = 0.009) and microalbumin/creatinine (r = 0.296, p < 0.001).

CONCLUSION

In patients with DN, Apelin-13 level increases with the severity of the disease and can be used as a biomarker for staging of DN.

Longitudinal relationship between albuminuria in infancy and childhood

BACKGROUND

Mildly increased albuminuria is common in the general adult population and is a strong predictor for cardiovascular events, even in otherwise healthy individuals. The underlying pathophysiological process could be endothelial dysfunction. Previously, we reported that increased albuminuria can also be found in 2-year-olds from the general population. We hypothesized that some individuals have constitutionally higher levels of albuminuria, possibly as an expression of early or inborn endothelial dysfunction. The aim of this study is to evaluate longitudinal persistence of albuminuria from infancy into school age.

METHODS

In the population-based GECKO (Groningen Expert Center for Kids with Obesity) cohort, urine was collected from 816 children at the age of 2 years as well as 12 years (random urine and first morning void urine, respectively). We evaluated prevalence and persistence of increased albuminuria (U_ACR ≥ 3 mg/mmol) at the two time points.

RESULTS

The prevalence of U_ACR ≥ 3 mg/mmol at 2 and 12 years of age was 31.9% (95% CI 28.7-35.2) and 3.1% (95% CI 2.0-4.5), respectively. U_ACR < 3 mg/mmol at both 2 and 12 years of age was present in 540 children (66.2%). Only 9 children (3.5%) of the 260 children with an U_ACR ≥ 3 mg/mmol at 2 years had an U_ACR ≥ 3 mg/mmol at 12 years (p < 0.001).

CONCLUSION

Albuminuria in 2-year-olds does largely not persist until the age of 12, indicating that albuminuria at 2 years of age is not a marker for constitutional endothelial dysfunction in this cohort. A higher resolution version of the Graphical abstract is available as Supplementary information.

Predictors of microalbuminuria and its relationship with glycemic control among Type 2 diabetic patients of Jazan Armed Forces Hospital, southwestern Saudi Arabia

BACKGROUND AND PURPOSE

Diabetic kidney disease (DKD) is highly prevalent among patients with diabetes mellitus. It affects approximately 20% of diabetic patients, who are believed to be more than 400 million individuals. The objectives of the present work were to assess patterns of albuminuria and determine microalbuminuria predictors among patients living with type 2 diabetes (T2D) who attended the family medicine department of Jazan Armed Forces Hospital.

METHODS

A case-control design was used and included two groups (n, 202/group), one with microalbuminuria and the other with a normal urine albumin/creatinine ratio (ACR). Data regarding patient history, glycosylated hemoglobin (HbA1c), lipid profile, renal function tests, ACR, ASCVD (atherosclerotic cardiovascular disease) risk, etc., were collected.

RESULTS

The prevalence rates of microalbuminuria and macroalbuminuria were 26.4% and 3.9%, respectively. HbA1c was significantly higher in patients with microalbuminuria (9.3 ± 2.2; P˂0.001) and macroalbuminuria (10.5 ± 2.3; P˂0.001) than in those with normal ACR (8.3 ± 1.9%). The predictors of microalbuminuria were poor glycemic control with HbA1c ≥ 7% {OR, 2.5 (95% C. I, 1.5-4.2)}; hypertension {(OR, 1.8 (95% C. I, 1.2-2.8)}; estimated glomerular filtration rate (eGFR) of ˂90 mL/min/1.73 m2 {OR, 2.2 (95% C. I, 1.4-3.6}; smoking {OR, 1.3 (95% C. I, 0.7-2.6}; and body mass index {OR, 1.05 (95% C. I, 1.01-1.09}.

CONCLUSION

Microalbuminuria is highly prevalent among patients with type 2 diabetes and is associated with poor glycemic control and hypertension, necessitating aggressive and timely screening and treatment.

Determinants of microalbuminuria among type 2 diabetes mellitus patients in Kuala Selangor district: A cross-sectional study

INTRODUCTION

Microalbuminuria presents significant health risks for the progression of endstage renal-failure (ESRF) among type 2 diabetes mellitus (T2DM) patients. This study aims to determine the proportion and associated factors of microalbuminuria among T2DM patients in Kuala Selangor district, Malaysia.

METHOD

A retrospective cross-sectional study was conducted from December 2020 to February 2021 using secondary data from the National Diabetic Registry (NDR), Malaysia, and reviewed patients' diabetic records for the year 2020. All T2DM patients aged >18 years who were registered with the NDR in 2020 and fulfilled the inclusion and exclusion criteria were included in the study. Descriptive statistics and multiple logistic regression analysis were performed. Data were analysed using SPSS version 26.0. A total of 343 samples were included in this study for the determination of the proportion of microalbuminuria and its associated factors.

RESULTS

Of 343 respondents, 34.4% had microalbuminuria. HbAlc >7.0% (AdjOR 2.19, 95% CI: 1.35, 3.55, p=0.001), HDL <1.04 mmol/L (AdjOR 2.44, 95% CI: 1.323, 4.52, p=0.004), dyslipidaemia (AdjOR 1.90, 95% CI: 1.03, 3.48, p=0.039), and peripheral neuropathy (AdjOR 3.01, 95% CI: 1.02, 8.93, p=0.047) were significantly associated with microalbuminuria. Conclusion: Microalbuminuria is a modifiable risk factor in preventing the progression of ESRF among T2DM patients. Therefore, identification of factors associated with microalbuminuria among this high-risk group is important to facilitate early screening and prompt treatment to prevent progression of diabetic kidney disease to ESRF.

A comparison of the utility of the urine dipstick and urine protein-to-creatinine ratio for predicting microalbuminuria in patients with non-diabetic lifestyle-related diseases -a comparison with diabetes

BACKGROUND

The utility of dipstick proteinuria for predicting microalbuminuria in non-diabetic lifestyle-related diseases compared with the urine protein-to-creatinine ratio (uPCR) and the effect of dipstick proteinuria on the cut-off value (CO) and accuracy of uPCR are unclear.

METHODS

The subjects included Japanese patients ≥ 18 years old with lifestyle-related diseases who had an estimated glomerular filtration rate of ≥ 15 ml/min/1.73 m² and uPCR of < 0.5 g/gCr at initiation. Urine dipstick, uPCR and urine albumin-to-creatinine ratio (uACR) were measured three times per case. Microalbuminuria was defined as uACR of 30-299 mg/gCr for at least 2 of 3 measurements. Youden's Index was used as the optimal CO. Factors associated with microalbuminuria were analyzed using a logistic regression model.

RESULTS

In 313 non-diabetic cases (median 70.8 years old), 3 dipstick proteinuria measurements were independently useful for detecting microalbuminuria, and the CO was set when a trace finding was obtained at least 1 of 3 times (sensitivity 0.56, specificity 0.80, positive predictive value [PPV] 0.73, negative predictive value [NPV] 0.65). A single uPCR measurement was more useful than 3 dipstick measurements, and was useful for detecting microalbuminuria even in cases with three consecutive negative proteinuria findings, indicating that the CO of the second uPCR with G1-3a (n = 136) was 0.06 g/gCr (sensitivity 0.76, specificity 0.84. PPV 0.68, NPV 0.89), while that with G3-b4 (n = 59) was 0.10 g/gCr (sensitivity 0.56, specificity 0.91. PPV 0.83, NPV 0.71). The sum of 3 uPCRs was useful for detecting microalbuminuria in cases with G1-3a (sensitivity 0.67, specificity 0.94, PPV 0.82, NPV 0.86) and G3b-4 (sensitivity 0.78, specificity 0.94, PPV 0.91 NPV 0.83), with both COs being 0.23 g/gCr. These COs of microalbuminuria did not change when trace or more proteinuria was included, although the sensitivity increased. A high uPCR and low urine specific gravity or creatinine level were independent factors for uACR ≥ 30 mg/gCr in cases with negative proteinuria, although the uPCR was a major predictive factor of a uACR ≥ 30 mg/gCr.

CONCLUSIONS

The uPCR (preferably determined using early-morning urine), including in dipstick-negative proteinuria cases with non-diabetic lifestyle-related diseases, can aid in the early detection of microalbuminuria.

TRIAL REGISTRATION

Retrospectively registered.

Tangled relationship between insulin resistance and microalbuminuria in children with obesity

Childhood obesity represents a complex disease with a well-known cardiometabolic burden including fatty liver, type 2 diabetes, metabolic syndrome, and cardiovascular disease. From a pathogenic point of view, insulin resistance (IR) represents the key factor underlying the spectrum of these obesity consequences. As observed in adults, recent data supported the occurrence of microalbuminuria (MA) as marker of early kidney dysfunction and its potential link with cardiometabolic factors also in children with obesity. In fact, a well-documented pathophysiological hypothesis both in adults and children supported an intimate correlation with the major feature of obesity such as IR through the influence of insulin on renal hemodynamics. Based on the clinical and prognostic relevance of this relationship in daily practice (including an increased risk of chronic kidney disease development overtime), more scientific attention needs to be paid to the evaluation of early kidney damage in children with obesity. In this paper, we attempt to address three debated questions regarding the intriguing liaison between IR and MA in children with obesity: (1) What is the prevalence of pediatric MA? (2) What is the state of art of MA in children with obesity? and (3) Is there a link between IR and MA in children with obesity?

Diabetic kidney disease in pediatric patients: A current review

In the last decades, a significant increase in the incidence of diabetic kidney disease (DKD) was observed concomitant with rising diabetes mellitus (DM) incidence. Kidney disease associated with DM in children and adolescents is represented by persistent albuminuria, arterial hypertension, progressive decline in estimated glomerular filtration rate to end-stage renal disease and increased cardiovascular and all-cause morbidity and mortality of these conditions. In medical practice, the common and still the “gold standard” marker for prediction and detection of diabetic kidney involvement in pediatric diabetes is represented by microalbuminuria screening even if it has low specificity to detect early stages of DKD. There are some known limitations in albuminuria value as a predictor biomarker for DKD, as not all diabetic children with microalbuminuria or macroalbuminuria will develop end-stage renal disease. As tubular damage occurs before the glomerular injury, tubular biomarkers are superior to the glomerular ones. Therefore, they may serve for early detection of DKD in both type 1 DM and type 2 DM. Conventional and new biomarkers to identify diabetic children and adolescents at risk of renal complications at an early stage as well as renoprotective strategies are necessary to delay the progression of kidney disease to end-stage kidney disease. New biomarkers and therapeutic strategies are discussed as timely diagnosis and therapy are critical in the pediatric diabetic population.

Etiology of Persistent Microalbuminuria in Nigeria (P_MICRO study): protocol and study design

BACKGROUND

Microalbuminuria is an independent risk factor for cardiovascular and kidney disease and a predictor of end organ damage, both in the general population and in persons with HIV (PWH). Microalbuminuria is also an important risk factor for mortality in PWH treated with antiretroviral therapy (ART). In the ongoing Renal Risk Reduction (R3) study in Nigeria, we identified a high prevalence of microalbuminuria confirmed by two measurements 4-8 weeks apart in ART-experienced, virologically suppressed PWH. Although Stage 1 or 2 hypertension and exposure to potentially nephrotoxic antiretroviral medications were common in R3 participants, other traditional risk factors for albuminuria and kidney disease, including diabetes, APOL1 high-risk genotype, and smoking were rare. Co-infection with endemic pathogens may also be significant contributors to albuminuria, but co-infections were not evaluated in the R3 study population.

METHODS

In Aim 1, we will cross-sectionally compare the prevalence of albuminuria and established kidney disease risk factors in a cohort of PWH to age- and sex-matched HIV-negative adults presenting for routine care at the Aminu Kano Teaching Hospital in Kano, Nigeria. We will leverage stored specimens from 2500 R3 participants and enroll an additional 500 PLWH recently initiated on ART (≤ 24 months) and 750 age- and sex-matched HIV-negative adults to determine the contribution of HIV, hypertension, and other comorbid medical conditions to prevalent albuminuria. In Aim 2, we will follow a cohort of 1000 HIV-positive, ART-treated and 500 HIV-negative normoalbuminuric adults for 30 months to evaluate the incidence and predictors of albuminuria.

DISCUSSION

The findings from this study will support the development of interventions to prevent or address microalbuminuria in PWH to reduce kidney and cardiovascular morbidity and mortality. Such interventions might include more intensive monitoring and treatment of traditional risk factors, the provision of renin-angiotensin aldosterone system or sodium-glucose cotransporter-2 inhibitors, consideration of changes in ART regimen, and screening and treatment for relevant co-infections.

Correlation between microalbuminuria and atherosclerotic intracranial and extracranial arterial stenosis in patients with cerebral infarction

BACKGROUND AND AIMS

Microalbuminuria (MAU) reflects the generalized vascular endothelial dysfunction. Whether MAU has correlation with atherosclerotic intracranial and extracranial arterial stenosis in cerebral infarction patients is not known and is explored in the present investigation.

METHODS

We enrolled 255 cerebral infarction patients hospitalized at the department of neurology. All patients underwent digital subtraction angiography (DSA) to evaluate the severity and distribution of intracranial and extracranial arterial stenosis. MAU was expressed as the urine albumin-to-creatinine ratio (UACR). We collected basic information, medical history reviews and laboratory results of each participant. The multivariate logistic regression analysis was utilized to analyze the risk factors for severity and distribution of cerebral arterial stenosis.

RESULTS

The prevalence of MAU in patients with cerebral infarction was 39.2%, patients with MAU had older age, lower blood uric acid, higher systolic blood pressure (SBP), higher prevalence of hypertension and diabetes (p < 0.05) and higher incidence of atherosclerotic intracranial and extracranial arterial stenosis (χ2 = 5.900, p = 0.015). In multiple logistic regression analysis for intracranial and extracranial arterial stenosis more than 50% or occlusion groups, UACR (OR 1.088 95%CI 1.012-1.170p = 0.022), male (OR 2.196 95%CI 1.085-4.442p = 0.029) as well as SBP (OR 5.870 95%CI 1.026-1.048p = 0.015) showed statistical significance. But UACR had no correlation with the distribution of intracranial and extracranial artery stenosis after adjusting for all potential confounders.

CONCLUSIONS

Microalbuminuria was an independent risk factor for intracranial and extracranial arterial stenosis more than 50% or occlusion.

Phosphate restriction using a processed clay mineral reduces vascular pathologies and microalbuminuria in rats with chronic renal failure

Background

The progression of chronic kidney disease (CKD) is associated with an increasing risk of cardiovascular morbidity and mortality due to elevated serum phosphate levels. Besides low phosphate diets and hemodialysis, oral phosphate binders are prescribed to treat hyperphosphatemia in CKD patients. This study reports on a processed clay mineral as a novel and efficient phosphate sorbent with comparable efficacy of a clinically approved phosphate binder.

Methods

5/6 nephrectomized rats, which develop chronic renal failure (CRF), received a high phosphate and calcium diet supplemented with either a processed Montmorillonite-Illite clay mineral (pClM) or lanthanum carbonate (LaC) for 12 weeks. Levels of plasma uremic toxins, glomerular filtration rates and microalbuminuria were determined and the histomorphology of blood vessels and smooth muscle cells was analyzed.

Results

5/6 nephrectomy induced an increase in plasma uremic toxins levels and progressive proteinuria. Treatment of CRF rats with pClM decreased observed vascular pathologies such as vascular fibrosis, especially in coronary vessels. The transition of vascular smooth muscle cells from a contractile to a secretory phenotype was delayed. Moreover, pClM administration resulted in decreased blood creatinine and urea levels, and increased glomerular filtration rates, reduced microalbuminuria and eventually the mortality rate in CRF rats.

Conclusion

Our study reveals pClM as a potent phosphate binding agent with beneficial impacts on pathophysiological processes in an animal model of CKD. pClM effectively attenuates the progression of vascular damage and loss of renal function which are the most severe consequences of chronic renal failure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02743-5.

Elevated Urinary VEGF-A, Transferrin, and Angiotensinogen Levels in Normoalbuminuric Children and Adolescents with Type 1 Diabetes: Can They Be Early Markers of Diabetic Kidney Disease?

OBJECTIVE

We hypothesized that diabetic kidney disease (DKD) begins early, before albuminuria occurs. We therefore aimed to assess potential early urinary biomarkers of DKD in normoalbuminuric and normotensive children and adolescents with type 1 diabetes (T1D) to evaluate the relationship between these markers and clinical and laboratory risk factors for DKD.

METHODS

This cross-sectional study included 75 children and adolescents with T1D (62% females, mean age 13.9 ± 3.2 years) with normoalbuminuria (an albumin/creatinine ratio [ACR] below 30 mg/g creatinine). Fifty-five age- and sex-matched healthy children and adolescents served as controls. For the assessment of early DKD, urinary levels of angiotensinogen (AGT), transferrin, nephrin, vascular endothelial growth factor-A (VEGF-A), and kidney injury molecule-1 (KIM-1) were measured in adequately collected 24-h urine samples using enzyme-linked immunoassays.

RESULTS

The mean disease duration was 7.3 ± 3.2 (range 2.1-15.7) years, and the mean HbA1c level was 8.8 ± 1.4%. The median levels of urine VEGF-A/Cr, AGT/Cr, and transferrin/Cr were significantly higher in normoalbuminuric patients with T1D, compared with those of controls (p < 0.001, p = 0.02, and p = 0.001, respectively), but there was no difference in nephrin/Cr and KIM-1/Cr between the 2 groups. Although none of the patients had albuminuria, the median level of urine ACR was significantly higher in the patient group than the control group (p = 0.003). The ACR was positively correlated with glomerular filtration rate (GFR). Urinary transferrin/Cr, AGT/Cr, and VEGF-A/Cr were significantly correlated with ACR, but not with either GFR or diabetic risk factors including HbA1c or disease duration.

CONCLUSION

Normoalbuminuric and normotensive children and adolescents with T1D have elevated urinary VEGF, AGT, and transferrin levels, which may indicate the development of DKD before albuminuria occurs.

Urinary C-megalin as a novel biomarker of progression to microalbuminuria: A cohort study based on the diabetes Distress and Care Registry at Tenri (DDCRT 22)

AIMS

Megalin is a multiligand receptor expressed in proximal tubular cells that reabsorbs filtered albumin and correlates cross-sectionally with albuminuria. We investigated the association between urinary C-megalin levels and the incidence of microalbuminuria in patients with diabetes mellitus.

METHODS

This cohort study included 752 patients with type 1 or 2 diabetes mellitus and a urinary albumin-to-creatinine (Cr) ratio (UACR) within the normoalbuminuric range (<30 mg/g Cr). The association between urinary C-megalin and persistent microalbuminuria, accounting for the possible interaction between baseline UACR and urinary C-megalin, was estimated using a Cox proportional hazards model.

RESULTS

During a median follow-up period of 1.99 years, 179 cases of persistent microalbuminuria were observed. The association between urinary C-megalin and persistent microalbuminuria was UACR-dependent (P for interaction < 0.001), with the highest association observed in the absence of UACR (per 100 fM/gCr of urinary C-megalin: adjusted hazard ratio, 1.13; 95% CI 1.07-1.19), gradually decreasing as UACR increased to 30 mg/g Cr. UACR dependence was confirmed by sensitivity analyses according to low-normal (<10 mg/gCr) or high-normal (10-<30 mg/gCr) UACR.

CONCLUSIONS

Urinary C-megalin is associated with progression to microalbuminuria, especially in those with low-normal UACR levels, and its usefulness to identify high risk patients requires further investigation.

Long-term follow-up of patients after acute kidney injury in the neonatal period: abnormal ambulatory blood pressure findings

Background

Data on the long-term effects of neonatal acute kidney injury (AKI) are limited.

Methods

We invited 302 children who had neonatal AKI and survived to hospital discharge; out of 95 patients who agreed to participate in the study, 23 cases were excluded due to primary kidney, cardiac, or metabolic diseases. KDIGO definition was used to define AKI. When a newborn had no previous serum creatinine, AKI was defined as serum creatinine above the mean plus two standard deviations (SD) (or above 97.5^th percentile) according to gestational age, weight, and postnatal age. Clinical and laboratory features in the neonatal AKI period were recorded for 72 cases; at long-term evaluation (2–12 years), kidney function tests with glomerular filtration rate (eGFR) by the Schwartz formula, microalbuminuria, office and 24-h ambulatory blood pressure monitoring (ABPM), and kidney ultrasonography were performed.

Results

Forty-two patients (58%) had stage I AKI during the neonatal period. Mean age at long-term evaluation was 6.8 ± 2.9 years (range: 2.3–12.0); mean eGFR was 152.3 ± 26.5 ml/min/1.73 m². Office hypertension (systolic and/or diastolic BP ≥ 95^th percentile), microalbuminuria (> 30 mg/g creatinine), and hyperfiltration (> 187 ml/min/1.73 m²) were present in 13.0%, 12.7%, and 9.7% of patients, respectively. ABPM was performed on 27 patients, 18.5% had hypertension, and 40.7% were non-dippers; 48.1% had abnormal findings. Female sex was associated with microalbuminuria; low birth weight (< 1,500 g) and low gestational age (< 32 weeks) were associated with hypertension by ABPM. Twenty-three patients (33.8%) had at least one sign of microalbuminuria, office hypertension, or hyperfiltration. Among 27 patients who had ABPM, 16 (59.3%) had at least one sign of microalbuminuria, abnormal ABPM (hypertension and/or non-dipping), or hyperfiltration.

Conclusion

Even children who experienced stage 1 and 2 neonatal AKI are at risk for subclinical kidney dysfunction. Non-dipping is seen in four out of 10 children. Long-term follow-up of these patients is necessary.

The association between serum interleukin-1 beta and heparin sulphate in diabetic nephropathy patients

Inflammation is considered an important mechanism in the development of diabetes mellitus (DM) and persists for a long time before the occurrence of diabetic nephropathy (DN). Many studies have demonstrated that a decrease in the endothelial glycocalyx (EG) is negatively correlated with proteinuria. To elucidate whether EG damage induced by inflammasomes in DM patients leads to the occurrence of microalbuminuria (MA) and accelerates the progression of DN, this study screened 300 diagnosed DM patients. Finally, 70 type 2 diabetes patients were invited to participate in this study and were divided into two groups: the T2DM group (patients with normal MA and without diabetic retinopathy, n = 35) and the T2DN group (patients with increased MA and diabetic retinopathy, n = 35). Circulating heparin sulphate (HS, EG biomarkers) and interleukin-1 beta (IL-1β, inflammasome biomarkers) of the patients were measured by ELISA. Laboratory data were measured using routine laboratory methods. Patients in the T2DN group had increased serum HS, increased IL-1β, increased CRP, decreased haemoglobin, and increased neutrophils compared to patients in the T2DM group (all P < 0.05). Increased HS and decreased haemoglobin were independently associated with T2DN patients. ROC curves showed that the AUC of HS for the prediction of T2DN was 0.67 (P < 0.05). The combination of HS and haemoglobin yielded a significant increasement in the AUC (0.75, P < 0.001) with optimal sensitivity (71.2%) and specificity (79%). Furthermore, serum IL-1β was positively correlated with HS and was an independent associated factor of HS in the T2DN group. The relationship between HS and IL-1β was not significant in the T2DM group. Our findings surgessed the inflammasome may be associated with and promote damage to the EG during the disease course of DN that manifests as increased MA.

Diabetic kidney disease in children and adolescents: an update

Diabetic kidney disease (DKD), previously encountered predominantly in adult patients, is rapidly gaining center stage as a childhood morbidity and one that pediatric nephrologists are likely to encounter with increasing frequency. This is in large part due to the obesity epidemic and the consequent rise in type 2 diabetes in children and adolescents, as well as the more aggressive diabetes phenotype in today's youth with more rapid β-cell decline and faster development and progression of diabetes-related complications along with lower responsiveness to the treatments used in adults. DKD, an end-organ complication of diabetes, is at the very least a marker of, and more likely a predisposing factor for, the development of adverse cardiovascular outcomes and premature mortality in children with diabetes. On an optimistic note, several new therapeutic approaches are now available for the management of diabetes in adults, such as GLP1 receptor agonists, SGLT2 inhibitors, and DPP4 inhibitors, that have also been shown to have a favorable impact on cardiorenal outcomes. Also promising is the success of very low-energy diets in inducing remission of diabetes in adults. However, the addition of these pharmacological and dietary approaches to the management toolbox of diabetes and DKD in children and adolescents awaits thorough assessment of their safety and efficacy in this population. This review outlines the scope of diabetes and DKD, and new developments that may favorably impact the management of children and young adults with diabetes and DKD.

Renal Complications and Duration of Diabetes: An International Comparison in Persons with Type 1 Diabetes

INTRODUCTION

Renal complications are both a marker of previous suboptimal glycaemic control and a major risk factor for cardiovascular disease in persons with type 1 diabetes (T1D). The aim of the study was to evaluate the prevalence of renal complications in persons with T1D in four geographical regions.

METHODS

Nationwide registry data from Austria/Germany, Sweden and the US were used to estimate the prevalence of renal complications from January 2016 until September 2018. Chronic kidney disease (CKD) and albuminuria in the study population and each registry were analysed by diabetes duration. Risk factors for renal complications were described by registry.

RESULTS

In the total cohort of 78.926 adults with T1D, mean age was 44.4 ± 18.43 years and mean diabetes duration was 21.6 ± 22 years. Mean estimated glomerular filtration rate (eGFR) was 94.0 ± 31.45 ml/min, 13.0% had microalbuminuria and 3.9% had macroalbuminuria. Mean age, diabetes duration, use of insulin pumps and continuous glucose monitoring, as well as presence of albuminuria, varied between registries. Albuminuria was present in approximately 10% of persons with diabetes duration < 20 years and impaired renal function (eGFR < 60 ml/min) was present in 17%. In persons with diabetes duration > 40 years, approximately one-third had albuminuria and 25% had impaired renal function.

CONCLUSIONS

This analysis used three nationwide registries of persons with T1D. Despite recent use of more effective diabetes therapies, a substantial proportion of persons with T1D have renal complications at < 20 years after diagnosis. Efficient glucose-lowering and renal-protective strategies are needed in persons with T1D.

Fluorimetric method for specific detection of human serum albumin in urine using its pseudoesterase property

Detection of microalbuminuria is an analytical challenge. There are dye-based methods and immunochemical methods. However, these methods are less specific and sensitive respectively. So, people are trying new approaches for microalbuminuria detection. In this context, we have developed a fluorescent spectroscopic method to detect human serum albumin using its pseudoesterase property. Recently, we had discovered that neostigmine does not inhibit Human serum albumin pseudoesterase activity. Using such a phenomenon, we have devised a specific fluorimetric detection method of HSA using 2NA as a substrate for the pseudoesterase activity. The developed method can sense as low as 0.1 μM of HSA in the urine matrix without dye or antibody. We have proposed a scheme of automation of the proposed method.

The effect of monomeric and oligomeric FLAVAnols in patients with type 2 diabetes and microalbuminuria (FLAVA-trial): A double-blind randomized controlled trial

BACKGROUND & AIMS

Microalbuminuria is an early sign of vascular complications of type 2 diabetes and predicts cardiovascular disease and mortality. Monomeric and oligomeric flavanols (MOFs) are linked to improved vascular health. The aim of this study was to assess the effect of 3 months MOFs on albuminuria and endothelial function markers in patients with type 2 diabetes and microalbuminuria.

METHODS

We conducted a double-blind, placebo-controlled trial among patients with type 2 diabetes and microalbuminuria. Patients with type 2 diabetes received either 200 mg MOFs or placebo daily on top of their habitual diet and medication. The primary endpoint was the between-group difference of the change in 24-h Albumin Excretion Rate (AER) over three months. Secondary endpoints were the between-group differences of the change in plasma levels of different markers of endothelial dysfunction. Mixed-modelling was applied for the longitudinal analyses.

RESULTS

Participants (n = 97) were 63.0 ± 9.5 years old; diabetes-duration was 15.7 ± 8.5 years. Median baseline AER was 60 (IQR 20-120) mg/24 h. There was no within-group difference in median change of AER from baseline to 3 months in the intervention (0 (-35-21) mg/24 h, p = 0.41) or the control group (0 (-20-10) mg/24 h, p = 0.91). There was no between-group difference in the course of AER over three months (log-transformed data: β = -0.02 (95%CI -0.23-0.20), p = 0.88), nor in the plasma levels of the endothelial dysfunction markers.

CONCLUSION

Daily 200 mg MOFs for three months on top of habitual diet and usual care did not reduce AER and plasma markers of endothelial dysfunction compared to placebo, in patients with long-term type 2 diabetes and microalbuminuria.

CLINICAL TRIALS REGISTRATION

NTR4669, www.trialregister.nl.

Choroidal thickness in relation to urinary albumin excretion rate in type 2 diabetes mellitus without retinopathy

Background

To evaluate choroidal thickness (CT) in diabetic patients without diabetic retinopathy (DR) in relation to the urinary albumin excretion rate (UAER).

Methods

This is a prospective case-control study that included a consecutive sample of 120 patients with type 2 diabetes without clinically evident DR and a group of 60 matched healthy controls. Diabetic patients were included in two groups according to their UAER (normoalbuminuria and microalbuminuria). Complete ophthalmological examination was performed followed by optical coherence tomography (SD-OCT) for retinal and choroidal assessment. Twenty-four-hour urine samples were collected for UAER and blood samples for HbA1c and serum creatinine were obtained.

Results

The study included 180 eyes from 180 subjects in three groups. Patients with higher levels of albuminuria had a thinner choroid than normal controls, with decremental thinning as albuminuria progressed. Diabetics with normoalbuminuria showed no significant differences from controls. Choroidal thickness showed a significant moderate negative correlation with UAER (r  =  − 0.58, p  <  0.001). Multiple regression analyses for diabetic patients with microalbuminuria demonstrated that UAER is the most important determinant of subfoveal choroidal thickness (SFCT) (p  <  0.001).

Conclusions

Decreased CT was significantly correlated with UAER in diabetic patients without retinopathy and otherwise normal kidney functions. This decrease in thickness might be a predictor of DR.

Pulse Wave Velocity, Central Haemodynamic Parameters, and Markers of Kidney Function in Children

OBJECTIVES

Chronic kidney disease (CKD) is a well-established risk factor for cardiovascular diseases. Studies in adults have demonstrated the association between mildly decreased kidney function or even normal values of markers of kidney function to pulse wave velocity (PWV), a measure of arterial stiffness and a predictor of cardiovascular events. Our study aimed to evaluate associations between markers of CKD, PWV, and central haemodynamic parameters in children and adolescents at risk of subclinical kidney damage.

METHODS

182 children and adolescents with hypertension, obesity, or hypercholesterolaemia (risk factors for subclinical kidney damage) were included in the study. The subjects were subdivided into 4 groups comprising children and adolescents with hypertension (group 1), obesity (group 2), hypercholesterolaemia (group 3), and a group with a combination of risk factors, such as obesity-related hypertension and metabolic syndrome (group 4). The study groups were compared to a group of healthy controls (group 5). PWV was measured by applanation tonometry (SphygmoCor, SCOR-Vx, Sydney, NSW, Australia) and laboratory parameters (serum creatinine, serum cystatin C, and microalbuminuria) were collected.

RESULTS

Pearson's correlation coefficient demonstrated a statistically significant correlation between PWV and serum creatinine in group of all subjects (r = 0.220, p = 0.002). Further subdivision showed the correlation was significant in group 4 (r = 0.370, p = 0.002). In group 2 a correlation between PWV and cystatin C was found (r = -0.535, p = 0.009). In multiple regression analysis of all subjects with PWV as the dependent variable, age and diastolic blood pressure were statistically significant. Correlations between markers of kidney function and central haemodynamic parameters also showed significant correlations between serum creatinine and heart rate (HR) (r = -0.476, p < 0.001) as well as associated parameters (augmentation index, standardized at HR 75/min, ejection duration, and subendocardial viability ratio).

CONCLUSIONS

Our study demonstrated a correlation between serum creatinine and PWV in children with combined risk factors for atherosclerosis and probable subclinical kidney damage. Further prospective research is needed to confirm the findings, and thus the preventive role of PWV determination in paediatric nephrology.

Increased risk for microvascular complications among women with gestational diabetes in the third trimester

AIMS

The risk of microvascular disease has been thought to commence with the onset of overt diabetes. Women with gestational diabetes have only had a short-term exposure to frank hyperglycemia, but, due to underlying β-cell dysfunction, they may also have had long-term exposure to mild degrees of hyperglycemia. The aim of the study was to determine whether women with gestational diabetes are at increased risk for microalbuminuria and retinopathy compared to women with normal glucose tolerance in pregnancy.

METHODS

We recruited women aged ≥ 25 years with singleton pregnancies at 32 to 40 weeks' gestational age, with and without gestational diabetes. Women with hypertension, preeclampsia, or pre-gestational diabetes were excluded.

RESULTS

Of 372 women included in the study, 195 had gestational diabetes. The prevalence of microalbuminuria was 15% among those with gestational diabetes versus 6% in those with normal glucose tolerance (adjusted odds ratio 2.4, 95% confidence interval 1.1 to 5.2, p = 0.006). Diastolic blood pressure and HbA1c were associated with microalbuminuria. The prevalence of retinopathy did not differ between groups (10% versus 11%).

CONCLUSIONS

Women with gestational diabetes have an increased risk of microalbuminuria in the third trimester, despite having been exposed to only a brief period of overt hyperglycemia.

Metabolic Syndrome, and Not Obesity, Is Associated with Chronic Kidney Disease

INTRODUCTION

Obese (OB) patients are at increased risk of chronic kidney disease, but it is still unclear whether this can be attributed to obesity per se or to the associated metabolic derangements. The aim of this study was to evaluate the relative impact of obesity and metabolic syndrome (MS) on kidney disease.

METHODS

This is a cross-sectional study based on data obtained in the 2005-2016 cycles of the National Health and Nutrition Examination Survey. We included all adult participants with available data on body mass index, estimated glomerular filtration rate (eGFR), urine albumin to creatinine ratio (UACR), and each of the MS components. Primary outcomes were eGFR <60 mL/min, UACR ≥30 mg/g, or a combination of the two.

RESULTS

The studied population comprised 12,335 participants. OB participants without MS (OB+ MS-) were younger and more commonly female. After adjustment for potential confounders, compared with OB- MS- participants, an increased prevalence of albuminuria and reduced eGFR were present in both OB- MS+ groups and the OB+ MS+ groups, but not in the OB+ MS- groups. When each of the MS components was evaluated separately, elevated blood pressure and low high-density lipoprotein cholesterol were associated with both UACR and reduced eGFR, while elevated blood glucose and triglycerides were only associated with UACR. Waist circumference was not associated with any of the renal outcomes.

DISCUSSION/CONCLUSION

This large cross-sectional study suggests that MS and not obesity is associated with kidney damage and that the OB+ MS- phenotype does not seem to carry an increased risk of kidney disease.

Comparison of urine albumin creatinine ratio with the pediatric index of mortality 2 score for prediction of pediatric intensive care unit outcomes

Background

Predicting morbidity and mortality in a pediatric intensive care unit (PICU) is of extreme importance to make precise decisions for better outcomes.

Aim

We compared the urine albumin creatinine ratio (ACR) with the established PICU score, pediatric index of mortality 2 (PIM 2) for predicting PICU outcomes.

Methods

This cross-sectional study enrolled 67 patients admitted to PICU with systemic inflammatory response syndrome. Urine ACR was estimated on admission, and PIM 2 score was calculated. ACR was compared with PIM 2 for PICU outcome measures: the need for inotropes, development of multiple organ dysfunction syndrome (MODS), duration of PICU stay, and survival.

Results

Microalbuminuria was found in 77.6% of patients with a median ACR of 80 mg/g. ACR showed a significant association with the need for inotropes (p < 0.001), MODS (p = 0.001), and significant correlation to PICU stay (p 0.001, rho = 0.361). The area under the receiver operating characteristic curve for ACR (0.798) was comparable to that of PIM 2 (0.896). The cutoff value of ACR derived to predict mortality was 110 mg/g. The study subjects were divided into 2 groups: below cutoff and above the cutoff. Outcome variables, inotrope use, MODS, mortality, and PICU stay compared between these subgroups, were statistically significant.

Conclusion

ACR is a good predictor of PICU outcomes and is comparable to PIM 2 for mortality prediction.

Optimal glycaemic and blood pressure but not lipid targets are related to a lower prevalence of diabetic microvascular complications

BACKGROUND

Diabetic microvascular complications are a major cause of morbidity and are related to glycaemic control and cardiovascular risk factors.

AIMS

We sought to determine the association of microvascular complications in relation to control of glycemia, blood pressure and lipids in T2DM patients attending secondary care in Qatar.

METHODS

This is a cross-sectional study undertaken in patients with T2DM attending Qatar's National Diabetes Centres. Patients underwent assessment of glycemia, blood pressure and lipids and prevalence of diabetic peripheral neuropathy (DPN), retinopathy and microalbuminuria.

RESULTS

We included 1114 subjects aged 52.1 ± 11.3 years with a duration of diabetes 10.0 ± 7.6 years and had a prevalence of 25.8% for DPN, 34.3% for painful DPN, 36.8% for microalbuminuria and 25.1% for retinopathy. Patients who achieved an HbA1c ≤ 7.0% compared to >7% had a significantly lower prevalence of DPN (P < 0.01), painful DPN (P < 0.01), retinopathy (P < 0.01) and microalbuminuria (P < 0.007). Patients who achieved a systolic BP ≤ 140 mmHg compared to >140 mmHg had a significantly lower prevalence of DPN (P < 0.001), painful DPN (P < 0.001), retinopathy (P < 0.001) and microalbuminuria (P < 0.001). Patients who achieved an LDL ≤2.6 mmol/l compared to >2.6 mmol/l had a significantly higher prevalence of DPN (P < 0.03), but no difference in other outcomes. There was no difference in microvascular complications between those who achieved a HDL-C ≥ 1.02 mmol/l, and among those who achieved triglycerides ≤1.7 mmol/l.

CONCLUSIONS

Optimal control of glycemia and blood pressure, but not lipids is associated with a lower prevalence of diabetic microvascular complications.

Is there a relationship between sleep apnoea and microalbuminuria?

Introduction

Obstructive sleep apnoea (OSA) is a cause of hypoxia, and the correlation between hypoxia and microvascular complications is well known. Microalbuminuria (MAU) is a marker for endovascular dysfunction and an indicator of cardiovascular events and all-cause mortality in the general population. The aim of this study was to investigate the relationship between microvascular damage and the metabolic complications of OSA based on the presence of MAU.

Material and method

Urinary albumin/creatinine ratio (ACR) and microalbumin level were examined in patients with an apnoea-hypopnoea index (AHI) greater than 5/h (study group) and in patients with an AHI less than 5/h (control group). The exclusion criteria were other possible causes of MAU (hypertension, nephropathy, coronary artery disease, and severe thyroid dysfunction).

Results

Of 103 patients enrolled, 80 formed the group with OSA and 23 served as controls. According to the AHI values, the patients were divided into four groups as normal, mild, moderate and severe. There was no significant difference between the four groups in terms of the microalbumin level and urinary albumin/creatinine ratio.

Conclusion

In this study, no significant relationship was found between MAU and sleep apnoea.

The next generation: Urinary epidermal growth factor is associated with an early decline in kidney function in children and adolescents with type 1 diabetes mellitus

AIMS

Micro-albuminuria is considered an early clinical sign of diabetes nephropathy, however, early decrease of glomerular filtration can be present years before the presence of microalbuminuria. In this study, we explored whether urinary epidermal growth factor (uEGF) might serve as an early marker of diabetes nephropathy compared to microalbuminuria in children and adolescents.

METHODS

Children with type 1 diabetes mellitus (n = 158) and healthy controls (n = 40) were included in this study. Serum and urine samples were collected three times with an interval of at least one month to determine creatinine (serum and urine), epidermal growth factor and albumin (urine). Demographic data and routine lab values were extracted out of the electronic patient files.

RESULTS

uEGF was significantly lower in children with T1DM compared to healthy controls (p = 0.032). A relatively lower glomerular filtration rate (eGFR) was associated with a decreased uEGF (p < 0.001). uEGF was independently associated with eGFR in a multivariate analysis.

CONCLUSION

This study provides evidence that uEGF can serve as an early marker of diabetes nephropathy in children and adolescents.

Modifiable Risk Factors for Chronic Kidney Disease in Adulthood seen among School Children in Asaba

BACKGROUND

The burden of chronic kidney disease (CKD) is huge especially in developing countries like Nigeria. In Nigeria, treatment modalities for ESRD (renal replacement therapy) are not readily available and, where available, they are not affordable. Consequently, preventive nephrology aimed at early detection and prompt treatment of children with CKD risk factors has become the viable alternative in curbing this rising problem.

AIM

To determine the burden of some modifiable risk factors for CKD in adulthood (hypertension, obesity, proteinuria, and microalbuminuria) among primary school children in Asaba and to ascertain if there is any association between the prevalence of such modifiable risk factors and socio-economic status (SES) or school type of the children.

SUBJECTS AND METHODS

This is a cross-sectional descriptive study involving 400 primary school students in Asaba. Albuminspecific dipstick urinalysis was used to determine microalbuminuria while standard dip-stick urinalysis was used to determine proteinuria. Weight, height, body mass index (BMI) and blood pressure were measured for each child.

RESULTS

Modifiable risk factors for CKD were found among primary school children in Asaba with prevalence rates of 3.5%, 9.8%, 17.3%, and 18.8% for hypertension, obesity, proteinuria and microalbuminuria respectively. Obesity and proteinuria showed significant linear trend with SES (p < 0.005 and P=0.004, respectively) and were significantly higher in those that attended private schools compared with public schools (P < 0.005 and P=0.004, respectively). The burden of hypertension and microalbuminuria among the children were not influenced by their SES (p =0.94 and P= 0.99, respectively) or the school type the children attended (P=0.35 and P=0.44, respectively).

CONCLUSION

Obesity and proteinuria which are known risk factors for CKD in adulthood were noted mostly among children of high socioeconomic status.

Liver fibrosis assessed by transient elastography is independently associated with albuminuria in the general United States population

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD) are frequent and progressive conditions that share traditional risk factors: obesity, type 2 diabetes and hypertension.

AIMS

To evaluate whether an independent relationship exists between liver steatosis and fibrosis and different CKD phenotypes.

METHODS

Cross sectional study based on data from the 2017-18 cycle of the National Health and Nutrition Examination Survey. Vibration controlled transient elastography (VCTE) was performed in a US representative sample allowing the simultaneous assessment of liver steatosis (CAP: controlled attenuation parameter) and fibrosis (LSM: liver stiffness measurement) and their relationships with CKD phenotypes (albuminuria and reduced estimated glomerular filtration rate, eGFR).

RESULTS

4746 adult participants had a complete VCTE exam. Prevalence of liver steatosis and significant fibrosis was 33.7% (95%CI: 30.9-36.6%) and 8.9% (95%CI: 7.5-10.5%), respectively. Logistic regression analysis showed that liver fibrosis, but not steatosis, was associated with albuminuria (OR 2.19, 95%CI: 1.49-3.20) and albuminuria or reduced eGFR (OR 2.18, 95%CI: 1.59-3.00) also when adjusted for age, sex, ethnicity, BMI, diabetes, blood pressure categories, glycated haemoglobin, use of renin-angiotensin-aldosterone system blockers and CAP.

CONCLUSIONS

In the general US population liver fibrosis assessed using VCTE is associated with CKD, and in particular with the albuminuric phenotype, regardless of traditional risk factors.

The progression and regression of metabolic dysfunction-associated fatty liver disease are associated with the development of subclinical atherosclerosis: A prospective analysis

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) has been proposed and diagnosed based on modified criteria. However, evidence for the risks of developing subclinical atherosclerosis with MAFLD transitions according to its new definition has never been reported.

METHODS

Using data from a community-based cohort, 6232 participants aged 40 years or older were included and were followed up for a median of 4.3 years during 2010-2015. Participants were categorized into four groups (stable non-MAFLD, MAFLD regressed to non-MAFLD, non-MAFLD progressed to MAFLD, and stable MAFLD). Subclinical atherosclerosis was defined as elevated carotid intima-media thickness (CIMT), elevated brachial-ankle pulse wave velocity (ba-PWV), or microalbuminuria.

RESULTS

Compared with the stable non-MAFLD category, participants who progressed to MAFLD at follow-up visit had a 1.356-fold increased risk of developing elevated CIMT [odds ratio (OR) = 1.356; 95% confidence interval (CI) = 1.134-1.620], and a 1.458-fold increased risk of incident microalbuminuria (OR = 1.458; 95% CI = 1.034-2.056) after adjustment for confounders, respectively. In addition, participants with stable MAFLD showed 17.6%, 32.4%, and 35.4% increased risks of developing elevated CIMT, elevated ba-PWV and microalbuminuria, respectively. Compared with the stable MAFLD category, participants with MAFLD and low probability of fibrosis at baseline who regressed to non-MAFLD at follow-up visit had a 29.4% decreased risk of developing elevated CIMT (OR = 0.706; 95% CI = 0.507-0.984), a 43.1% decreased risk of developing elevated ba-PWV (OR = 0.569; 95% CI = 0.340-0.950), but was not significantly associated with incident microalbuminuria (OR = 0.709; 95% CI = 0.386-1.301). The decreased risks attributed to MAFLD regression were more evident in participants without diabetes or dyslipidemia, as well as in those with 0-1 metabolic risk abnormalities, respectively.

CONCLUSIONS

MAFLD was significantly associated with higher risks of developing subclinical atherosclerosis. Moreover, the regression of MAFLD might modify the risks of developing subclinical atherosclerosis, especially among those with low probability of fibrosis or less metabolic risk abnormalities. Since 40% of baseline participants with missing data on MAFLD measurement at follow-up were excluded, the conclusions should be speculated with caution.

Albuminuric and non-albuminuric reduced eGFR phenotypes in youth with type 1 diabetes: Factors associated with cardiometabolic risk

BACKGROUND AND AIM

Albuminuria and reduced eGFR are hallmarks of Diabetic Kidney Disease in adults. Our aim was to analyze factors associated with albuminuric and non-albuminuric mildly reduced eGFR phenotypes in youths with type 1 diabetes.

METHODS AND RESULTS

This multicenter cross-sectional study included 1549 youths (age 5-17 years) with type 1 diabetes enrolled at 14 Italian Pediatric Diabetes Centers. Albuminuria, creatinine, glycosylated hemoglobin (HbA1c), lipids, blood pressure (BP), neutrophils (N) and lymphocytes (L) count were analyzed. Uric acid (UA) was available in 848 individuals. Estimated GFR (eGFR) was calculated using bedside Schwartz's equation. The sample was divided in three phenotypes: 1) normoalbuminuria and eGFR ≥90 mL/min/1.73 m² (reference category, n = 1204), 2) albuminuric and normal GFR phenotype (n = 106), 3) non-albuminuric mildly reduced GFR (MRGFR) phenotype (eGFR 60-89 mL/min/1.73 m², n = 239). Albuminuric and non-albuminuric reduced eGFR phenotypes were significantly associated with autoimmune thyroiditis (P =0.028 and P=0.044, respectively). Albuminuric phenotype showed high risk of high HbA1c (P=0.029), high BP (P < 0.001), and low HDL-C (P =0.045) vs reference category. Non-albuminuric MRGFR phenotype showed high risk of high BP (P < 0.0001), low HDL-C (P =0.042), high Triglycerides/HDL-C ratio (P =0.019), and high UA (P < 0.0001) vs reference category.

CONCLUSION

Non albuminuric MRGFR phenotype is more prevalent than albuminuric phenotype and shows a worst cardiometabolic risk (CMR) profile). Both phenotypes are associated with autoimmune thyroiditis. Our data suggest to evaluate both albuminuria and eGFR earlier in type 1 diabetes to timely identify young people with altered CMR profile.

Relationship between diabetic retinopathy microalbuminuria and other modifiable risk factors

BACKGROUND

Diabetic Retinopathy (DR) is an important microvascular complication of diabetes that can lead to irreversible blindness. Microalbuminuria is strongly associated with diabetic retinopathy and can be used as a reliable marker of diabetic retinopathy.

AIM

To assess the association between DR, microalbuminuria, and other modifiable risk factors in patients with type 2 diabetes.

METHODOLOGY

3090 patients with T2DM visiting North Delhi Diabetes Centre, New Delhi between July 2016 to October 2019 were evaluated for the clinical and biochemical parameters that included urinary albumin, HbA1C, lipid profiles, serum creatinine estimation and underwent biothesiometry.

RESULTS

3090 patients (1350 females and 1740 males), with mean age of 52.7 ± 9.2 years and diabetes duration ranging from 1 to 19 years (mean 9.4 ± 6), duration of less than 5 years, 6-10 years and more than 10 years in 52%, 26% and in 22%, respectively. Duration of diabetes was strong predictor of retinopathy (p = 0.001). The HbA1c and BMI in patients with DR was significantly higher than in those without DR. 18.2% patients were diagnosed to have retinopathy. Peripheral neuropathy was observed in 24.2% and was positively associated with DR (p = 0.002). 33.9% and 4.5% patients had microalbuminuria macroalbuminuria, respectively and 9.7% patients had creatinine >1.3 mg/dL. There was significant positive relationship between different grades of retinopathy and albuminuria.

CONCLUSIONS

Our study is a large real-world study that demonstrates that HbA1c, BMI, duration of diabetes, microalbuminuria and peripheral neuropathy are relatively, yet cohesively contributing factors towards varying grade of retinopathy.

Urinary biomarkers as point-of-care tests for predicting progressive deterioration of kidney function in congenital anomalies of kidney and urinary tract: trefoil family factors (TFFs) as the emerging biomarkers

BACKGROUND

Children with congenital anomalies of kidney and urinary tract (CAKUT) are at high risk of progressive deterioration of kidney function and further developing stage 5 chronic kidney disease (CKD 5), even after a successful surgery. This prospective study was designed to determine whether urinary biomarkers can predict progressive deterioration of kidney function in children with CAKUT.

METHODS

The study included 50 consecutive children, aged < 14 years, who were diagnosed with congenital uropathies (PUV, VUR, and PUJO) and 20 age-matched controls. Examination of four urinary biomarkers, i.e., trefoil family factors (TFF) 1 and 3, neutrophil gelatinase-associated lipocalin (NGAL) and microalbuminuria (MALB) was done at the beginning of follow-up. Kidney function was assessed, at the beginning and after 12-months of follow-up, by technetium-99m diethylene triamine pentaacetic acid (DTPA) and technetium-99m dimercaptosuccinic acid (DMSA) scans. Progressive deterioration in the kidney function was defined as a fall in the GFR from ≥ 60 to < 60 ml/min/1.73 m² on comparing the baseline and latest DTPA scans; and/or new-onset cortical scar/scars or increase in the size of previous scar/scars on serial DMSA scans. Group 1 and group 2 included children without and with progressive functional deterioration respectively.

RESULTS

The median (IQR) age of children with CAKUT and controls was 3 (1.5-5) and 2.3 (1.2-3.6) years, respectively, and showed no significant difference (p = 0.29). Median concentrations of TFF1, TFF3, NGAL, and microalbumin in patients were 44.5, 176.5, 281.2, and 15.5 mcg/gCr, respectively, and were significantly elevated as compared to controls (p < 0.05). Children belonging to group 2 had significantly higher concentration of biomarkers as compared to those in group 1. TFF3 was found have the highest AUC (0.9198) on ROC curve for predicting progressive functional deterioration.

CONCLUSION

Urinary TFFs, NGAL, and microalbumin significantly correlate with progressive deterioration of kidney function in children harboring CAKUT. TFF3, with the strongest prediction of functional deterioration, is an emerging peptide showing sufficient potential to be included in the biomarker panel. Graphical abstract.

Nailfold capillary changes in newly diagnosed hypertensive patients: An observational analytical study

INTRODUCTION

Nail Fold capillaroscopy (NFC) is used to evaluate microvascular changes in the horizontally lying capillaries in the proximal nail fold. Arterial hypertension affects the microvascular beds producing structural changes. Our objective was to evaluate qualitative and quantitative NFC changes in newly diagnosed hypertensives as compared to age and sex matched normotensive controls and to determine association, if any, with microvascular changes visualized on fundoscopy.

MATERIALS AND METHODS

This observational, analytical study involved 41 newly diagnosed hypertensives (18-60 years) with 41 normotensive age and sex matched normotensive controls. The mean capillary density (MCD) and morphological changes were assessed for all, while fundoscopy was done for study group participants. The collected data was statistically analyzed.

RESULTS

The MCD in newly diagnosed hypertensives (5.21 ± 0.90 capillaries/mm) was significantly lower than normotensive controls (6.50 ± 0.65 capillaries/mm) (p < 0.001) in our study. Qualitative morphologic changes were more common in hypertensive patients including meandering capillaries, capillary dilation, avascular areas, bushy capillaries, and microhemorrhages (p value <0.001). Capillary disarray (73.17%) was a unique morphologic change seen significantly more commonly in study group (p < 0.001). Among hypertensives, MCD was lesser in patients with retinopathy (p = 0.125) and with microalbuminuria, while avascular areas and dilated capillaries were significantly more common.

CONCLUSION

Our study supports the role of NFC with USB dermatoscope in detecting unique microvascular morphological alterations in hypertensives, which were more frequent as well as distinctive, as compared to healthy controls. A good correlation with fundoscopic features and microalbuminuria suggests that it could be useful in predicting/detecting cardiovascular, or renal complications early, with an advantage of easy accessibility and repeatability.

Effects of Highly Active Antiretroviral Therapy on Albuminuria in HIVinfected Persons

BACKGROUND

Highly active antiretroviral therapy (HAART), especially tenofovir DFcontaining regimens, has been implicated in albuminuria.

OBJECTIVE

We prospectively evaluated the effects of HAART on albumin-to-creatinine ratios (ACRs) in antiretroviral-naïve HIV-infected individuals.

METHODS

One hundred and two (102) newly diagnosed, antiretroviral-naïve, human immunodeficiency virus (HIV)-infected persons were treated with Tenofovir disoproxil fumarate/ Emtricitabine/Efavirenz (TDF/FTC/EFV), n=33; Zidovudine/Lamivudine/Nevirapine (ZDV/3TC/NVP), n=53; and Zidovudine/Lamivudine/Efavirenz (ZDV/3TC/EFV), n=16. Diabetes mellitus and hypertension were excluded. ACRs and glomerular filtration rates (eGFR) were estimated at baseline, and at 1, 3, 6 and 9 months post-therapy; the prevalence of albuminuria (ACR ≥ 300mg/g), and microalbuminuria (ACR 30-300mg/g) were similarly estimated. HAART effects on normal ACR (0-30mg/g) were also monitored.

RESULTS

At baseline, one patient (0.9%) had nephrotic-range albuminuria with ACR of 2450mg/g. Overall, 8 (7.8%) patients had albuminuria; 53 (51.9%) had microalbuminuria; while 41 (40.2%) had normal ACRs, 28 (27.5% of 102) of which had nonalbuminuric renal insufficiency. eGFR and ACRs improved concurrently on HAART (ACR, Wilks' lambda 0.439, power 0.763, p=0.032); albuminuria improved significantly on all the 3 regimens at 9 months (p=0.006, 0.012 and <0.001 respectively). Microalbuminuria resolved earlier (1 month) with ZDV/3TC/NVP than with TDF/FTC/EFV and ZDV/3TC/EFV (24.31mg/g versus 76.51mg/g and 63.59mg/g; p=0.028, 0.016 respectively). Microalbuminuria relapsed on TDF/FTC/EFV and ZDV/3TC/EFV at 6 months but resolved again at 9 months (66.7 versus 29 mg/g, p=0.006; and 51.2 versus 9.5mg/g, p=0.001 respectively); no relapse on ZDV/3TC/NVP. At 9 months, ZDV/3TC/EFV caused the greatest resolution of microalbuminuria (85.7% decline in ACR from baseline) compared with ZDV/3TC/NVP (72.5% decline) and TDF/FTC/EFV (63.9% decline). In multivariate analyses, predictors of ACR include older age (Odds ratio OR 2.8, p= 0.025); female gender (OR, 3.4, p =0.014); CD4+ (OR 0.99, p=0.002).

CONCLUSION

HIV induces renal impairment. Thus, albuminuria, microalbuminuria and nonalbuminuric renal insufficiency are highly prevalent in antiretroviral-naïve HIV-infected persons but nephrotic-range albuminuria is uncommon. Albuminuria and/microalbuminuria and eGFR improve concurrently on HAART (with/without tenofovir DF). Zidovudine-based HAART (ZDV/3TC/NVP) resolves microalbuminuria earlier, and without relapse, unlike Tenovofir-based regimen and zidovudine with efavirenz (ZDV/3TC/EFV).

Relations Between Urinary Albumin Excretion and a Dietary Intake of Fruits in Patients With Type 2 Diabetes

Background

It was reported that microalbuminuria and a decline in renal function were associated with cardiovascular disease (CVD) mortality and renal events and prognostic serious complications. Dietary factors and nutrients affecting microalbuminuria in type 2 diabetes remain unclear, and accordingly we conducted a cross-sectional study on the possible relevance of dietary factors to urinary albumin excretion in patients with type 2 diabetes.

Methods

Forty-two patients with type 2 diabetes participated in this study, and these subjects were categorized into patients without microalbuminuria group with urine albumin-to-creatinine ratio (ACR) of less than 30 mg/g Cr (n = 29) and a microalbuminuria group with ACR of 30 - 299 mg/g Cr (n = 13). ACR levels were measured using spot urine samples. At the time of examination, body mass index (BMI) and systolic and diastolic blood pressures were measured and recorded. We performed sampling fasting-blood and spot urine and conducted a food frequency questionnaire based on food groups to examine dietary habits for the past 1 - 2 months.

Results

There were no significant differences in sex, age, duration, BMI, blood pressures, biochemical data, and the median of daily intakes of energy and macronutrients between patients without microalbuminuria and microalbuminuria groups. In the intake of 17 food groups per day, fruits were significantly lower in the microalbuminuria group than in patients without microalbuminuria group (the median was 38 g vs. 120 g/day, P < 0.05), but intakes of other food groups were not significantly different between the two groups. Moreover, we examined a model of partial correlation between ACR to the intake of fruits, adjusted by age, sex, glycated hemoglobin and BMI. This partial correlation was insignificantly seen but close to a significant level (partial correlation coefficient: -0.270, P = 0.102).

Conclusions

These results suggest that the intake of fruits may be inversely associated with microalbuminuria in Japanese type 2 diabetic patients. It would be necessary to investigate the exact types and amounts of fruits to be consumed to address microalbuminuria.

Effect of Bariatric Surgery on Diagnosed Chronic Kidney Disease and Cardiovascular Events in Patients with Insulin-treated Type 2 Diabetes: a Retrospective Cohort Study from a Large UK Primary Care Database

Aims

To compare the effect of bariatric surgery on renal, chronic kidney disease (CKD) and cardiovascular (CV) outcomes among obese patients with insulin-treated type 2 diabetes (T2D) with and without microalbuminuria (i.e., uACR > 3.0 mg/mmol).

Methods

A retrospective cohort study was conducted among 11,125 active patients with T2D from The Health Improvement Network (THIN) database. Propensity score matching (up to 1:6 ratio) was used to identify patients who underwent bariatric surgery (N = 131) with a non-bariatric cohort (N = 579). Follow-up was undertaken for 10 years (6487 person-years) to compare differences in risk of cardiovascular events and in renal outcomes.

Results

For the matched cohort at baseline: mean age 52 ± 13 years (60% female); weight 116 ± 25 kg, body mass index (BMI) 41 ± 9kg/m², estimated glomerular filtration rate (eGFR); 70.4 ± 20 mL/min/1.73 m², and median albumin-creatinine ratio (uACR) 2.0 mg/mmol (interquartile range (IQR): 0.9–5.2 mg/mmol). Bariatric surgery was associated with a 54% reduction in developing CKD compared to their matched non-bariatric cohort (adjusted hazard ratio [aHR]: 0.46; 95%CI: 0.24–0.85, P = 0.02). Among patients with microalbuminuria at baseline, bariatric surgery was protective against CKD (aHR: 0.42, 95%CI: 0.18–0.99, P = 0.050). eGFR was significantly increased from baseline favouring the bariatric group during 75% of the follow-up time (calculated mean difference between groups: 4.1 mL/min/1.73 m²; P < 0.05), especially at 5-year point (74.2 vs 67.8 mL/min/1.73 m²; P < 0.001). However, no significant change was observed with non-fatal CVD episodes (aHR: 0.36, 95%CI: 0.11–1.13, P = 0.079). Albumin levels were significantly reduced throughout the 2 years following the surgery (3.9 vs 4.1 g/dL, P < 0.001). uACR and total protein levels had little or no statistical association to the intervention.

Conclusion

Bariatric surgery may protect patients with diabetes with or without microalbuminuria against the risk of CKD and with a modest protective effect on non-fatal CVD risk. Bariatric surgery is also associated with improvements in overall renal outcomes such as eGFR.

Early detection of neuropathy in patients with type 2 diabetes with or without microalbuminuria in the absence of peripheral neuropathy and retinopathy

PURPOSE

Our goal is early detection of neuropathy in patients with type 2 diabetes with or without microalbuminuria in the absence of diabetic retinopathy and peripheral neuropathy by using in vivo corneal confocal microscopy (IVCCM).

METHODS

A total of 60 type-2 diabetic patients, assigned to either a diabetes mellitus (DM) with microalbuminuria group (DM/MA+, n=30) or a DM without microalbuminuria group (DM/MA-, n=30), and 30 age-matched control subjects were enrolled in this study. All cases underwent evaluation of blood glucose level, HbA_1c, lipid fractions, body mass index (BMI), and corneal sensitivity (CS). Corneal nerve fiber length (NFL), nerve fiber density (NFD), nerve branch density (NBD), and tortuosity coefficient (TC) were quantified by IVCCM. None of the patients had peripheral neuropathy or retinopathy.

RESULTS

Compared with the healthy subjects, NFL and NFD were reduced in both diabetic groups (P<0.0001), while NBD was significantly reduced in the DM/MA+ group. Between the diabetic groups, NFL, NFD, and NBD were significantly higher in the DM/MA- group (all P's<0.001). CS was significantly lower in DM/MA+ compared with DM/MA- and controls (both P's<0.0001). NFD and NFL were inversely correlated with age, triglyceride level, and BMI.

CONCLUSION

These results indicate that significant damage to small nerves, quantified using IVCCM, can be detected in the absence of retinopathy, peripheral neuropathy or microalbuminuria in type 2 diabetic patients. The severity of corneal nerve involvement may further increase in the presence of nephropathy. This feature may also be valuable for early detection of microvascular complications of DM, allowing for the prevention of progression of life threatening microvascular complications.

Short term cardiovascular risk in normotensive women after hypertensive pregnancy

INTRODUCTION

Hypertensive pregnancy was recognized as a risk factor of cardiovascular events. The aim of our study was to evaluate the short-term cardiovascular risk in normotensive females with previous hypertensive pregnancy.

MATERIAL AND METHODS

A prospective cohort study was conducted on 50 females with previous normotensive pregnancy and 50 females with previous hypertensive pregnancy. All patients were re-evaluated three months postpartum to be sure that they became normotensive. One year postpartum, all patients were subjected to renal function tests, urinary albumin/creatinine ratio for microalbuminuria, glycated hemoglobin, complete lipid profile, echocardiographic assessment of left ventricular mass index and carotid duplex for measurement of intimal-medial thickness, presence of carotid plaques and stenosis.

RESULTS

No significant difference between both groups regarding blood pressure level three months postpartum. No significant difference between both groups regarding serum creatinine. Patients with previous hypertensive pregnancy group had significantly higher microalbuminuria compared with previous normotensive pregnancy group (p=0.000). Serum LDL and triglycerides were significantly higher however HDL was significantly lower in those with previous hypertensive pregnancy, however all lipid profile measures were within normal range. No significant difference between both groups regarding left ventricular mass index and carotid intima-media thickness. No evidence of carotid plaques or stenosis in both groups.

CONCLUSIONS

Previous hypertensive pregnancy was associated with increased risk of microalbuminuria at short term level even after normalization of blood pressure post-partum. Longer period of follow up is required to establish the potential cardiovascular risk in these patients.