Extracellular matrix turnover proteins as risk markers in people with type 2 diabetes and microalbuminuria

BACKGROUND

This post-hoc study investigated whether biomarkers reflecting extracellular matrix (ECM) turnover predicted cardiovascular disease (CVD), mortality, and progression of diabetic kidney disease (DKD) in individuals with type 2 diabetes (T2D) and microalbuminuria.

METHODS

Serum levels of specific ECM turnover biomarkers were assessed in 192 participants with T2D and microalbuminuria from an observational study conducted at Steno Diabetes Center Copenhagen from 2007 to 2008. Endpoints included CVD events, mortality, and DKD progression, defined as decline in estimated glomerular filtration rate (eGFR) of >30 %.

RESULTS

Participants had a mean age of 59 years, with 75 % males. Over a median follow-up of 4.9 to 6.3 years, the study recorded 38 CVD events, 24 deaths, and 40 DKD events. Elevated levels of a degradation fragment of collagen type I (C1M) were associated with an increased risk of >30 % eGFR decline, although this association was not independent of other risk factors. No significant associations were found between other ECM turnover biomarkers and DKD progression, mortality, or CVD risk.

CONCLUSION

Elevated C1M levels were linked to DKD progression in individuals with T2D and microalbuminuria, but not independently of other risk factors. None of the ECM turnover biomarkers were associated with CVD or mortality.

Efficacy of 1-hour postload plasma glucose as a suitable measurement in predicting type 2 diabetes and diabetes-related complications: A post hoc analysis of the 30-year follow-up of the Da Qing IGT and Diabetes Study

AIM

To evaluate whether 1-hour plasma glucose (1hPG) can be a comparable measurement to 2-hour plasma glucose (2hPG) in identifying individuals at high risk of developing diabetes.

METHODS

A total of 1026 non-diabetic subjects in the Da Qing IGT and Diabetes Study were included and classified according to baseline postload 1hPG. The participants were followed up and assessed at 6-, 20- and 30year follow-up for outcomes including diabetes, all-cause and cardiovascular mortality, cardiovascular disease (CVD) events, and microvascular disease. We then conducted a proportional hazards analysis in this post hoc study to determine the risks of developing type 2 diabetes and its complications in a '1hPG-normal' group (1hPG <8.6 mmol/L) and a '1hPG-high' group (≥8.6 mmol/L). The predictive values of 1hPG and 2hPG were evaluated using a time-dependent receiver-operating characteristic (ROC) curve.

RESULTS

Compared with the 1hPG-normal group, the 1hPG-high group had increased risk of diabetes (hazard ratio [HR] 4.45, 95% CI 3.43-5.79), all-cause mortality (HR 1.46, 95% CI 1.07-2.01), CVD mortality (HR 1.84, 95% CI 1.16-2.95), CVD events (HR 1.39, 95% CI 1.03-1.86) and microvascular disease (HR 1.70, 95% CI: 1.03-2.79) after adjusting for confounders. 1hPG exhibited a higher area under the ROC curve (AUC) for predicting diabetes than 2hPG during the long-term follow-up (AUC [1hPG vs. 2hPG]: 10 years: 0.86 vs. 0.84, p = 0.08; 20 years: 0.88 vs. 0.87, p = 0.04; 30 years: 0.85 vs. 0.82, p = 0.009).

CONCLUSIONS

Elevated 1hPG level (≥8.6 mmol/L) was associated with increased risk of developing type 2 diabetes and its long-term complications, and could be considered as a suitable measurement for identifying individuals at high risk of type 2 diabetes.

Association of the systemic immuno-inflammation index, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio with diabetic microvascular complications

Background

The systemic immuno-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) are widely used and have been shown to be predictive indicators of various diseases. Diabetic nephropathy (DN), retinopathy (DR), and peripheral neuropathy (DPN) are the most prominent and common microvascular complications, which have seriously negative impacts on patients, families, and society. Exploring the associations with these three indicators and diabetic microvascular complications are the main purpose.

Methods

There were 1058 individuals with type 2 diabetes mellitus (T2DM) in this retrospective cross-sectional study. SII, NLR, and PLR were calculated. The diseases were diagnosed by endocrinologists. Logistic regression and subgroup analysis were applied to evaluate the association between SII, NLP, and PLR and diabetic microvascular complications.

Results

SII, NLR, and PLR were significantly associated with the risk of DN [odds ratios (ORs): 1.52, 1.71, and 1.60, respectively] and DR [ORs: 1.57, 1.79, and 1.55, respectively] by multivariate logistic regression. When NLR ≥2.66, the OR was significantly higher for the risk of DPN (OR: 1.985, 95% confidence interval: 1.29-3.05). Subgroup analysis showed no significant positive associations across different demographics and comorbidities, including sex, age, hypertension, HbA1c (glycated hemoglobin), and dyslipidemia.

Conclusion

This study found a positive relationship between NLR and DN, DR, and DPN. In contrast, SII and PLR were found to be only associated with DN and DR. Therefore, for the diagnosis of diabetic microvascular complications, SII, NLR and PLR are highly valuable.

Downregulation of Erythrocyte miR-210 Induces Endothelial Dysfunction in Type 2 Diabetes

Red blood cells (RBC) act as mediators of vascular injury in type 2 diabetes mellitus (T2DM). miR-210 plays a protective role in cardiovascular homeostasis and is decreased in whole blood of T2DM mice. We hypothesized that downregulation of RBC miR-210 induces endothelial dysfunction in T2DM. RBC were coincubated with arteries and endothelial cells ex vivo and transfused in vivo to identify the role of miR-210 and its target protein tyrosine phosphatase 1B (PTP1B) in endothelial dysfunction. RBC from patients with T2DM and diabetic rodents induced endothelial dysfunction ex vivo and in vivo. miR-210 levels were lower in human RBC from patients with T2DM (T2DM RBC) than in RBC from healthy subjects. Transfection of miR-210 in human T2DM RBC rescued endothelial function, whereas miR-210 inhibition in healthy subjects RBC or RBC from miR-210 knockout mice impaired endothelial function. Human T2DM RBC decreased miR-210 expression in endothelial cells. miR-210 expression in carotid artery plaques was lower in T2DM patients than in patients without diabetes. Endothelial dysfunction induced by downregulated RBC miR-210 involved PTP1B and reactive oxygen species. miR-210 mimic attenuated endothelial dysfunction induced by RBC via downregulating vascular PTP1B and oxidative stress in diabetic mice in vivo. These data reveal that the downregulation of RBC miR-210 is a novel mechanism driving the development of endothelial dysfunction in T2DM.

Fetuin-A and risk of diabetes-related vascular complications: a prospective study

BACKGROUND

Fetuin-A is a hepatokine which has the capacity to prevent vascular calcification. Moreover, it is linked to the induction of metabolic dysfunction, insulin resistance and associated with increased risk of diabetes. It has not been clarified whether fetuin-A associates with risk of vascular, specifically microvascular, complications in patients with diabetes. We aimed to investigate whether pre-diagnostic plasma fetuin-A is associated with risk of complications once diabetes develops.

METHODS

Participants with incident type 2 diabetes and free of micro- and macrovascular disease from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam cohort (n = 587) were followed for microvascular and macrovascular complications (n = 203 and n = 60, respectively, median follow-up: 13 years). Plasma fetuin-A was measured approximately 4 years prior to diabetes diagnosis. Prospective associations between baseline fetuin-A and risk of complications were assessed with Cox regression.

RESULTS

In multivariable models, fetuin-A was linearly inversely associated with incident total and microvascular complications, hazard ratio (HR, 95% CI) per standard deviation (SD) increase: 0.86 (0.74; 0.99) for total, 0.84 (0.71; 0.98) for microvascular and 0.92 (0.68; 1.24) for macrovascular complications. After additional adjustment for cardiometabolic plasma biomarkers, including triglycerides and high-density lipoprotein, the associations were slightly attenuated: 0.88 (0.75; 1.02) for total, 0.85 (0.72; 1.01) for microvascular and 0.95 (0.67; 1.34) for macrovascular complications. No interaction by sex could be observed (p > 0.10 for all endpoints).

CONCLUSIONS

Our data show that lower plasma fetuin-A levels measured prior to the diagnosis of diabetes may be etiologically implicated in the development of diabetes-associated microvascular disease.

Relationship of musculoskeletal diseases with microvascular and macrovascular complications in patients with diabetes in Iran

BACKGROUND AND AIMS

Musculoskeletal manifestations (carpal tunnel syndrome, Dupuytren's contracture, etc.) may occur in poorly controlled and longstanding diabetes. In this study, we evaluated the relationship of musculoskeletal diseases with microvascular and macrovascular complicationsin patients with diabetes.

METHODS

A total of 600 patients with diabetes were enrolled in this cross-sectional study. Demographic data and historical records of the patients were retrieved. Musculoskeletal diseases were assessed by clinical examinations and then confirmed by a rheumatologist.

RESULTS

Out of the 600 patients with diabetes, 61.5% (369/600) were female and 38.5% (231/600) were male. Diabetic retinopathy, diabetic nephropathy, diabetic peripheral neuropathy, CVA, and diabetes related ischemic heart disease were rated as 43.1%, 33.2%, 7.8%, 7.5%, and 39.6%, respectively. Significant gender differences were observed in the rates of diabetic nephropathy [56.28% for women and 43.71% for men (p value < 0.000)], diabetic peripheral neuropathy [72.34% for women and 27.65% for men (p value < 0.002)], and ischemic heart disease [57.98% for women and 42.01% for men(p value < 0.001)].

CONCLUSION

Musculoskeletal diseases usually occur in patients with poorly controlled and long-term diabetes. Due to the clear association of microvascular complications with musculoskeletal disease, more attention should be paid to the early detection of these complications in patients with diabetes.

Nicotinamide Adenine Dinucleotide Phosphate Oxidases in Glucose Homeostasis and Diabetes-Related Endothelial Cell Dysfunction

Oxidative stress within the vascular endothelium, due to excess generation of reactive oxygen species (ROS), is thought to be fundamental to the initiation and progression of the cardiovascular complications of type 2 diabetes mellitus. The term ROS encompasses a variety of chemical species including superoxide anion (O₂^•-), hydroxyl radical (OH^-) and hydrogen peroxide (H₂O₂). While constitutive generation of low concentrations of ROS are indispensable for normal cellular function, excess O₂^•- can result in irreversible tissue damage. Excess ROS generation is catalysed by xanthine oxidase, uncoupled nitric oxide synthases, the mitochondrial electron transport chain and the nicotinamide adenine dinucleotide phosphate (NADPH) oxidases. Amongst enzymatic sources of O₂^•- the Nox2 isoform of NADPH oxidase is thought to be critical to the oxidative stress found in type 2 diabetes mellitus. In contrast, the transcriptionally regulated Nox4 isoform, which generates H₂O₂, may fulfil a protective role and contribute to normal glucose homeostasis. This review describes the key roles of Nox2 and Nox4, as well as Nox1 and Nox5, in glucose homeostasis, endothelial function and oxidative stress, with a key focus on how they are regulated in health, and dysregulated in type 2 diabetes mellitus.

Deteriorated regional calf microcirculation measured by contrast-free MRI in patients with diabetes mellitus and relation with physical activity

OBJECTIVE

To evaluate regional calf muscle microcirculation in people with diabetes mellitus (DM) with and without foot ulcers, compared to healthy control people without DM, using contrast-free magnetic resonance imaging methods.

METHODS

Three groups of subjects were recruited: non-DM controls, DM, and DM with foot ulcers (DM + ulcer), all with ankle brachial index (ABI) > 0.9. Skeletal muscle blood flow (SMBF) and oxygen extraction fraction (SMOEF) in calf muscle were measured at rest and during a 5-min isometric ankle plantarflexion exercise. Subjects completed the Yale physical activity survey.

RESULTS

The exercise SMBF (ml/min/100 g) of the medial gastrocnemius muscle were progressively impaired: 63.7 ± 18.9 for controls, 42.9 ± 6.7 for DM, and 36.2 ± 6.2 for DM + ulcer, p < 0.001. Corresponding exercise SMOEF was the lowest in DM + ulcers (0.48 ± 0.09). Exercise SMBF in the soleus muscle was correlated moderately with the Yale physical activity survey (r = 0.39, p < 0.01).

CONCLUSIONS

Contrast-free MR imaging identified progressively impaired regional microcirculation in medial gastrocnemius muscles of people with DM with and without foot ulcers. Exercise SMBF in the medial gastrocnemius muscle was the most sensitive index and was associated with HbA1c. Lower exercise SMBF in the soleus muscle was associated with lower Yale score.

Elevated HDL-bound miR-181c-5p level is associated with diabetic vascular complications in Australian Aboriginal people

AIMS/HYPOTHESIS

Diabetes is a major burden on Australia's Indigenous population, with high rates of disease and vascular complications. Diabetic vascular complications are associated with impaired ischaemia-driven angiogenesis. MicroRNAs (miRNAs) are key players in the regulation of angiogenesis. HDL-cholesterol (HDL-c) levels are inversely associated with the risk of developing diabetic complications and HDL can carry miRNAs. HDL-miRNA profiles differ in disease states and may present as biomarkers with the capacity to act as bioactive signalling molecules. Recent studies have demonstrated that HDL becomes dysfunctional in a diabetic environment, losing its vasculo-protective effects and becoming more pro-atherogenic. We sought to determine whether HDL-associated miRNA profiles and HDL functionality were predictive of the severity of diabetic vascular complications in Australia's Indigenous population.

METHODS

HDL was isolated from plasma samples from Indigenous participants without diabetes ('Healthy'), with type 2 diabetes mellitus ('T2DM') and with diabetes-associated macrovascular complications (specifically peripheral artery disease, 'T2DM+Comp'). To assess HDL angiogenic capacity, human coronary artery endothelial cells were treated with PBS, reconstituted HDL (rHDL, positive control) or isolated HDL and then exposed to high-glucose (25 mmol/l) conditions. The expression levels of two anti-angiogenic miRNAs (miR-181c-5p and miR-223-3p) and one pro-angiogenic miRNA (miR-27b-3p) were measured in the HDL fraction, plasma and treated human coronary artery endothelial cells by quantitative real-time PCR. In vitro endothelial tubule formation was assessed using the Matrigel tubulogenesis assay.

RESULTS

Strikingly, we found that the levels of the anti-angiogenic miRNA miR-181c-5p were 14-fold higher (1454 ± 1346%) in the HDL from Aboriginal people with diabetic complications compared with both the Healthy (100 ± 121%, p < 0.05) and T2DM (82 ± 77%, p < 0.05) groups. Interestingly, we observed a positive correlation between HDL-associated miR-181c-5p levels and disease severity (p = 0.0020). Under high-glucose conditions, cells treated with rHDL, Healthy HDL and T2DM HDL had increased numbers of tubules (rHDL: 136 ± 8%, p < 0.01; Healthy HDL: 128 ± 6%, p < 0.01; T2DM HDL: 124 ± 5%, p < 0.05) and branch points (rHDL: 138 ± 8%, p < 0.001; Healthy HDL: 128 ± 6%, p < 0.01; T2DM HDL: 127 ± 5%, p < 0.01) concomitant with elevations in mRNA levels of the key hypoxia angiogenic transcription factor HIF1A (rHDL: 140 ± 10%, p < 0.01; Healthy HDL: 136 ± 8%, p < 0.01; T2DM HDL: 133 ± 9%, p < 0.05). However, this increase in angiogenic capacity was not observed in cells treated with T2DM + Comp HDL (tubule numbers: 113 ± 6%, p = 0.32; branch points: 113 ± 5%, p = 0.28; HIF1A: 117 ± 6%, p = 0.43), which could be attributed to the increase in cellular miR-181c-5p levels (T2DM + Comp HDL: 136 ± 7% vs PBS: 100 ± 9%, p < 0.05).

CONCLUSIONS/INTERPRETATION

In conclusion, HDL from Aboriginal people with diabetic complications had reduced angiogenic capacity. This impairment is associated with an increase in the expression of anti-angiogenic miR-181c-5p. These findings provide the rationale for a new way to better inform clinical diagnosis of disease severity with the potential to incorporate targeted, personalised HDL-miRNA intervention therapies to prevent further development of, or to reverse, diabetic vascular complications in Australian Aboriginal people.

Association between fasting blood glucose and intracranial cerebral artery stenosis: a secondary analysis based on a retrospective cross-sectional study in Korean adults

AIMS

Diabetes mellitus (DM) is one of the main risk factors for intracranial cerebral artery stenosis (ICAS), and fasting blood glucose (FBG) might be an effective predictor of ICAS. However, there are a few studies revealing the relationship between FBG and ICAS. We aim to identify the association between FBG and ICAS in Koreans.

METHODS

This was a secondary study based on a cross-sectional study. A total of 1011 Korean individuals who were asymptomatic but with high cerebrovascular risk underwent an examination in a Korean medical centre from March 2008 to December 2014. The main measure was FBG, while the main outcome was ICAS. Multivariate logistic regression analyses of FBG in the presence of ICAS were performed to examine the potential association. The author used the data provided by the paper "Association between Serum Alkaline Phosphatase Level and Cerebral Small Vessel Disease" for secondary analysis.

RESULTS

The average age of the participants was 64.2 ± 9.1 years old, and approximately 35% of them were males. There were 24 participants suffering from ICAS in the first FBG tertile (< 5.4 mmol/L), while there were 26 in the second tertile (5.4-7.1 mmol/L) and 50 in the third tertile (≥ 7.1 mmol/L). The non-adjusted relationship between FBG and ICAS was positive. After controlling potential confounders, the association of FPG with ICAS remained positive, as well as in subgroups analysis, such as age, sex, hypertension, diabetes mellitus, hyperlipidaemia and COAD. The association remained unchanged after adjusted sex, age, hypertension, DM, uric acid, hyperlipidaemia, and CAOD (OR = 1.08, 95% CI = 1.02-1.15). The analyses also showed that the positive association was statistically significant (P < 0.05) among individuals without diabetes.

CONCLUSIONS

This study showed a positive relationship between FBG and ICAS, which suggests that clinicians may need to be simultaneously concerned about FBG and ICAS.

Low-density lipoprotein cholesterol-to-apolipoprotein B ratio as a potential indicator of LDL particle size and plasma atherogenicity in type 2 diabetes

AIMS

Atherogenic dyslipidemia, associated with small, dense low-density lipoprotein-cholesterol (S-LDL) particles and impaired metabolism of triglycerides (TGs) and high-density lipoprotein-cholesterol (HDL-c), leads to the development of atherosclerosis-related complications of type 2 diabetes mellitus. Based on the hypothesis that an LDL-c-to-apolipoprotein B ratio (LDL/ApoB) < 1.2 may predict the prevalence of S-LDL, this study aimed to evaluate the LDL/ApoB ratio in patients with type 2 diabetes with moderately elevated TG levels.

METHODS

The study population consisted of 121 outpatients with type 2 diabetes (S-LDL group, LDL/ApoB < 1.2, n = 79; L-LDL group, LDL/ApoB > 1.2, n = 42) and 58 healthy subjects. The LDL/ApoB ratio was calculated from the measured LDL-c and ApoB levels in participants with TG levels lower than 4.5 mmol/L. Since TGs and HDL-c are included in the atherogenic index of plasma (AIP), we evaluated the relationship between LDL/ApoB and the AIP.

RESULTS

Higher levels of AIP, TG (both P < 0.0001), and lipid hydroperoxides (LOOH) (P < 0.001) and lower levels of HDL-c, total cholesterol, and non-HDL-c (P < 0.001, <0.01, <0.05, respectively) were found in the S-LDL group compared to the L-LDL group. There were significant relationships between the LDL/ApoB ratio and the AIP, TG (both P < 0.0001), LOOH (P < 0.0005), and HDL-c levels (P < 0.05) in the S-LDL group.

CONCLUSIONS

The prevalence of S-LDL particles (65%) and the close association of LDL/ApoB with the AIP suggest that this ratio may be a potential indicator of increased cardiovascular risk in patients with type 2 diabetes.

Cardiovascular risk assessment by coronary artery calcium score in subjects with maturity-onset diabetes of the young caused by glucokinase mutations

AIMS

Maturity-Onset Diabetes of the Young (MODY) caused by glucokinase (GCK) mutations is characterized by lifelong mild non-progressive hyperglycemia, with low frequency of coronary artery disease (CAD) compared to other types of diabetes. The aim of this study is to estimate cardiovascular risk by coronary artery calcification (CAC) score in this group.

MATERIALS AND METHODS

Twenty-nine GCK-MODY cases, 26 normoglycemic controls (recruited among non-affected relatives/spouses of GCK mutation carriers), and 24 unrelated individuals with type 2 diabetes were studied. Patients underwent CAC score evaluation by computed tomography and were classified by Agatston score ≥ or < 10. Framingham Risk scores of CAD in 10 years were calculated.

RESULTS

Median [interquartile range] CAC score in GCK-MODY was 0 [0,0], similar to controls (0 [0,0], P = 0.49), but lower than type 2 diabetes (39 [0, 126], P = 2.6 × 10^-5). A CAC score ≥ 10 was seen in 6.9% of the GCK group, 7.7% of Controls (P = 1.0), and 54.2% of individuals with type 2 diabetes (P = 0.0006). Median Framingham risk score was lower in GCK than type 2 diabetes (3% vs. 13%, P = 4 × 10^-6), but similar to controls (3% vs. 4%, P = 0.66).

CONCLUSIONS

CAC score in GCK-MODY is similar to control individuals from the same family and/or household and is significantly lower than type 2 diabetes. Besides demonstrating low risk of CAD in GCK-MODY, these findings may contribute to understanding the specific effect of hyperglycemia in CAD.

Diabetes management during cardiac surgery in the UK: A survey

AIM

To determine current practice regarding the diabetes management of people undergoing cardiac surgery in the UK.

METHODS

We conducted an online survey of UK cardiothoracic surgeons. All cardiothoracic surgeons listed in the Society of Cardiothoracic Surgery membership directory were invited to participate. The survey, compiled using SurveyMonkey software, comprised 15 closed and open-ended questions about the management of people with diabetes pre- and peri-operatively.

RESULTS

Sixty-two cardiothoracic surgeons from all 33 UK cardiac centres completed the survey. Of these, 44% responded that they routinely measure HbA_1c preoperatively for all patients, 19% had an HbA_1c threshold above which they would not operate and 21% currently undertake a point-of-care HbA_1c measurement during the cardiothoracic outpatient visit. A total of 74% of respondents reported that it was 'easy' or 'very easy' to obtain a diabetes team review; diabetes nurse specialists were the members of the diabetes team working most closely with cardiac surgeons. Up to a third of the surgeons did not provide physical activity recommendations prior to admission and over 80% did not have a different preoperative or surgical diabetes protocol. Inconsistency in the responses within centres suggests that differences in practice may depend on individual surgeons rather than local policy.

CONCLUSIONS

The study demonstrates there is only limited peri-operative management of diabetes in people undergoing cardiac surgery in the UK. There is an opportunity for greater involvement of the diabetes specialist team both before and during admission for surgery to improve outcomes. (Trial registration: ISRCTN10170306).

Fasting Glucose Variation Predicts Microvascular Risk in ACCORD and VADT

AIMS

The association of glycemic variability with microvascular disease complications in type 2 diabetes (T2D) has been under-studied and remains unclear. We investigated this relationship using both Action to Control Cardiovascular Risk in Diabetes (ACCORD) and the Veteran Affairs Diabetes Trial (VADT).

METHODS

In ACCORD, fasting plasma glucose (FPG) was measured 1 to 3 times/year for up to 84 months in 10 251 individuals. In the VADT, FPG was measured every 3 months for up to 87 months in 1791 individuals. Variability measures included coefficient of variation (CV) and average real variability (ARV) for fasting glucose. The primary composite outcome was time to either severe nephropathy or retinopathy event and secondary outcomes included each outcome individually. To assess the association, we considered variability measures as time-dependent covariates in Cox proportional hazard models. We conducted a meta-analysis across the 2 trials to estimate the risk of fasting glucose variability as well as to assess the heterogenous effects of FPG variability across treatment arms.

RESULTS

In both ACCORD and the VADT, the CV and ARV of FPG were associated with development of future microvascular outcomes even after adjusting for other risk factors, including measures of average glycemic control (ie, cumulative average of HbA1c). Meta-analyses of these 2 trials confirmed these findings and indicated FPG variation may be more harmful in those with less intensive glucose control.

CONCLUSIONS

This post hoc analysis indicates that variability of FPG plays a role in, and/or is an independent and readily available marker of, development of microvascular complications in T2D.

Diagnosing type 2 diabetes using Hemoglobin A1c: a systematic review and meta-analysis of the diagnostic cutpoint based on microvascular complications

AIMS

Diabetic microvascular complications of retinopathy, nephropathy and neuropathy may occur at hemoglobin A1c levels (HbA1c) below the 6.5% (48 mmol/mol) diagnostic threshold. Our objective was to assess the validity of the HbA1c diagnostic cutpoint of 6.5% based upon published evidence of the prevalence of retinopathy, nephropathy and neuropathy as markers of diabetes.

METHODS

Data Sources PubMed, Embase, Cochrane, Scopus and CINAHL from 1990-March 2019, grey literature sources. Study Selection All studies reported after 1990 (to ensure standardized HbA1c values) where HbA1c levels were presented in relation to prevalence of retinopathy, nephropathy or neuropathy in subjects not known to have diabetes. Data Extraction Studies were screened independently, data abstracted, and risk of bias appraised. Data Synthesis Data were synthesized using HbA1c categories of < 6.0% (< 42 mmol/mol), 6.0-6.4% (42-47 mmol/mol) and ≥ 6.5% (≥ 48 mmol/mol). Random-effects meta-analyses were conducted for retinopathy, nephropathy and neuropathy prevalence stratified by HbA1c categories. Random-effects multivariable meta-regression was conducted to identify predictors of retinopathy prevalence and sources of between-study heterogeneity.

RESULTS

Pooled mean prevalence was: 4.0%(95% CI: 3.2-5.0%) for retinopathy, 10.5% (95% CI: 4.0-19.5%) for nephropathy, 2.5% (95% CI: 1.1-4.3%) for neuropathy. Mean prevalence when stratified for HbA1c < 6.0%, 6.0-6.4% and ≥ 6.5% was: retinopathy: 3.4% (95% CI: 1.8-5.4%), 2.3% (95% CI: 1.6-3.2%) and 7.8%(95% CI: 5.7-10.3%); nephropathy: 7.1% (95% CI: 1.7-15.9%), 9.6% (95% CI: 0.8-26.4%) and 17.1% (95% CI: 1.0-46.9%); neuropathy: 2.1% (95% CI: 0.0-6.8%), 3.4% (95% CI: 0.0-11.6%) and 2.8% (95% CI: 0.0-12.8%). Multivariable meta-regression showed HbA1c ≥ 6.5% (OR: 4.05; 95% CI: 1.92-8.57%), age > 55 (OR: 3.23; 95% CI 1.81-5.77), and African-American race (OR: 10.73; 95% CI: 4.34-26.55), to be associated with higher retinopathy prevalence. Marked heterogeneity in prevalence estimates was found across all meta-analyses (Cochran's Q-statistic p < 0.0001).

CONCLUSIONS

The prevalence of nephropathy and moderate retinopathy was increased in subjects with HbA1c values ≥ 6.5% confirming the high specificity of this value for diagnosing T2DM; however, at HbA1c < 6.5% retinopathy increased at age > 55 years and, most strikingly, in African-Americans, suggesting there may be excess microvascular complication prevalence (particularly nephropathy) in individuals below the diabetes diagnostic threshold.

The impact of homocysteine on the risk of coronary artery diseases in individuals with diabetes: a Mendelian randomization study

AIMS

Observational studies have reported that homocysteine (Hcy) is associated with an increased risk of coronary artery disease (CAD) in individuals with diabetes, though controversy remains. The present study aimed to investigate the causal association between Hcy and CAD in individuals with diabetes.

METHODS

A 2-sample Mendelian randomization (MR) study was designed to infer causality. Genetic summary data on the association of single nucleotide polymorphisms (SNPs) with Hcy were extracted from the hitherto largest genome-wide association study (GWAS) of up to 44,147 individuals of European ancestry. SNP-CAD data were obtained from another recently published GWAS which included 15,666 individuals with diabetes (3,968 CAD cases, 11,696 controls). The fixed-effects inverse variance-weighted method was employed to calculate the effect estimates. Other robust methods and leave-one-out analyses were used in the follow-up sensitivity analyses. Potential pleiotropy was assessed with the MR-Egger intercept test.

RESULTS

The 2-sample MR analysis suggested no evidence of an association between genetically predicted plasma Hcy levels and CAD risk in individuals with diabetes (odds ratio = 1.14, 95% confidence interval: 0.82-1.58, p = 0.43) using 9 SNPs as instrumental variables. Similar results were observed in the follow-up sensitivity analyses. The MR-Egger intercept test indicated no evidence of directional pleiotropy (intercept = 0.03, 95% confidence interval: - 0.08-0.03, p = 0.35).

CONCLUSION

This 2-sample MR analysis found no evidence of a causal association between plasma Hcy levels and CAD risk in individuals with diabetes.

Mean and visit-to-visit variability of glycemia and left ventricular diastolic dysfunction: A longitudinal analysis of 3025 adults with serial echocardiography

OBJECTIVE

We aimed to determine the mean glucose thresholds to increase the risk of left ventricular diastolic dysfunction (LVDD) and whether visit-to-visit variability of fasting plasma glucose (FPG) and glycated hemoglobin (A1C) could independently increase the risk in a cohort with serial echocardiography.

METHODS

This was a 3.5-year (range, 0.5-8.3) retrospective longitudinal cohort study of 3025 adults (age, 55.15 ± 7.6 years; without diabetes, n = 2755) with LV ejection fraction > 50% by serial echocardiography between 2006 and 2016. Mean, standard of deviation (SD) and coefficient of variation (CV) of FPG and A1C obtained from three consecutive measurements preceding the first echocardiography. The definition of LVDD in this study was primarily based on early peak mitral inflow velocity and early diastolic mitral annulus motion velocity.

RESULTS

LVDD developed in 611/3025 subjects (20.2%). Cox proportional hazard models showed increased adjusted hazard ratios (HRs) for incident LVDD in the highest quartile of FPG-mean (HR 1.76, 95% confidence interval [CI]; 1.36-2.30), FPG-SD (HR 1.63, 95% CI; 1.27-2.09), FPG-CV (HR 1.47, 95% CI; 1.15-1.89), and A1C-mean (HR 1.83, 95% CI; 1.41-2.38) versus the lowest quartile, which was consistent even in subjects without diabetes. Mean glucose thresholds for the increased risk were below the lower limits for pre-diabetes.

CONCLUSIONS

In terms of mean glycemia, LVDD may be initiated in the earliest diabetic continuum, and such changes could be measurable within several years. Visit-to-visit variability of FPG, but not that of A1C, predicted accelerated development of LVDD.

Lack of evidence of the correlation between plasma Asymmetrical Dimethylarginine correlation and IMT in type 2 diabetic patients with chronic vascular complication

INTRODUCTION

Patients with type 2 diabetes represent 50% of all sudden cardiac deaths. Disseminated arteriosclerotic lesions are the cause of vascular incidents that cause permanent disability resulting from lower limb amputations.

OBJECTIVES

Our study was designed to investigate the relationship between asymmetrical dimethylarginine (ADMA), symmetric dimethylarginine (SDMA) plasma concentration and intima-media thickness (IMT) in subjects with diabetes mellitus without vascular complications (group A) and a group of diabetic patients diagnosed with diabetes micro- and macroangiopathy (group B).

PATIENTS AND METHOD

The experimental groups included 42 diabetic patients. Group A - 22 patients (9 W and 13 M), free from vascular complications (mean age 55.83±7.37 years), group B - 20 patients (6 W, 14 M) with accompanying micro- and macropathic changes (mean age 63.80±8.79 years). Group C (n=22), the control group, consisted of healthy volunteers (12 W and 10 M), between the ages of 40 to 60 (mean age 51.16±6.39), selected in reference to the age and sex of the research group. The carotid artery intima-media complex thickness (IMT) was evaluated with the use of a duplex ultrasound.

CONCLUSIONS

There was no correlation between ADMA and the maximal or mean intima-media thickness (IMT) of the common carotid artery (CCA) and internal carotid artery (ICA). We demonstrated a correlation between symmetric dimethylarginine (SDMA) concentration and CCA IMT. The results suggest that ICA IMT may serve as a marker of vascular complication among patients with diabetes.

Five-year follow-up observation of interventional therapy for lower extremity vascular disease in type 2 diabetes and analysis of risk factors for restenosis

BACKGROUND

The high incidence of type 2 diabetes, the low rate of compliance, and the complex mechanism of vascular disease caused by diabetes make its complications increase year by year. Our study aimed to investigate the clinical characteristics of lower extremity vascular diseases in type 2 diabetes and evaluate the long-term efficacy of vascular intervention for these diseases.

METHODS

From 2007 to 2014, 362 patients who underwent vascular intervention in our hospital due to lower extremity vascular diseases in type 2 diabetes were followed up for 5 years and their clinical characteristics were analyzed in this retrospective study.

RESULTS

Compared with those before treatment, the values of blood pressure, fasting blood glucose, glycated hemoglobin (HbA1c), total cholesterol (TC), triglyceride Ester (TG), and low density lipoprotein-cholesterol (LDL-C) of patients were significantly lower 5 years after intervention (P < 0.01). We found that the levels of fibrinogen, blood glucose, HbA1c, TC, TG, LDL-C, and small dense low-density lipoprotein (sdLDL) in the vascular restenosis group were significantly higher than those in the vascular patency group (P < 0.001), whereas the level of HDL-C in the vascular restenosis group was significantly lower compared with the vascular patency group.

CONCLUSIONS

Vascular intervention can significantly improve a series of biochemical indicators in patients with lower extremity vascular diseases caused by type 2 diabetes. Postoperative restenosis may be related to hypertension, duration of diabetes, rate of inferior knee disease, fibrinogen, and sdLDL. Good survival and limb salvage were achieved in the patients in this series with interventions and medical treatment provided by endocrinologists.

Quantification of serum C-mannosyl tryptophan by novel assay to evaluate renal function and vascular complications in patients with type 2 diabetes

C-Mannosyl tryptophan (CMW) is a unique glycosylated amino acid, and a candidate novel biomarker of renal function. In type 2 diabetes (T2D), a combination of metabolites including CMW has recently been the focus of novel biomarkers for the evaluation of renal function and prediction of its decline. However, previous quantification methods for serum CMW have several limitations. We recently established a novel assay for quantifying serum CMW. Serum CMW from 99 Japanese patients with T2D was quantified by this assay using hydrophilic interaction liquid chromatography. The serum CMW levels were cross-sectionally characterized in relation to clinical features, including renal function and vascular complications. Serum CMW level was more strongly correlated with serum creatinine and cystatin C levels and with eGFR than with albumin urea level. The ROC curve to detect eGFR < 60 ml/min/1.73 m2 revealed that the cutoff serum CMW level was 337.5 nM (AUC 0.883). Serum CMW levels were higher in patients with a history of macroangiopathy than in those without history. They correlated with ankle-brachial pressure index, whereas cystatin C did not. Serum CMW levels quantified by the novel assay could be useful in evaluation of glomerular filtration of renal function and peripheral arterial disease in T2D.

Positive Association of Leptin and Artery Calcification of Lower Extremity in Patients With Type 2 Diabetes Mellitus: A Pilot Study

OBJECTIVE

We aimed to explore the role and possible mechanism of leptin in lower-extremity artery calcification in patients with type 2 diabetes mellitus (T2DM).

METHODS

We recruited 59 male patients with T2DM and 39 non-diabetic male participants. All participants underwent computed tomography scan of lower-extremity arteries. The calcification scores (CSs) were analyzed by standardized software. Plasma leptin level was determined by radioimmunoassay kits. Human vascular smooth muscle cells (VSMCs) calcification model was established by beta-glycerophosphate and calcium chlorideinduction. Calcium deposition and mineralization were measured by the o-cresolphthalein complexone method and Alizarin Red staining. The mRNA expression of bone morphogenic protein 2 (BMP2), runt-related transcription factor 2 (Runx2), osteocalcin (OCN) and osteopontin (OPN) was determined by quantitative RT-PCR. The protein levels of BMP2, Runx2, α-smooth muscle actin (α-SMA) and (p)-Akt was determined by Western-blot analysis, and α-SMA was also measured by immunofluorescence analysis.

RESULTS

Compared with controls, patients with T2DM showed higher median calcification score in lower-extremity artery [286.50 (IQR 83.41, 1082.00) vs 68.66 (3.41, 141.30), p<0.01]. Plasma leptin level was higher in patients with calcification score ≥300 than ≥100 (252.67 ± 98.57 vs 189.38 ± 44.19 pg/ml, p<0.05). Compared with calcification medium, intracellular calcium content was significantly increased in VSMCs treated by leptin (200, 400 and 800 ng/ml) combined with calcification medium [11.99 ± 3.63, 15.18 ± 4.55, and 24.14 ± 5.85 mg/ml, respectively, vs 7.27 ± 1.54 mg/ml, all p<0.01]. Compared with calcification medium, Alizarin Red staining showed calcium disposition was more obvious, and the mRNA level of BMP2, Runx2 and OCN was significantly increased, and immunofluorescence and Western blot analysis showed that the expression of α-SMA was downregulated in VSMCs treated by leptin (400 ng/ml) combined with calcification medium, respectively. Compared with calcification medium, the protein level of BMP2 and Runx2 was upregulated in VSMCs treated by leptin (400 ng/ml) combined with calcification medium. Moreover, blocking PI3K/Akt signaling pathway can decrease the protein expression of BMP2 and Runx2 in VSMCs treated by leptin (400 ng/ml) combined with calcification medium.

CONCLUSIONS

Leptin promoted lower-extremity artery calcification of T2DM by upregulating the expression of BMP2 and Runx2, and regulating phenotypic switch of VSMCs via PI3K/Akt signaling pathway.

Serum glycated albumin predicts all-cause mortality in dialysis patients with diabetes mellitus: meta-analysis and systematic review of a predictive biomarker

BACKGROUND AND AIM

HbA1c, the traditional and current gold standard biomarker guiding diabetic management, has been scrutinized for low predictive value for patients with chronic kidney disease due to variables affecting erythrocyte number and turnover. Glycated albumin, the precursor to advanced glycation end products, reflects glycemic status over the preceding 2-3 week period and already outperforms HbA1c for glycemic monitoring. Our aim was to establish whether serum GA can be further used to predict mortality risk in dialysis patients with diabetes mellitus (DM) METHODS: We did systematic review of the literature in PubMed/Medline, Web of Science, Embase (Elsevier) and the Cochrane Central Register of Controlled Trials (Wiley) up to and including February 2020.

RESULTS

This meta-analysis included 25,932 dialysis patients across 12 studies with maximum follow-up of 11 years. Higher GA levels were associated with the risk of all-cause mortality in dialysis patients with DM (HR 1.02, 95% CI 1.01 to 1.03, P < 0.001) irrespective of the type of dialysis, whereas higher GA was not associated with cardiovascular mortality (HR 1.03, 95% CI 0.99 to 1.06, P = 0.15) and cardiovascular events (both fatal and non-fatal) (HR 1.03, 95% CI 0.97 to 1.09, P = 0.31) in dialysis patients with DM.

CONCLUSION

Serum glycated albumin predicts all-cause mortality risk in dialysis patients with DM. The endpoints of cardiovascular mortality and cardiovascular events trended similarly, but did not reach significance at the current sample size.

Circulating human anti nucleolus antibody (ANCAb) and biochemical parameters in type 2 diabetic patients with and without complications

Introduction

There is no evidence on the role of Human Anti Nucleolus Antibody (ANCAb) in type 2 diabetes mellitus (T2DM). We compared prevalence and concentration of ANCAb between age and a gender-matched sample of T2DM with and without diabetes-related complications.

Methods

In this study, the reaction to ANCAb was compared quantitatively between 38 T2DM patients complicated with microvascular conditions and 43 T2DM without complications as controls.

Results

The patients in complicated and non-complicated groups were comparable in diabetes duration (9.0 vs. 5.0 years; P = 0.065), respectively. The study found that 27 cases (71.1%) of the complicated group reacted to ANCAb test compared to 25 (58.1%) in non-complicated patients (P = 0.226; 3.53 vs. 2.72 ng/mL; P = 0.413). The reaction response to ANCAb in patients with neuropathy and cardiovascular complications was 80.0%, 76.2% in patients with neuropathy compared to 58.1% in the control group (P = 0.398). The reaction response to ANCAb in patients with mono-complication was 72.7% compared 68.8% in patients with multi-complication (P = 0.466). Similarly, 76.2% of patients with T2DM and complicated with neuropathy (n = 21 patients) reacted to ANCAb compared to 58.1% in control patients with (P = 0.158).

Conclusions

Reaction to ANCAb was not statistically different between the T2DM patients with and without complications.

Serum discrimination and phenotype assessment of coronary artery disease patents with and without type 2 diabetes prior to coronary artery bypass graft surgery

Diabetes Mellitus (DM) accelerates coronary artery disease (CAD) and atherosclerosis, the causes of most heart attacks. The biomolecules involved in these inter-related disease processes are not well understood. This study analyzes biomolecules in the sera of patients with CAD, with and without type (T) 2DM, who are about to undergo coronary artery bypass graft (CABG) surgery. The goal is to develop methodology to help identify and monitor CAD patients with and without T2DM, in order to better understand these phenotypes and to glean relationships through analysis of serum biomolecules. Aorta, fat, muscle, and vein tissues from CAD T2DM patients display diabetic-related histologic changes (e.g., lipid accumulation, fibrosis, loss of cellularity) when compared to non-diabetic CAD patients. The patient discriminatory methodology utilized is serum biomolecule mass profiling. This mass spectrometry (MS) approach is able to distinguish the sera of a group of CAD patients from controls (p value 10⁻¹⁵), with the CAD group containing both T2DM and non-diabetic patients. This result indicates the T2DM phenotype does not interfere appreciably with the CAD determination versus control individuals. Sera from a group of T2DM CAD patients however are distinguishable from non-T2DM CAD patients (p value 10⁻⁸), indicating it may be possible to examine the T2DM phenotype within the CAD disease state with this MS methodology. The same serum samples used in the CAD T2DM versus non-T2DM binary group comparison were subjected to MS/MS peptide structure analysis to help identify potential biochemical and phenotypic changes associated with CAD and T2DM. Such peptide/protein identifications could lead to improved understanding of underlying mechanisms, additional biomarkers for discriminating and monitoring these disease conditions, and potential therapeutic targets. Bioinformatics/systems biology analysis of the peptide/protein changes associated with CAD and T2DM suggested cell pathways/systems affected include atherosclerosis, DM, fibrosis, lipogenesis, loss of cellularity (apoptosis), and inflammation.

Two-hour postload plasma glucose and pigment epithelium-derived factor levels are markers of coronary artery inflammation in type 2 diabetic patients

BACKGROUND

We have previously found that pioglitazone attenuates inflammation in the left main trunk of coronary artery (LMT), evaluated as target-to-background ratio (TBR) by 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) in patients with impaired glucose tolerance or type 2 diabetes.

OBJECTIVES

We assessed which clinical variables could predict the change in TBR in the LMT after 4-month add-on therapy with oral hypoglycemic agents (OHAs).

METHODS

A total of 38 type 2 diabetic patients with carotid atherosclerosis who had already received OHAs except for pioglitazone was enrolled. At baseline and 4 months after add-on therapy with pioglitazone or glimepiride, all patients underwent 75 g oral glucose tolerance test, blood chemistry analysis, and FDG-PET/CT.

RESULTS

Fasting plasma glucose, 30-, 60-, 90-, 120-minutes postload plasma glucose, HbA1c, and LMT-TBR values were significantly decreased by add-on therapy, whereas high-density lipoprotein-cholesterol and adiponectin levels were increased. Increased serum levels of pigment epithelium-derived factor (PEDF), a marker of insulin resistance and non-use of aspirin at baseline could predict the favorable response of LMT-TBR to add-on therapy. Moreover, Δ120-minutes postload plasma glucose and ΔPEDF were independent correlates of ΔLMT-TBR.

CONCLUSIONS

Our present study suggests that 120-minutes postload plasma glucose and PEDF values may be markers and potential therapeutic targets of coronary artery inflammation in type 2 diabetic patients.

CLINICAL TRIAL REGISTRATION

URL: http://clinicaltrials.gov . Unique identifier: NCT00722631. New markers for diabetes and CAD is on the horizon! Two-hour postload plasma glucose and pigment epithelium derived factor are markers of coronary artery inflammation in type 2 diabetic patients.

Association between fasting blood glucose and outcomes and mortality in acute ischaemic stroke patients with diabetes mellitus: a retrospective observational study in Wuhan, China

OBJECTIVE

To evaluate the predictive value of fasting blood glucose (FBG) on unfavourable outcomes and mortality in diabetes mellitus (DM) patients after acute ischaemic stroke (AIS).

STUDY DESIGN

A hospital-based observational cohort study was conducted. Clinical data, including sex, age, body mass index, vascular risk factors and systolic/diastolic blood pressure, were routinely collected. National Institutes of Health Stroke Scale score was used to assess stroke severity on admission. FBG was determined on the first day after fasting for at least 8 hours. The modified Rankin Scale was used to assess functional outcome at 90 days: 3-6, unfavourable outcome and 6, death.

SETTING

Renmin Hospital of Wuhan University, Wuhan, China.

PARTICIPANTS

Patients who had AIS with DM, who were consecutively admitted within 24 hours of onset from January 2018 to June 2019.

RESULTS

For the 568 patients, the median age was 65 years (IQR, 55-74 years). There were 377 (66.4%) men. The median FBG values were 7.37 mmol/L (IQR, 5.99-10.10 mmol/L), and the median glycated haemoglobin (HbA1c) values were 6.6 (IQR, 5.8-8.3). Multivariable logistic and Cox regression analysis of confounding factors showed that FBG at the time of admission was an independent predictor of unfavourable outcome (OR, 1.25 (1.14-1.37); p<0.0001) and mortality (HR, 1.10 (1.03-1.15); p<0.05) at 90 days after onset. Time to death was analysed by Kaplan-Meier curves based on FBG quartiles. The risk of death in the two highest quartile groups (FBG, 7.38-10.10 mmol/L; FBG, ≥10.11 mmol/L) was significantly higher than that in the two lowest quartile groups (FBG, ≤6.00 mmol/L; FBG, 6.01-7.37 mmol/L; p<0.0001).

CONCLUSIONS

Higher FBG levels are associated with unfavourable outcomes and mortality in Chinese patients who had AIS with DM. Our data contribute to the knowledge regarding the relationship between FBG and prognosis in patients with DM who had AIS.

Loss of association between HbA1c and vascular disease in older adults with type 1 diabetes

Aims

Robust evidence supports intensive glucose control in those with recently diagnosed type 1 diabetes to reduce the risk of developing micro- and macrovascular complications. Data to support longitudinal glycaemic targets is lacking. We aimed to explore if longer duration of diabetes and greater age might reduce the impact of glycaemia on the risk of vascular complications.

Research and design methods

Data for adults age 20 years or more, was extracted from a clinical database of people with type 1 diabetes cared for at a London teaching hospital. The presence or absence of micro- and macro-vascular complications was recorded. Multivariable logistic regression analysis was performed using HbA1c as independent variable, diabetes duration and age as continuous variable and obesity, hypertension, hypercholesterolaemia, low HDL cholesterol and hypertriglyceridaemia as categorical variables.

Results

Data from 495 patients was used. HbA1c above 60 mmol/mol (7.6%) was associated with increased microvascular complications in patients aged 20–44 years, independent of age and duration of diabetes. In older people with T1DM duration of diabetes was the major risk factor.

Conclusions

Our study suggests that increased age and greater duration of diabetes reduce the impact of glycaemia on the risk of vascular complications. Intensive blood glucose management in patients aged ≥45 years may have limited benefits in terms of reducing the risk of complications although this does not dismiss the benefits of good glycaemic control in older people with T1DM.

A potent risk model for predicting new-onset acute coronary syndrome in patients with type 2 diabetes mellitus in Northwest China

AIMS

Type 2 diabetes mellitus (T2DM) is now very prevalent in China. Due to the lower rate of controlled diabetes in China compared to that in developed countries, there is a higher incidence of serious cardiovascular complications, especially acute coronary syndrome (ACS). The aim of this study was to establish a potent risk predictive model in the economically disadvantaged northwest region of China, which could predict the probability of new-onset ACS in patients with T2DM.

METHODS

Of 456 patients with T2DM admitted to the First Affiliated Hospital of Xi'an Jiaotong University from January 2018 to January 2019 and included in this study, 270 had no ACS, while 186 had newly diagnosed ACS. Overall, 32 demographic characteristics and serum biomarkers of the study patients were analysed. The least absolute shrinkage and selection operator regression was used to select variables, while the multivariate logistic regression was used to establish the predictive model that was presented using a nomogram. The area under the receiver operating characteristics curve (AUC) was used to evaluate the discriminatory capacity of the model. A calibration plot and Hosmer-Lemeshow test were used for the calibration of the predictive model, while the decision curve analysis (DCA) was used to evaluate its clinical validity.

RESULTS

After random sampling, 319 and 137 T2DM patients were included in the training and validation sets, respectively. The predictive model included age, body mass index, diabetes duration, systolic blood pressure (SBP), diastolic blood pressure (DBP), low-density lipoprotein cholesterol, serum uric acid, lipoprotein(a), hypertension history and alcohol drinking status as predictors. The AUC of the predictive model and that of the internal validation set was 0.830 [95% confidence interval (CI) 0.786-0.874] and 0.827 (95% CI 0.756-0.899), respectively. The predictive model showed very good fitting degree, and DCA demonstrated a clinically effective predictive model.

CONCLUSIONS

A potent risk predictive model was established, which is of great value for the secondary prevention of diabetes. Weight loss, lowering of SBP and blood uric acid levels and appropriate control for DBP may significantly reduce the risk of new-onset ACS in T2DM patients in Northwest China.

The emerging role of dyslipidemia in diabetic microvascular complications

PURPOSE OF REVIEW

To summarize recent advancements in our understanding of the impact of dyslipidemia on microvascular complications in type 2 diabetes (T2D), with an emphasis on peripheral neuropathy and nephropathy.

RECENT FINDINGS

Mounting evidence suggests that rigorous glycemic control only mitigates certain microvascular complications in T2D patients. Particularly, well regulated blood glucose levels only marginally improve peripheral neuropathy in the T2D setting. Dyslipidemia, an abnormal lipid profile, is emerging as a key factor in peripheral neuropathy. Furthermore, although glycemic control may prevent or slow nephropathy, recent developments demonstrate that dyslipidemia can also affect kidney outcomes in normoglycemic patients. Transcriptomic, epigenomic, and lipidomic investigations, as well as integrative approaches, are shedding light on potential pathomechanisms. These molecular studies are identifying possible targets for therapeutic intervention. Complementing molecular research, lifestyle interventions are on-going to assess whether dietary choices and/or exercise, weight-loss, or surgical interventions, such as bariatric surgery, can ameliorate peripheral neuropathy and nephropathy in T2D patients.

SUMMARY

Dyslipidemia is an emerging mechanism in microvascular complications in T2D. Elucidating the molecular pathomechanisms may pinpoint potential lipid-centric treatments. Interventional studies of dietary changes, exercise, or weight-loss surgery may also positively impact these highly prevalent and morbid complications.

Troponin T Parallels Structural Nerve Damage in Type 2 Diabetes: A Cross-sectional Study Using Magnetic Resonance Neurography

Clinical studies have suggested that changes in peripheral nerve microcirculation may contribute to nerve damage in diabetic polyneuropathy (DN). High-sensitivity troponin T (hsTNT) assays have been recently shown to provide predictive values for both cardiac and peripheral microangiopathy in type 2 diabetes (T2D). This study investigated the association of sciatic nerve structural damage in 3 Tesla (3T) magnetic resonance neurography (MRN) with hsTNT and N-terminal pro-brain natriuretic peptide serum levels in patients with T2D. MRN at 3T was performed in 51 patients with T2D (23 without DN, 28 with DN) and 10 control subjects without diabetes. The sciatic nerve's fractional anisotropy (FA), a marker of structural nerve integrity, was correlated with clinical, electrophysiological, and serological data. In patients with T2D, hsTNT showed a negative correlation with the sciatic nerve's FA (r = -0.52, P < 0.001), with a closer correlation in DN patients (r = -0.66, P < 0.001). hsTNT further correlated positively with the neuropathy disability score (r = 0.39, P = 0.005). Negative correlations were found with sural nerve conduction velocities (NCVs) (r = -0.65, P < 0.001) and tibial NCVs (r = -0.44, P = 0.002) and amplitudes (r = -0.53, P < 0.001). This study is the first to show that hsTNT is a potential indicator for structural nerve damage in T2D. Our results indirectly support the hypothesis that microangiopathy contributes to structural nerve damage in T2D.

Traditional Chinese medicine Shenqi compound to improve lower extremity atherosclerosis of patients with type 2 diabetes by affecting blood glucose fluctuation: Study protocol for a randomized controlled multicenter trial

BACKGROUND

Clinical and basic research supports that blood glucose fluctuation is an important predictor of diabetic vascular disease and an etiology of lower extremity atherosclerosis, which is an important pathological basis for lower extremity vascular diseases. Previous Chinese National Natural Science Foundation trials (No. 81503566) have reported that the traditional Chinese medicine Shenqi compound can reduce blood glucose fluctuation and low-grade inflammation, and protect blood vessels; however, there are no high-quality clinical evidences available to support the same. This multicenter randomized controlled trial aims to obtain more clinical evidence to confirm the efficacy and safety of Shenqi compound in type 2 diabetes with lower extremity atherosclerosis.

METHODS

A multicenter RCT will be implemented in this study for a 32-week study period (8 weeks for intervention and 24 weeks for follow-up). Participants will be recruited from the Teaching Hospital of Chengdu University of TCM, Mianyang Hospital of TCM, and Shuangliu Hospital of TCM. Sixty participants will be randomly divided into a treatment group (basic treatment combined with traditional Chinese medicine Shenqi Compound) or a control group (basic treatment combined with Chinese medicine placebo) with 30 participants in each group. Patients will be selected considering the following inclusion criteria: age between 35 and 65 years, and a positive diagnosis for type 2 diabetes with lower extremity atherosclerosis and TCM syndromes. Primary outcome indicator is an arterial color Doppler ultrasound. Secondary outcome indicators include: blood glucose fluctuation indicators (MBG, SDBG, LAGE), islet β-cell function evaluation indicators (Homa-IR, Homa-islet, SG, SCP), inflammation indicators (NLR, CRP, IL-6), blood lipids, and HbA1c. Safety index includes vital signs (T, P, R, BP), blood, urine, stool routine, liver and renal function, electrocardiogram, and adverse event records. The endpoint event is defined as the presence of gangrene in the lower limbs.

DISCUSSION

Explore the clinical effect of traditional Chinese medicine "Shenqi Compound" to reduce blood glucose fluctuation and use HOMA-IR, the area under the glucose curve, and the area under the C-peptide curve to evaluate the effect of protecting islet β cell function.

TRIAL REGISTRATION

Chinese clinical trial registry (ChiCTR-1900027693). Registered on November 23, 2019. http://www.chictr.org.cn.

The effect of dulaglutide on stroke: an exploratory analysis of the REWIND trial

BACKGROUND

Cardiovascular outcome trials have suggested that glucagon-like peptide 1 (GLP-1) receptor agonists might reduce strokes. We analysed the effect of dulaglutide on stroke within the researching cardiovascular events with a weekly incretin in diabetes (REWIND) trial.

METHODS

REWIND was a multicentre, randomised, double-blind, placebo-controlled trial done at 371 sites in 24 countries. Men and women (aged ≥50 years) with established or newly detected type 2 diabetes whose HbA_1c was 9·5% or less (with no lower limit) on stable doses of up to two oral glucose-lowering drugs with or without basal insulin therapy were eligible if their body-mass index was at least 23 kg/m². Participants were randomly assigned (1:1) to weekly subcutaneous injections of either masked dulaglutide 1·5 mg or the same volume of masked placebo (containing the same excipients but without dulaglutide). Randomisation was done by a computer-generated random code with an interactive web response system with stratification by site. Participants, investigators, the trial leadership, and all other personnel were masked to treatment allocation until the trial was completed and the database was locked. During the treatment period, participants in both groups were instructed to inject study drug on the same day at around the same time, each week. Strokes were categorised as fatal or non-fatal, and as either ischaemic, haemorrhagic, or undetermined. Stroke severity was assessed using the modified Rankin scale. Participants were seen at 2 weeks, 3 months, 6 months, and then every 3 months for drug dispensing and every 6 months for detailed assessments, until 1200 confirmed primary outcomes accrued. The primary endpoint was the first occurrence of any component of the composite outcome, which comprised non-fatal myocardial infarction, non-fatal stroke, or death from cardiovascular or unknown causes. All analyses were done according to an intention-to-treat strategy that included all randomly assigned participants, irrespective of adherence. The trial is registered with ClinicalTrials.gov, number NCT01394952.

FINDINGS

Between Aug 18, 2011, and Aug 14, 2013, we screened 12 133 patients, of whom 9901 with type 2 diabetes and additional cardiovascular risk factors were randomly assigned to either dulaglutide (n=4949) or an equal volume of placebo (n=4952). During a median follow-up of 5·4 years, cerebrovascular and other cardiovascular outcomes were ascertained and adjudicated. 158 (3·2%) of 4949 participants assigned to dulaglutide and 205 (4·1%) of 4952 participants assigned to placebo had a stroke during follow-up (hazard ratio [HR] 0·76, 95% CI 0·62-0·94; p=0·010). Dulaglutide reduced ischaemic stroke (0·75, 0·59-0·94, p=0·012) but had no effect on haemorrhagic stroke (1·05, 0·55-1·99; p=0·89). Dulaglutide also reduced the composite of non-fatal stroke or all-cause death (0·88, 0·79-0·98; p=0·017) and disabling stroke (0·74, 0·56-0·99; p=0·042). The degree of disability after stroke did not differ by treatment group.

INTERPRETATION

Long-term dulaglutide use might reduce clinically relevant ischaemic stroke in people with type 2 diabetes but does not affect stroke severity.

FUNDING

Eli Lilly and Company.

Optimal fasting glucose levels with regard to cardiovascular and mortality outcomes in people treated with or without antidiabetic medication

AIMS

To investigate the optimal fasting blood glucose (FBG) levels among individuals actively treated or untreated with antidiabetic drugs.

METHODS

In two population-based cohorts of Korean adults extracted from the National Health Information Database, multivariable-adjusted hazard ratios of outcomes over 10 and 8 years of follow-up were estimated according to achieved FBG levels and antidiabetic drug use. The primary outcomes were major cardiovascular disease (CVD) events and all-cause mortality.

RESULTS

In total, 66 533 of 450 537 and 100 556 of 767 382 participants in the respective cohorts received antidiabetic treatment. For untreated FBG, the CVD risk and mortality increased linearly from an FBG threshold of 5.6 mmol/L; however, for FBG treated with antidiabetic drugs there were J-shaped associations with the outcome risks. For treated FBG levels of 4.4 to 5.5 mmol/L, 7.8 to 8.8 mmol/L, 8.9 to 9.9 mmol/L and ≥ 10.0 mmol/L, vs 6.1 to 6.9 mmol/L, the hazard ratios for major CVD events were 1.17 (95% confidence interval [CI] 1.04-1.32), 1.06 (95% CI 0.96-1.18), 1.37 (95% CI 1.22-1.53) and 1.61 (95% CI 1.46-1.78), respectively, and those for all-cause mortality were 1.20 (95% CI 1.11-1.29), 1.05 (95% CI 0.99-1.12), 1.29 (95% CI 1.10-1.50) and 1.69 (95% CI 1.59-1.81), respectively.

CONCLUSIONS

These findings indicate that pharmacological therapy achieving FBG levels of <7.8 to 8.9 mmol/L and a non-pharmacological approach to maintaining normal glucose levels help reduce the risk of adverse outcomes, while lowering FBG to normal levels through antidiabetic drugs is not beneficial or may even be harmful.

MiRNA Expression is Associated with Clinical Variables Related to Vascular Remodeling in the Kidney and the Brain in Type 2 Diabetes Mellitus Patients

Background: The association of vascular remodeling in the kidney and the brain with a particular microRNAs (miRNA) profile is not well studied.Methods: Seventy-six patients with Type 2 diabetes and 11 healthy subjects were assessed concerning urine albumin: creatinine ratio (UACR), biomarkers of podocyte injury and of proximal tubule (PT) dysfunction. MiRNA were quantified in blood and urine by a real-time PCR System. Cerebrovascular ultrasound measurements were performed in the carotid and middle cerebral arteries.Results: MiRNA21 and miRNA124 correlated positively with nephrin, podocalyxin, synaptopodin, urinary N-acetyl-D-glucosaminidase (NAG), urinary kidney-injury molecule-1 (KIM-1), UACR, and negatively with eGFR; miRNA125a, 126, 146a, 192 correlated negatively with nephrin, podocalyxin, synaptopodin, urinary NAG, urinary KIM-1, UACR, and directly with eGFR. Plasma miRNA-21 and miRNA192 correlated directly with cerebral hemodynamics parameters of atherosclerosis and arteriosclerosis. MiRNA-124, 125a, 126, 146a showed negative correlations with the same parameters.Conclusions: In Type 2 diabetes patients there is an association of vascular remodeling in the brain and the kidney with a specific miRNAs pattern. Cerebrovascular changes occur even in normoalbuminuric patients, with 'high-to-normal' levels of podocyte injury and PT dysfunction biomarkers. These phenomena may be explained by the variability of miRNA expression within the two organs in early DKD.

Risk of first stroke in people with type 2 diabetes and its relation to glycaemic control: A nationwide observational study

AIMS

To compare stroke incidence in people with type 2 diabetes (T2D) with that in a matched control group, and to investigate whether glucose exposure in people with T2D can predict a first-time stroke event and mortality.

MATERIAL AND METHODS

In a nationwide observational cohort study, individuals with T2D were linked in the Swedish National Diabetes Register and matched with five individual population-based control subjects. We calculated crude incidence rates and 95% confidence intervals (CIs), and used Cox regression and multivariable hazard ratios (HRs), to estimate the risk of stroke and mortality in relation to glycated haemoglobin (HbA1c) levels.

RESULTS

A total of 406 271 people with T2D (age 64.1 ± 12.4 years, 45.7% women) and 2086 440 control subjects (age 64.0 ± 12.4 years, 45.7% women) were included. During a median follow-up of 7.3 years, 26 380 people with T2D (6.5%) versus 92 375 control subjects (4.4%) were diagnosed with a stroke. The incidence rate was 10.12 events per 1000 person-years versus 7.26 events per 1000 person-years (HR 1.54, 95% CI 1.52-1.56). In the T2D group after multivariable adjustments, the HRs for stroke stratified by HbA1c level were: 54-64 mmol/mol: 1.27 (95% CI 1.22-1.32); 65-75 mmol/mol: 1.68 (95% CI 1.60-1.76); 76-86 mmol/mol: 1.89 (95% CI, 1.75-2.05); and > 87 mmol/mol: 2.14 (95% CI 1.90-2.42), respectively, compared with the reference category of HbA1c ≤53 mmol/mol. There was a stepwise increased risk of death after stroke, for every 10-mmol/mol categorical increment of HbA1c (HR 1.71; 95% CI 1.47-2.00) for the highest HbA1c category.

CONCLUSIONS

An increased risk of stroke and death was associated with poor glycaemic control in people with T2D.

Associations between Triglyceride-Glucose Index and Micro- and Macro-angiopathies in Type 2 Diabetes Mellitus

The aim of this study was to investigate the associations between the triglyceride-glucose (TyG) index, a marker of insulin resistance, and microangiopathies and macroangiopathies in patients with type 2 diabetes mellitus (DM). Our study enrolled 1990 type 2 diabetic patients from local hospitals in Taiwan during the period of 2002–2004. Multivariate logistic regression analysis was used to identify the factors related to microangiopathies, macroangiopathiess and TyG index. The patients were stratified by TyG index quartile (Q1–Q4). Adjusted odds ratios (aORs) of albuminuria for Q3 versus Q1 and Q4 versus Q1 were 1.424 (95% confidence interval [CI], 1.062–1.910, p = 0.018) and 1.948 (95% CI, 1.437–2.642, p < 0.001), respectively. The aOR of cerebrovascular disease (CVA) was 2.264 for Q4 versus Q1 (95% CI, 1.243–4.122, p = 0.008), but there were no significant associations with diabetic retinopathy (DR), coronary artery disease (CAD) or peripheral artery occlusive disease (PAOD). Significant stepwise increases were found in CVA (p = 0.0013) and albuminuria ≥30 mg/g (p < 0.001) corresponding to TyG index quartiles, but not DR (p = 0.573), CAD (p = 0.880) or PAOD (p = 0.223). There was a significant association between a high TyG index and a high risk of microalbuminuria and CVA in the study cohort. Further studies to investigate the use of medications in patients with DM to prevent micro- and macro-angiopathies are thus warranted.

Diabetic microcirculatory disturbances and pathologic erythropoiesis are provoked by deposition of amyloid-forming amylin in red blood cells and capillaries

In the setting of type-2 diabetes, there are declines of structural stability and functionality of blood capillaries and red blood cells (RBCs), increasing the risk for microcirculatory disturbances. Correcting hyperglycemia is not entirely effective at reestablishing normal cellular metabolism and function. Therefore, identification of pathological changes occurring before the development of overt hyperglycemia may lead to novel therapeutic targets for reducing the risk of microvascular dysfunction. Here we determine whether RBC-capillary interactions are altered by prediabetic hypersecretion of amylin, an amyloid forming hormone co-synthesized with insulin, and is reversed by endothelial cell-secreted epoxyeicosatrienoic acids. In patients, we found amylin deposition in RBCs in association with type-2 diabetes, heart failure, cancer and stroke. Amylin-coated RBCs have altered shape and reduced functional (non-glycated) hemoglobin. Amylin-coated RBCs administered intravenously in control rats upregulated erythropoietin and renal arginase expression and activity. We also found that diabetic rats expressing amyloid-forming human amylin in the pancreas (the HIP rat model) have increased tissue levels of hypoxia-inducible transcription factors, compared to diabetic rats that express non-amyloid forming rat amylin (the UCD rat model). Upregulation of erythropoietin correlated with lower hematocrit in the HIP model indicating pathologic erythropoiesis. In the HIP model, pharmacological upregulation of endogenous epoxyeicosatrienoic acids protected the renal microvasculature against amylin deposition and also reduced renal accumulation of HIFs. Thus, prediabetes induces dysregulation of amylin homeostasis and promotes amylin deposition in RBCs and the microvasculature altering RBC-capillary interaction leading to activation of hypoxia signaling pathways and pathologic erythropoiesis. Hence, dysregulation of amylin homeostasis could be a therapeutic target for ameliorating diabetic vascular complications.

Association of Serum Adiponectin with Intima Media Thickness of Dorsalis Pedis Artery and Macroangiopathy in Type 2 Diabetes

OBJECTIVE

To investigate the association of the serum adiponectin level with the intima media thickness of the dorsalis pedis artery (D-IMT) and macroangiopathy in type 2 diabetes (T2DM).

METHODS

We recruited 173 patients with T2DM, of whom 83 had macroangiopathy (MA group) and 90 did not have macroangiopathy (NM group), and 40 normal control subjects (NC group). We measured D-IMT using color B-mode Doppler ultrasonography. Serum adiponectin, blood glucose, lipids, and other clinical characteristics were analyzed. Participants were divided into three subgroups according to serum adiponectin level (high, moderate, and low).

RESULTS

Compared with the NM and NC groups, serum adiponectin levels were significantly decreased in the MA group after adjusting for sex and body mass index. Compared with the NM and NC groups, D-IMT was significantly increased in the MA group. Compared with the moderate- and high-adiponectin subgroups, D-IMT was significantly increased in the low-adiponectin subgroup. The prevalence of diabetic macroangiopathy increased gradually with decreasing adiponectin levels. After controlling for age, sex, smoking, and alcohol drinking, partial correlation analysis showed that adiponectin was negatively correlated with D-IMT. Elevated serum adiponectin was independently associated with a decreased risk for diabetic macroangiopathy by logistic regression analysis. Multiple linear regression analysis revealed that adiponectin was an independent factor of D-IMT. In receiver operating characteristic analyses, the area under the curve for traditional risk factors plus adiponectin for prediction of macroangiopathy was 0.984, while that of traditional risk factors alone was 0.972.

CONCLUSIONS

Adiponectin is lower in patients with T2DM with macroangiopathy. We suggest that D-IMT could represent a noninvasive indicator of diabetic macroangiopathy. Decrease of adiponectin as an independent risk factor for both macroangiopathy and D-IMT among Chinese patients with T2DM suggests that adiponectin might have clinical utility in the prediction of diabetic macroangiopathy. This clinical trial is registered in the "Chinese Clinical Trial Registry." The registration number is ChiCTR-ROC-17011731.

Associations between the Neutrophil-to-Lymphocyte Ratio and Diabetic Complications in Adults with Diabetes: A Cross-Sectional Study

OBJECTIVE

The neutrophil-to-lymphocyte ratio (NLR) is an inexpensive and easily measurable laboratory index indicating systemic inflammation, while the application of many other inflammatory markers has been limited in daily clinical practice. However, large population studies about investigating the associations of the NLR level with diabetic complications including cardiovascular and cerebrovascular diseases (CVD), diabetic kidney disease (DKD), and diabetic retinopathy (DR) in the same population were limited. The aim of our study is to evaluate the associations between the NLR level and the prevalence of CVD, DKD, and DR in adults with diabetes simultaneously.

METHODS

A cross-sectional survey of 4,813 diabetic adults was conducted in seven communities in China. Persons underwent several medical examinations, including the measurement of anthropometric factors, blood pressure, routinely analyzed leukocyte characteristics, glucose, lipid profiles, urine albumin/creatinine ratio, and fundus photographs.

RESULTS

Compared with the first quartile of the NLR level, the odds of having CVD was significantly increased by 21% for participants in the highest quartile (OR 1.21; 95% CI 1.00, 1.47) (P for trend < 0.05). Similarly, the prevalence of DKD among participants in the highest quartile of the NLR level was significantly increased by 150% (OR 2.50; 95% CI 1.95, 3.19) (P for trend < 0.05). However, no association was found between the NLR level and the prevalence of DR (P for trend > 0.05). These associations were all fully adjusted.

CONCLUSIONS

A higher NLR level was associated with an increased prevalence of CVD and DKD, other than DR, in diabetic adults.

Diabetes affects endothelial cell function and alters fibrin clot formation in a microvascular flow model: A pilot study

Diabetes is a proinflammatory and prothrombotic condition that increases the risk of vascular complications. The aim of this study was to develop a diabetic microvascular flow model that allows to study the complex interactions between endothelial cells, blood cells and plasma proteins and their effects on clot formation. Primary human cardiac microvascular endothelial cells from donors without diabetes or donors with diabetes (type 1 or type 2) were grown in a microfluidic chip, perfused with non-diabetic or diabetic whole blood, and clot formation was assessed by measuring fibrin deposition in real time by confocal microscopy. Clot formation in non-diabetic whole blood was significantly increased in the presence of endothelial cells from donors with type 2 diabetes compared with cells from donors without diabetes. There was no significant difference in clot formation between non-diabetic and diabetic whole blood. We present for the first time a diabetic microvascular flow model as a new tool to study clot formation as a result of the complex interactions between endothelial cells, blood cells and plasma proteins in a diabetes setting. We show that endothelial cells affect clot formation in whole blood, attributing an important role to the endothelium in the development of atherothrombotic complications.

Improved carotid intima-media thickness-induced high-intensity interval training associated with decreased serum levels of Dkk-1 and sclerostin in type 2 diabetes

AIMS

Carotid intima-media thickness (cIMT) is a validated surrogate marker of atherosclerosis. Dickkopf-1 (Dkk-1) and sclerostin modulate wingless signaling, which is involved in atherosclerosis. The purpose of this study was to investigate whether 12 weeks of high-intensity interval training (HIIT) would improve cIMT and serum Dkk-1 and sclerostin levels in patients with type 2 diabetes.

METHODS

Seventy-four sedentary patients with type 2 diabetes were randomly divided into HIIT and control groups. The HIIT group intervention was 6 intervals (4 min) at 85%-90% HR_max separated by 3 min at 45%-50% HR_max in 3 sessions/week for 12 weeks. Before and after the intervention, cIMT, artery diameter and wall/lm ratio were recorded with high-resolution ultrasound. Serum sclerostin and Dkk-1 were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

cIMT decreased significantly in the HIIT group (0.83 ± 0.17 baseline, 0.71 ± 0.14 follow-up) compared to the control group (0.84 ± 0.20 baseline, 0.85 ± 0.19 follow-up) (P < .05). Dkk-1 and sclerostin decreased significantly after 12 weeks of HIIT (P < .01). In addition, VO_2peak was increased in the HIIT group than the control group (by 6.2 mL/kg/min) (P < .05). There was a positive correlation between percent changes in cIMT and percent changes in Dkk-1 and sclerostin (both P < .01). Additionally, there were a negative correlation between percent changes VO2peak and cIMT (r = - 0.740, P = .003), Dkk-1 (r = - 0.844, P < .001) and sclerostin (r = - 0.575, P = .001) in HIIT group.

CONCLUSION

Our results indicate that HIIT decreases cIMT, serum levels of Dkk-1 and sclerostin and improves VO_2peak in patients with type 2 diabetes.

Proatherogenic Importance of Carbamylation-induced Protein Damage and Type 2 Diabetes Mellitus: A Systematic Review

INTRODUCTION & BACKGROUND

Protein carbamylation is a non-enzymatic and irreversible posttranslational process. It affects functions of numerous enzymes, hormones and receptors playing several roles in diabetes pathogenesis by changing their native structures. Detrimental consequences of oxidative protein damage comprise, but are not limited to glyoxidation, lipoxidation and carbonylation reactions. Since the carbamylated plasma proteins are strongly related to the glycemic control parameters of diabetes, they may have an additive value and emerge as potential biomarkers for the follow up, prognosis and treatment of diabetes mellitus.

METHODS & RESULTS

To conduct our systematic review, we used PubMed and Semantic Scholar, and used 'Protein carbamylation and diabetes' and 'Protein carbamylation and atherosclerosis' as keywords and looked into about five hundred manuscripts. Manuscripts that are not in English were excluded as well as manuscripts that did not mention carbamylation to maintain the focus of the present article. Similar to glycation, carbamylation is able to alter functions of plasma proteins and their interactions with endothelial cells and has been shown to be involved in the development of atherosclerosis.

CONCLUSION

At this stage, it seems clear that protein carbamylation leads to worse clinical outcomes. To improve patient care, but maybe more importantly to improve healthcare-prevention, we believe the next stage involves understanding how exactly protein carbamylation leads to worse outcomes and when and in what group of people anti-carbamylation therapies must be employed.

Beneficial Effects of Ipragliflozin on the Renal Function and Serum Uric Acid Levels in Japanese Patients with Type 2 Diabetes: A Randomized, 12-week, Open-label, Active-controlled Trial

Objective To examine the add-on effects, compared to the existing antidiabetes treatment, of the sodium-glucose cotransporter 2 inhibitor ipragliflozin on glycemic control and the risk factors of cardiovascular disease (CVD) and chronic kidney disease (CKD) in patients with inadequately controlled type 2 diabetes. Methods This 12-week, randomized, open-label, active-controlled trial included 30 patients with type 2 diabetes who were randomized 1:1 to ipragliflozin and control groups (n=15 each). The ipragliflozin group received 50 mg of ipragliflozin once daily in addition to conventional therapy. The primary outcome was the change in hemoglobin A1c (HbA1c) from the baseline. Secondary outcomes were changes from the baseline in indices of glycemic control, uric acid (UA), renal function, and arterial stiffness. Results The patients' diminished estimated glomerular filtration rate (eGFR) was alleviated in the ipragliflozin group compared to the control group [difference between groups (Δ) =4.6 (95% confidence interval (CI): 1.5-7.7) mL/min/1.73 m², p=0.006] prior to significant improvements in HbA1c and other parameters, including anthropometric indices and arterial stiffness. Furthermore, ipragliflozin add-on therapy resulted in a greater reduction in serum UA levels than control therapy [Δ=-52.3 (95% CI: -85.5-19.1) μmol/L, p=0.003]. The changes in the eGFR with ipragliflozin treatment were associated with ipragliflozin-mediated changes in the UA, even after adjusting for the age, sex, baseline HbA1c, baseline UA, and baseline eGFR (standardized regression coefficient=-0.535, p=0.010). Conclusion Ipragliflozin add-on therapy was associated with beneficial renal effects in parallel with reducing serum UA levels.

Increased Plasma Soluble Interleukin-2 Receptor Alpha Levels in Patients With Long-Term Type 1 Diabetes With Vascular Complications Associated With IL2RA and PTPN2 Gene Polymorphisms

Type 1 diabetes (T1D) is largely considered an autoimmune disease leading to the destruction of insulin-producing pancreatic β cells. Further, patients with T1D have 3-4-fold increased risk of developing micro- and macrovascular complications. However, the contribution of immune-related factors contributing to these diabetes complications are poorly understood. Individuals with long-term T1D who do not progress to vascular complications offer a great potential to evaluate end-organ protection. The aim of the present study was to investigate the association of inflammatory protein levels with vascular complications (retinopathy, nephropathy, cardiovascular disease) in individuals with long-term T1D compared to individuals who rapidly progressed to complications. We studied a panel of inflammatory markers in plasma of patients with long-term T1D with (n = 81 and 26) and without (n = 313 and 25) vascular complications from two cross-sectional Scandinavian cohorts (PROLONG and DIALONG) using Luminex technology. A subset of PROLONG individuals (n = 61) was screened for circulating immune cells using multicolor flow cytometry. We found that elevated plasma levels of soluble interleukin-2 receptor alpha (sIL-2R) were positively associated with the complication phenotype. Risk carriers of polymorphisms in the IL2RA and PTPN2 gene region had elevated plasma levels of sIL-2R. In addition, cell surface marker analysis revealed a shift from naïve to effector T cells in T1D individuals with vascular complications as compared to those without. In contrast, no difference between the groups was observed either in IL-2R cell surface expression or in regulatory T cell population size. In conclusion, our data indicates that IL2RA and PTPN2 gene variants might increase the risk of developing vascular complications in people with T1D, by affecting sIL-2R plasma levels and potentially lowering T cell responsiveness. Thus, elevated sIL-2R plasma levels may serve as a biomarker in monitoring the risk for developing diabetic complications and thereby improve patient care.

Association of serum angiopoietin-like protein 2 with elevated risk of cardiovascular diseases in subjects with type 2 diabetes

AIMS

Although previous data have suggested ANGPTL2 and ANGPTL8 (betatrophin) to be related to atherosclerosis in humans, little is known whether this applies in patients with type 2 diabetes (T2D). In this work, we investigate association of serum ANGPTL2 and betatrophin with the risk of cardiovascular diseases (CVD) in T2D patients.

METHODS

We measured serum levels of ANGPTL2 and betatrophin in 150 T2D patients with and without CVD and in 100 control subjects.

RESULTS

Serum ANGPTL2 was significantly higher in T2D patients than in controls (p < 0.0001), and in T2D + CVD patients than T2D only patients (p = 0.0002). Serum betatrophin was lower in T2D patients than in controls but with no statistical significance (p = 0.07). Elevated serum ANGPTL2 associated with 2.83-fold increased risk of T2D and with 1.18-fold elevated risk of CVD among T2D patients with positive correlations with markers of hyperglycemia, insulin resistance and atherogenic lipid profile. ROC curve indicated ANGPTL2 as risk biomarker for T2D and CVD with sensitivity of 92.2% and 86%; and specificity of 86.7% and 58%; respectively.

CONCLUSION

We indicate for the first time serum ANGPTL2 as an independent risk biomarker for CVD in T2D patients. Future studies are needed to reveal its role in disease pathogenesis.

Increased CRP: An extended biomarker of microvascular risk in men with type 2 diabetes

BACKGROUND

The usefulness of C-reactive protein (CRP) to predict cardiovascular disease (CVD) in type 2 diabetes (T2DM) remains controversial. As many factors linked to obesity can modulate CRP in T2DM, we comprehensively revisited the cardiometabolic phenotype of patients with normal or raised CRP, taking into account the sexual dimorphism of its serum value.

METHODS

1005 T2DM patients (651 males, 354 females; macroangiopathy 38%; coronary artery disease 26%; microangiopathy 47%) were divided depending on whether CRP level was ≤ or >3 mg/L. Thirty percent of men (n = 195) and 39% of women (n = 137) had raised CRP. Their cardiometabolic phenotype and presence of micro- and macrovascular complications were compared to those with normal CRP.

RESULTS

In both gender, patients with elevated CRP had higher body mass index, waist circumference, fat mass, visceral fat, insulinemia, HbA1c, and lower muscle mass and insulin sensitivity. They had more atherogenic dyslipidemia, higher non-HDL-C and apolipoprotein B₁₀₀, and more lipoprotein(a) (+59% in men and +38% in women). In both sexes, there was no difference between patients with normal or high CRP regarding overall macroangiopathy (42% vs. 45% [men]; 27% vs. 28% [women]), coronary and peripheral artery disease, or stroke. Only in men, microangiopathy was more prevalent when CRP was raised (61% vs 44%; p < 0.0001).

CONCLUSIONS

This study shows major sex-related differences in microangiopathies in T2DM patients with high CRP levels. The latter are unrelated to prevalent CVD despite an unfavorable metabolic phenotype. By contrast, increased CRP may represent an extended biomarker of microvascular risk in men with T2DM.

Serum pigment epithelium-derived factor: Relationships with cardiovascular events, renal dysfunction, and mortality in the Veterans Affairs Diabetes Trial (VADT) cohort

BACKGROUND

To determine if serum pigment epithelium-derived factor (PEDF) levels predict cardiovascular events, renal dysfunction and mortality in the Veterans Affairs Diabetes Study (VADT).

METHODS

PEDF was evaluated in relation to subsequent cardiovascular outcomes, mortality, and renal dysfunction (defined as urinary albumin creatinine ratio (ACR) ≥300 mg/g), or chronic kidney disease (CKD) stages 3 (eGFR<60 ml/min) or 4 (eGFR<60 and <30 ml/min respectively). PEDF was measured by ELISA on sera from 881 participants collected a median (range) of 1.7 (0-5.0) years post-baseline, and later, from 832 participants 4.0 (1.5-6.9) years post-baseline.

RESULTS

In 743 participants, PEDF was measured at both time-points. PEDF increased over time from (mean ± SD) 10.5 ± 4.03 to 11.0 ± 4.86 ng/ml (paired t-test p = 0.0092). Lower eGFR (p < 0.01), higher serum creatinine (p < 0.01) and urinary ACR (p < 0.01) were associated with increasing PEDF. Multivariate event time models included either one or two follow-up windows (i.e., between first and second PEDF measures; and, when available, from second PEDF measure until study-end). PEDF tertiles were not associated with cardiovascular events, but were significantly associated with all-cause mortality [HR = 2.00 (1.03, 3.89) comparing first to third tertile] in models adjusted for age, minority status, VADT treatment arm and prior cardiovascular event status. Higher PEDF levels also associated with development of kidney dysfunction with adjusted HRs (95% CI comparing third to first PEDF tertiles: 2.74 (1.71, 4.39) for stage 3 CKD; and 3.84 (95% CI: 1.17, 12.5) for stage 4 CKD.

CONCLUSIONS

Over 2-years, higher serum PEDF levels predicted advanced nephropathy in patients with type 2 diabetes.

Cardiovascular outcome trials and major cardiovascular events: does glucose matter? A systematic review with meta-analysis

PURPOSE

We did a meta-analysis with meta-regression to evaluate the relationship between hemoglobin A1c (A1C) reduction and the primary CV outcome of cardiovascular outcome trials (CVOTs).

METHODS

We used a random effects meta-analysis of the 12 CVOTs to quantify the effect of A1C reduction on major cardiovascular events (MACE) risk by stratifying the difference in achieved A1C (drug vs placebo) in three strata: A1c < 0.3%, A1c ≥ 0.3% and < 0.5%, and A1c ≥ 0.5%.

RESULTS

We found a relation between the reduction in achieved A1C and the hazard ratio reduction for MACE (P = 0.002), explaining almost all (94.1%) the between-study variances: lowering A1C by 0.5% conferred a significant HRR of 20% (95% CI 4-33%) for MACE.

CONCLUSIONS

Blood glucose reduction may play a more important role than previously thought in reducing the risk of MACE during treatment with the newer glucose-lowering drugs, including peptidase-4 inhibitors, glucagon-like peptide 1 receptor agonists and sodium-glucose co-transporter-2 inhibitors.