Long-term effects of intensive glycemic and blood pressure control and fenofibrate use on kidney outcomes

Background and objectives In people with type 2 diabetes, aggressive control of glycemia, BP, and lipids have resulted in conflicting short-term (<5 years) kidney outcomes. We aimed to determine the long-term kidney effects of these interventions. Design, setting, participants, & measurements The Action to Control Cardiovascular Risk in Diabetes (ACCORD) was a multifactorial intervention study in people with type 2 diabetes at high risk for cardiovascular disease (n=10,251), to examine the effects of intensive glycemic control (hemoglobin A1c <6.0% versus 7%-7.9%), BP control (systolic BP <120 mm Hg versus <140 mm Hg) or fenofibrate versus placebo added to simvastatin on cardiovascular events and death. The glycemia trial lasted 3.7 years and participants were followed for another 6.5 years in ACCORDION, the ACCORD Follow-On Study. The post hoc primary composite kidney outcome was defined as incident macroalbuminuria, creatinine doubling, need for dialysis, or death by any cause. Cox proportional hazards regression estimated the effect of each intervention on the composite outcome and individual components. In secondary outcome analyses, competing risk regression was used to account for the risk of death in incident kidney outcomes. Analyses were adjusted for sociodemographics, randomization groups, and clinical factors. Results There were 988 cases of incident macroalbuminuria, 954 with doubling of creatinine, 351 requiring dialysis, and 1905 deaths. Hazard ratios (HRs) for the composite outcome with intensive glycemic, BP control, and fenofibrate use compared with standard therapy were 0.92 (95% confidence interval [95% CI], 0.86 to 0.98), 1.16 (95% CI, 1.05 to 1.28), and 1.16 (95% CI, 1.06 to 1.27). Multivariable, secondary outcome analyses showed that in the glycemia trial, only macroalbuminuria was significantly decreased (HR, 0.68; 95% CI, 0.59 to 0.77). In the BP and lipid trials, only creatinine doubling was affected (HR, 1.64; 95% CI, 1.30 to 2.06 and HR, 2.00; 95% CI, 1.61 to 2.49, respectively). Conclusions In people with type 2 diabetes at high risk for cardiovascular disease, intensive glycemic control may result in a long-term reduction in macroalbuminuria; however, intensive BP control and fenofibrates may increase the risk for adverse kidney events

Plant functional and taxonomic diversity in European grasslands along climatic gradients

Aim: European grassland communities are highly diverse, but patterns and drivers of their continental-scale diversity remain elusive. This study analyses taxonomic and functional richness in European grasslands along continental-scale temperature and precipitation gradients. Location: Europe. Methods: We quantified functional and taxonomic richness of 55,748 vegetation plots. Six plant traits, related to resource acquisition and conservation, were analysed to describe plant community functional composition. Using a null-model approach we derived functional richness effect sizes that indicate higher or lower diversity than expected given the taxonomic richness. We assessed the variation in absolute functional and taxonomic richness and in functional richness effect sizes along gradients of minimum temperature, temperature range, annual precipitation, and precipitation seasonality using a multiple general additive modelling approach. Results: Functional and taxonomic richness was high at intermediate minimum temperatures and wide temperature ranges. Functional and taxonomic richness was low in correspondence with low minimum temperatures or narrow temperature ranges. Functional richness increased and taxonomic richness decreased at higher minimum temperatures and wide annual temperature ranges. Both functional and taxonomic richness decreased with increasing precipitation seasonality and showed a small increase at intermediate annual precipitation. Overall, effect sizes of functional richness were small. However, effect sizes indicated trait divergence at extremely low minimum temperatures and at low annual precipitation with extreme precipitation seasonality. Conclusions: Functional and taxonomic richness of European grassland communities vary considerably over temperature and precipitation gradients. Overall, they follow similar patterns over the climate gradients, except at high minimum temperatures and wide temperature ranges, where functional richness increases and taxonomic richness decreases. This contrasting pattern may trigger new ideas for studies that target specific hypotheses focused on community assembly processes. And though effect sizes were small, they indicate that it may be important to consider climate seasonality in plant diversity studies