The Clinical Characteristics of Normoalbuminuric Renal Insufficiency in Korean Type 2 Diabetic Patients: A Possible Early Stage Renal Complication

It has been recently reported that a considerable portion of diabetic patients with renal insufficiency show normoalbuminuria. As little is known about normoalbuminuric renal insufficiency in the Asian population, we examined its prevalence and clinical characteristics in Korean type 2 diabetic patients. We studied 562 patients with type 2 diabetes from Seoul National University Hospital. The estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease formula and the degree of albuminuria was evaluated by spot urine albumin-creatinine ratio. Of 562 patients, 151 (26.9%) patients had renal insufficiency (eGFR <60 mL/min/1.73m2). Among them, 44 (29.1%) patients had normoalbuminuria. After excluding the patients using renin-angiotensin system (RAS) inhibitors, the prevalence of normoalbuminuric renal insufficiency was 35.3% (18 of 51 patients). Compared with micro- and macroalbuminuric renal insufficiency, normoalbuminuric renal insufficiency was associated with the female predominance, shorter duration of diabetes, lower prevalence of diabetic retinopathy, and lower prevalence of using antihypertensive drugs except RAS inhibitors. The prevalence decreased progressively with an increase in the duration of diabetes and an increase in the severity of retinopathy. Normoalbuminuric renal insufficiency was prevalent in Korean type 2 diabetic patients. The association with a shorter duration of the diabetes and a lower prevalence of retinopathy suggests that it might be an early stage renal complication

Long-term prevention of renal insufficiency, excess matrix gene expression, and glomerular mesangial matrix expansion by treatment with monoclonal antitransforming growth factor-ß antibody in \u3ci\u3edb/db\u3c/i\u3e diabetic mice

Emerging evidence suggests that transforming growth factor-(TGF-β) is an important mediator of diabetic nephropathy. We showed previously that short-term treatment with a neutralizing monoclonal anti-TGF-antibody (αT) in streptozotocin-diabetic mice prevents early changes of renal hypertrophy and increased matrix mRNA. To establish that overactivity of the renal TGF-system mediates the functional and structural changes of the more advanced stages of nephropathy, we tested whether chronic administration of αT prevents renal insufficiency and glomerulosclerosis in the db/db mouse, model of type 2 diabetes that develops overt nephropathy. Diabetic db/db mice and nondiabetic db/m littermates were treated intraperitoneally with α or control IgG, 300 µg three times per week for 8 wk. Treatment with αT, but not with IgG, significantly decreased the plasma TGF-β1 concentration without decreasing the plasma glucose concentration. The IgG-treated db/db mice developed albuminuria, renal insufficiency, and glomerular mesangial matrix expansion associated with increased renal mRNAs encoding α 1(IV) collagen and fibronectin. On the other hand, treatment with α completely prevented the increase in plasma creatinine concentration, the decrease in urinary creatinine clearance, and the expansion of mesangial matrix in db/db mice. The increase in renal matrix mRNAs was substantially attenuated, but the excretion of urinary albumin factored for creatinine clearance was not significantly affected by α treatment. We conclude that chronic inhibition of the biologic actions of TGF-with neutralizing monoclonal antibody in db/db mice prevents the glomerulosclerosis and renal insufficiency resulting from type diabetes

Evaluation of oxidative stress biomarkers in patients with chronic renal failure: a case control study

<p>Abstract</p> <p>Background</p> <p>Oxidative stress is related to several diseases, including chronic renal insufficiency. The disequilibrium in the oxidant-antioxidant balance is the result of several metabolic changes. The majority of studies to-date have evaluated the grade of oxidative stress with a single biomarker, or a very limited number of them.</p> <p>Findings</p> <p>The present study used several important biomarkers to establish a score relating to oxidative stress status (glutathione S-transferase, superoxide dismutase, catalase, glutathione peroxidase, glutathione reductase, reduced and oxidized glutathione, thiobarbituric acid reactive substances and hemolysis test). The score of oxidative stress (SOS) was then applied to a group of patients with renal insufficiency not on hemodialysis, and compared to healthy control individuals.</p> <p>The score for patients with chronic renal insufficiency was significantly different from that of the healthy control group (0.62 ± 1.41 vs. -0.05 ± 0.94; p < 0.001). The comparison between patients with chronic renal insufficiency and control individuals showed significant differences with respect to changes in the enzymatic antioxidant systems (glutathione S-transferase, glutathione reductase), non-enzymatic antioxidant system (oxidized glutathione) and oxidizability (hemolysis test) indicating significant oxidative stress associated with chronic renal insufficiency.</p> <p>Conclusions</p> <p>Patients with chronic renal insufficiency not on hemodialysis are susceptible to oxidative stress. The mechanisms that underlie this status are the consequence of changes in glutathione and related enzymes. The SOS scoring system is a useful biochemical parameter to evaluate the influence of oxidative stress on the clinical status of these patients.</p

Is preoperative serum creatinine a reliable indicator of outcome in patients undergoing coronary artery bypass surgery?

ObjectiveEvaluating renal function by calculating creatinine clearance as an alternative measure to serum creatinine may give a better estimation of postoperative renal function in patients undergoing coronary artery bypass grafting.MethodsUsing our database, we conducted a retrospective review of the records of all 11,884 patients aged 21 years or older undergoing pure bypass grafting who required cardiopulmonary bypass. Preoperative renal function was categorized as normal renal function (serum creatinine ≤1.1 mg/dL and creatinine clearance > 60 mL/min), occult renal insufficiency (serum creatinine ≤ 1.1 mg/dL and creatinine clearance ≤ 60 mL/min), mild renal insufficiency (1.1 mg/dL < serum creatinine ≤ 1.5 mg/dL and creatinine clearance ≤ 60 mL/min) or moderate renal insufficiency (serum creatinine > 1.5 mg/dL and creatinine clearance ≤ 60 mL/min).ResultsOut of 11,884 patients in the sample, 7856 (66.1%) had normal renal function, and 706 (5.9%) had occult renal insufficiency. The rate of postoperative mortality, renal failure, atrial fibrillation, prolonged ventilation, intra-aortic balloon pump usage, and prolonged hospital stay (>7 days) was higher in patients with occult renal insufficiency than in the normal group in univariable analysis. Multivariable logistic regression analysis demonstrated that patients with occult renal insufficiency compared with the group with normal renal function were at higher risk for mortality (odds ratio = 2.59, 95% confidence interval 1.15–5.86; P = .022) and prolonged hospital stay (>7 d) (odds ratio = 1.30, 95% confidence interval 1.08–1.57; P = .005).ConclusionsTo identify higher-risk patients requiring special intensive care, and in whom new interventions can be performed to improve outcome, we recommend the preoperative calculation of creatinine clearance, especially in older women with a lower body mass index

Concomitant renal insufficiency and diabetes mellitus as prognostic factors for acute myocardial infarction

<p>Abstract</p> <p>Background</p> <p>Diabetes mellitus and renal dysfunction are prognostic factors after acute myocardial infarction (AMI). However, few studies have assessed the effects of renal insufficiency in association with diabetes in the context of AMI. Here, we investigated the clinical outcomes according to the concomitance of renal dysfunction and diabetes mellitus in patients with AMI.</p> <p>Methods</p> <p>From November 2005 to August 2008, 9905 patients (63 ± 13 years; 70% men) with AMI were enrolled in a nationwide prospective Korea Acute Myocardial Infarction Registry (KAMIR) and were categorized into 4 groups: Group I (n = 5700) had neither diabetes nor renal insufficiency (glomerular filtration rate [GFR] ≥ 60 ml/min/1.73 m²), Group II (n = 1730) had diabetes but no renal insufficiency, Group III (n = 1431) had no diabetes but renal insufficiency, and Group IV (n = 1044) had both diabetes and renal insufficiency. The primary endpoints were major adverse cardiac events (MACE), including a composite of all cause-of-death, myocardial infarction, target lesion revascularization, and coronary artery bypass graft after 1-year clinical follow-up.</p> <p>Results</p> <p>Primary endpoints occurred in 1804 (18.2%) patients. There were significant differences in composite MACE among the 4 groups (Group I, 12.5%; Group II, 15.7%; Group III, 30.5%; Group IV, 36.5%; <it>p </it>< 0.001). In a Cox proportional hazards model, after adjusting for multiple covariates, the 1-year mortality increased stepwise from Group III to IV as compared with Group I (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.34-2.86; <it>p </it>= 0.001; and HR, 2.42; 95% CI, 1.62-3.62; <it>p </it>< 0.001, respectively). However, Kaplan-Meier analysis showed no significant difference in probability of death at 1 year between Group III and IV (p = 0.288).</p> <p>Conclusions</p> <p>Renal insufficiency, especially in association with diabetes, is associated with the occurrence of composite MACE and indicates poor prognosis in patients with AMI. Categorization of patients with diabetes and/or renal insufficiency provides valuable information for early-risk stratification of AMI patients.</p

Urbanization and non-communicable disease mortality in Thailand: an ecological correlation study.

This study provides strong evidence from an LMIC that urbanization is associated with mortality from three lifestyle-associated diseases at an ecological level. Furthermore, our data suggest that both average household income and number of doctors per population are important factors to consider in ecological analyses of mortality

The Incidence of Anemia and the Impact of Poor Glycemic Control in Type-2 Diabetic Patients with Renal Insufficiency

Background: Anemia is a common finding in patients with diabetes and renal insufficiency but the effect of poor glycemic control in such patients is not clearly defined. Aim: To determine the impact of poor glycemic control in the incidence of anemia in type-2 diabetic patients with renal insufficiency. Methods: This cross-sectional study was conducted in 2012 and comprised 72 type-2 diabetic patients and 32 non-diabetic controls recruited from diabetes clinics of the Igbinedion University Teaching Hospital, Okada, Edo state, Nigeria. Patients were divided into groups according to glycemic control and renal function. Serum creatinine, hemoglobin concentration, blood glucose and glycated hemoglobin of subjects were measured. The pre­sence of anemia was defined by hemoglobin level &lt;13.0 g/dL in men and &lt;12.0 g/dL in women. Renal insufficiency was defined as serum creatinine level &gt;1.5 mg/dL. Results: Incidence of anemia in the study population was 27%. Diabetic patients with poor glycemic control had greater odds (OR = 3.71; 95% CI, 1.09 – 12.56) for anemia compared to those with good glycemic control irrespective of renal function. Furthermore, patients with poor glycemic control and renal insufficiency were at a greater risk of anemia compared to those with normal renal function (OR = 5.78; 95% CI, 1.34 – 24.92). Conclusion: Higher incidence of anemia is associated with poor glycemic control especially in diabetic patients with renal insufficiency. Keywords: Anemia, Type-2 diabetes mellitus, Glycemic control, Renal insufficienc

Impact of renal insufficiency on long-term clinical outcome in patients with heart failure treated by cardiac resynchronization therapy

AbstractBackgroundRenal insufficiency is recognized as a predictor of mortality and adverse outcome in heart failure (HF) patients. However, the long-term clinical outcome of cardiac resynchronization therapy (CRT) in Japanese HF patients with renal insufficiency remains uncertain.MethodsWe evaluated 67 consecutive patients who underwent CRT at our hospital. The patients were divided into two groups according to a baseline estimated glomerular filtration rate (e-GFR) cut-off value of 50ml/min, which is defined as the time at which patients should be referred to a nephrologist, by the Japanese Society of Nephrology. Follow-up echocardiographic findings and renal function were examined at 3–6 months after CRT. Then, we compared long-term clinical outcomes between the two groups, and analyzed the effect of CRT on renal function, echocardiographic parameters and cardiac survival.ResultsDuring a mean follow-up period of 30.3 months, patients with advanced renal insufficiency (e-GFR<50ml/min) had significant higher all-cause mortality (log-rank p=0.033) and higher cardiac mortality combined with HF hospitalization (log-rank p=0.017) than patients with e-GFR≥50ml/min. Multivariate analysis revealed that advanced renal insufficiency was an independent predictor of cardiac mortality combined with HF hospitalization (odds ratio=3.01, p=0.008). Subgroup analysis in the baseline advanced renal insufficiency group revealed that patients with preserved renal function by CRT (<10% reduction in e-GFR) had a higher rate of decrease of left ventricular end-systolic diameter (−14.0% vs. −0.8%, p=0.023) and lower cardiac mortality combined with HF hospitalization (log-rank p=0.029) compared with patients with deterioration of renal function (≥10% reduction in e-GFR).ConclusionsThe present study suggests that advanced renal insufficiency is quite useful for the prediction of worsening clinical outcomes in HF patients treated by CRT. Preservation of renal function by CRT brings about better cardiac survival through prevention of adverse cardiac events, even in HF patients with advanced renal insufficiency

The Needs of Patients in a Rural/Frontier Setting with Renal Insufficiency

The purpose of this study was to identify any needs patients with renal insufficiency living in a rural/frontier setting may have. A chart review was conducted in a rural health care facility of all patients with diagnostic code 593.9. The following questions were asked: What are the characteristics of the patients in this rural/frontier setting? What is the difference in their levels of renal insufficiency? What risk factors are related to the level of renal insufficiency? In what ways do their risk factors compare with those identified in literature? The results of this study were compared to what is stated in literature about the cause of renal insufficiency. After reviewing the data collected it was found that females were older, more likely to have congestive heart failure, and had higher glomelular filtration rates (GFR) than males at all four time periods. There was a significant decrease in systolic and diastolic blood pressure and GFR over time. The significant predictors of GFR at Time 1 were younger age, higher systolic blood pressure, lower diastolic blood pressure, and more miles from the clinic. The results demonstrate the need for more aggressive management of hypertension by providers

Binding of bromocresol green and bromocresol purple to albumin in hemodialysis patients

BACKGROUND: Colorimetric albumin assays based on binding to bromocresol purple (BCP) and bromocresol green (BCG) yield different results in chronic kidney disease. Altered dye binding of carbamylated albumin has been suggested as a cause. In the present study, a detailed analysis was carried out in which uremic toxins, acute phase proteins and Kt/V, a parameter describing hemodialysis efficiency, were compared with colorimetrically assayed (BCP and BCG) serum albumin. METHODS: Albumin was assayed using immunonephelometry on a BN II nephelometer and colorimetrically based on, respectively, BCP and BCG on a Modular P analyzer. Uremic toxins were assessed using high-performance liquid chromatography. Acute phase proteins (C-reactive protein and α1-acid glycoprotein) and plasma protein α2-macroglobulin were assayed nephelometrically. In parallel, Kt/V was calculated. RESULTS: Sixty-two serum specimens originating from hemodialysis patients were analyzed. Among the uremic toxins investigated, total para-cresyl sulfate (PCS) showed a significant positive correlation with the BCP/BCG ratio. The serum α1-acid glycoprotein concentration correlated negatively with the BCP/BCG ratio. The BCP/BCG ratio showed also a negative correlation with Kt/V. CONCLUSIONS: In renal insufficiency, the BCP/BCG ratio of serum albumin is affected by multiple factors: next to carbamylation, uremic toxins (total PCS) and α1-acid glycoprotein also play a role