Systolic blood pressure as a predictor of incident albuminuria and rapid renal function decline in type 2 diabetic patients
Introduction
The prevalence of diabetic renal disease is growing at an alarming rate worldwide and has imposed a high burden of disease-related morbidity and mortality in the recent decades (Huang et al., 2012, Jindal et al., 2013, Reeves et al., 2012). Diabetic nephropathy shares many risk factors with cardiovascular disease (Luo et al., 2010, Sheen et al., 2013), and usually occurs in conjunction with various metabolic abnormalities, such as hyperglycemia (Coresh et al., 2003, Ritz, 2008), dyslipidemia (Chawla et al., 2010, Lee et al., 2009), or overweight/obesity (Inker et al., 2014, Jindal et al., 2013); hypertension (Coresh et al., 2003, Haroun et al., 2003, Whelton et al., 1996); and smoking (Ritz, 2008). Traditionally, two biomarkers, namely the glomerular filtration rate (GFR) and albuminuria, have been used for the diagnosis, severity classification, and outcome prediction of chronic kidney disease (CKD). In fact, based on the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guidelines, both the estimated GFR (eGFR) and albuminuria are required for assessing the progression and identifying the stage of CKD (Inker et al., 2014), and previous studies have demonstrated that an eGFR decline is a prognostic marker for the outcomes of systemic disease-related nephropathy (Drury et al., 2011, Weng et al., 2014). Moreover, a low eGFR has been demonstrated to be associated with progressive arterial stenosis and stiffening (Bertomeu et al., 2008, Bouchi et al., 2011, Kshirsagar et al., 2004, Meguro et al., 2009, Nakamura et al., 2010, Sheen et al., 2012).
Albuminuria is considered to be an early sign of renal damage in diabetic patients (Seaquist & Ibrahim, 2010), and is an established marker for predicting the progression of renal function, adverse cardiovascular outcomes, and mortality in patients with diabetes and nephropathy (Halbesma et al., 2006, Holtkamp et al., 2011, Stephen et al., 2014). Previous studies, such as UKPDS (Retnakaran, Cull, Thorne, Adler, & Holman, 2006), have investigated the factors predicting progression of renal function in type 2 diabetes; however, the progression rate of diabetic kidney disease is highly variable. In most cases, diabetic kidney disease progresses over decades, and rapid renal function progression can lead to renal failure within months (Levey & Coresh, 2012). The potential causes of variations in the progression rate of renal function in type 2 diabetic patients are still undetermined.
Therefore, we here aimed to evaluate the potential determinants of incident albuminuria and rapid decline of eGFR in type 2 diabetic outpatients.
Section snippets
Study population
We retrospectively analyzed data obtained from an outpatient clinic of a community hospital in central Taiwan. Type 2 diabetic patients who regularly visited the outpatient department, underwent ankle-brachial index (ABI) examinations between October 2008 and August 2009, and had measured their renal function every 6 months and urinary albumin-to-creatinine ratio (UACR) annually for at least 1 year were reviewed. Patients were excluded if they were undergoing dialysis or had been diagnosed with
Results
Table 1A shows the baseline clinical characteristics of the study population. Twenty (15.2%) of the 132 patients with normoalbuminuria at baseline progressed to a more advanced stage of albuminuria during the 1-year follow up. These patients had significantly higher mean values of SBP and PP, presented with higher baseline UACR, and were taking sulfonylurea more frequently than those who did not develop incident albuminuria (Table 2). Table 3 illustrates the results of the multivariate logistic
Discussion
In the present study, we demonstrated that SBP was an independent factor associated with both incident albuminuria and a rapid decline of eGFR in type 2 diabetic outpatients without apparent cardiovascular complications during a 1-year follow-up.
Albuminuria is traditionally considered an early marker of diabetic nephropathy, and may appear before the reduction of eGFR (Jindal et al., 2013, Seaquist and Ibrahim, 2010). Accordingly, the level of albuminuria is reported to be a better marker than
Acknowledgments
This study was supported by grants from the Taichung Hospital, Ministry of Health and Welfare, Taiwan, and was approved by the Institutional Review Board of the Taichung Hospital (B-100001).
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2018, Toxicology and Applied PharmacologyCitation Excerpt :Since our study indicates a significant interaction between kidney function and urinary Cd in relation to blood pressure, stratified analysis is appropriate in addressing the modifying effect of kidney function. One possible explanation for the observation that urinary Cd was positively associated with levels of DBP, but inversely related to SBP is that two previous studies found SBP, but not DBP was significantly associated with a rapid decline in eGFR in the general population (Hirayama et al., 2015) or in individuals with type 2 diabetes (Sheen, Lin, Li, Bau, and Sheu, 2014). This possibility is supported by the change in the inverse association between urinary Cd and SBP to a null or positive association after stratification by eGFR.
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Conflict of Interest: The authors declare no conflicts of interest.