Diabetic nephropathy in a sibling and albuminuria predict early GFR decline: a prospective cohort study.

BACKGROUND: Diabetic nephropathy is a growing clinical problem, and the cause for >40% of incident ESRD cases. Unfortunately, few modifiable risk factors are known. The objective is to examine if albuminuria and history of diabetic nephropathy (DN) in a sibling are associated with early DN progression or mortality. METHODS: In this longitudinal study of adults >18 yrs with diabetes monitored for up to 9 yrs (mean 4.6 ± 1.7 yrs), 435 subjects at high risk (DN family history) and 400 at low risk (diabetes >10 yrs, normoalbuminuria, no DN family history) for DN progression were evaluated for rate of eGFR change using the linear mixed effects model and progression to ESRD. All-cause mortality was evaluated by Kaplan-Meier analyses while controlling for baseline covariates in a Cox proportional hazards model. Covariates included baseline eGFR, age, gender, race, diabetes duration, blood pressure, hemoglobin A1c and urine albumin:creatinine ratio. Propensity score matching was used to identify high and low risk group pairs with balanced covariates. Sensitivity analyses were employed to test for residual confounding. RESULTS: Mean baseline eGFR was 74 ml/min/1.73 m2 (86% of cohort >60 ml/min/1.73 m2). Thirty high risk and no low risk subjects developed ESRD. eGFR decline was significantly greater in high compared to low risk subjects. After controlling for confounders, change in eGFR remained significantly different between groups, suggesting that DN family history independently regulates GFR progression. Mortality was also significantly greater in high versus low risk subjects, but after controlling for baseline covariates, no significant difference was observed between groups, indicating that factors other than DN family history more strongly affect mortality. Analyses of the matched pairs confirmed change in eGFR and mortality findings. Sensitivity analyses demonstrated that the eGFR results were not due to residual confounding by unmeasured covariates of a moderate effect size in the propensity matching. CONCLUSIONS: Diabetic subjects with albuminuria and family history of DN are vulnerable for early GFR decline, whereas subjects with diabetes for longer than 10 years, normoalbuminuria and negative family history, experience slower eGFR decline, and are extremely unlikely to require dialysis. Although we would not recommend that patients with low risk characteristics be neglected, scarce resources would be more sensibly devoted to vulnerable patients, such as the high risk cases in our study, and preferably prior to the onset of albuminuria or GFR decline.

Use of diffusion tensor MRI to identify early changes in diabetic nephropathy.

BACKGROUND/AIMS: Currently available clinical indicators of kidney disease lack the sensitivity and/or specificity to identify early-stage diabetic nephropathy (DN). Quantitative diffusion magnetic resonance imaging (MRI), specifically diffusion tensor imaging (DTI), has been used to quantify pathophysiologic changes in other organs but has not been well studied in kidney diseases, including DN. The goal of this pilot study was to examine differences in kidney DTI parameters in diabetic subjects versus healthy controls. METHODS: 16 diabetic and 5 healthy control subjects were recruited for this institutional review board-approved/Health Insurance Portability and Accountability Act-compliant study. Kidneys were scanned using DTI to generate apparent diffusion coefficient (ADC) and fractional anisotropy (FA) data. Mean cortical and medullary ADC and FA values were calculated by selecting multiple regions of interest. Diabetics were stratified by estimated glomerular filtration rate (eGFR) into 2 groups: eGFR ≥60 (n = 10) and eGFR <60 (n = 6) ml/min/1.73 m(2). Mean diffusion parameters and eGFRs were compared between these groups of diabetic subjects and healthy controls. RESULTS: Medullary FA, ADC and cortical ADC values were significantly lower in diabetics with eGFR <60 compared to controls. Notably, both mean medullary FA and ADC were significantly lower in diabetics with eGFR ≥60 compared to controls (p = 0.001 and p = 0.042, respectively). For the study subjects in aggregate, medullary FA correlated significantly with eGFR (R = 0.69, p < 0.01); the other diffusion parameters showed no significant correlations. CONCLUSIONS: This pilot study suggests that changes in medullary DTI assessments may serve as indicators of early DN. Further studies are needed to determine if these findings could serve as biomarkers to identify diabetics at risk of DN progression.

Risk factors for development and progression of diabetic kidney disease and treatment patterns among diabetic siblings of patients with diabetic kidney disease.

BACKGROUND: Diabetic siblings of patients with treated kidney failure from diabetic kidney disease are at a 5-fold increased risk of future kidney failure. The objective of this study is to define risk factors for kidney disease, clinical features, and treatment patterns in diabetic siblings of patients with diabetes with diabetic kidney disease. STUDY DESIGN: Cross-sectional analysis using data collected from diabetic siblings of patients with diabetic kidney disease. SETTING & PARTICIPANTS: 295 diabetic siblings with mean diabetes duration of 15 years from within a 400-mile radius of Cleveland, OH, or Winston-Salem, NC. PREDICTORS: Demographic data, diabetes duration, blood pressure (BP), access to health care, and diabetes control. OUTCOMES: Albuminuria (defined as urinary albumin-creatinine ratio >or= 30 mg/g, with microalbuminuria with albumin of 30 to 300 mg/g and macroalbuminuria with albumin > 300 mg/g), renal function. MEASUREMENTS: BP, urinary albumin-creatinine ratio, serum creatinine, glycosylated hemoglobin (HbA(1c)), estimated glomerular filtration rate. RESULTS: Mean diabetes duration was 14.6 +/- 10.6 years. Albuminuria was present in 46% of participants. In individuals with diabetes duration of 11 to 15 years, 25% had microalbuminuria and 18.2% had macroalbuminuria. Despite a positive family history and a high prevalence of albuminuria, only 35.3% of participants had a target systolic BP less than 130 mm Hg. HbA(1c) levels were 7% or greater in 57.4% of patients, and 26.4% of participants were smokers. Only 58% of patients received angiotensin-converting enzyme inhibitors or receptor blockers. In microalbuminuric participants, HbA(1c) level was greater than 10% in 28.6% versus 13.3% in those without albuminuria (P = 0.02). LIMITATIONS: A control group of diabetic siblings without a family history of diabetic kidney disease was not obtained. CONCLUSIONS: Diabetic siblings of patients with diabetic kidney disease have a high prevalence of albuminuria and poor glycemic and BP control. Targeting these high-risk individuals for interventions to improve their BP and blood glucose control might prevent or slow the progression of diabetic kidney disease.

Glutamine and leucine nitrogen kinetics and their relation to urea nitrogen in newborn infants.

Glutamine kinetics and its relation to transamination of leucine and urea synthesis were quantified in 16 appropriate-for-gestational-age infants, four small-for-gestational-age infants, and seven infants of diabetic mothers. Kinetics were measured between 4 and 5 h after the last feed (fasting) and in response to formula feeding using [5-(15)N]glutamine, [1-(13)C,(15)N]leucine, [(2)H(5)]phenylalanine, and [(15)N(2)]urea tracers. Leucine nitrogen and glutamine kinetics during fasting were significantly higher than those reported in adults. De novo synthesis accounted for approximately 85% of glutamine turnover. In response to formula feeding, a significant increase (P = 0.04) in leucine nitrogen turnover was observed, whereas a significant decrease (P = 0.002) in glutamine and urea rate of appearance was seen. The rate of appearance of leucine nitrogen was positively correlated (r(2) = 0.59, P = 0.001) with glutamine turnover. Glutamine flux was negatively correlated (r(2) = 0.39, P = 0.02) with the rate of urea synthesis. These data suggest that, in the human newborn, glutamine turnover is related to a high anaplerotic flux into the tricarboxylic acid cycle as a consequence of a high rate of protein turnover. The negative relationship between glutamine turnover and the irreversible oxidation of protein (urea synthesis) suggests an important role of glutamine as a nitrogen source for other synthetic processes and accretion of body proteins.

Serine metabolism in human pregnancy.

Serine plays an important role in intermediary metabolism as a source of one carbon pool for nucleotide biosynthesis, as a precursor for glycine and glucose, and as a contributor to cysteine biosynthesis. A unique serine-glycine cycling between the liver and the placenta has been demonstrated in the sheep fetus. We hypothesized that, because of serine's role in growth and development, significant changes in serine metabolism will occur in pregnancy with advancing gestation. The rate of appearance (R(a)) of serine and its metabolism were quantified in healthy women longitudinally through pregnancy with a [2-(15)N(13)C]serine tracer. The contribution of serine N to urea and the rate of oxidation of serine were measured using the precursor-product relation. Plasma serine concentrations and serine R(a) were lower in pregnant (P) women, in both early and late gestation, compared with nonpregnant (NP) women [plasma serine: NP, 113 +/- 24.5; P early, 71.9 +/- 6.2; P late, 68.5 +/- 9.6 micromol/l; serine R(a): NP (n = 7), 152.9 +/- 42.8; P early (n = 12), 123.7 +/- 21.5; P late (n = 8), 102.8 +/- 18.2 micromol x kg(-1) x h(-1)]. Serine contributed approximately 6% to urea N and 15-20% to the plasma glycine pool, and oxidation of serine represented approximately 8% of R(a). There was no significant difference between P and NP subjects. Glucose infusion, at 3 mg x kg(-1) x min(-1) in P subjects, resulted in a decrease in serine R(a) and an increase in oxidation. The decrease in serine turnover in pregnancy may represent a decrease in alpha-amino nitrogen turnover related to a decreased rate of branched-chain amino acid transamination and caused by pregnancy-related hormones aimed at nitrogen conservation and accretion.