A low-cost laboratory-based method for predicting newly diagnosed biopsy-proven diabetic nephropathy in people with type 2 diabetes.

AIMS: To identify significant prognostic factors for newly diagnosed biopsy-proven diabetic nephropathy using routine laboratory measures, from which to derive a low-cost explanatory model, and to use this model to examine associations between the potential low-cost test panels and the risk of diabetic nephropathy in people with type 2 diabetes with normal kidney function. METHOD: A population-based case-control study was undertaken to test the association between diabetic nephropathy and 47 laboratory variables using a 'hypothesis-free' strategy and five routinely recorded factors in diabetes care (BMI, systolic and diastolic blood pressure, HbA1c , fasting glucose). Factors that were significant after Bonferroni correction were included in different test panels and used to develop diabetic nephropathy (outcome) explanatory models. Models were derived using risk-set sampling among 950 biopsy-proven diabetic nephropathy cases newly diagnosed in the period between 2012 and 2018 and among 4750 age- and gender-matched controls. RESULTS: A total of 15 Bonferroni-corrected significant laboratory predictors in the three test panels (blood cell, serum electrolytes and blood coagulation) were identified through multivariable analysis and used to develop the three explanatory models. The optimism-adjusted C-statistics and calibration slope were 0.725 (95% CI 0.723-0.728) and 0.978 (95% CI 0.912-0.999) for the blood cell model, 0.688 (95% CI 0.686-0.690) and 0.923 (95% CI 0.706-0.977) for the serum electrolytes model, 0.648 (95% CI 0.639-0.658) and 0.914 (95% CI 0.641-1.115) for the blood coagulation model, respectively. CONCLUSIONS: A total of 15 predictors were significantly associated with newly diagnosed biopsy-proven diabetic nephropathy in type 2 diabetes. The blood cell model appeared to be the low-cost model with the best predictive ability.

Diabetic Nephropathy: An Overview.

Diabetic nephropathy (DN) is one of the most feared diabetic chronic microvascular complications and the major cause of end-stage renal disease (ESRD). The classical presentation of DN is characterized by hyperfiltration and albuminuria in the early phases which is then followed by a progressive renal function decline. The presentation of diabetic kidney disease (DKD) can vary especially in patients with T2DM where concomitant presence of other glomerular/tubular pathologies and severe peripheral vascular disease can become important confounders. All-cause mortality in individuals with DKD is approximately 30 times higher than that in diabetic patients without nephropathy and a great majority of patients with DKD will die from cardiovascular disease before they reach ESRD. The management of metabolic and hemodynamic perturbations for the prevention and for the delay of progression of DKD is very important. DKD is a global challenge and a significant social and economic burden; research should aim at developing new ideas to tackle this devastating condition.

Method and its Composition for encapsulation, stabilization, and delivery of siRNA in Anionic polymeric nanoplex: An In vitro- In vivo Assessment.

Small interfering RNA (siRNA) are synthetic RNA duplex designed to specifically knockdown the abnormal gene to treat a disease at cellular and molecular levels. In spite of their high potency, specificity, and therapeutic potential, the full-fledged utility of siRNA is predominantly limited to in vitro set-up. Till date, Onpattro is the only USFDA approved siRNA therapeutics available in the clinic. The lack of a reliable in vivo siRNA delivery carrier remains a foremost obstacle towards the clinical translation of siRNA therapeutics. To address the obstacles associated with siRNA delivery, we tested a dendrimer-templated polymeric approach involving a USFDA approved carrier (albumin) for in vitro as well as in vivo delivery of siRNA. The developed approach is simple in application, enhances the serum stability, avoids in vivo RNase-degradation and mediates cytosolic delivery of siRNA following the endosomal escape process. The successful in vitro and in vivo delivery of siRNA, as well as targeted gene knockdown potential, was demonstrated by HDAC4 inhibition in vitro diabetic nephropathy (DN) podocyte model as well as in vivo DN C57BL/6 mice model. The developed approach has been tested using HDAC4 siRNA as a model therapeutics, while the application can also be extended to other gene therapeutics including micro RNA (miRNA), plasmids oligonucleotides, etc.

Assessment of kidney function and associated risk factors among type 2 diabetic patients.

AIM: diabetic patients are required for continuous monitoring programs hence continuous assessment of kidney function parameters is crucial. So, we aimed to determine the prevalence of Chronic Kidney Disease (CKD) and abnormal renal parameters, with poorly controlled type 2 diabetes mellitus pateints MATERIALS AND METHODS: A cross-sectional study was carried out at private health care centre. A total of 300 diabetic patients aged 18 years and above attended the clinic from February 2018 to Dec 2018 were included. Socio-demographic, clinical, and laboratory data were obtained from the medical records of patients. Statistical analysis was carried out using (SPSS, version 23). RESULTS: out of the 300 diabetes patients recruited 42% of patients with type 2 diabetes had abnormal Creatinine Serum levels and 22.3% had abnormal glomerular filtration rate (GFR). Abnormal albumin urine levels were found in 28.3% and 11.3% had abnormal creatinine in urine. Abnormal Albumin: Creatinine Ratios (Alb/Cr), were found in 23%. Of the total, 77% (n = 231) had normal Alb: Cr Ratio, 20% had risk of nephropathy and 9% had nephropathy. CONCLUSION: Current study revealed a high prevalence of abnormal renal parameters in patients with type 2 diabetes Mellitus. This necessitates the need for early and universal screening of renal functions. There is also an urgent demand for measures that target tight glycaemic, Vitamin D level and life style modifications is also required to all diabetic patients to achieve target value of HbA1C ≤ 7.

Multi-radial LBP Features as a Tool for Rapid Glomerular Detection and Assessment in Whole Slide Histopathology Images.

We demonstrate a simple and effective automated method for the localization of glomeruli in large (~1 gigapixel) histopathological whole-slide images (WSIs) of thin renal tissue sections and biopsies, using an adaptation of the well-known local binary patterns (LBP) image feature vector to train a support vector machine (SVM) model. Our method offers high precision (>90%) and reasonable recall (>70%) for glomeruli from WSIs, is readily adaptable to glomeruli from multiple species, including mouse, rat, and human, and is robust to diverse slide staining methods. Using 5 Intel(R) Core(TM) i7-4790 CPUs with 40 GB RAM, our method typically requires ~15 sec for training and ~2 min to extract glomeruli reproducibly from a WSI. Deploying a deep convolutional neural network trained for glomerular recognition in tandem with the SVM suffices to reduce false positives to below 3%. We also apply our LBP-based descriptor to successfully detect pathologic changes in a mouse model of diabetic nephropathy. We envision potential clinical and laboratory applications for this approach in the study and diagnosis of glomerular disease, and as a means of greatly accelerating the construction of feature sets to fuel deep learning studies into tissue structure and pathology.

The Effectiveness of the Semi-quantitative Assessment of Microalbuminuria Using Routine Urine Dipstick Screening in Patients with Diabetes.

Objective The early diagnosis and treatment of microalbuminuria is important for preventing the progression of diabetic kidney disease in patients with diabetes. In this study, we assessed the accuracy of the semi-quantitative measurement of microalbuminuria by urine dipstick screening in patients with diabetes. Methods The semi-quantitative urinary albumin-to-creatinine ratio (QUACR) was used for microalbuminuria screening. A total of 291 diabetes patients with normoalbuminuria [urine albumin-to-creatinine ratio (UACR) <30 mg/g・Cre; n=205] or microalbuminuria (UACR 30-299 mg/g・Cre; n=86) were enrolled as study participants. Both the qualitative test of albumin (QUA) and the QUACR of early-morning or spot urine samples were performed at the same time. A receiver operating characteristic (ROC) analysis was performed to compare the diagnostic utility of the QUACR to that of the QUA in the detection of microalbuminuria. Results The sensitivity and specificity values of the QUACR were 84.9% and 76.6%, respectively. Those of the QUA were 53.5% and 84.4%, respectively. In the ROC analysis, the area under the curve values of the QUACR and QUA for the diagnosis of microalbuminuria were 0.807 (95% confidence interval: 0.752-0.863) and 0.689 (0.618-0.760), respectively. Conclusion These results suggest that the QUACR is a simple and efficient test-with high levels of sensitivity and specificity-for the detection of microalbuminuria in patients with diabetes.

Real-time in vivo mitochondrial redox assessment confirms enhanced mitochondrial reactive oxygen species in diabetic nephropathy.

While increased mitochondrial reactive oxygen species have been commonly implicated in a variety of disease states, their in vivo role in the pathogenesis of diabetic nephropathy remains controversial. Using a two-photon imaging approach with a genetically encoded redox biosensor, we monitored mitochondrial redox state in the kidneys of experimental models of diabetes in real-time in vivo. Diabetic (db/db) mice that express a redox-sensitive Green Fluorescent Protein biosensor (roGFP) specifically in the mitochondrial matrix (db/dbmt-roGFP) were generated, allowing dynamic monitoring of redox changes in the kidneys. These db/dbmt-roGFP mice exhibited a marked increase in mitochondrial reactive oxygen species in the kidneys. Yeast NADH-dehydrogenase, a mammalian Complex I homolog, was ectopically expressed in cultured podocytes, and this forced expression in roGFP-expressing podocytes prevented high glucose-induced increases in mitochondrial reactive oxygen species. Thus, in vivo monitoring of mitochondrial roGFP in diabetic mice confirms increased production of mitochondrial reactive oxygen species in the kidneys.

Increased renal resistive index in type 2 diabetes: Clinical relevance, mechanisms and future directions.

Type 2 diabetes is a global health challenge. In type 2 diabetes both microvascular (nephropathy, retinopathy, neuropathy) and macrovascular complications arise. In kidney, renal pathological changes leading to diabetic nephropathy are mainly secondary to atherosclerosis of the intra and extra renal arteries together with microangiopathy of the glomerular capillaries, afferent arterioles and efferent arterioles. Renal resistive index (RRI) is defined as a ratio of the difference between maximum and minimum (end-diastolic) flow velocity to maximum flow velocity derived from the Doppler measurements of main renal and intrarenal (segmental/interlobar) arteries. Renal resistive index is tightly related to renal arteriolosclerosis, and represents an integrated index of arterial compliance, pulsatility and downstream microvascular impedance. In meantime, growing suggest that RRI has also been closely related with atherosclerosis. Most studies performed in type 2 diabetes showed RRI is increased in type 2 diabetes. In this review, we summarize the data regarding RRI with regard to performed studies, pathogenesis and prognosis, especially focusing on type 2 diabetes (T2D). We also review the data regarding the development of metabolic syndrome (MetS) and RRI.

Risk identification in haemodialysis patients by appropriate body composition assessment. / Identificar situaciones de riesgo para los pacientes en hemodiálisis mediante la adecuada valoración de su composición corporal.

INTRODUCTION: Circumstances such as gender, age, diabetes mellitus (DM) and renal failure impact on the body composition of patients. However, we use nutritional parameters such as lean and fat tissue with reference values from healthy subjects to assess the nutritional status of haemodialysis (HD) patients. AIMS: To analyse body composition by bioimpedance spectroscopy (BIS) of 6395 HD patients in order to obtain reference values of lean tissue index (LTI) and fat tissue index (FTI) from HD patients; and to confirm its validity by showing that those patients with LTI below the 10th percentile calculated for their group have greatest risk of death. MATERIAL AND METHODS: We used the BIS to determine the LTI and FTI in our cohort of HD patients in Spain. We calculated the 10th percentile and 90th percentile of LTI and FTI in each age decile for patients grouped by gender and presence of DM. We collected clinical, laboratory and demographic parameters. RESULTS: The LTI/FTI 10 and 90 percentile values varied by group (age, gender and presence of DM) and, after adjusting for other risk factors such as fluid overload, those patients with LTI lower than percentile 10 had a higher relative risk of death (OR 1.57) than those patients with higher values. CONCLUSIONS: Monitoring the LTI and FTI of patients on HD using suitable reference values may help to identify risk in this patient population.

Assessment of early renal damage in diabetic rhesus monkeys.

The objectives of the study were to improve the model system of diabetic nephropathy in nonhuman primates and assess the early renal damage. Diabetes was induced in monkeys by streptozotocin, and the animals were administered exogenous insulin to control blood glucose (BG). Animals were divided into four groups, including the normal group (N = 3), group A (streptozotocin diabetic model with control of BG < 10 mmol/L, N = 3), group B (streptozotocin diabetic model with control of BG between 15 and 20 mmol/L, N = 4), and group C (streptozotocin diabetic model with control of BG between 15 and 20 mmol/L and high-sodium and high-fat diet, N = 4). The following parameters were evaluated: (1) blood biochemistry and routine urinalysis, (2) color Doppler ultrasound, (3) angiography, (4) renal biopsy, and (5) renal fibrosis-related gene expression levels. Animals in group C developed progressive histologic changes with typical diabetic nephropathy resembling diabetic nephropathy in human patients and exhibited accelerated development of diabetic nephropathy compared with other nonhuman primate models. Significant changes in the expression of the Smad2/3 gene and eNOS in renal tissue were also observed in the early stage of diabetic nephropathy. In conclusion, our model is an excellent model of diabetic nephropathy for understanding the pathogenesis of diabetic nephropathy.

MG132 ameliorates kidney lesions by inhibiting the degradation of Smad7 in streptozotocin-induced diabetic nephropathy.

BACKGROUND: Smad7 is the main negative regulatory protein in the transforming growth factor-ß (TGF-ß) downstream signaling pathway, which plays an important role in diabetic nephropathy (DN) and may be related to the ubiquitin proteasome pathway (UPP). AIM: We investigated the role of UPP in regulating TGF-ß/SMAD signaling and explored the therapeutic effect of the ubiquitin proteasome inhibitor MG132 on DN. METHODS: Wistar rats were randomly divided into a diabetes group and a normal control group. Rats in the diabetes group were injected intraperitoneally with streptozotocin. Diabetic rats were then randomly divided into a diabetic nephropathy group (DN group), an MG132 high concentration (MH) group, and an MG132 low concentration (ML) group. After 8 weeks of treatment, 24-hour urinary microalbumin (UAlb), urinary protein/urinary creatinine (Up/Ucr) values, ALT, AST, Bcr, kidney damage, TGF-ß, Smad7, fibronectin (FN), and Smurf2 were detected. RESULTS: The body mass and Smad7 protein expression decreased in DN group, but kidney weight, kidney weight index, UAlb, Up/Ucr, FN and Smurf2 mRNA expression, and TGF-ß protein expression increased. However, these changes diminished following treatment with MG132, and a more pronounced effect was evident in MH group compared to ML group. CONCLUSION: MG132 alleviates kidney damage by inhibiting Smad7 ubiquitin degradation and TGF-ß activation in DN.

Assessment of diabetic nephropathy in the Akita mouse.

Akita mice have type 1 diabetes mellitus caused by a spontaneous point mutation in the Ins2 gene which leads to misfolding of insulin, resulting in pancreatic ß-cell failure. Akita mice develop pronounced and sustained hyperglycemia, high levels of albuminuria, and consistent histopathological changes, suggesting that these mice may be suitable as an experimental platform for modeling diabetic nephropathy. One key feature of diabetic kidney disease in Akita mice is that the severity of renal injury is significantly influenced by genetic background. In this chapter, we describe the Akita model and present some of the experimental studies utilizing Akita mice as a model of type 1 diabetes. For example, deficiency in bradykinin receptors, endothelial nitric oxide synthase, or angiotensin-converting enzyme 2 leads to development of functionally and structurally more advanced diabetic nephropathy in these mice, while ketogenic diet has been shown to reverse kidney injury associated with diabetes. This chapter also describes the application of 24-h urine collections from mice for careful measurement of urinary albumin excretion.

Prospective assessment of renal histopathological lesions in patients with end-stage liver disease: effects on long-term renal function after liver transplantation.

BACKGROUND & AIMS: The incidence of organic renal lesions in patients with end-stage liver disease is unknown. The goal of this study was to make a prospective evaluation of renal histological lesions in a group of unselected patients awaiting liver transplantation. METHODS: Sixty cirrhotic patients underwent a renal biopsy via the transjugular route. The potential effect of renal lesions on renal function was evaluated five years after transplantation. RESULTS: The yield of biopsies enabling satisfactory analysis was 77%, and no major complications occurred. Proteinuria>0.5 g/day was observed in only 8.7% of these patients, microscopic haematuria in 4.3%, creatinine levels>133 mmol/L (1.5mg/dl) in 10.9%, and Modification of the Diet in Renal Disease (MDRD) clearance<60 ml/min in 13.0%. Twenty-five patients (55.3%) had a morphological diagnosis of renal disease, 15 displayed IgA nephropathy and immunofluorescence testing showed that 12 had specific diabetic linear staining for IgG and albumin, of whom seven had associated histological lesions of diabetic nephropathy. Five years after liver transplantation, renal function had significantly deteriorated more in patients with initial diabetic lesions than in those with normal histology or IgA nephropathy alone. CONCLUSIONS: In patients with end-stage liver disease, IgA nephropathy and diabetic lesions were frequently found despite the absence of renal impairment and/or urinalysis anomalies. Our results strongly suggest that severe renal failure develops preferentially in liver transplant recipients with diabetes or carbohydrate intolerance, and that pre-existing arterial lesions may favour the nephrotoxicity of calcineurin inhibitors. Diabetes prior to transplantation needs to be strictly managed and requires a renal sparing immunosuppressive regimen after transplantation.

Determinants of resting energy expenditure in hemodialysis patients, and comparison with healthy subjects.

OBJECTIVE: This study evaluated the factors that affect the resting energy expenditure (REE) and nutritional status of hemodialysis patients, and to assess any differences with healthy subjects. DESIGN: This was an observational case-control study. SETTING: This study took place at the Hemodialysis Units of the Laikon General Hospital and 401 General Military Hospital (Athens, Greece). PATIENTS: Twenty-five patients undergoing hemodialysis and 23 controls were recruited. Controls were healthy volunteers with no history of diseases or medication use. Patients with active infectious or inflammatory disease were excluded. INTERVENTION: We measured REE using indirect calorimetry. Body composition as measured by Bioelectrical Impedance Analysis (BIA), anthropometry, and biochemical parameters were assessed in both groups. MAIN OUTCOME MEASURE: Adjusted or unadjusted for muscle mass, REE was compared between the two groups. Multiple linear regression analysis was used to study independent determinants of REE. RESULTS: Patients had no clinical signs of malnutrition. Resting energy expenditure was not different between the two groups, but REE adjusted for muscle mass was significanlty higher in hemodialysis patients. There were no differences in body composition, with the exception of muscle mass. Patients had lower muscle mass than controls, as determined by duration of disease. The only significant determinant of REE was muscle mass. CONCLUSION: Patients had a higher REE adjusted for muscle mass than did controls, implying that they might be at a catabolic stage, and at risk of malnutrition. These findings indicate the need for determining body composition and for nutritional assessment and support in hemodialysis patients, even without indications of malnutrition.

A discrete-state discrete-time model using indirect observation.

This research was motivated by a desire to model the progression of a chronic disease through various disease stages when data are not available to directly estimate all the transition parameters in the model. This is a common occurrence when time and expense make it unfeasible to follow a single cohort to estimate all the transition parameters. One difficulty of developing a model of chronic disease progression from such data is that the available studies often do not include the transitions of interest. For example, in our model of diabetic nephropathy, many clinical studies did not differentiate between patients without nephropathy and those who had microalbuminuria (a pre-clinical stage of nephropathy). Another difficulty was a lack of data to directly estimate parameters of interest. We consider models which can accommodate such difficulties. In this paper we consider the problem of estimating parameters of a discrete-time Markov process when longitudinal data describing the entire process are not available. First, we present a likelihood approach to estimate parameters of a discrete-time Markov model. Next, we use simulation to investigate the finite-sample behaviour of our approach. Finally, we present two examples: a model of diabetic nephropathy and a model of cardiovascular disease in diabetes.

Resting energy expenditure in pre-dialysis diabetic patients.

BACKGROUND: The metabolic derangements of diabetes mellitus (DM) associated with those of chronic renal failure (CRF) may interfere with the energy and protein balance of patients with both diseases. The aim of this study was to verify whether the resting energy expenditure (REE) of non-dialysis chronic renal failure diabetic patients differs from that of chronic renal failure patients without DM. METHODS: REE was measured by indirect calorimetry in 24 CRF diabetic patients (CRF diabetes group), matched for age, gender, and degree of renal impairment to 24 CRF patients without DM (CRF control group). RESULTS: The CRF diabetes group had a significantly higher REE (1538+/-230 kcal/day) than the CRF control group (1339+/-315 kcal/day, P = 0.009). This difference was maintained even when the REE was adjusted for lean body mass (LBM; 30.3+/-4.3 vs 26.3+/-5.4 kcal/kg LBM/day, P = 0.004). Mean protein intake was significantly higher in the CRF diabetes than in the CRF control group (0.89+/-0.20 vs 0.76+/-0.25 g/kg/day, P = 0.02). Mean protein equivalent of nitrogen appearance (PNA) was also significantly higher in the CRF diabetes patients (1.21+/-0.31 vs 1.03+/-0.22 g/kg/day, P = 0.02), reflecting a higher protein intake and/or elevated protein breakdown. Accordingly, REE was directly correlated with PNA mainly in the CRF diabetes group (r = 0.57, P < 0.003). CONCLUSION: Metabolic disturbances of poorly controlled DM may account for the higher REE observed in the CRF diabetes group. The role of the apparently higher protein breakdown in this increased REE remains to be clarified.

Can bone histomorphometry be predicted by clinical assessment and noninvasive techniques in peritoneal dialysis?

In an attempt to evaluate whether bone histology could be predicted by clinical assessment and noninvasive techniques in patients on peritoneal dialysis, bone histomorphometry was correlated with symptoms of renal osteodystrophy, serum bone markers and parathyroid hormone (PTH) as well as radiographs and forearm osteodensitometry (bone mineral content, BMC). No correlations were found between clinical symptoms, biochemical markers, radiographic bone surveys, BMC measurements, and bone diagnosis. Serum 1,25-(OH)2D3 correlated negatively with the intracortical resorption and the degree of osteoporosis. No other correlations were seen between the serum markers measured, PTH and the radiographic parameters. Alkaline phosphatase correlated negatively with mineralization lag time and positively with eroded surface, mineral appositional rate, tetracycline-labelled surface and bone formation rates. HCO-3 correlated negatively with osteoid thickness and osteoid surface. Ca2+ correlated with osteoid surface, osteoid volume and cortical thickness. Mg correlated with the duration of azotemia, cortical porosity and bone aluminum content, while serum phosphate correlated with the mineral appositional rate. Osteocalcin and PTH correlated with osteoid thickness, the mineral appositional rate, tetracycline-labelled surface, the adjusted apposition rate, mineralization lag time and the bone formation rates. BMC measurements correlated with PTH and Ca2+ and inversely with sex and trabecular bone volume, osteoid thickness, osteoid surface, osteoid volume, eroded surface, osteoclast surface, tetracycline-labelled surface and the bone formation rates. Seven of the histomorphometric parameters correlated significantly with the radiological bone features. However, the clinical assessment and the serum markers of bone metabolism were of limited value. Thus, bone histology cannot be comprehensively predicted by non-invasive methods, although radiographs and forearm osteodensitometry provided some valuable information.