Diabetes triples the risk for active tuberculosis, thus the increasing burden of type 2 diabetes will help to sustain the present tuberculosis epidemic. Recommendations have been made for ...bidirectional screening, but evidence is scarce about the performance of specific tuberculosis tests in individuals with diabetes, specific diabetes tests in patients with tuberculosis, and screening and preventive therapy for latent tuberculosis infections in individuals with diabetes. Clinical management of patients with both diseases can be difficult. Tuberculosis patients with diabetes have a lower concentration of tuberculosis drugs and a higher risk of drug toxicity than tuberculosis patients without diabetes. Good glycaemic control, which reduces long-term diabetes complications and could also improve tuberculosis treatment outcomes, is hampered by chronic inflammation, drug-drug interactions, suboptimum adherence to drug treatments, and other factors. Besides drug treatments for tuberculosis and diabetes, other interventions, such as education, intensive monitoring, and lifestyle interventions, might be needed, especially for patients with newly diagnosed diabetes or those who need insulin. From a health systems point of view, delivery of optimum care and integration of services for tuberculosis and diabetes is a huge challenge in many countries. Experience from the combined tuberculosis and HIV/AIDS epidemic could serve as an example, but more studies are needed that include economic assessments of recommended screening and systems to manage concurrent tuberculosis and diabetes.
Diabetic nephropathy (DN) has mainly been considered a glomerular disease, although tubular dysfunction may also play a role. This study assessed the predictive value for progression of a tubular ...marker, urinary liver-type fatty acid-binding protein (L-FABP), at all stages of DN.
At baseline, 1,549 patients with type 1 diabetes had an albumin excretion rate (AER) within normal reference ranges, 334 had microalbuminuria, and 363 had macroalbuminuria. Patients were monitored for a median of 5.8 years (95% CI 5.7-5.9). In addition, 208 nondiabetic subjects were studied. L-FABP was measured by ELISA and normalized with urinary creatinine. Different Cox proportional hazard models for the progression at every stage of DN were used to evaluate the predictive value of L-FABP. The potential benefit of using L-FABP alone or together with AER was assessed by receiver operating characteristic curve analyses.
L-FABP was an independent predictor of progression at all stages of DN. As would be expected, receiver operating characteristic curves for the prediction of progression were significantly larger for AER than for L-FABP, except for patients with baseline macroalbuminuria, in whom the areas were similar. Adding L-FABP to AER in the models did not significantly improve risk prediction of progression in favor of the combination of L-FABP plus AER compared with AER alone.
L-FABP is an independent predictor of progression of DN irrespective of disease stage. L-FABP used alone or together with AER may not improve the risk prediction of DN progression in patients with type 1 diabetes, but further studies are needed in this regard.
Osteopontin (OPN) is a multifunctional protein suggested to be a player in the arterial disease of patients with type 2 diabetes. However, its role for complications in patients with type 1 diabetes ...(T1D) is unknown. We therefore investigated the associations between OPN and diabetic vascular complications and all-cause mortality in patients with T1D.
Serum OPN was measured in 2,145 adults with T1D without end-stage renal disease (ESRD; dialysis or transplantation) as part of the Finnish Diabetic Nephropathy (FinnDiane) Study. Data on renal status, cardiovascular disease (CVD), and all-cause mortality during follow-up were verified from medical files, hospital discharge registries, and the Finnish National Death Registry, respectively. The median follow-up time was 10.5 (interquartile range 8.9-11.8) years.
Serum OPN was higher at baseline in patients who developed incident microalbuminuria (16.0 ± 0.9 vs. 14.1 ± 0.2 µg/L; P = 0.04), progressed to ESRD (28.3 ± 1.7 vs. 15.4 ± 0.2 µg/L; P < 0.001), suffered an incident CVD event (20.2 ± 1.2 vs. 15.5 ± 0.2 µg/L; P < 0.001), or died (23.3 ± 1.4 vs. 15.8 ± 0.2 µg/L; P < 0.001) during follow-up. In multivariate Cox regression analysis, OPN was independently associated with the development of incident microalbuminuria, an incident CVD event, and death, after adjustments for associated risk factors. Even after calculating reclassification indexes, OPN was predictive of CVD and all-cause mortality beyond the Framingham risk score covariates and hs-CRP.
Serum OPN is a strong predictor of incipient diabetic nephropathy, a first-ever CVD event, and all-cause mortality in patients with T1D. Serum OPN may be of clinical significance for the risk prediction of CVD events in patients with T1D.
We evaluated the predictive value and clinical benefit of urinary kidney injury molecule (KIM)-1 for progression of diabetic nephropathy (DN) in type 1 diabetes. We also investigated its causal role ...for the decrease of estimated glomerular filtration rate (eGFR) by a Mendelian randomization (MR) approach.
We followed 1,573 patients with type 1 diabetes for 6 years. KIM-1 was measured at baseline and normalized with urinary creatinine. KIM-1 predictive value was evaluated by Cox regression, while its added predictive benefit was evaluated using a panel of statistical indexes. The causality for the loss of renal function was evaluated with MR, utilizing the top signal from our genome-wide association study (GWAS) as the instrumental variable.
KIM-1 was not an independent predictor of progression of DN when adjusted for albumin excretion rate (AER) and added no prognostic benefit to AER or eGFR. In multiple regressions, KIM-1 was associated with lower eGFR independently of diabetes duration (β = -4.066; P < 0.0001) but not of AER. In our GWAS, rs2036402 in the KIM1 gene was strongly associated with KIM-1 (β = -0.51; P = 6.5 × 10(-38)). In the MR, KIM-1 was associated with lower eGFR, independently of diabetes duration and AER (β = -5.044; P = 0.040), suggesting a causal relationship.
KIM-1 did not predict progression to end-stage renal disease independently of AER and added no prognostic benefit to current biomarkers. Nevertheless, the MR showed that the inverse association of increased KIM-1 levels with lower eGFR is likely to represent a causal link.
We investigated the predictive value of urinary adiponectin (uADP) for the progression of diabetic nephropathy (DN) as well as for the principal determinants of uADP concentrations.
uADP was measured ...in 2,090 patients with type 1 diabetes followed for a median of 5.8 (4.4-6.9) years and in 111 subjects without diabetes. Progression was defined as a change in albuminuria (albumin excretion rate AER) to a higher stage or development of end-stage renal disease (ESRD). Various Cox regression and competing risk models were used to evaluate the predictive value of uADP for DN progression. The added predictive benefit to AER or estimated glomerular filtration rate (eGFR) was estimated by the area under the receiver operating characteristic curve, integrated discrimination improvement (IDI), continuous net reclassification improvement (NRI), and other statistical indexes. The determinants of uADP were investigated by multiple regression analyses.
uADP was an independent predictor of progression to ESRD (hazard ratio 1.60, P < 0.001) and was an even better predictor than AER (P = 0.04) or as good as eGFR (P = 0.79). Furthermore, uADP added a significant benefit when used together with AER (NRI 0.794, P = 0.03; IDI 0.115, P < 0.0001) or eGFR (NRI 0.637, P < 0.001; IDI 0.087, P < 0.0001). The common determinants of uADP were glycemic control, tubular injury, and AER.
uADP is a strong independent predictor of DN progression from macroalbuminuria to ESRD and adds a significant predictive benefit to current biomarkers in patients with type 1 diabetes.
Aims/hypothesis
In type 1 diabetes, cardiovascular disease (CVD) and diabetic nephropathy progress in parallel, thereby potentiating the risk of premature death during their development. Since ...urinary liver-type fatty acid binding protein (L-FABP) predicts the progression of diabetic nephropathy, the aim of this study was to investigate whether urinary L-FABP also predicts cardiovascular outcomes and mortality.
Methods
We tested our hypothesis in a Finnish cohort of 2329 individuals with type 1 diabetes and a median follow-up of 14.1 years. The L-FABP to creatinine ratio was determined from baseline urine samples. The predictive value of urinary L-FABP was evaluated using Cox regression models, while its added predictive benefit for cardiovascular outcomes and mortality was evaluated using a panel of statistical indexes.
Results
Urinary L-FABP predicted incident stroke independently of traditional risk factors (HR 1.33 95% CI 1.20, 1.49) and after further adjustment for eGFR (HR 1.28 95% CI 1.14, 1.44) or AER (HR 1.24 95% CI 1.06, 1.44). In addition, it predicted mortality independently of traditional risk factors (HR 1.34 95% CI 1.24, 1.45), and after adjustment for eGFR (HR 1.29 95% CI 1.18, 1.39) or AER (HR 1.22 95% CI 1.09, 1.36). Urinary L-FABP was as good a predictor as eGFR or AER, and improved the AUC for both outcomes on top of traditional risk factors, with no reclassification benefit (integrated discrimination improvement/net reclassification improvement) for stroke or mortality when AER or eGFR were added to traditional risk factors. However, urinary L-FABP was not a predictor of other cardiovascular endpoints (coronary artery disease, peripheral vascular disease and overall CVD events) when adjusted for the AER.
Conclusions/interpretation
Urinary L-FABP is an independent predictor of stroke and mortality in individuals with type 1 diabetes.
Background
Insulin resistance (IR) is present in type 1 diabetes mellitus (T1DM) and is suggested to be related to chronic diabetic complications. The primary aim of our study was to assess IR in ...T1DM patients with and without chronic complications. A secondary aim was to evaluate the possible association between IR and chronic diabetic complications.
Methods
This cross‐sectional study enrolled 272 patients with T1DM. Insulin resistance was quantified using the estimated glucose disposal rate (eGDR). Associations between eGDR and each diabetes complication were first evaluated using binary logistic regression, then multiparametric logistic regression with stepwise selection of covariates. The discriminative value of eGDR was assessed by receiver operating characteristic (ROC) curve analysis.
Results
Estimated GDR was lower in patients with chronic diabetic complications (6.1 vs 6.9 mg/kg per min P = 0.02 for retinopathy; 6.3 vs 7.3 mg/kg per min P < 0.01 for nephropathy; 6.5 vs 7.6 mg/kg per min P < 0.01 for neuropathy; and 5.2 vs 7.5 mg/kg per min P < 0.01 for cardiovascular complications). In univariate analysis eGDR was associated all diabetic complications. These associations remained significant after adjustment for different variables in the final regression models. In addition, eGDR was a good discriminator for each diabetic complication, with an area under the curve between 0.609 and 0.759.
Conclusions
Patients with chronic diabetic complications are more insulin resistant than those without complications. Moreover, IR was independently associated with the presence of each chronic diabetic complication, and seems to be a good discriminator for them all.
摘要
背景
1型糖尿病若存在胰岛素抵抗(Insulin resistance,IR)则提示与慢性糖尿病并发症相关。我们研究的主要目的是评估合并或者不合并慢性并发症的1型糖尿病患者的IR。次要目的是评估IR与慢性糖尿病并发症之间可能存在的关系。
方法
这项横向研究纳入了272名1型糖尿病患者。使用预估葡萄糖处置率(estimated glucose disposal rate,eGDR)来量化胰岛素抵抗。首先使用二元对数回归法,接着使用多参数对数回归法(逐步选择协变量)来评估eGDR与每种糖尿病并发症之间的关系。使用受试者工作特征曲线分析法来评估eGDR的鉴别价值。
结果
合并慢性糖尿病并发症的患者预估的GDR更低(对于视网膜病变来说,分别为6.1与6.9 mg/kg每分钟P = 0.02 ;对于肾病来说,分别为6.3与7.3 mg/kg/分钟P < 0.01;对于神经病变来说,分别为6.5与7.6 mg/kg每分钟P < 0.01;对于心血管并发症来说,分别为5.2与7.5 mg/kg每分钟P<0.01)。在单变量分析中eGDR与所有的糖尿病并发症都相关。在最终的回归模型中经过不同的变量校正之后这种相关性仍然有显著性意义。另外,对于每种糖尿病并发症来说eGDR都是一种很好的鉴别工具,曲线下面积介于0.609与0.759之间。
结论
与那些没有并发症的患者相比,合并慢性糖尿病并发症的患者胰岛素抵抗更严重。此外,IR与每种慢性糖尿病并发症的存在都具有独立的相关性,对于所有的慢性并发症来说它似乎都是一种很好的鉴别工具。
Aims/hypothesis
Diabetic nephropathy is a major diabetic complication, and diabetes is the leading cause of end-stage renal disease (ESRD). Family studies suggest a hereditary component for diabetic ...nephropathy. However, only a few genes have been associated with diabetic nephropathy or ESRD in diabetic patients. Our aim was to detect novel genetic variants associated with diabetic nephropathy and ESRD.
Methods
We exploited a novel algorithm, ‘Bag of Naive Bayes’, whose marker selection strategy is complementary to that of conventional genome-wide association models based on univariate association tests. The analysis was performed on a genome-wide association study of 3,464 patients with type 1 diabetes from the Finnish Diabetic Nephropathy (FinnDiane) Study and subsequently replicated with 4,263 type 1 diabetes patients from the Steno Diabetes Centre, the All Ireland-Warren 3-Genetics of Kidneys in Diabetes UK collection (UK–Republic of Ireland) and the Genetics of Kidneys in Diabetes US Study (GoKinD US).
Results
Five genetic loci (
WNT4/ZBTB40-
rs12137135,
RGMA/MCTP2-
rs17709344,
MAPRE1P2-
rs1670754,
SEMA6D/SLC24A5-
rs12917114 and
SIK1-
rs2838302) were associated with ESRD in the FinnDiane study. An association between ESRD and rs17709344, tagging the previously identified rs12437854 and located between the
RGMA
and
MCTP2
genes, was replicated in independent case–control cohorts. rs12917114 near
SEMA6D
was associated with ESRD in the replication cohorts under the genotypic model (
p
< 0.05), and rs12137135 upstream of
WNT4
was associated with ESRD in Steno.
Conclusions/interpretation
This study supports the previously identified findings on the
RGMA
/
MCTP2
region and suggests novel susceptibility loci for ESRD. This highlights the importance of applying complementary statistical methods to detect novel genetic variants in diabetic nephropathy and, in general, in complex diseases.
Background Insulin resistance (IR) is present in type 1 diabetes mellitus (T1DM) and is suggested to be related to chronic diabetic complications. The primary aim of our study was to assess IR in ...T1DM patients with and without chronic complications. A secondary aim was to evaluate the possible association between IR and chronic diabetic complications. Methods This cross-sectional study enrolled 272 patients with T1DM. Insulin resistance was quantified using the estimated glucose disposal rate (eGDR). Associations between eGDR and each diabetes complication were first evaluated using binary logistic regression, then multiparametric logistic regression with stepwise selection of covariates. The discriminative value of eGDR was assessed by receiver operating characteristic (ROC) curve analysis. Results Estimated GDR was lower in patients with chronic diabetic complications (6.1 vs 6.9mg/kg per min P = 0.02 for retinopathy; 6.3 vs 7.3mg/kg per min P < 0.01 for nephropathy; 6.5 vs 7.6mg/kg per min P < 0.01 for neuropathy; and 5.2 vs 7.5mg/kg per min P < 0.01 for cardiovascular complications). In univariate analysis eGDR was associated all diabetic complications. These associations remained significant after adjustment for different variables in the final regression models. In addition, eGDR was a good discriminator for each diabetic complication, with an area under the curve between 0.609 and 0.759. Conclusions Patients with chronic diabetic complications are more insulin resistant than those without complications. Moreover, IR was independently associated with the presence of each chronic diabetic complication, and seems to be a good discriminator for them all. èOE 1è°(Insulin resistance,IR)1IRIRè½ è¿(TM)2721使置(estimated glucose disposal rate,eGDR)è°ä½¿å...å½',使å½'()eGDR使ä½oeå¾eGDR GDRä½Z(ç½',6.16.9 mg/kgP = 0.02 ;,6.37.3 mg/kg/P < 0.01;,6.57.6 mg/kgP < 0.01;å¿,5.27.5 mg/kgP<0.01)eGDRé½å½'è¿double daggerè¿(TM),eGDRé½å¾^,0.6090.759 ,è°,IRé½,å®é½å¾^
Abstract
Background
Insulin resistance (
IR
) is present in type 1 diabetes mellitus (
T
1
DM
) and is suggested to be related to chronic diabetic complications. The primary aim of our study was to ...assess
IR
in
T
1
DM
patients with and without chronic complications. A secondary aim was to evaluate the possible association between IR and chronic diabetic complications.
Methods
This cross‐sectional study enrolled 272 patients with
T
1
DM
. Insulin resistance was quantified using the estimated glucose disposal rate (e
GDR
). Associations between e
GDR
and each diabetes complication were first evaluated using binary logistic regression, then multiparametric logistic regression with stepwise selection of covariates. The discriminative value of e
GDR
was assessed by receiver operating characteristic (
ROC
) curve analysis.
Results
Estimated
GDR
was lower in patients with chronic diabetic complications (6.1 vs 6.9 mg/kg per min
P
= 0.02 for retinopathy; 6.3 vs 7.3 mg/kg per min
P
< 0.01 for nephropathy; 6.5 vs 7.6 mg/kg per min
P
< 0.01 for neuropathy; and 5.2 vs 7.5 mg/kg per min
P
< 0.01 for cardiovascular complications). In univariate analysis e
GDR
was associated all diabetic complications. These associations remained significant after adjustment for different variables in the final regression models. In addition, e
GDR
was a good discriminator for each diabetic complication, with an area under the curve between 0.609 and 0.759.
Conclusions
Patients with chronic diabetic complications are more insulin resistant than those without complications. Moreover,
IR
was independently associated with the presence of each chronic diabetic complication, and seems to be a good discriminator for them all.
摘要
背景
1型糖尿病若存在胰岛素抵抗(Insulin resistance,IR)则提示与慢性糖尿病并发症相关。我们研究的主要目的是评估合并或者不合并慢性并发症的1型糖尿病患者的IR。次要目的是评估IR与慢性糖尿病并发症之间可能存在的关系。
方法
这项横向研究纳入了272名1型糖尿病患者。使用预估葡萄糖处置率(estimated glucose disposal rate,eGDR)来量化胰岛素抵抗。首先使用二元对数回归法,接着使用多参数对数回归法(逐步选择协变量)来评估eGDR与每种糖尿病并发症之间的关系。使用受试者工作特征曲线分析法来评估eGDR的鉴别价值。
结果
合并慢性糖尿病并发症的患者预估的GDR更低(对于视网膜病变来说,分别为6.1与6.9 mg/kg每分钟
P
= 0.02 ;对于肾病来说,分别为6.3与7.3 mg/kg/分钟
P
< 0.01;对于神经病变来说,分别为6.5与7.6 mg/kg每分钟
P
< 0.01;对于心血管并发症来说,分别为5.2与7.5 mg/kg每分钟
P
<0.01)。在单变量分析中eGDR与所有的糖尿病并发症都相关。在最终的回归模型中经过不同的变量校正之后这种相关性仍然有显著性意义。另外,对于每种糖尿病并发症来说eGDR都是一种很好的鉴别工具,曲线下面积介于0.609与0.759之间。
结论
与那些没有并发症的患者相比,合并慢性糖尿病并发症的患者胰岛素抵抗更严重。此外,IR与每种慢性糖尿病并发症的存在都具有独立的相关性,对于所有的慢性并发症来说它似乎都是一种很好的鉴别工具。
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