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      Clinicopathological features of fast eGFR decliners among patients with diabetic nephropathy

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          Abstract

          Introduction

          The speed of declining kidney function differs among patients with diabetic nephropathy. This study was undertaken to clarify clinical and pathological features that affect the speed of declining kidney function in patients with diabetic nephropathy.

          Research design and methods

          This study was design as multicenter retrospective study. The subjects (377 patients with diabetic nephropathy diagnosed by kidney biopsy at 13 centers in Japan) were classified into three groups based on the estimated glomerular filtration rate (eGFR) declining speed. The eGFR increasing group, the control group, and the eGFR declining group were divided at 0 and 5 mL/min/1.73 m 2/year, respectively. Characteristics of clinicopathological findings of declining kidney function were evaluated.

          Results

          The mean observation period of this study was 6.9 years. The control group, the eGFR increasing group, and the eGFR declining group included 81, 66, and 230 patients, respectively. The incidences of composite kidney events represented by 100 persons/year were 25.8 in the eGFR declining group and 2.0 in the eGFR increasing group. After adjustment for age, sex, systolic blood pressure, hemoglobin, and urinary albumin levels, three clinicopathological findings (urinary albumin levels, presence of nodular lesion, and mesangiolysis) were risk factors for inclusion in the eGFR declining group (the ORs were 1.49, 2.18, and 2.08, respectively). In contrast, the presence of subendothelial space widening and polar vasculosis were characteristic findings for inclusion in the eGFR increasing group (the ORs were 0.53 and 0.41, respectively).

          Conclusions

          As well as urinary albumin elevation, nodular lesion and mesangiolysis were characteristic pathological features of patients with fast declining kidney function.

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          Predictors of estimated GFR decline in patients with type 2 diabetes and preserved kidney function.

          Vittorio Ortalda, Giacomo Zoppini, Giovanni Targher … (2012)
          This study examined predictors of the annual decline in estimated GFR (eGFR) in patients with type 2 diabetes and preserved kidney function. In a prospective, observational cohort study, 1682 individuals with type 2 diabetes and baseline eGFR ≥60 ml/min per 1.73 m(2) (as estimated by the Chronic Kidney Disease Epidemiology Collaboration equation) were followed for 10 years. Linear regression was used to estimate participants' changes in eGFR over time. During follow-up, 263 (15.6%) individuals had a rapid eGFR decline defined as >4.0% per year. Average eGFR decline was -5.8 ± 3 and -0.6 ± 2 ml/min per 1.73 m(2) per year in rapid decliners and nondecliners, respectively. Compared with normotensive, normoalbuminuric patients (-0.2 ± 0.2 ml/min per 1.73 m(2) per year), those with hypertension (-1.0 ± 0.1 ml/min per 1.73 m(2) per year), hemoglobin A(1c)≥7% (-1.0 ± 0.1 ml/min per 1.73 m(2) per year), longer diabetes duration (-1.0 ± 0.1 ml/min per 1.73 m(2) per year), obesity (-1.2 ± 0.1 ml/min per 1.73 m(2) per year), insulin treatment (-1.5 ± 0.1 ml/min per 1.73 m(2) per year), microalbuminuria (-1.3 ± 0.2 ml/min per 1.73 m(2) per year), or macroalbuminuria (-2.7 ± 0.4 ml/min per 1.73 m(2) per year) had significantly faster age-adjusted annual eGFR declines. Multivariable linear regression analyses revealed that albuminuria (P<0.001) was the strongest predictor of annual eGFR decline. Other independent predictors of annual eGFR decline were older age, hypertension, insulin treatment, and lower baseline eGFR. Annual eGFR decline is predicted by multiple modifiable risk factors in patients with type 2 diabetes and preserved kidney function.
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            Fast renal decline to end-stage renal disease: an unrecognized feature of nephropathy in diabetes.

            Andrzej Krolewski, Jan Skupien, Peter Rossing … (2017)
            A new model of diabetic nephropathy in type 1 diabetes emerged from our studies of Joslin Clinic patients. The dominant feature is progressive renal decline, not albuminuria. This decline is a unidirectional process commencing while patients have normal renal function and, in the majority, progressing steadily (linearly) to end-stage renal disease (ESRD). While an individual's rate of renal decline is constant, the estimated glomerular filtration rate (eGFR) slope varies widely among individuals from -72 to -3.0 ml/min/year. Kidney Disease: Improving Global Outcomes guidelines define rapid progression as rate of eGFR declines > 5 ml/min/year, a value exceeded by 80% of patients in Joslin's type 1 diabetes ESRD cohort. The extraordinary range of slopes within the rapid progression category prompted us to partition it into "very fast," "fast" and "moderate" decline. We showed, for the first time, that very fast and fast decline from normal eGFR to ESRD within 2 to 10 years constitutes 50% of the Joslin cohort. In this review we present data about frequency of fast decliners in both diabetes types, survey some mechanisms underlying fast renal decline, discuss methods of identifying patients at risk and comment on the need for effective therapeutic interventions. Whether the initiating mechanism of fast renal decline affects glomerulus, tubule, interstitium or vasculature is unknown. Since no animal model mimics progressive renal decline, studies in humans are needed. Prospective studies searching for markers predictive of the rate of renal decline yield findings that may make detection of fast decliners feasible. Identifying such patients will be the foundation for developing effective individualized methods to prevent or delay onset of ESRD in diabetes.
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              Progressive Renal Decline: The New Paradigm of Diabetic Nephropathy in Type 1 Diabetes

              Andrzej Krolewski (2015)
              On the basis of extensive studies in Joslin Clinic patients over 25 years, we propose a new model of diabetic nephropathy in type 1 diabetes. In this model, the predominant clinical feature of both early and late stages of diabetic nephropathy is progressive renal decline, not albuminuria. Progressive renal decline (estimated glomerular filtration rate loss >3.5 mL/min/year) is a unidirectional process that develops while patients have normal renal function. It progresses at an almost steady rate until end-stage renal disease is reached, albeit at widely differing rates among individuals. Progressive renal decline precedes the onset of microalbuminuria, and as it continues, it increases the risk of proteinuria. Therefore, study groups ascertained for microalbuminuria/proteinuria are enriched for patients with renal decline (decliners). We found prevalences of decliners in 10%, 32%, and 50% of patients with normoalbuminuria, microalbuminuria, and proteinuria, respectively. Whether the initial lesion of progressive renal decline is in the glomerulus, tubule, interstitium, or vasculature is unknown. Similarly unclear are the initiating mechanism and the driver of progression. No animal model mimics progressive renal decline, so etiological studies must be conducted in humans with diabetes. Prospective studies searching for biomarkers predictive of the onset and rate of progression of renal decline have already yielded positive findings that will help to develop not only accurate methods for early diagnosis but also new therapeutic approaches. Detecting in advance which patients will have rapid, moderate, or minimal rates of progression to end-stage renal disease will be the foundation for developing personalized methods of prevention and treatment of progressive renal decline in type 1 diabetes.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open Diabetes Res Care
                Journal ID (iso-abbrev): BMJ Open Diabetes Res Care
                Journal ID (hwp): bmjdrc
                Journal ID (publisher-id): bmjdrc
                Title: BMJ Open Diabetes Research & Care
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2052-4897
                Publication date Collection: 2020
                Publication date (Electronic): 4 June 2020
                Volume: 8
                Issue: 1
                Electronic Location Identifier: e001157
                Affiliations
                [1 ] departmentDepartment of Nephrology , Kanazawa Medical University School of Medicine , Uchinada, Japan
                [2 ] departmentDepartment of Nephrology and Laboratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Graduate School of Medical Sciences , Kanazawa University , Kanazawa, Ishikawa, Japan
                [3 ] departmentNephrology Center , Toranomon Hospital , Tokyo, Japan
                [4 ] departmentDepartment of Nephrology , Fujita Health University School of Medicine , Toyoake, Japan
                [5 ] departmentDepartment of Pathology, Clinical Research Center , National Hospital Organization Chiba-East National Hospital , Chiba, Japan
                [6 ] departmentHealth Administration Center , Niigata University , Niigata, Japan
                [7 ] departmentClinical Pharmacology and Therapeutics , Tohoku University Graduate School of Pharmaceutical Sciences , Sendai, Japan
                [8 ] departmentDepartment of Pathology, Faculty of Medicine , Fukuoka University , Fukuoka, Japan
                [9 ] departmentDepartment of Pathology , Dokkyo Medical University, Saitama Medical Center , Koshigaya, Japan
                [10 ] departmentDivision of Nephrology and Kidney Center , Kobe University Graduate School of Medicine , Kobe, Japan
                [11 ] departmentDepartment of Nephrology , Nagasaki University Hospital , Nagasaki, Japan
                [12 ] departmentDepartment of Nephrology , Nara Medical University , Nara, Japan
                [13 ] departmentDepartment of Cardiovascular Medicine, Nephrology and Neurology , University of the Ryukyus School of Medicine , Nakagami-gun, Okinawa, Japan
                [14 ] departmentDivision of Nephrology, Department of Internal Medicine , St. Marianna University, School of Medicine , Kawasaki, Japan
                [15 ] departmentDepartment of Nephrology, Rheumatology, Endocrinology and Metabolism , Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences , Okayama, Japan
                [16 ] departmentDivision of Nephrology, Department of Internal Medicine , Nagoya University Graduate School of Medicine , Nagoya, Japan
                Author notes
                [Correspondence to ] Professor Kengo Furuichi; furuichi@ 123456kanazawa-med.ac.jp
                Author information
                http://orcid.org/0000-0002-7069-0938
                http://orcid.org/0000-0003-3264-9691
                Article
                Publisher ID: bmjdrc-2019-001157
                DOI: 10.1136/bmjdrc-2019-001157
                PMC ID: 7282298
                PubMed ID: 32503809
                SO-VID: 72cb3c1c-fab1-4a78-bc90-c8130cb7d638
                Copyright © © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
                License:

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                Date received : 25 December 2019
                Date revision received : 26 March 2020
                Date accepted : 04 May 2020
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100009619, Japan Agency for Medical Research and Development;
                Award ID: 15ek0310003h0001
                Categories
                Subject: Pathophysiology/Complications
                Subject: 1506
                Subject: 1869
                Custom metadata
                special-feature unlocked

                Keywords: nephropathology,nephropathy,kidney biopsies,kidney failure
                Data availability:
                Keywords: nephropathology, nephropathy, kidney biopsies, kidney failure

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