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      The effects of AER and eGFR on outcomes of CVD in patients with T2DM in an urban community over 8 years of multifactorial treatment: the Beijing Communities Diabetes Study 18

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          Abstract

          Objective

          It is well known that diabetic kidney disease is a risk factor for cardiovascular diseases (CVD) in patients with type 2 diabetes mellitus (T2DM). In this study, the effects of urine albumin excretion rate (AER) and estimated glomerular filtration rate (eGFR) on CVD outcomes were analyzed in a population of T2DM.

          Methods

          The study was carried out using recorded information of a cohort study. A total of 1,914 patients with T2DM with no prevalent CVD were enrolled in an 8 years prospective study and received multifactorial intervention. The risk of CVD outcomes was assessed according to chronic kidney disease staging, which was categorized using AER (mg/d) and eGFR (mL/min/1.73 m 2). The effects of AER and eGFR on risk of CVD onset were also analyzed.

          Results

          During the follow-up period (median 6.8 years), 71 CVD events occurred. At baseline, those with AER ≥300 mg/d and coexisting eGFR 60–89 mL/min/1.73 m 2 or <60 mL/min/1.73 m 2 showed increased risk for CVD outcomes when compared with “no chronic kidney disease” (AER <30 mg/d and eGFR ≥90 mL/min/1.73 m 2). The increased CVD risk was observed in patients who progressed to AER ≥30 mg/d during the follow-up period, whereas patients who progressed to eGFR <90 mL/min/1.73 m 2 alone showed no increased CVD risk. During the follow-up period, after multifactorial intervention, 8.7% patients with microalbuminuria and 1.8% patients with overt nephropathy reversed to normoalbuminuria or microalbuminuria.

          Conclusion

          AER is a more sensitive predictor than eGFR for CVD outcomes in T2DM patients. Overt nephropathy can be reversed after multifactorial intervention.

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          Most cited references 20

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          Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis.

          Chronic kidney disease is characterised by low estimated glomerular filtration rate (eGFR) and high albuminuria, and is associated with adverse outcomes. Whether these risks are modified by diabetes is unknown. We did a meta-analysis of studies selected according to Chronic Kidney Disease Prognosis Consortium criteria. Data transfer and analyses were done between March, 2011, and June, 2012. We used Cox proportional hazards models to estimate the hazard ratios (HR) of mortality and end-stage renal disease (ESRD) associated with eGFR and albuminuria in individuals with and without diabetes. We analysed data for 1,024,977 participants (128,505 with diabetes) from 30 general population and high-risk cardiovascular cohorts and 13 chronic kidney disease cohorts. In the combined general population and high-risk cohorts with data for all-cause mortality, 75,306 deaths occurred during a mean follow-up of 8·5 years (SD 5·0). In the 23 studies with data for cardiovascular mortality, 21,237 deaths occurred from cardiovascular disease during a mean follow-up of 9·2 years (SD 4·9). In the general and high-risk cohorts, mortality risks were 1·2-1·9 times higher for participants with diabetes than for those without diabetes across the ranges of eGFR and albumin-to-creatinine ratio (ACR). With fixed eGFR and ACR reference points in the diabetes and no diabetes groups, HR of mortality outcomes according to lower eGFR and higher ACR were much the same in participants with and without diabetes (eg, for all-cause mortality at eGFR 45 mL/min per 1·73 m(2) [vs 95 mL/min per 1·73 m(2)], HR 1·35; 95% CI 1·18-1·55; vs 1·33; 1·19-1·48 and at ACR 30 mg/g [vs 5 mg/g], 1·50; 1·35-1·65 vs 1·52; 1·38-1·67). The overall interactions were not significant. We identified much the same findings for ESRD in the chronic kidney disease cohorts. Despite higher risks for mortality and ESRD in diabetes, the relative risks of these outcomes by eGFR and ACR are much the same irrespective of the presence or absence of diabetes, emphasising the importance of kidney disease as a predictor of clinical outcomes. US National Kidney Foundation. Copyright © 2012 Elsevier Ltd. All rights reserved.
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            Chronic kidney disease: a public health priority and harbinger of premature cardiovascular disease.

            The epidemics of cardiovascular disease, obesity, diabetes, HIV and cancer have all received much attention from the public, media and policymakers. By contrast, chronic kidney disease (CKD) has remained largely a 'silent' epidemic. This is unfortunate because early diagnosis of renal disease based on proteinuria and/or reduced estimated glomerular filtration rate could enable early intervention to reduce the high risks of cardiovascular events, end-stage renal disease (ESRD) and death that are associated with CKD. Given the global increase in the incidence of the leading causes of CKD--hypertension, obesity and diabetes mellitus--better disease management and prevention planning are needed, as effective strategies are available to slow the progression of CKD and reduce cardiovascular risk. CKD may be regarded as a clinical model of accelerated vascular disease and premature ageing, and the risk-factor profile changes during the progression from mild/moderate CKD to ESRD. Although many randomized controlled trials in patients with mild to moderate CKD have shown beneficial effects of interventions aimed at preventing the progression of CKD, most trials have been unable to demonstrate a beneficial effect of interventions aimed at improving outcome in ESRD. Thus, novel treatment strategies are needed in this high-risk patient group. © 2010 The Association for the Publication of the Journal of Internal Medicine.
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              • Article: not found

              Microalbuminuria and risk for cardiovascular disease: Analysis of potential mechanisms.

              Microalbuminuria is a strong and independent indicator of increased cardiovascular risk among individuals with and without diabetes. Therefore, microalbuminuria can be used for stratification of risk for cardiovascular disease. Once microalbuminuria is present, cardiovascular risk factor reduction should be more "aggressive." The nature of the link between microalbuminuria and cardiovascular risk, however, remains poorly understood. There is no strong evidence that microalbuminuria causes atherothrombosis or that atherothrombosis causes microalbuminuria. Many studies have tested the hypothesis that a common risk factor underlies the association between microalbuminuria and cardiovascular disease but, again, have found no strong evidence in favor of this contention. At present, the most likely possibility is that a common pathophysiologic process, such as endothelial dysfunction, chronic low-grade inflammation, or increased transvascular leakage of macromolecules, underlies the association between microalbuminuria and cardiovascular disease, but more and prospective studies of these hypotheses are needed.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2018
                31 August 2018
                : 14
                : 1537-1545
                Affiliations
                [1 ]Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, People’s Republic of China, fulvic@ 123456126.com
                [2 ]Medical Records and Statistics Department, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
                [3 ]Clinical and Translational Science Institute, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
                [4 ]Department of General Practice, Jinsong Community Health Service Center, Beijing, People’s Republic of China
                [5 ]Department of General Practice, Cuigezhuang Community Health Service Center, Beijing, People’s Republic of China
                [6 ]Department of General Practice, Xinjiekou Community Health Service Center, Beijing, People’s Republic of China
                [7 ]Department of General Practice, Yuetan Community Health Service Center of Fuxing Hospital, Capital Medical University, Beijing, People’s Republic of China
                [8 ]Department of General Practice, Jiangtai Community Health Service Center, Beijing, People’s Republic of China
                [9 ]Department of General Practice, Sanlitun Community Health Service Center, Beijing, People’s Republic of China
                [10 ]Department of General Practice, Zuojiazhuang Community Health Service Center, Beijing, People’s Republic of China
                [11 ]Department of General Practice, The First People’s Hospital of Chongwen District, Beijing, People’s Republic of China
                [12 ]Department of General Practice, Balizhuang Community Health Service Center, Beijing, People’s Republic of China
                [13 ]Department of General Practice, Majiapu Community Health Service Center, Beijing, People’s Republic of China
                [14 ]Department of Endocrinology, Beijing Aerospace General Hospital, Beijing, People’s Republic of China
                [15 ]Department of Endocrinology, China-Japan Friendship Hospital, Beijing, People’s Republic of China, guangwei_li@ 123456medmail.com.cn
                [16 ]Center of Endocrinology and Cardiovascular Disease, Department of Endocrinology, National Center of Cardiology and Fuwai Hospital, Beijing, People’s Republic of China, guangwei_li@ 123456medmail.com.cn
                Author notes
                Correspondence: Shen-Yuan Yuan, Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, 1 Dong Jiao Min Xiang, Beijing 100730, People’s Republic of China, Tel +86 10 5826 8466, Email fulvic@ 123456126.com
                Guang-Wei Li, Department of Endocrinology, China-Japan Friendship Hospital, 167 Bei Li Shi Lu, Beijing 100029, People’s Republic of China, Email guangwei_li@ 123456medmail.com.cn
                Article
                tcrm-14-1537
                10.2147/TCRM.S170915
                6124448
                © 2018 Zhang et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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