Renal outcomes and clinical course of nondiabetic renal diseases in patients with type 2 diabetes.

BACKGROUND/AIMS: In several recent studies, renal biopsies in patients with type 2 diabetes and renal disease have revealed a heterogeneous group of disease entities. Our aim was to study the prognosis and clinical course of nondiabetic renal disease (NDRD) and to determine risk factors for NDRD in patients with type 2 diabetes. METHODS: Renal biopsy reports of 110 patients with type 2 diabetes who were seen at Kyung Hee University Medical Center and Kyung Hee University Hospital at Gangdong, Seoul, Korea between January 2000 and December 2011 were retrospectively analyzed. RESULTS: Of 110 patients with type 2 diabetes, 41 (37.3%) had diabetic nephropathy (DN), 59 (53.6%) had NDRD, and 10 (9.1%) had NDRD superimposed on DN. Immunoglobulin A nephropathy (43.5%) was the most common NDRD. Patients with NDRD had a shorter duration of diabetes, lower frequency of diabetic retinopathy, and better renal outcomes, which might have resulted from the use of aggressive disease-specific treatments such as steroids and immunosuppressants in patients with NDRD. CONCLUSIONS: Compared with DN, NDRD was associated with better renal outcomes in patients with type 2 diabetes, as evidenced by a higher cumulative renal survival rate and lower rate of end-stage renal disease (ESRD). Shorter duration of diabetes and absence of retinopathy were independent predictors of NDRD in patients with type 2 diabetes and renal involvement. Renal biopsy is recommended for patients with type 2 diabetes and risk factors for NDRD, to obtain an accurate diagnosis, prompt initiation of disease-specific treatment, and ultimately better renal outcomes with the avoidance of ESRD.

Angiotensinogen polymorphisms and post-transplantation diabetes mellitus in Korean renal transplant subjects.

BACKGROUND: Post-transplant diabetes mellitus (PTDM) is a common and serious metabolic complication. Genetic polymorphisms of angiotensin-converting enzyme (ACE) and angiotensinogen (AGT) genes have been reported to be related to diabetes mellitus and insulin sensitivity; however, the role of these genes in the development of PTDM is not known. For this purpose, we investigated the association of ACE and AGT genetic polymorphisms with PTDM. METHODS: A total of 302 subjects without previously diagnosed diabetes who had received kidney transplants were included. One ACE single nucleotide polymorphism (SNP) (rs4291) and two AGT SNPs (rs 699 and rs 4762) were genotyped from genomic DNA with direct sequencing. RESULTS: PTDM developed in 49 (16.2%) of 302 subjects. Subjects in the PTDM were older than those in the non-PTDM. There was a significant difference between the two groups in tacrolimus use (p=0.03). Of the three SNPs, the rs4762 of the AGT gene was significantly associated with the development of PTDM in the dominant models (p = 0.03) after adjusting for age and tacrolimus usage. CONCLUSIONS: AGT gene rs4762 polymorphisms may serve as genetic markers for the development of PTDM. The exact molecular mechanisms still need to be clarified.

Novel Biomarkers for Cardio-renal Syndrome.

Cardio-renal syndrome (CRS) is a frequent and life-threatening syndrome. It is a disorder of the heart and kidneys in which acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other organ. Acute kidney injury (AKI) is strongly associated with increased morbidity and mortality in patients with CRS. Early detection of renal dysfunction is not possible using the traditional marker, serum creatinine, and therefore efforts to explore possible biomarkers for early detection of AKI are being made. Apart from predicting AKI, several biomarker studies also identified predictors for poor prognosis such as the need for renal replacement therapy (RRT) or death. It is possible that biomarkers can become risk factors in an improvement of clinical outcomes of CRS. Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with renal dysfunction and the treatment for this disease can be modified based on cardiac biomarkers. In addition to natriuretic peptides, which are established cardiac markers, several new biomarkers have been identified and may play important roles in CRS. In this review, we will briefly summarize the literature on novel renal and cardiac biomarkers and discuss their potential roles in the clinical outcome of CRS.

Platelet reactivity in patients with chronic kidney disease receiving adjunctive cilostazol compared with a high-maintenance dose of clopidogrel: results of the effect of platelet inhibition according to clopidogrel dose in patients with chronic kidney disease (PIANO-2 CKD) randomized study.

BACKGROUND: Chronic kidney disease (CKD) is a factor of low response to clopidogrel. We sought to assess the functional impact of cilostazol in CKD patients with undergoing hemodialysis. METHODS: Seventy-four patients with CKD undergoing hemodialysis and percutaneous coronary intervention were enrolled. Patients were randomly assigned to receive clopidogrel (75 mg/d [group 1, n = 24]), high-maintenance dose of clopidogrel (150 mg/d [group 2, n = 25]), or clopidogrel (75 mg/d) with cilostazol (200 mg/d [group 3, n = 25]) for 14 days. Another 50 patients with normal renal function undergoing percutaneous coronary intervention were treated with 75 mg of clopidogrel and served as the control group. Platelet function was evaluated before and after antiplatelet therapy with light transmittance aggregometry and with VerifyNow P2Y12 assay (Accumetrics, San Diego, CA). Platelet activation markers (soluble CD40 ligand and soluble P-selectin) were also assessed. RESULTS: The baseline platelet function measurements were similar in the 3 groups of patients; however, the CKD groups had significantly higher platelet aggregation activity compared with the control groups. The rate of high on-treatment platelet reactivity was significantly lower in group 3 than in groups 1 and 2 (10% vs 43% vs 32%, respectively; P < .05). After 14 days of antiplatelet therapy, the changes in plasma soluble CD40 ligand and soluble P-selectin levels were significantly higher in group 3 compared with groups 1 and 2 (P < .01); however, there were no significant differences in platelet function and activation markers between groups 1 and 2. CONCLUSIONS: Adjunctive cilostazol improves platelet inhibition compared with 75 or 150 mg of clopidogrel in CKD patients undergoing hemodialysis.

Repeated administration of bone marrow-derived mesenchymal stem cells improved the protective effects on a remnant kidney model.

Mesenchymal stem cell (MSC) has been implied to have the therapeutic potential on chronic kidney disease (CKD). However, the underlying mechanism is still unclear and administration frequency of MSCs could be an issue in a chronic disease model. We evaluated the effect of repeated administration of MSCs on a remnant kidney model. MSCs from 5-week male Sprague-Dawley rats were infused by tail vein into 7-week female 5/6 nephrectomized rats after tagging with a fluorescent probe, chloromethyl-1,1-dioctadecyl-3,3,3',3'-tetramethyl- indocarbocyanine perchlorate (CM-Dil). Effect of weekly administration of MSCs was compared with the effect of once injection of MSCs and mesangial cells (MCs) at 1 and 5 weeks, respectively. Engraftment of MSCs into the kidney was evaluated by the presence of CM-Dil fluorescence or SRY gene expression. Weekly MSCs administration showed significant improvement in systolic blood pressure (SBP), urinary protein excretion amount, and serum creatinine level at 5 weeks, whereas once MSCs or MCs administration did not. Although once MSCs administration attenuated glomerulosclerosis and infiltration of ED-1 positive cells at 5 weeks as compared with MCs, weekly MSC administration led to a more significant improvement. Renal SRY gene expression and presence of CM-Dil-tagged cells could be confirmed at 1 week after injection of MSCs or weekly injected group, but not at 5 weeks after once injection. MSCs attenuated cortical expression of interleukin (IL)-6 and elevated the expression of IL-10, but these effects were only sustained in the weekly group. Thus, repeated administration of MSCs improves the protective effect on remnant kidney injury, but primarily via the paracrine effect rather than differentiation.

A case of multiple endocrine neoplasia type 1 with primary liver gastrinoma.

Gastrinoma is the most frequent functional pancreaticoduodenal endocrine tumor in patients with multiple endocrine neoplasia type 1 (MEN 1). Primary hepatic gastrinomas in MEN 1 are very rare, with no previous reports published in the literature. We reported the case of a 39 yr old female patient with a history of repeated peptic ulcers and a hypoglycemia episode. Abdominal CT indicated a well-defined liver mass and a pancreatic head mass. Somatostatin-receptor scintigraphy with [(111)In] DTPA octreotide demonstrated a strong uptake of the radiotracer in the left lateral segment at the site of the hepatic mass. After operation, immunohistochemical staining was consistent with pancreatic insulinoma and primary hepatic gastrinoma. As the liver is a common site of metastases from gastrinoma, primary liver gastrinoma has not yet been reported with MEN 1. We diagnosed this patient using immunohistochemical studies and treated this patient by hepatic segmentectomy.