Atrial high-rate episodes intensify R2CHA2DS2-VASc score for prognostic stratification in pacemaker patients.

Patients with device detected atrial high-rate episodes (AHRE) have an increased risk of MACE. The R2CHA2DS2-VASc, CHADS2, R2CHADS2 and CHA2DS2-VASc score have been investigated for predicting major adverse cardiovascular events (MACE) in different groups of patients. We aimed to evaluate the R2CHA2DS2-VASc score in combination with AHRE ≥ 6 min for predicting MACE in patients with dual-chamber PPM but no prior atrial fibrillation (AF). We retrospectively enrolled 376 consecutive patients undergoing dual-chamber PPM implantation and no prior AF. The primary endpoint was subsequent MACE. For all patients in the cohort, CHADS2, R2CHADS2, CHA2DS2-VASc, R2CHA2DS2-VASc scores and AHRE ≥ or < 6 min were determined. AHRE was recorded as a heart rate > 175 bpm (Medtronic) or > 200 bpm (Biotronik) lasting ≥ 30 s. Multivariate Cox regression analysis with time-dependent covariates was used to determine the independent predictors of MACE. ROC-AUC analysis was performed for CHADS2, R2CHADS2, CHA2DS2-VASc, and R2CHA2DS2-VASc scores and then adding AHRE ≥ 6 min to the four scores. The median age was 77 years, and 107 patients (28.5%) developed AHRE ≥ 6 min. After a median follow-up of 32 months, 46 (12.2%) MACE occurred. Multivariate Cox regression analysis showed that R2CHA2DS2-VASc score (HR, 1.485; 95% CI, 1.212-1.818; p < 0.001) and AHRE ≥ 6 min (HR, 2.125; 95% CI, 1.162-3.887; p = 0.014) were independent predictors for MACE. The optimal R2CHA2DS2-VASc score cutoff value was 4.5 (set at ≥ 5), with the highest Youden index (AUC, 0.770; 95% CI, 0.709-0.831; p < 0.001). ROC-AUC analysis of the four risk scores separately combined with AHRE ≥ 6 min all showed better discriminatory power than the four scores alone (All Z-statistic p < 0.05). In patients with PPM who develop AHRE ≥ 6 min, it is crucial to perform risk assessment with either four scores to further stratify risk for MACE.

The performance of five models compared with atrial high rate episodes predicts new atrial fibrillation after cardiac implantable electronic devices implantation.

AIMS: Several predicting models have been evaluated for new-onset atrial fibrillation (AF) in several clinical conditions, but never in patients with cardiac implantable electronic devices (CIED). We aimed to evaluate the five predicting models compared with atrial high rate episodes (AHRE) to predict new AF in patients with CIED. METHODS AND RESULTS: We retrospective enrolled 470 consecutive patients with CIED and without a history of AF. The five predicting models, including CHA2 DS2 -VASc score, C2 HEST score, mCHEST score, HAT2 CH2 score, and HAVOC score were used. The primary endpoint was new AF documented by 12-lead electrocardiography (ECG) or 30-s ECG strip. Multivariable Cox regression analysis was used to determine variables associated with independent factors of new AF. Patients' median age was 76 years and 58.7% were male. During follow-up (median 29 months), 34 new AF occurred (incidence rate 2.99/100 patient-years, 95% CI 1.67-6.20). Multivariable Cox regression analysis showed AHRE ≥6 min and 24 h, and HAT2 CH2 score were independent predictors for new AF. Optimal AHRE cutoff value was 9.3 min with highest Youden index (AUC, 0.806; 95% CI, 0.722-0.889; p < .001). The AF occurrence rate of AHRE ≥9.3 min was 7 times AHRE <9.3 min (p < .001). CONCLUSIONS: We compared 5 predicting models for new AF in patients with CIED and without a history of AF. AHRE ≥6 min and 24 h, and HAT2 CH2 score were independent predictors for AF.

HAT2CH2 score performance predicting neurologic events after cardiac implantable electronic device.

Objectives: The HAT2CH2 score has been evaluated for predicting new-onset atrial fibrillation in several clinical conditions, but never for adverse neurologic events. We aimed to evaluate the effectiveness of HAT2CH2 score in predicting neurologic events in patients with cardiac implantable electronic device (CIED), comparing with atrial high-rate episodes (AHRE). Methods: This case-control study enrolled 314 consecutive patients aged 18 years or older with CIED implantation between January 2015 and April 2021. Patient data were analyzed retrospectively. The primary endpoint was subsequent neurologic events (NE) after implantation. AHRE was defined as > 175 bpm (Medtronic®) lasting ≥ 30 seconds. Variables associated with independent risk of NE were identified using multivariate Cox regression analysis with time-dependent covariates. Results: Patients' median age was 73 years and 61.8% of them were male. During follow-up (median 32 months), 18 NE occurred (incidence rate 2.15/100 patient-years, 95% CI 1.32-4.30). Multiple Cox regression analysis showed that the HAT2CH2 score (HR 2.424, 95% CI 1.683 - 3.492, p < 0.001) was an independent predictor for NE. Optimal HAT2CH2 score cutoff value was 3 with highest Youden index (AUC, 0.923; 95% CI, 0.881-0.966; p < 0.001). Both AHRE ≥ 1 minute and HAT2CH2 score ≥ 3 had the highest AUC of the receiver-operating characteristic (0.898, 95% CI, 0.831-0.965, p < 0.001). Significant increase was observed in NE occurrence rates using the HAT2CH2 score (p < 0.001). Conclusion: The HAT2CH2 score and episodes of AHRE lasting ≥ 1 minute are independent risk factors for NE in patients with CIED.

The HAT2CH2 score predicts neurologic events in patients with cardiac implantable electronic devices without atrial fibrillation.

BACKGROUND: The HAT2CH2 score has been evaluated for predicting new-onset atrial fibrillation (AF) in several clinical conditions but never for adverse neurologic events. We aimed to evaluate the HAT2CH2 score for predicting neurologic events in patients with cardiac implantable electronic devices (CIED). METHODS AND RESULTS: We retrospectively reviewed 470 consecutive patients who had CIED without a history of AF. The primary endpoint was a neurologic event, i.e. ischemic stroke or transient ischemic attack. Multivariate Cox regression analysis with time-dependent covariates was used to determine variables associated with independent factors of neurologic events. Patients' median age was 76 years, and 58.7% were male. During follow-up (median 29 months), 21 neurologic events occurred (incidence rate 1.85/100 patient-years, 95% CI 1.03-3.83). Multivariable Cox regression analysis revealed that the HAT2CH2 score (HR 3.397, 95% CI 2.357-4.895, p < 0.001) was an independent predictor for neurologic events. Optimal HAT2CH2 score cut-off value was 3, with highest Youden index (AUC, 0.923; 95% CI, 0.886-0.959; p < 0.001). The rate of neurologic events increased significantly with increasing HAT2CH2 score (p < 0.001). CONCLUSIONS: The HAT2CH2 score can predict the occurrence of neurologic events in patients with CIED with no history of AF. Further study of the utility of the HAT2CH2 score for the assessment of neurologic event risk and the selection of anti-thrombotic therapy in patients with CIED without prior AF is warranted.

HATCH Score and Left Atrial Size Predict Atrial High-Rate Episodes in Patients With Cardiac Implantable Electronic Devices.

Background: Patients with sustained atrial high-rate episodes (AHRE) have a high risk of major adverse cardio/cerebrovascular events (MACCE). However, the prediction model and factors for the occurrence of AHRE are unknown. We aimed to identify independent factors and various risk models for predicting MACCE and AHRE. Methods: We retrospectively enrolled 314 consecutive patients who had cardiac implantable electronic devices (CIEDs). The primary endpoint was MACCE after AHRE ≥3, 6 min, and 6 h. Atrial high-rate episodes was defined as >175 bpm (Medtronic®) lasting ≥30 s. Multivariate Cox and logistic regression analysis with time-dependent covariates were used to determine variables associated with independent risk of MACCE and occurrence of AHRE ≥3 min, respectively. Results: One hundred twenty-five patients (39.8%) developed AHRE ≥3 min, 103 (32.8%) ≥6 min, and 55 (17.5%) ≥6 h. During follow-up (median 32 months), 77 MACCE occurred (incidence 9.20/100 patient years, 95% CI 5.66-18.39). The optimal AHRE cutoff value was 3 min for MACCE, with highest Youden index 1.350 (AUC, 0.716; 95% CI, 0.638-0.793; p < 0.001). Atrial high-rate episodes ≥3 min-6 h were independently associated with MACCE. HATCH score and left atrial diameter were independently associated with AHRE ≥3 min. The optimal cutoff for HATCH score was 3 and for left atrial diameter was 4 cm for AHRE ≥3 min. Conclusion: Patients with CIEDs who develop AHRE ≥3 min have an independently increased risk of MACCE. Comprehensive assessment using HATCH score and echocardiography of patients with CIEDs is warranted.

Atrial high-rate episodes predict major adverse cardio/cerebrovascular events in patients with cardiac implantable electrical devices.

Patients with atrial high-rate episodes (AHRE) have a high risk of neurologic events, although the causal role and optimal cutoff threshold of AHRE for major adverse cardio/cerebrovascular events (MACCE) are unknown. This study aimed to identify independent factors for AHRE and subsequent atrial fibrillation (AF) after documented AHRE. We enrolled 470 consecutive patients undergoing cardiac implantable electrical device (CIED) implantations. The primary endpoint was subsequent MACCE after AHRE ≥ 6 min, 6 h, and 24 h. AHRE was defined as > 175 beats per minute (bpm) (Medtronic®) or > 200 bpm (Biotronik®) lasting ≥ 30 s. Multivariate Cox regression analysis with time-dependent covariates was used to determine variables associated with independent risk of MACCE. The patients' median age was 76 year, and 126 patients (26.8%) developed AHRE ≥ 6 min, 63 (13.4%) ≥ 6 h, and 39 (8.3%) ≥ 24 h. During follow-up (median: 29 months), 142 MACCE occurred in 123 patients. Optimal AHRE cutoff value was 6 min, with highest Youden index for MACCE. AHRE ≥ 6 min ~ 24 h was independently associated with MACCE and predicted subsequent AF. Male gender, lower body mass index, or BMI, and left atrial diameter were independently associated with AHRE ≥ 6 min ~ 24 h. Patients with CIEDs who develop AHRE ≥ 6 min have an independently increased risk of MACCE. Comprehensive assessment of patients with CIEDs is warranted.

The optimal cutoff of atrial high-rate episodes for neurological events in patients with dual chamber permanent pacemakers.

BACKGROUND: Patients with atrial high-rate episode (AHRE) are at higher risk of neurological events. This study aimed to identify the optimal cutoff threshold for AHRE duration in patients with dual chamber permanent pacemakers (PPM) without prior atrial fibrillation. METHODS: We included 355 consecutive patients receiving dual chamber pacemaker implantation. Primary outcome was composite endpoint of subsequent neurological events after various AHRE durations. AHRE was defined as >175 bpm (MEDTRONIC) or > 200 bpm (BIOTRONIK) for longer than 30 s. Cox regression analysis with time-dependent covariates was conducted. RESULTS: The mean age of included patients was 75.6 ± 11.3 years. Among 355 included patients, some had multiple AHREs; 125 patients (35.2%) developed AHRE ≥2 min, 107 (30.1%) had ≥5 min, 55 (15.5%) had ≥6 h, and 37 (10.4%) had ≥24 h. The mean follow-up was 42.1 ± 31.2 months. During follow-up, 19 neurological events occurred. After adjustment for CHA2 DS2 -VASc score and device type, multivariate Cox regression analysis indicated AHRE ≥2 min (HR 13.605, 95% CI 3.010-61.498), and AHRE ≥5 min (HR 5.819, 95% CI 2.056-16.470) were significantly associated with neurological events. Hence, the optimal AHRE cutoff value was 2 min with the highest Youden index (sensitivity, 89.5%; specificity, 67.8%; AUC, 0.823, 95% CI, 0.763-0.884; p < 0.001). CONCLUSIONS: Patients with dual chamber PPM who develop AHRE have increased risk of neurological events. Comprehensive assessment of the risks and benefits of prescribing anticoagulants should be considered in PPM patients with AHRE ≥2 min.

Atrial high­rate episodes and risk of major adverse cardiovascular events in patients with dual chamber permanent pacemakers: a retrospective study.

Patients with atrial high-rate episodes (AHRE) are at higher risk of major adverse cardiovascular events (MACE). The cutoff threshold for AHRE duration for MACE, with/without history of atrial fibrillation (AF) or myocardial infarction (MI), is unknown. A total of 481 consecutive patients with/without history of AF or MI receiving dual-chamber pacemaker implantation were included. The primary outcome was a composite endpoint of MACE after AHRE ≥ 5 min, ≥ 6 h, and ≥ 24 h. AHRE was defined as > 175 bpm (MEDTRONIC) or > 200 bpm (BIOTRONIK) lasting ≥ 5 min. Cox regression analysis with time-dependent covariates was conducted. Patients' mean age was 75.3 ± 10.7 years and 188 (39.1%) developed AHRE ≥ 5 min, 115 (23.9%) ≥ 6 h, and 83 (17.3%) ≥ 24 h. During follow-up (median 39.9 ± 29.8 months), 92 MACE occurred (IR 5.749%/year, 95% CI 3.88-5.85). AHRE ≥ 5 min (HR 5.252, 95% CI 2.575-10.715, P < 0.001) and ≥ 6 h (HR 2.548, 95% CI 1.284-5.058, P = 0.007) was independently associated with MACE, but not AHRE ≥ 24 h. Patients with history of MI (IR 17.80%/year) had higher MACE incidence than those without (IR 3.77%/year, p = 0.001). Significant differences were found between MACE patients with/without history of AF in AHRE ≥ 5 min but not AHRE ≥ 6 h or ≥ 24 h. Patients with dual-chamber pacemakers who develop AHRE have increased risk of MACE, particularly after history of AF or MI.

HAT2CH2 Score Predicts Systemic Thromboembolic Events in Elderly After Cardiac Electronic Device Implantation.

Background: The HAT2CH2 score has been evaluated for predicting new onset atrial fibrillation, but never for adverse systemic thromboembolic events (STE) in elderly. We aimed to evaluate the HAT2CH2 score and comparing to atrial high rate episodes (AHRE) ≥24 h for predicting STE in older patients with cardiac implantable electronic devices (CIED) implantation. Methods: We retrospective enrolled 219 consecutive patients ≥ 65 years of age undergoing CIED implantation. The primary endpoint was subsequent STE. For all patients in the cohort, the CHA2DS2-VASc, C2HEST, mC2HEST, HAVOC, HAT2CH2 scores and AHRE ≥ 24 h were determined. AHRE was defined as > 175 bpm lasting ≥ 30 s. Multivariate Cox regression analysis with time-dependent covariates was used to determine variables associated with independent risk of STE. Results: The median patient age was 77 years, and 61.2% of the cohort was male. During follow-up (median, 35 months), 16 STE occurred (incidence rate, 2.51/100 patient-years; 95% CI, 1.65-5.48). Multiple Cox regression analysis showed that the HAT2CH2 score (HR, 3.405; 95% CI, 2.272-5.104; p < 0.001) was an independent predictor for STE. The optimal HAT2CH2 score cutoff value was 3, with the highest Youden index (AUC, 0.907; 95% CI, 0.853-0.962; p < 0.001). The STE rate increased with increasing HAT2CH2 score (p < 0.001). Conclusions: This study is the first to show the prognostic value of the HAT2CH2 score for STE occurrence in older patients with CIEDs.

Duration of atrial high-rate episodes and CHA2DS2-VASc score to predict cardiovascular and cerebrovascular events in patients with dual chamber permanent pacemakers.

BACKGROUND: Patients with atrial high-rate episodes (AHRE) have a high risk of cardiovascular and cerebrovascular events (CCE); however, the optimal cut-off threshold for AHRE duration and the prediction power of AHRE with CHA2DS2-VASc score is unknown. METHODS: We enrolled 355 consecutive patients undergoing dual chamber pacemaker implantations. The primary endpoint was subsequent CCE after AHRE ≥ 30 seconds, 1 minute, 2 minutes, 5 minutes, 6 hours, and 24 hours. AHRE was defined as >175 bpm (Medtronic, Dublin, Ireland) or >200 bpm (Biotronik, Berlin, Germany) lasting ≥30 seconds. Multivariate Cox regression analysis with time-dependent covariates was used to determine the variables associated with higher risks of CCE. RESULTS: The average age of the patients was 75.6 ± 11.3 years, and 162 patients (45.6%) developed AHRE ≥ 30 seconds, 145 (40.8%) ≥1 minute, 125 (35.2%) ≥2 minutes, 107 (30.1%) ≥5 minutes, 55 (15.5%) ≥6 hours, and 37 (10.4%) ≥24 hours. During follow-up (mean 42.1 ± 31.2 months), 145 CCE occurred in 107 patients (incidence rate 11.64/100 patient-years, 95% CI 9.99-13.70). The optimal AHRE cut-off value was 1 minute (sensitivity, 57.9%; specificity, 66.0%; area-under-the-curve, 0.631; 95% CI, 0.563-0.698; p < 0.001). Multivariate Cox regression analysis demonstrated that all categories of AHRE duration were independently associated with CCE. The occurrence of CCE increased with AHRE ≥30 seconds and CHA2DS2-VASc score ≥2 (males) or ≥3 (females). CONCLUSION: Patients with dual chamber pacemakers who develop AHRE ≥ 30 seconds have an increased risk of CCE. The combination of AHRE duration ≥30 seconds and CHA2DS2-VASc score ≥2 (males) or ≥3 (females) is a useful risk-stratification predictor for subsequent CCE.

Comparison of Minimally Invasive Thrombectomy with Percutaneous Balloon Angioplasty for Organized Thrombi in Hemodialysis Access.

BACKGROUND: Thrombi are an important challenge when establishing hemodialysis access for hemodialysis. We developed a minimally invasive thrombectomy (MIT) salvage treatment to solve this problem when traditional percutaneous transluminal angioplasty (PTA) fails. OBJECTIVES: The study aimed to investigate the safety and patency rate following MIT as a rescue procedure for traditional PTA with organized thrombi obstructing hemodialysis access. METHODS: This was a prospective study of MIT as a rescue procedure for traditional PTA to remove organized thrombi and establish hemodialysis access. We included patients with (1) stenotic lesions, (2) vascular access thrombi, (3) high venous pressure, (4) vascular collapse and suction. Nephrologists evaluated hemodialysis access immediately post-thrombi removal and patency at 7, 30, 60, 120, and 180 days post-removal, in addition to complications. Kaplan-Meier survival analysis was performed to analyze the primary and secondary patency rates after clinical procedural success. RESULTS: From June 2014 to May 2015, 746 patients underwent PTA in our hospital, and 425 patients consented to participate in this study. Of these patients, we enrolled 46 who underwent simultaneous PTA and MIT. Immediate clinical success was achieved in 100% of the patients in the MIT group. No complications were observed in any of the 46 patients, including major bleeding, shock, or hospitalization. The primary and secondary patency rates did not differ between MIT and PTA alone (p = 0.93 and p = 0.28, respectively). CONCLUSIONS: MIT can be considered a safe rescue procedure for removing organized thrombi to establish vascular access for hemodialysis when initial and traditional PTA fails.

Proteomic analysis of liver mitochondria of db/db mice treated with grape seed procyanidin B2.

Hepatic damage has been recognized as one of the major complications in diabetes mellitus. Our previous studies have verified that grape seed procyanidin B2 (GSPB2) played a protective effect on hepatic damage of diabetes. We used isobaric tag for relative and absolute quantitation proteomics here to identify the alterant mitochondrial protein profile in diabetic liver and to seek the protective targets of GSPB2. Proteomics found that 171 proteins were upregulated or downregulated in the liver mitochondria of diabetic group compared to the control group. Of these proteins, 61 were normalized after GSPB2 treatment. These back-regulated proteins are involved in the process of fatty acid oxidation, tricarboxylic acid cycle, oxidative phosphorylation, oxidative stress, and apoptosis. Some differentially expressed proteins were confirmed by western blotting. Our study might help to better understand the mechanism of mitochondrial dysfunction in diabetic liver damage, and provide novel targets for estimating the protective effects of GSPB2. PRACTICAL APPLICATIONS: Grape seed procyanidin B2 (GSPB2), a polyphenolic component found in red wine and grapes, has beneficial effects such as antioxidative stress, antiapoptosis, and cardiovascular protection. We used proteomics here to identify the differentially expressed mitochondrial proteins in diabetic liver after GSPB2 treatment and to seek the protective targets of GSPB2. We found that the differentially expressed proteins were involved in carbon metabolism, oxidative phosphorylation, fatty acid metabolism, citrate cycle, oxidative stress, and apoptosis. These proteins may play a key role in diabetic hepatic damage as functional proteins. Targeting these proteins including apply of GSPB2 could potentially lead to an effective treatment in the diabetic hepatic disease.

Proposed treatment algorithm for cardiac device-related subclavian vein stenosis: a case series.

BACKGROUND: Subclavian vein obstruction may occur in patients with pacemaker leads, which may make the implantation of new pacemaker leads difficult. CASE SUMMARY: We report two cases in which upgrading to cardiac resynchronization therapy pacemaker was challenging due to total central vein occlusion. In the first case, a 78-year-old woman with permanent pacemaker implantation, 5 years ago, was successfully treated by balloon venoplasty. In the second case, balloon venoplasty was unsuccessful in a 46-year-old woman who has received twice single-chamber implantable cardioverter-defibrillator, 12 years and 5 years ago, due to vessel crowding, so a contralateral side puncture, along with a tunnel technique, was performed to solve this problem. DISCUSSION: Cardiac implantable electronic device-related subclavian vein stenosis can present a challenge to common cardiac resynchronization therapy device upgrades in the absence of appropriate techniques.

Asclepius and Yellow Ribbon techniques: Efficacious alternative strategies for advancing a coronary sinus electrophysiology catheter.

BACKGROUND: Inserting an electrophysiological (EP) catheter into the coronary sinus (CS) via the femoral vein can be difficult and time-consuming in patients with variants of the CS orifice or lumen curve. Our experience with such patients inspired us to develop two new techniques: the Asclepius and Yellow Ribbon techniques. METHODS: Data from a 4-year period were retrieved from records of patients undergoing radiofrequency ablation for paroxysmal supraventricular tachycardia (PSVT) or Wolff-Parkinson-White (WPW) syndrome. Data were analyzed to determine the success and complication rates of conventional and alternative techniques for catheter placement. RESULTS: The success rate of the Asclepius technique was 96.7% (30/31) and that of the Yellow Ribbon technique was 100.0% (7/7). The overall success rate of these two techniques was 97.3% (37/38). CONCLUSIONS: With a high success rate, shorter procedure time, and no complications, the Asclepius and Yellow ribbon techniques may be safe, inexpensive, and effective alternative strategies for EP catheter placement in patients with difficult coronary sinus orifice access.

Beneficial effects of phlorizin on diabetic nephropathy in diabetic db/db mice.

AIMS: This study observes the effects of phlorizin on diabetic nephrology in db/db diabetic mice and explores possible underlying mechanisms. METHODS: Sixteen diabetic db/db mice and eight age-matched db/m mice were divided into three groups: vehicle-treated diabetic group (DM group), diabetic group treated with phlorizin (DMT group) and normal control group (CC group). Phlorizin was given in normal saline solution by intragastric administration for 10 weeks. Differentially expressed proteins in three groups were identified using iTRAQ quantitative proteomics and the data were further analyzed with ingenuity pathway analysis. RESULTS: The body weight and serum concentrations of fasting blood glucose (FBG), advanced glycation end products (AGEs), total cholesterol, triglycerides, blood urea nitrogen, creatinine and 24-h urine albumin were increased in the DM group compared to those of the CC group (P<0.05), and they were decreased by treatment with phlorizin (P<0.05). Morphologic observations showed phlorizin markedly attenuated renal injury. Phlorizin prevented diabetic nephropathy by regulating the expression of a series of proteins involved in renal and urological disease, molecular transport, free radical scavenging, and lipid metabolism. CONCLUSIONS: Phlorizin protects mice from diabetic nephrology and thus may be a novel therapeutic approach for the treatment of diabetic nephrology.

Proteomic analysis of kidney and protective effects of grape seed procyanidin B2 in db/db mice indicate MFG-E8 as a key molecule in the development of diabetic nephropathy.

Diabetic nephropathy, as a severe microvascular complication of diabetic mellitus, has become the leading cause of end-stage renal diseases. However, no effective therapeutic strategy has been developed to prevent renal damage progression to end stage renal disease. Hence, the present study evaluated the protective effects of grape seed procyanidin B2 (GSPB2) and explored its molecular targets underlying diabetic nephropathy by a comprehensive quantitative proteomic analysis in db/db mice. Here, we found that oral administration of GSPB2 significantly attenuated the renal dysfunction and pathological changes in db/db mice. Proteome analysis by isobaric tags for relative and absolute quantification (iTRAQ) identified 53 down-regulated and 60 up-regulated proteins after treatment with GSPB2 in db/db mice. Western blot analysis confirmed that milk fat globule EGF-8 (MFG-E8) was significantly up-regulated in diabetic kidney. MFG-E8 silencing by transfection of MFG-E8 shRNA improved renal histological lesions by inhibiting phosphorylation of extracellular signal-regulated kinase1/2 (ERK1/2), Akt and glycogen synthase kinase-3beta (GSK-3ß) in kidneys of db/db mice. In contrast, over-expression of MFG-E8 by injection of recombinant MFG-E8 resulted in the opposite effects. GSPB2 treatment significantly decreased protein levels of MFG-E8, phospho-ERK1/2, phospho-Akt, and phospho-GSK-3ß in the kidneys of db/db mice. These findings yield insights into the pathogenesis of diabetic nephropathy, revealing MFG-E8 as a new therapeutic target and indicating GSPB2 as a prospective therapy by down-regulation of MFG-E8, along with ERK1/2, Akt and GSK-3ß signaling pathway.