CYSTATIN C-A Monitoring Perspective of Chronic Kidney Disease in Patients with Diabetes.

Chronic kidney disease (CKD) is a microvascular complication that frequently affects numerous patients diagnosed with diabetes. For the diagnosis of CKD, the guidelines recommend the identification of the urinary albumin/creatinine ratio and the determination of serum creatinine, based on which the estimated rate of glomerular filtration (eGFR) is calculated. Serum creatinine is routinely measured in clinical practice and reported as creatinine-based estimated glomerular filtration rate (eGFRcr). It has enormous importance in numerous clinical decisions, including the detection and management of CKD, the interpretation of symptoms potentially related to this pathology and the determination of drug dosage. The equations based on cystatin C involve smaller differences between race groups compared to GFR estimates based solely on creatinine. The cystatin C-based estimated glomerular filtration rate (eGFRcys) or its combination with creatinine (eGFRcr-cys) are suggested as confirmatory tests in cases where creatinine is known to be less precise or where a more valid GFR estimate is necessary for medical decisions. Serum creatinine is influenced by numerous factors: age, gender, race, muscle mass, high-protein diet, including protein supplements, and the use of medications that decrease tubular creatinine excretion (H2 blockers, trimethoprim, fenofibrate, ritonavir, and other HIV drugs). The low levels of creatinine stemming from a vegetarian diet, limb amputation, and conditions associated with sarcopenia such as cirrhosis, malnutrition, and malignancies may lead to inaccurately lower eGFRcr values. Therefore, determining the GFR based on serum creatinine is not very precise. This review aims to identify a new perspective in monitoring renal function, considering the disadvantages of determining the GFR based exclusively on serum creatinine.

Clinical and Metabolic Particularities of a Roma Population with Diabetes-Considering Ethnic Disparities in Approaching Healthcare Management.

The Roma population is Europe's largest ethnic minority, yet data on the prevalence of non-communicable diseases remain scarce in medical literature. This study aimed to compare the clinical and metabolic particularities of a Roma population with diabetes with a group of non-Roma. We conducted an observational, transversal study and evaluated 808 adult patients with diabetes mellitus, from a tertiary diabetes care hospital. The prevalence of metabolic syndrome was high among both groups, 94.3% in the Roma patients and 89.1% in the non-Roma. A slightly higher mean value of the triglyceride-glucose (TyG) index was observed among the Roma group (10.07 ± 0.71 versus 9.71 ± 0.82). Among the non-Roma, variables that were significantly associated with the TyG index were glycated hemoglobin (HbA1c), total cholesterol (TC), high density lipoprotein-cholesterol (HDL-c), and low-density lipoprotein-cholesterol (LDL-c), while among the Roma, HbA1c and HDL-c were correlated with this index. There were no differences concerning myocardial infarction; however, the number of patients with a history of stroke was 2.1 times higher in the Roma group compared to the non-Roma group. The prevalence of cardiovascular risk factors, cardiovascular disease, and microvascular complications among the study's Roma population are quite significant, underscoring the importance of ethnic disparities in approaching healthcare management strategies.

Progression of Chronic Kidney Disease to Dialysis in the Roma Population With Type 2 Diabetes Mellitus in Comparison With Caucasian Patients.

Background Chronic kidney disease (CKD) poses a significant health challenge among patients, contributing to substantial morbidity and mortality outcomes. However, there remains a paucity of data within the medical literature on the Roma population, one of the most significant minority groups globally, with studies indicating that these individuals are disproportionately affected by CKD compared to the general population, with higher prevalence rates. Materials and methods We conducted an observational, cross-sectional study from October 2022 to March 2024, evaluating 735 adult patients with type 2 diabetes mellitus, of which 402 were Roma, aged 18 to 89 years, following the hospital's standard protocols for diabetes management, at the "Nicolae Malaxa" Clinical Hospital in Bucharest, Romania, a tertiary care center for diabetes. Results The prevalence of CKD was higher among the Roma patients, reaching 56.50% (n=203), in comparison with the Caucasian group (43.50%, n=156), however, with a lower mean age (55.53±10.56 years versus 63.32±10.04 years). Roma patients with CKD had a higher prevalence of cardiovascular disease compared to Caucasians, including myocardial infarction, stroke, stable angina, and heart failure. Cardiovascular risk factors, such as hypertension, obesity, and dyslipidemia, in patients with CKD, were also more prevalent among the Roma population. Taking into consideration the natural progression of CKD, the anthropometric measurements and laboratory parameters stratified by ethnicity revealed that Roma patients in the very high risk of CKD progression category had a lower mean age, and a lower median duration of diabetes (56.37±10.79 versus 59.92±7.48 years, and 4.00±2.00 versus 10.00±10.30 years, respectively), as well as a more elevated mean waist circumference (WC), body mass index (BMI), total cholesterol (TC), and low-density lipoprotein-cholesterol (LDL-c) compared to Caucasians. Moreover, patients in the very high risk of CKD progression category among both groups showed the highest level of insulin resistance, measured by the triglyceride-glucose (TyG) index (mean value of 10.13±0.60 among the Roma patients, and 10.09±0.82 among Caucasians). Among the study group, weight, WC, BMI, and A Body Shape Index (ABSI) were associated with a very high risk of progression of CKD. In Caucasian patients, it was demonstrated that weight, WC, BMI, ABSI, and triglycerides (TG) have contributed to the very high risk of progression of CKD, while among the Roma patients, no association was found. Conclusion In conclusion, our findings suggested a high prevalence of CKD among both groups. There is still a need for further investigation of additional risk factors, such as genetics, limited access to health education, and appropriate treatments that could synergistically accelerate the progression of CKD among Roma patients.

Sudoscan's Effectiveness in Identifying Chronic Kidney Disease in Patients With Type 2 Diabetes.

Chronic kidney disease (CKD) represents a significant public health issue, particularly prevalent among patients with type 2 diabetes mellitus (T2DM). CKD occurs in approximately 20% to 40% of adults with diabetes mellitus. Sudoscan potentially detects CKD early, providing a non-invasive and convenient alternative to traditional screening methods that rely on serum creatinine and urine albumin levels. This research involves 271 patients from a single medical center over one year, with all participants providing informed consent. The prevalence of CKD in our group was 26.5% (n = 72). This study integrates a comprehensive examination, including anthropometric measurements, biochemical profiles, and Sudoscan's electrochemical skin conductance testing. CKD diagnosis was confirmed via estimated glomerular filtration rate (eGFR) and albumin-to-creatinine ratio (ACR). The aim of this study was to explore the utility of Sudoscan in detecting CKD among patients with T2DM. Statistical analysis reveals moderate correlations between Sudoscan scores and traditional CKD markers like eGFR and albuminuria. It is beneficial in settings where conventional testing is less accessible, suggesting potential for broader CKD screening programs. Key findings suggest that Sudoscan can identify early renal dysfunction with reasonable sensitivity and specificity. Integrating Sudoscan in regular CKD screening could enhance early detection, allowing for timely interventions to prevent progression to end-stage renal disease and reduce healthcare burdens associated with advanced CKD. The results contribute to the ongoing assessment of innovative technologies in managing chronic diseases related to diabetes.

The Relationship between the Ewing Test, Sudoscan Cardiovascular Autonomic Neuropathy Score and Cardiovascular Risk Score Calculated with SCORE2-Diabetes.

Background and Objectives: Cardiac autonomic neuropathy (CAN) is a severe complication of diabetes mellitus (DM) strongly linked to a nearly five-fold higher risk of cardiovascular mortality. Patients with Type 2 Diabetes Mellitus (T2DM) are a significant cohort in which these assessments have particular relevance to the increased cardiovascular risk inherent in the condition. Materials and Methods: This study aimed to explore the subtle correlation between the Ewing test, Sudoscan-cardiovascular autonomic neuropathy score, and cardiovascular risk calculated using SCORE 2 Diabetes in individuals with T2DM. The methodology involved detailed assessments including Sudoscan tests to evaluate sudomotor function and various cardiovascular reflex tests (CART). The cohort consisted of 211 patients diagnosed with T2DM with overweight or obesity without established ASCVD, aged between 40 to 69 years. Results: The prevalence of CAN in our group was 67.2%. In the study group, according SCORE2-Diabetes, four patients (1.9%) were classified with moderate cardiovascular risk, thirty-five (16.6%) with high risk, and one hundred seventy-two (81.5%) with very high cardiovascular risk. Conclusions: On multiple linear regression, the SCORE2-Diabetes algorithm remained significantly associated with Sudoscan CAN-score and Sudoscan Nephro-score and Ewing test score. Testing for the diagnosis of CAN in very high-risk patients should be performed because approximately 70% of them associate CAN. Increased cardiovascular risk is associated with sudomotor damage and that Sudoscan is an effective and non-invasive measure of identifying such risk.

Diabetes Distress Among the Roma Population From a Tertiary Care Center in Romania.

Background Distress in patients with diabetes is a condition that has received significant attention in recent years; however, data regarding the psychological assessment and the impact of the emotional burden of diabetes among the Roma population are still scarce in the medical literature. Material and methods We conducted an observational, transversal study that included 310 adult patients with diabetes mellitus, aged between 18 and 85 years old, of which the majority (61%) were women; patients were selected from a tertiary hospital providing diabetes care; diabetes distress was evaluated using a standardized questionnaire, the diabetes distress scale (DDS), validated on Romanian patients. Results In the study population, a great proportion of patients showed diabetes distress, with 24.8% (N=82) having moderate distress and 29.7% (N=121) having severe distress. In the Caucasian group, there were significantly more patients without distress than in the Roma patients,while on the contrary, more Roma patients experienced severe distress compared to the opposite group (64.5%, N=78 versus 35.5%, N=43). In the Caucasian group, a statistical significance was observed regarding interpersonal distress, with Caucasian women having a higher score than men. Concerning the Roma patients, total DDS and all subscales´ scores were statistically significant, with Roma women having higher scores than men. A statistical significance was observed between ethnicity and diabetes distress scores, with the Roma population having higher median values than Caucasian patients. It was also demonstrated that the lack of education, a higher diabetes evolution, and a higher glycated hemoglobin (HbA1c) level (above 8%) have influenced the risk of severe DDS in the Caucasian group, while in the Roma patients, employment status (being unemployed) represents a risk factor for severe DDS. Conclusion The Roma patients included in our study experienced higher distress scores compared to Caucasians. These results are substantial as they emphasize the need to include the evaluation of diabetes distress in clinical practice to facilitate the early initiation of intervention measures. There is nevertheless limited data regarding this particular ethnic group; therefore, further research is still needed.

The Importance of Evaluating Sudomotor Function in the Diagnosis of Cardiac Autonomic Neuropathy.

INTRODUCTION:  Cardiac autonomic neuropathy (CAN) is a disorder affecting the autonomic nerves that regulate the cardiovascular system, leading to irregular heart rate and blood pressure control. It is commonly associated with diabetes mellitus but can also result from other conditions such as autoimmune disorders, chronic kidney disease, alcohol abuse, and certain medications. Screening for CAN is essential, particularly in individuals with poor glycemic control, cardiovascular risk factors, or complications. Early identification of CAN is vital for timely intervention to prevent or manage cardiovascular complications effectively. Regular screening helps detect CAN before symptoms emerge, enabling early intervention to slow or halt its progression. This study examined the relationship between sudomotor function and cardiovascular reflex tests. MATERIAL AND METHODS:  This was a cross-sectional study conducted between June 2019 and June 2020. The study included 271 subjects aged 18 years and above who provided informed consent, were diagnosed with type 2 diabetes mellitus (T2DM), and were overweight or obese. Exclusion criteria encompassed patients with other types of diabetes, pregnant women, those with recent neoplasm diagnoses, stroke sequelae, history of myocardial infarction, or pelvic limb amputations. The assessment of cardiac autonomic neuropathy involved conducting an electrocardiogram and evaluating the QTc interval in the morning before taking medication. Additionally, cardiovascular reflex tests (CART) were conducted, including assessments of heart rate variability during deep breathing, the Valsalva maneuver, and changes in orthostatic position. Simultaneously, the diagnosis of CAN was assessed by performing a sweat test using a Sudoscan assessment (Impeto Medical, Moulineaux, France).  Results: More than half of the participants (52%, n=143) were female. Significant differences in statistical measures were noted between females and males regarding age, systolic blood pressure, fasting blood glucose, A1c level, total cholesterol, triglycerides, gamma-glutamyl transferase, and bilirubin levels. Within the CAN-diagnosed group (CAN+), 40.92% were classified as mild cases (n=90), 47.27% as moderate cases (n=104), and 11.81% as severe cases (n=26). Among the CAN+ group, 54% (n=119) were women. Electrochemical skin conductance was lower in the CAN+ group than the CAN- group in hands (67.34±15.51 µS versus 72.38±12.12 µS, p=0.008) and feet (73.37±13.38 µS versus 82.84 ±10.29 µS, p<0.001). The Sudoscan-CAN score significantly correlated with Ewing scores (r= 0.522, p<0.001). In multiple linear regression analysis, the Sudoscan-CAN score remained significantly associated with age, high BMI, long-standing diabetes, and Ewing score. CONCLUSIONS:  Sudoscan demonstrates potential in identifying patients with an increased risk of CAN. Its integration into clinical practice can improve patient outcomes through early detection, risk stratification, and personalized treatment approaches. Its non-invasive, portable, and user-friendly features render it suitable for utilization in outreach programs or resource-constrained settings as part of screening efforts designed to pinpoint high-risk individuals for additional assessment.

Risks and Benefits of SGLT-2 Inhibitors for Type 1 Diabetes Patients Using Automated Insulin Delivery Systems-A Literature Review.

The primary treatment for autoimmune Diabetes Mellitus (Type 1 Diabetes Mellitus-T1DM) is insulin therapy. Unfortunately, a multitude of clinical cases has demonstrated that the use of insulin as a sole therapeutic intervention fails to address all issues comprehensively. Therefore, non-insulin adjunct treatment has been investigated and shown successful results in clinical trials. Various hypoglycemia-inducing drugs such as Metformin, glucagon-like peptide 1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, amylin analogs, and Sodium-Glucose Cotransporters 2 (SGLT-2) inhibitors, developed good outcomes in patients with T1DM. Currently, SGLT-2 inhibitors have remarkably improved the treatment of patients with diabetes by preventing cardiovascular events, heart failure hospitalization, and progression of renal disease. However, their pharmacological potential has not been explored enough. Thus, the substantial interest in SGLT-2 inhibitors (SGLT-2is) underlines the present review. It begins with an overview of carrier-mediated cellular glucose uptake, evidencing the insulin-independent transport system contribution to glucose homeostasis and the essential roles of Sodium-Glucose Cotransporters 1 and 2. Then, the pharmacological properties of SGLT-2is are detailed, leading to potential applications in treating T1DM patients with automated insulin delivery (AID) systems. Results from several studies demonstrated improvements in glycemic control, an increase in Time in Range (TIR), a decrease in glycemic variability, reduced daily insulin requirements without increasing hyperglycemic events, and benefits in weight management. However, these advantages are counterbalanced by increased risks, particularly concerning Diabetic Ketoacidosis (DKA). Several clinical trials reported a higher incidence of DKA when patients with T1DM received SGLT-2 inhibitors such as Sotagliflozin and Empagliflozin. On the other hand, patients with T1DM and a body mass index (BMI) of ≥27 kg/m2 treated with Dapagliflozin showed similar reduction in hyperglycemia and body weight and insignificantly increased DKA incidence compared to the overall trial population. Additional multicenter and randomized studies are required to establish safer and more effective long-term strategies based on patient selection, education, and continuous ketone body monitoring for optimal integration of SGLT-2 inhibitors into T1DM therapeutic protocol.

Changes in C-Peptide Values in Children with Type 1 Diabetes - a Three-Year Study.

Background: C-peptide is used as an important indicator of residual insulin secretion in patients diagnosed with type 1 diabetes mellitus (T1DM) and treated with insulin. Aim:We have aimed to monitor the serum C-peptide (CP) levels during the first three years after diagnosis of T1DM in a cohort of children admitted to the Diabetes Department of "M. S. Curie" Emergency Clinical Hospital for Children, Bucharest, Romania, and to investigate the factors that could influence the rate of decline in its secretion. Method:We conducted a longitudinal, retrospective cohort study on a group of 215 children and adolescents who met the inclusion criteria and were monitored in our clinic over the course of a long period of time. We analyzed several parameters, including fasting serum CP values at diagnosis and yearly throughout T1DM evolution, the severity of diabetic ketoacidosis (DKA) at onset, HbA1c at diagnosis, family history of T1DM/T2DM, patient gender and presence of concurrent acute infectious disease at diagnosis, with the purpose of evaluating their influence on the preservation of endogenous insulin secretion. Based on serum CP value measured three years after T1DM onset, patients were divided into two groups: group 1, with low insulin residual secretion (CP < 0.6 ng/mL), and group 2, with preserved insulin residual secretion (CP ≥0.6 ng/mL) Results:At the moment of diagnosis, patients in group 1 were younger than those in group 2 (6.03 ± 3.54 years and 9.76 ± 2.75 years, respectively). The proportion of children with diabetic ketoacidosis (DKA) at onset was greater in group 1 (68% of patients) than group 2, in which the majority of subjects (60%) did not have DKA. The C-peptide value at diagnosis was significantly lower (0.55 ± 0.36 ng/mL) among patients in group 1 than those in group 2 (1.11 ± 0.59 ng/mL). In group 1 there was a higher proportion of patients (65%) with acute infectious disease at onset. Family history of T1DM/T2DM was associated with a more rapid decline in CP values. Our data showed no correlation between CP levels monitored for three years and HbA1c at diagnosis and no association with the gender of each patient. Conclusion:Patients with higher CP concentrations at diagnosis maintained increased values (> 0.6 ng/mL) three years after disease onset. Younger children had a faster decline of CP secretion during the first three years following diabetes diagnosis. In patients with severe symptoms (DKA) and associated infectious disease at onset, a risk of rapid CP decline was found.

Current Technologies for Managing Type 1 Diabetes Mellitus and Their Impact on Quality of Life-A Narrative Review.

Type 1 diabetes mellitus is a chronic autoimmune disease that affects millions of people and generates high healthcare costs due to frequent complications when inappropriately managed. Our paper aimed to review the latest technologies used in T1DM management for better glycemic control and their impact on daily life for people with diabetes. Continuous glucose monitoring systems provide a better understanding of daily glycemic variations for children and adults and can be easily used. These systems diminish diabetes distress and improve diabetes control by decreasing hypoglycemia. Continuous subcutaneous insulin infusions have proven their benefits in selected patients. There is a tendency to use more complex systems, such as hybrid closed-loop systems that can modulate insulin infusion based on glycemic readings and artificial intelligence-based algorithms. It can help people manage the burdens associated with T1DM management, such as fear of hypoglycemia, exercising, and long-term complications. The future is promising and aims to develop more complex ways of automated control of glycemic levels to diminish the distress of individuals living with diabetes.