The GFR and GFR decline cannot be accurately estimated in type 2 diabetics

Gaspari, Flavio; Ruggenenti, Piero; Porrini, Esteban; Mondaini, Nicola; Cannatà, Antonio; Carrara, Fabiola; Sosa, Alejandro Jiménez; Cella, Claudia; Ferrari, Silvia; Stucchi, Nadia; Parvanova, Aneliya; Iliev, Ilian; Trevisan, Roberto; Bossi, Antonio; Zaletel, Jelka; Remuzzi, Giuseppe

doi:10.1038/ki.2013.47

Cited by 138 publications

(111 citation statements)

References 38 publications

(44 reference statements)

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“…The reported rates were between 4.5 and 6.6 mL/min/1.73 m 2 /year (30-33). It is wellknown that eGFR and decline in eGFR underestimate the real GFR values (34,35). Furthermore, the studies differ in definition of DN.…”

Section: Discussionmentioning

confidence: 99%

Improved Survival and Renal Prognosis of Patients With Type 2 Diabetes and Nephropathy With Improved Control of Risk Factors

et al. 2014

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OBJECTIVETo evaluate long-term survival, development of renal end points, and decline in glomerular filtration rate (GFR) in patients with type 2 diabetes and diabetic nephropathy (DN) after renin-angiotensin system (RAS) inhibition and multifactorial treatment of cardiovascular risk factors have become standard of care. RESEARCH DESIGN AND METHODSAll patients with type 2 diabetes and DN (n = 543) at the Steno Diabetes Center were followed during 2000-2010. GFR was measured yearly with 51 Cr-EDTA plasma clearance. Annual decline in GFR was determined in patients with at least three measurements over a minimum of 3 years (ΔGFR cohort, n = 286). Results were compared with historical data, obtained using identical criteria at our hospital, before implementation of current treatment guidelines. RESULTSBaseline mean (SD) GFR was 74 (32) mL/min/1.73 m 2 . More than 93% received RAS inhibition. During median 7.8 (interquartile range 5.7-9.8) years, mean (SE) annual GFR decline was 4.4 (0.24) compared with previously 5.2 (0.27) mL/min/ 1.73 m 2 /year (P = 0.04). Doubling of plasma creatinine or end-stage renal disease (ESRD) developed in 19%, and 37% died during 5.7 (3.3-8.8) years. Mortality from onset of DN in the ΔGFR cohort was compared with that of our prior ΔGFR cohort from 1983 to 2003 (n = 227). Crude mortality risk was reduced by 42% and after age adjustment by 50% (P < 0.001 for both). In a multistate model accounting for competing risks of ESRD and death, prior cardiovascular disease and lower GFR were predictors of mortality, whereas albuminuria, HbA 1c , and low GFR predicted ESRD. CONCLUSIONSOverall prognosis has improved considerably with current multifactorial treatment of DN in type 2 diabetes, including long-term RAS inhibition.

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Section: Discussionmentioning

confidence: 99%

Improved Survival and Renal Prognosis of Patients With Type 2 Diabetes and Nephropathy With Improved Control of Risk Factors

et al. 2014

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“…47 In addition, the eGFR needs to be interpreted with caution in patients with diabetes (e.g., all patients in the VITAL trial), because a recent study showed poor agreement between eGFR and measured GFR. 48 Clearly, future randomized trials are needed to address the efficacy and safety of active vitamin D analogs on hard end points, such as doubling of serum creatinine, ESRD, and all-cause and cardiovascular events.…”

Section: Discussionmentioning

confidence: 99%

Active Vitamin D Treatment for Reduction of Residual Proteinuria

Borst

Hajhosseiny

Tamez

et al. 2013

Journal of the American Society of Nephrology

129

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Despite renin-angiotensin-aldosterone system blockade, which retards progression of CKD by reducing proteinuria, many patients with CKD have residual proteinuria, an independent risk factor for disease progression. We aimed to address whether active vitamin D analogs reduce residual proteinuria. We systematically searched for trials published between 1950 and September of 2012 in the Medline, Embase, and Cochrane Library databases. All randomized controlled trials of vitamin D analogs in patients with CKD that reported an effect on proteinuria with sample size$50 were selected. Mean differences of proteinuria change over time and odds ratios for reaching $15% proteinuria decrease from baseline to last measurement were synthesized under a random effects model. From 907 citations retrieved, six studies (four studies with paricalcitol and two studies with calcitriol) providing data for 688 patients were included in the meta-analysis. Most patients (84%) used an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker throughout the study. Active vitamin D analogs reduced proteinuria (weighted mean difference from baseline to last measurement was 216% [95% CI, 213% to 218%]) compared with controls (16% [95% CI, 0% to 112%]; P,0.001). Proteinuria reduction was achieved more commonly in patients treated with an active vitamin D analog (204/390 patients) than control patients (86/298 patients; OR, 2.72 [95% CI, 1.82 to 4.07]; P,0.001). Thus, active vitamin D analogs may further reduce proteinuria in CKD patients in addition to current regimens. Future studies should address whether vitamin D therapy also retards progressive renal functional decline. 24: 186324: -187124: , 201324: . doi: 10.1681 CKD is a worldwide health burden, affecting about 15% of the Western adult population. 1 CKD is associated with premature death, cardiovascular disease, infection, and cancer, and it consumes disproportionate health care resources. [2][3][4] The mainstay of current CKD treatment is pharmacological blockade of the renin-angiotensin-aldosterone system (RAAS) by angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). Although these drugs may retard progression of both renal and cardiovascular disease 5-9 partly through their capacity to reduce proteinuria, 10,11 progression to ESRD and cardiovascular complications cannot be prevented in many CKD patients. J Am Soc NephrolA recent single-level meta-analysis including over 2 million participants showed that albuminuria is independently associated with mortality and ESRD, regardless of age. 12 The amount of residual albuminuria/proteinuria under RAAS blockade is a strong predictor of both long-term renal disease progression 13,14 and cardiovascular complications, 15

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“…However, this study had several limitations. The health status of the subjects was poorly described and an unknown number had type 2 diabetes, a disorder known to have a marked influence on GFR, even in the absence of proteinuria [10] . Moreover, GFR itself was not measured and 24 h endogenous Ccr is no longer recommended to estimate GFR because of lack of precision and high intra-individual, between test variation [11] .…”

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confidence: 99%