Clinical and Experimental Nephrology

, Volume 13, Issue 5, pp 473–479 | Cite as

Anemia and hypertension are risk factors for both renal prognosis and survival in patients with diabetes mellitus

  • Yoshie Sasatomi
  • Hidetoshi Kaneoka
  • Yasuhiro Abe
  • Atunori Ishimura
  • Satoru Ogahara
  • Toshiaki Murata
  • Noriko Uesugi
  • Shigeo Takebayashi
  • Hiroshi Iwasaki
  • Takao Saito
Original Article
First Online:
Received:
Accepted:

Abstract

Background

Diabetic nephrosclerosis is the most common cause of renal failure in the industrialized countries. At the same time, the mortality rate of patients with diabetes mellitus is high.

Methods

To clarify the factors influencing the prognosis and survival of patients with diabetic nephrosclerosis, we carried out a retrospective follow-up study of 166 cases (age, 55.6 ± 1.0 years; male/female, 110/56) by simple and multifactorial analyses of clinical data recorded at time of renal biopsy, including survival after diagnosis of diabetic mellitus (months), body mass index (BMI) (kg/m2) [body weight/(body height)2], age (years), mean blood pressure (mBP) (mmHg) [diastolic BP + (systolic BP − diastolic BP)/3], serum levels of albumin (mg/dl), urea nitrogen (BUN) (mg/dl), serum creatinine (s-Cr) (mg/dl), total cholesterol (mg/dl), triglyceride (mg/dl), and fasting blood sugar (FBS) (mg/dl), hematocrit (%), HbA1c (%), urinary protein secretion (g/day), insulin resistance, BP control (good, <140/90 mmHg or poor, ≥140/90 mmHg) after biopsies, and pathomorphological parameters at the biopsy.

Results

We found a significant association between renal prognosis and several factors, e.g., hypoalbuminemia, anemia, high levels of BUN and s-Cr, hypercholesteremia, hypertriglyceridemia at biopsy, poor control of BP after biopsies, Kimmelstiel–Wilson nodule, and severe glomerular and tubulointerstitial damages at the biopsy. In addition, associations between survival and factors such as low value of BMI, elderly age at the biopsy, and poor control of BP after biopsies were significant. By multivariate analysis we also found a significant association of renal prognosis with anemia, BUN, severe glomerular damage at the biopsy, and poor control of BP after biopsies. At the same time, poor control of BP after biopsies had a significant association with survival. On Kaplan–Meier analysis, anemia at biopsy and hypertension after biopsies are risk factors for both renal prognosis and survival in diabetes mellitus patients.

Conclusions

Our data strongly suggest that good control of BP after biopsies and anemia at the biopsy play pivotal roles in the prognosis and survival of patients with diabetic glomerulosclerosis.

Keywords

Diabetic nephrosclerosis Renal prognosis and survival Anemia Hypertension 
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Notes

Acknowledgment

This study was supported in part by a grant for the Progressive Renal Diseases Research Projects from the Ministry of Health, Labor and Welfare, Japan.

References

  1. 1.
    The statistic analyzed commission of Japan Society for Dialysis therapy: an overview of dialysis treatment in Japan (as of December 31, 2002).Google Scholar
  2. 2.
    Bertoni AG, Kirk JK, Goff DC Jr, Wagenknecht LE. Excess mortality related to diabetes mellitus in elderly Medicare beneficiaries. Ann Epidemiol. 2004;14(5):362–7.CrossRefPubMedGoogle Scholar
  3. 3.
    De Groote P, Lamblin N, Mouquet F, Plichon D, Mcfadden E, Van Belle E, et al. Impact of diabetes mellitus on long-term survival in patients with congestive heart failure. Eur heart J. 2004;25(8):656–62.CrossRefPubMedGoogle Scholar
  4. 4.
    Otter W, Kleybrink s, Doering W, Standl E, Schnell O. Hospital outcome of acute myocardial infarction in patients with and without diabetes mellitus. Diabet Med. 2004;21(2):183–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Hoffart N, Nissenson AR. The future of end-stage renal disease care: nephrology enters a new millennium. Adv Ren Replace Ther. 1988;5:257–66.CrossRefGoogle Scholar
  6. 6.
    Lee H, Manns B, Taub K, Ghali WA, Dean S, Johnson D, et al. Cost analysis of ongoing care of patients with end stage renal disease: the impact of dialysis modality and dialysis access. Am J Kidney Dis. 2002;40:611–22.CrossRefPubMedGoogle Scholar
  7. 7.
    Ohkubo Y, Kishikawa H, Araki E, Miyata T, Isami S, Motoyoshi S, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: randamized prospective 6-year study. Diabetes Res Clin Pract. 1995;28:103–17.CrossRefPubMedGoogle Scholar
  8. 8.
    Fioretto P, Steffes MW, Sutherland DE, Goetz FC, Mauer M. Reversal of lesions of diabetic nephropathy after pancreas transplantation. N Engl J Med. 1998;339:69–75.CrossRefPubMedGoogle Scholar
  9. 9.
    Hovind P, Rossing P, Tarnow L, Smidt UM, Parving HH. Remission and regression in the nephropathy of type 1 diabetes when blood pressure is controlled aggressively. Kidney Int. 2001;60:277–83.CrossRefPubMedGoogle Scholar
  10. 10.
    American Diabetes Association: treatment of hypertension in adults with diabetes. Diabetes Care. 2002;25(Suppl 1):S71–S73.Google Scholar
  11. 11.
    Inomata S, Itoh M, Imai H, Sato T. Serum levels of erythropoietin as a novel marker reflecting the severity of diabetic nephropathy. Nephron. 1997;75:426–30.CrossRefPubMedGoogle Scholar
  12. 12.
    Keane WF, Brenner BM, de Zeeuw D, Grunfeld JP, McGill J, Mitch WE, et al. The risk of developing end stage renal disease in patients with type 2 diabetes and nephropathy: the RENAAL Study. Kidney Int. 2003;63:1499–507.CrossRefPubMedGoogle Scholar
  13. 13.
    Hansen HP, Tauber-Lassen E, Jensen BR, Parving HH. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy. Kidney Int. 2002;62(1):202–28.CrossRefGoogle Scholar
  14. 14.
    Remuzzi G, Schieppati A, Ruggenenti P. Nephropathy in patients with type 2 diabetes. N Engl J Med. 2002;346:1145–51.CrossRefPubMedGoogle Scholar
  15. 15.
    Narita T, Koshimura J, Suzuki K, Murata M, Meguro H, Fujita H, et al. Effects of short-term glycemic control, low protein diet and administration of enalapril on renal hemodynamics and protein permselectivity in type 2 diabetic patients with microalbuminuria. Tohoku J Exp Med. 1999;189(2):117–33.CrossRefPubMedGoogle Scholar
  16. 16.
    Shestakova MV, Chugunova LA, Shamkhalova MSh, Dirochka IuA, Dedov II. Diabetic nephropathy: risk factors of rapid progression of renal failure. Ter Arkh. 1999;71(6):45–9.PubMedGoogle Scholar
  17. 17.
    Furuta T, Saito T, Ootaka T, Soma J, Obara K, Abe K, et al. The role of macrophages in diabetic glomerulosclerosis. AJKD. 1993;21:480–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Gellman DD, Dirani DL, Soothill JF, Muehrcke RC, Kark RM. Diabetic nephropathy: a clinical and pathologic study based on renal biopsies. Medicine. 1959;38:321–67.CrossRefPubMedGoogle Scholar
  19. 19.
    Sasatomi Y, Sato H, Chiba Y, Abe Y, Takeda S, Ogahara S, et al. Prognostic factors for renal amyloidosis: a clinicopathological study using cluster analysis. Int Med. 2007;46:213–219.CrossRefGoogle Scholar
  20. 20.
    UK prospective Diabetes study Group: tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998; 317:703–713.Google Scholar
  21. 21.
    Heart Outcomes Prevention Evaluation (HOPE) study investigators: effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000;355:253–259.CrossRefGoogle Scholar
  22. 22.
    Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the hypertension optimal treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351:1755–62.CrossRefPubMedGoogle Scholar
  23. 23.
    Hunsicker LG, Adler S, Caggiula A, England BK, Greene T, Kusek JW, et al. Predictors of the progression of renal disease study. Kidney Int. 1997;51:1908–19.CrossRefPubMedGoogle Scholar
  24. 24.
    Samuelsson O. Complex apolipoprotein-B containing lipoprotein particles are associated with a high rate of progression of human progressive renal insufficiency. J Am Soc Nephrol. 1998;9:1482–8.PubMedGoogle Scholar
  25. 25.
    Tozawa M, Iseki K, Iseki C, Oshiro S, Ikemiya Y, Takishita S. Triglyceride, but not total cholesterol or low-density lipoprotein cholesterol levels, predict development of proteinuria. Kidney Int. 2002;62(5):1743–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Mulec H, Johnsen SA, Wiklund O, Bjorck S. Cholesterol: a renal risk factor in diabetic nephropathy? Am J Kidney Dis. 1993;22(1):196–201.CrossRefPubMedGoogle Scholar
  27. 27.
    Ellis D, Lloyd C, Becker DJ, Forrest KY, Orchard TJ. The changing course of diabetic nephropathy: low density lipoprotein cholesterol and blood pressure correlate with regression of proteinuria. Am J Kidney Dis. 1996;27:809–18.CrossRefPubMedGoogle Scholar
  28. 28.
    Olefsky JM, Farquhar JW, Reaven GM. Reappraisal of the role of insulin in hypertriglyceridemia. AM J Med. 1974;57:551–60.CrossRefPubMedGoogle Scholar
  29. 29.
    Pollar T, Vessby B, Lithell H. Lipoprotein lipase activity in skeletal muscle is related to insulin sensitivity. Arterioscler Thromb. 1991;11:1192–203.CrossRefGoogle Scholar
  30. 30.
    Yildiz A, Hursit M, Celik AV, Kayacan SM, Yazici H, Akkaya V, et al. Doxazosin, but not amlodipine decreases insulin resistance in patients with chronic renal failure: a prospective, randomized-controlled study. Clin Nephrol. 2002;58(6):405–10.CrossRefPubMedGoogle Scholar
  31. 31.
    Harada N, Takishita E, Ishimura N, Minami A, Sakamoto S, Nakaya Y. Combined effect of ACE inhibitor and exercise training on insulin resistance In type 2 diabetic rats. Life Sci. 2002;70(15):1811–20.CrossRefPubMedGoogle Scholar
  32. 32.
    Suzuki Y, Ueno M, Hayashi H, Nishi S, Satou H, Karasawa R, et al. A light microscopic study of glomerulosclerosis in Japanese patients with noninsulin-dependent diabetes mellitus: the relationship between clinical and histological features. Clin Nephrol. 1994;42(3):155–62.PubMedGoogle Scholar
  33. 33.
    Yun YS, Lee HC, Yoo NC, Song YD, Lim SK, Kim KR, et al. Reduced erythropoietin responsiveness to anemia in diabetic patients before advanced diabetic nephropathy. Diabetes Res Clin Pract. 1999;46:223–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Bosman DR, Winkler AS, Marsden JT, Macdougall IC, Watkins PJ. Anemia with erythropoietin deficiency occurs early in diabetic nephropathy. Diabetes Care. 2001;24:495–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Winkler AS, Marsden J, Chaudhuri KR, Mambley H, Watkins PJ. Erythropoietin depletion and anemia in diabetes mellitus. Diabet Med. 1999;16:813–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Bayes B, Serra A, Junca J, Lauzurica R. Successful treatment of anemia of nephrotic syndrome with recombinant human erythropoietin. Nephrol Dial Transplant. 1998;13:1894–5.CrossRefPubMedGoogle Scholar
  37. 37.
    Laffel LM, McGill JB, Ganx DJ. The beneficial effect of angiotensin-converting enzyme inhibition with captopril on diabetic nephropathy in normotensive IDDM patients with microalbuminuria. Am J Med. 1995;99:497–504.CrossRefPubMedGoogle Scholar
  38. 38.
    The microalbuminuria Captopril Study Group: captopril reduces the risk of nephropathy in IDDM patients with microalbuminuria. Diabetologia. 1996;39:587–593.CrossRefGoogle Scholar
  39. 39.
    Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. N Engl J Med. 1993;329:1456–62.CrossRefPubMedGoogle Scholar
  40. 40.
    Parving HH, Lehnert H, Brochner-Mortensen J, Gomis R, Andersen S, Arner P. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med. 2001;345:870–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345:851–60.CrossRefPubMedGoogle Scholar
  42. 42.
    Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345:861–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Locatelli F, Pisoni RL, Combe C, Bommer J, Andreucci VE, Piera L, et al. Anemia in haemodialysis patients of five European countries: association with morbidity and mortality in the Dialysis Outcomes and Practice Patterns study (DOPPS). Nephrol dial Transplant. 2004;19:121–32.CrossRefPubMedGoogle Scholar
  44. 44.
    Licatelli F, Pisoni RL, Bragg JL. Higher hemoglobin levels are associated with lower rates of mortality and hospitalization among European hemodialysis patients: results from the DOPPS. Nephrol Dial Transplant. 2002;17(S-1):23.Google Scholar
  45. 45.
    UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837–53.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Nephrology 2009

Authors and Affiliations

  • Yoshie Sasatomi
    • 1
  • Hidetoshi Kaneoka
    • 1
  • Yasuhiro Abe
    • 1
  • Atunori Ishimura
    • 1
  • Satoru Ogahara
    • 1
  • Toshiaki Murata
    • 1
  • Noriko Uesugi
    • 2
  • Shigeo Takebayashi
    • 2
  • Hiroshi Iwasaki
    • 2
  • Takao Saito
    • 1
  1. 1.Division of Nephrology and Rheumatology, Department of Internal MedicineFukuoka University School of MedicineFukuokaJapan
  2. 2.Department of PathologyFukuoka University School of MedicineFukuokaJapan

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