Seung Min Chung

Critical Shear Stress is Associated with Diabetic Kidney Disease in Patients with Type 2 Diabetes

Critical shear stress (CSS, mPa) is an index of red blood cell (RBC) aggregability, defined as the minimal shear stress required to disperse RBC aggregates. This study aimed to investigate the association between CSS and the risk of diabetic kidney disease (DKD). A total of 421 (mean age, 58.1 ± 11.5 years; male, 250) individuals with T2DM were enrolled and divided into three groups according to CSS level. CSS was measured using a transient microfluidic technique. DKD was defined as a glomerular filtration rate (GFR) <60 ml/min/1.73 m2 or a urine albumin-to-creatinine ratio (uACR) ≥30 mg/g. CSS was significantly higher in patients with DKD than in those without (317.43 ± 125.11 vs 385.22 ± 182.89, p < 0.001). Compared to the lowest CSS tertile, the highest CSS tertile was independently associated with the risk of DKD after adjusting for age, sex, duration of diabetes, presence of hypertension and haemoglobin. The cut-off value of CSS for DKD was approximately 310 mPa. These results suggest that haemorheologic changes may contribute to DKD, and further prospective studies are warranted to determine the role of CSS as a DKD screening tool.

Author Correction: Critical Shear Stress is Associated with Diabetic Kidney Disease in Patients with Type 2 Diabetes

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Low urine pH affects the development of metabolic syndrome, associative with the increase of dyslipidemia and dysglycemia: Nationwide cross-sectional study (KNHANES 2013-2015) and a single-center retrospective cohort study

Introduction Low urine pH (UpH) and high serum uric acid are considered evidence of metabolic disorders. The effect of low UpH on the development of metabolic syndrome (MetS) is less clear than that of high serum uric acid. We investigated the association between low UpH on the development of MetS and its components: central obesity, dyslipidemia, hypertension, and dysglycemia. Methods Two studies were conducted based on 2 datasets. The cross-sectional study included 14,511 subjects aged 19–80 years, based on the Korea National Health and Nutrition Examination Survey in 2013–2015. The retrospective cohort study included 3,453 subjects aged 19–80 years without MetS at the first checkup, who underwent at least 3 health checkups at a single tertiary hospital between 2011 and 2017. UpH was measured using an automatic urine analyzer in the range of 5.0–9.0 at first visit. Results In the cross-sectional study, low UpH (= 5.0) was associated with the prevalence of MetS (odds ratio [OR] = 1.480, 95% confidence interval [CI] 1.334–1.643, p<0.001), particularly central obesity, dyslipidemia, and dysglycemia (OR ranges 1.282–1.422, p<0.001, all). In the retrospective cohort study, compared with the highest UpH subgroup, the lowest UpH subgroup (= 5.0) was associated with higher risk of MetS development (hazard ratio = 1.394, 95% CI 1.096–1.772, p = 0.007). The incident risk of MetS increased from the highest to lowest UpH subgroups (p for trend = 0.020), among which dyslipidemia and dysglycemia increased (p for trend <0.01, all). Conclusion Low UpH can be used as a surrogate marker of MetS and affects the development of MetS, associative with the increase of dyslipidemia and dysglycemia in those without MetS. If UpH is ≤5.0, efforts to prevent metabolic disorders are warranted.

Serum cystatin C is associated with subclinical atherosclerosis in patients with type 2 diabetes: A retrospective study:

Background: The aim of this study was to investigate the association between the serum cystatin C level and cardiovascular disease risk in patients with type 2 diabetes mellitus. Methods: We studied 523 patients with type 2 diabetes mellitus and calculated estimated 10-year risk of atherosclerotic cardiovascular disease (%). Subclinical atherosclerosis was defined as brachial-ankle pulse wave velocity ⩾1700 ms, indicating the presence of arterial stiffness. Results: Cystatin C level was significantly higher in the subclinical atherosclerosis group (brachial-ankle pulse wave velocity ⩾ 1700 ms) than in the non-subclinical atherosclerosis group (brachial-ankle pulse wave velocity < 1700 ms) (7.54 ± 3.15 mg/L vs 10.04 ± 5.12 mg/L, p < 0.001). Subclinical atherosclerosis was mainly determined by age, duration of diabetes and cystatin C level, but not by serum creatinine, 10-year risk of atherosclerotic cardiovascular disease score and estimated glomerular filtration rate in the multiple linear regression analysis. In addition, an increase in cystatin C level was independently associated with the risk of subclinical atherosclerosis after adjusting for age, sex, duration of diabetes, smoking, hypertension, 10-year risk of atherosclerotic cardiovascular disease risk score, serum creatinine level, total cholesterol, high-density lipoprotein cholesterol and haemoglobin A1c (odds ratio = 1.200, 95% confidence interval: 1.04–1.38, p = 0.011). Conclusion: Serum cystatin C level was significantly associated with subclinical atherosclerosis. This result suggests that an increase in cystatin C level could be a valuable surrogate marker for the risk of cardiovascular disease in patients with type 2 diabetes mellitus.

Novel nomogram for screening the risk of developing diabetes in a Korean population

AIMS We propose a novel nomogram, which graphically expresses the numerical relationship between type 2 diabetes (T2D) and disease-related risk factors. METHODS Data of 8999 patients from the 2013-2014 Korean National Health and Nutrition Examination Survey were analyzed. Multiple logistic regression analysis was performed to assess risk factors for T2D and a nomogram was constructed based on screened risk factors. A receiver operating curve (ROC) and calibration plot were created to evaluate the accuracy of the nomogram. RESULTS The risk factor with the greatest impact on the prevalence of T2D was age over 60 years (95% CI 5.97-15.00, OR = 9.46), followed by presence of dyslipidemia and cardiovascular disease (95% CI 5.90-13.68, OR = 8.98), family history of T2D (95% CI 2.33-3.64, OR = 2.92), abdominal obesity (OR = 1.76), hypertension (OR = 1.75), male gender (OR = 1.55), current-smoking status (OR = 1.52), lower education level (OR = 1.42), and lower income (OR = 1.30). The area under the ROC curve (AUC) showed statistically significant determination (AUC = 0.83). The equation of the calibration plot was drawn along the ideal line; coefficient of determination was 0.864. CONCLUSION Our proposed nomogram could accurately predict the risk of T2D from nationwide data. The novel nomogram can be a useful tool for screening patients with T2D risk in a Korean population.

The Changes of Trends in the Diagnosis and Treatment of Diabetic Foot Ulcer over a 10-Year Period: Single Center Study

Background This study aims to describe the trends in the severity and treatment modality of patients with diabetic foot ulcer (DFU) at a single tertiary referral center in Korea over the last 10 years and compare the outcomes before and after the introduction of a multidisciplinary diabetic foot team. Methods In this retrospective observational study, electronic medical records of patients from years 2002 to 2015 at single tertiary referral center were reviewed. Based on the year of first admission, patients were assigned to a group either before or after the year 2012, the year the diabetes team launched. Results Of the 338 patients with DFU, 229 were first admitted until the year 2011 (group A), while 109 were first admitted since the year 2012 (group B). Mean age was higher in group B, and ulcer size was larger than those of group A. Whereas duration of diabetes was longer in group B, glycemic control was improved (mean glycosylated hemoglobin, 9.48% vs. 8.50%). The proportion of minor lower extremity amputation (LEA) was increased, but length of hospital stay was decreased (73.7±79.6 days vs. 39.8±36.9 days). As critical ischemic limb increased, the proportion of major LEA was not decreased. Conclusion Improved glycemic control, multidisciplinary strategies with prompt surgical treatment resulted in reduced length of hospital stay, but these measures did not reduce major LEAs. The increase in critical ischemic limb may have played a role in the unexpected outcome, and may suggest the need for increased vascular intervention strategies in DFU treatment.

Clinicopathological analysis and risk factors of advanced colorectal neoplasms incidentally detected by 18F-FDG PET-CT.

Background As the clinical use of fluorine-18-fluorodeoxyglucose PET-computed tomography (18F-FDG PET-CT) has increased, the incidental finding of 18F-FDG uptake with subsequent diagnosis of advanced neoplasm at colorectum has increased. The aim of this study is to analyze the characteristics and risk factors of advanced colorectal neoplasm incidentally detected by 18F-FDG PET-CT. Patients and methods Patients who underwent colonoscopy because of an incidental finding of 18F-FDG uptake at the colorectum from January 2006 to January 2015 at Yeungnam University Hospital were reviewed retrospectively. Advanced neoplasm was defined as adenoma of at least 10 mm, adenoma with serrated or villous component, high-grade dysplasia, and adenocarcinoma. Results Of the 19 798 candidates, 180 patients with incidental colorectal 18F-FDG uptake were included in this study. The indications of PET-CT were metastasis work-up, health screening, and others. The male to female ratio was 1.6 : 1 and the mean age was 62.7±11.4 years. A total of 156 lesions were detected in the colorectum and 86 (47.8%) were diagnosed as advanced neoplasms. Of the 86 patients with advanced neoplasms, 34 (39.5%) underwent an operation, 34 (39.5%) underwent endoscopic resection, and 18 (20.9%) underwent chemotherapy or conservative treatments. In univariate analysis, age of 62.5 years or older, carcinoembryonic antigen (CEA) of at least 3.4 ng/ml, maximum standardized uptake value (SUVmax) of at least 8.0, hypertension, 18F-FDG uptake on the rectosigmoid, and PET-CT for metastasis work-up showed a significant association with advanced neoplasm. In multivariate analysis, CEA (P=0.028), SUVmax (P<0.001) and an indication of PET-CT for metastasis work-up (P=0.008) were independent predictors of advanced neoplasm. Conclusion Colonoscopy should be recommended in case of 18F-FDG uptake at the colorectum, particularly in patients with CEA of at least 3.4 ng/ml, SUVmax of at least 8.0, or metastasis work-up of malignancy.

Simple Screening Using Ultrasonography for Prediction of Gestational Diabetes Mellitus

Corresponding author: Jun Sung Moon https://orcid.org/0000-0003-1569-3068 Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, 170 Hyeonchung-ro, Nam-gu, Daegu 42415, Korea E-mail: mjs7912@yu.ac.kr Gestational diabetes mellitus (GDM) is a disease status of glucose intolerance that is first recognized during pregnancy. The ongoing epidemic of obesity has led to increased incidence of GDM and type 2 diabetes mellitus in women of childbearing age [1]. As maternal obesity and diabetes increases the risk of metabolic consequences in offspring [2], the prediction and treatment of GDM is essential. It is well-known that Asian women are at a high risk of GDM [3], and genetic factors related to pancreatic β-cell function rather than insulin resistance contribute to the development of GDM [4]. Koo et al. [5] reported the recent prevalence of GDM in Korea using data from nationwide health insurance and claimed that it is at about 7.5 %, and that the rate was steadily increasing (5.7% in 2009 vs. 9.5% in 2011). In addition, they reaffirmed the gestational age as a major risk factor of GDM (age <30 vs. age ≥30, 6.5% vs. 11.3% in 2011). Since marriage and pregnancy are being increasingly delayed in Korea, GDM screening is becoming more important. The current screening test of GDM are performed at 24 to 28 weeks of gestation; 75-g oral glucose tolerance test (OGTT) or 50-g (non-fasting) screen followed by a 100-g OGTT for those who screen positive (Table 1) [1]. However, there is no official screening test to predict the occurrence of GDM before 24 weeks of gestation. In non-Asian populations, pre-pregnancy body mass index (BMI) is the most significant risk factor for GDM. On the other hand, in Korea, the contribution of prepregnancy BMI is low because of the low population fraction of GDM with BMI >25 kg/m [6]. Sommer et al. [7] reported that the risk of GDM increases when there is a large amount of subcutaneous fat during early pregnancy in South Asian population. In addition, Kennedy et al. [8] and Suresh et al. [9] revealed that abdominal subcutaneous fat thickness (ASFT) measurement was better for predicting adverse pregnancy outcome than pre-pregnancy BMI. Yang et al. [10] measured ASFT at 1st trimester and performed 2-step OGTT at 2nd trimester in about 300 pregnant women. The authors found that ASFT is highly correlated with the risk of GDM than well-established risk factors such as age and BMI, and suggested a cut-off value to discriminate the high-risk groups. This could be helpful to physicians because ASFT can be easily obtained during routine obstetric screening and it is cost-effective. Furthermore, due to the limitation of choice of imaging during pregnancy, the proposed test is expected to be a preferable option for screening. However, some questions remain about the role of subcutaneous fat in GDM. Although recent studies suggested subcutaneous adipose tissue as a surrogate of insulin resistance [11, 12], visceral adipose tissue has traditionally been regarded as a major cause of insulin resistance development. Visceral adipocytes are more metabolically active, lipolysis sensitive, and insulin-resistant than subcutaneous adipocytes [13]. Visceral fat thickness measurement is expected to be limited because of uterus and fetus, but it might be a more reliable indicator than ASFT measurement. In addition, further studies are warranted to determine the effect of ASFT measurement on progression from GDM to type 2 diabetes mellitus after childbirth. Editorial Obesity and Metabolic Syndrome