Abstract
BackgroundIncreased urinary albumin excretion (UAE) in diabetes is a sensitive marker of microvascular injury and a reliable predictor of cardiovascular outcomes. Hypertension-induced hemodynamic pressure load, diabetes-related metabolic processes and large artery stiffening have all been implicated in the development of microalbuminuria. We investigated whether hyperglycemia per se, or rather increased blood pressure (BP) and macrovascular dysfunction, is a stronger predictor of UAE at the earliest stages of diabetes.MethodsConsecutive newly diagnosed patients with diabetes type 2, who were normoglycemic within a year’s time prior to diagnosis, were enrolled. UAE was estimated in 24-h urine samples. Both office and 24-h ambulatory BP was recorded. Arterial stiffness was evaluated by measurement of carotid-femoral pulse wave velocity (PWV) with applanation tonometry.ResultsAmong 71 newly diagnosed patients with median diabetes duration of just 1 month, 15.5% presented microalbuminuria. UAE did not differ between hypertensive and normotensive diabetics; however, newly diagnosed patients for both hypertension and diabetes exhibited significantly higher levels of UAE, compared to diabetic patients with long-standing hypertension. UAE strongly and significantly correlated with office systolic BP, HbA1c, PWV and estimated glomerular filtration rate. However, in the multivariate analysis adjusting for these factors, only HbA1c was independently associated with UAE (beta = 0.278, p = 0.049).ConclusionsHyperglycemic state emerges as a powerful predictor of increased UAE even at the earliest stages of diabetes. The relative contribution of hypertension and macrovascular dysfunction to the development of microalbuminuria seems to be obscured by hyperglycemia, even in patients whose diabetes onset does not exceed a few months’ time.
Highlights
Increased urinary albumin excretion (UAE) in diabetes is a sensitive marker of microvascular injury and a reliable predictor of cardiovascular outcomes
In this very meticulously selected group of newly diagnosed diabetic patients, UAE correlated with all the known factors, which contribute to its progression in patients with long standing diabetes mellitus type II (DMII), including Glycated Haemoglobin (HbA1c), fasting blood glucose (FBG), office Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP), as well as day- and nighttime SBP (Table 2)
Levels of UAE did not significantly differ between diabetics with or without hypertension [9.1 (3.65–17.8) vs 5.1 (2.5–8.7), p = 0.111], patients who were simultaneously diagnosed with both hypertension and DMII exhibited significantly higher levels of UAE, compared to diabetics who presented long-standing hypertension [13.3 (9.0–58.0) vs 7.0 (25–7.5) mg, p = 0.007]
Summary
Increased urinary albumin excretion (UAE) in diabetes is a sensitive marker of microvascular injury and a reliable predictor of cardiovascular outcomes. Apart from diabetes, hypertension represents a major risk factor for increased UAE When both diseases coincide in the same individual, which is typically the case for the vast majority of patients with diabetes mellitus type II (DMII), the risk of developing microalbuminuria is substantially aggravated [3]. Another contributor that has been proposed for the development of microalbuminouria, is arterial stiffness and the interplay between micro- and macro-vascular dysfunction. Most patients with DMII already suffer from hypertension at the time of diagnosis, which substantially increases the risk for microalbuminuria
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