Increased urinary miR-196a level predicts the progression of renal injury in patients with diabetic nephropathy

2018 ◽  
Vol 35 (6) ◽  
pp. 1009-1016 ◽  
Author(s):  
Yu An ◽  
Changming Zhang ◽  
Feng Xu ◽  
Wei Li ◽  
Caihong Zeng ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Diabetic Nephropathy ◽  
Renal Injury ◽  
Cox Regression ◽  
Interstitial Fibrosis ◽  
Glomerular Sclerosis ◽  
Tubular Atrophy ◽  
Cox Regression Analysis ◽  
Stage Renal Disease ◽  
End Stage

Abstract Background Recent data suggest that miR-196a is predominantly expressed in the kidney and plays an inhibitory role in the progress of renal interstitial fibrosis (IF). However, the predictive value of miR-196a in diabetic nephropathy (DN) remains unknown. We validated the role of urinary miR-196a in the progression of renal injury in a cohort of patients with type 2 diabetes mellitus. Methods Our study included 209 patients with biopsy-proven DN. The mean follow-up time was 54.03 ± 32.94 months. Histological lesions were assessed using the pathological classification established by the Renal Pathology Society. Percentages of IF and tubular atrophy were assessed using the Aperio ScanScope system. We measured the correlation of urinary miR-196a with clinical and pathological parameters using the Spearman’s correlation test. The influence of urinary miR-196a on renal outcomes was assessed using Cox regression analysis. Results Urinary miR-196a levels correlated positively with proteinuria (ρ = 0.385, P < 0.001), duration of diabetes mellitus (ρ = 0.255, P < 0.001) and systolic blood pressure (ρ = 0.267, P < 0.001). The baseline estimated glomerular filtration rate (eGFR) and hemoglobin level showed a negative correlation with urinary miR-196a (ρ = −0.247, P < 0.001 and ρ = −0.236, P = 0.001, respectively). Pathologically, urinary miR-196a levels correlated with glomerular sclerosis and IF in patients with DN. Urinary miR-196a was significantly associated with progression to end-stage renal disease [hazard ratio (HR) 2.03, P < 0.001] and a 40% reduction of baseline eGFR (HR 1.75, P = 0.001), independent of age, gender, body mass index, mean arterial pressure and hemoglobinA1c level. However, urinary miR-196a did not improve predictive power to proteinuria and eGFR in DN patients. Conclusions Increased urinary miR-196a was significantly associated with the progression of renal injury and might be a noninvasive prognostic marker of renal fibrosis in DN patients.

P0417THE ABSENCE OF C3 DEPOSIT IN MEMBRANOUS NEPHROPATHY IS ASSOCIATED WITH SPONTANEOUS REMISSION

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Cristina Rabasco ◽  
Ana Martínez ◽  
Rosa Ortega ◽  
Mario Espinosa
Keyword(s):  
Membranous Nephropathy ◽  
Interstitial Fibrosis ◽  
Immunosuppressive Treatment ◽  
Spontaneous Remission ◽  
Glomerular Sclerosis ◽  
Tubular Atrophy ◽  
Positive Group ◽  
Stage Renal Disease ◽  
End Stage

Abstract Background and Aims Membranous nephropathy (MN) is the most common cause of biopsied nephrotic syndrome in adults. Recently, it has been reported that the pathogenesis of MN may be associated with an activation of the complement system. The pathway of activation is not clearly established. The intensity of C3 deposition could be a good marker of this activation in MN as has been shown in other diseases (IgA nephropathy, crescentic GN). The aim of this study is to evaluate clinical-pathological data in a cohort of patients with MN and the significance of glomerular C3 staining as a possible predictor of renal outcomes. Method We analysed patients with idiopathic MN biopsied in our department between January 2000 and December 2019, excluding those who had no material for IF (n = 115). The patients were divided into positive (87 cases) and negative (28 cases) based on glomerular C3 deposition. We assessed the clinical and histological characteristics and the percentage of spontaneous remission (SR) and end-stage renal disease (ESRD). Results A total of 115 patients with MN were followed with a median follow-up of 65 (25-161) months. We found no differences in baseline characteristics between both groups, with the exception that patients with C3 deposit had less albumin at the time of biopsy that negative patients [2.4 (2-2.9) vs 2.8 (2.3-3.1) g/dl, P=0.011)]. Patients with C3-negative had a higher percentage of SR than patients with C3-positive (75 vs 24%, P = 0.000) and less need for immunosuppressive treatment (18 vs 56%, P =0.001). At the most recent follow-up, C3-positive group had higher creatinine [1.42 (0.8-1.7) vs 0.97 (0.71-1) mg/dl, P=0.045] and proteinuria [1.64 (0.08-3.2) vs. 0.62 (0.05-0.79) g / 24h, P = 0.039]. Regarding histology, we found no differences in glomerular sclerosis, tubular atrophy and interstitial fibrosis. The renal survival analysis showed no statistically significant differences between both groups (P = 0.091). We analysed a subgroup of patients (n = 23) with antibodies against the phospholipase receptor on blood at the time of the biopsy (13/23 were positive). 84% of this positive group presented C3-positive in the renal biopsy vs 25% of the C3-negative group (P =0.008). Conclusion Patients without C3 staining show a higher rate of SR and less need for immunosuppressive treatment than patients with C3-positive. These results would support the theory that complement activation in this entity can play an important role. It is possible that these patients with negative C3 deposit represent a MN with evolution to SR and in these patients and that these patients do not need immunosuppressive treatment.

scholarly journals Clinical and pathological characteristics of ANA/anti-dsDNA positive patients with antineutrophil cytoplasmic autoantibody-associated vasculitis

2020 ◽  
Author(s):  
Xiaohong Zhao ◽  
Qiong Wen ◽  
Yagui Qiu ◽  
Fengxian Huang
Keyword(s):  
Interstitial Fibrosis ◽  
Kidney Damage ◽  
Glomerular Sclerosis ◽  
Histopathological Changes ◽  
Tubular Atrophy ◽  
Double Stranded Dna ◽  
Antineutrophil Cytoplasmic Autoantibody ◽  
Stage Renal Disease ◽  
End Stage ◽  
Dsdna Antibodies

Abstract Antineutrophil cytoplasmic autoantibodies (ANCA) associated vasculitis (AAV) consists of a group of systemic autoimmune diseases. The roles of serum anti-nuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies in AAV patients remain unknown. This study investigated the prevalence of serum ANAs and anti-dsDNA antibodies in AAV patients and characterized the clinical and pathological features of these patients. A total of 218 AAV patients were enrolled. Clinical and pathological data of patients were analyzed retrospectively. Of the 218 AAV patients, 109 (50.0%) were positive for ANA, 45 (20.6%) were positive for anti-dsDNA, and 43 (19.7%) were positive for both. The AAV patients with ANA had severer kidney damage and more chronic renal histopathological changes compared to those who were negative for ANA. Specifically, patients positive for ANA had more hypertension, higher levels of urea nitrogen and serum creatinine, lower estimated glomerular filtration rate (eGFR), more end-stage renal disease (ESRD), severer proteinuria, glomerular sclerosis, tubular interstitial fibrosis and tubular atrophy, and were more likely to receive renal biopsies compared to ANA negative patients. The study found ANA and anti-dsDNA in AVV patients were not rare, ANA-positive AAV patients had severer kidney damage and more chronic renal histopathological changes compared to ANA-negative AAV patients. Renal biopsy is strongly recommended for differential diagnosis in such cases.

scholarly journals Real-world evidence and optimization of vocal dysfunction in end-stage renal disease patients with secondary hyperparathyroidism

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Geng-He Chang ◽  
Fong-Fu Chou ◽  
Ming-Shao Tsai ◽  
Yao-Te Tsai ◽  
Ming-Yu Yang ◽  
...  
Keyword(s):  
Renal Disease ◽  
Secondary Hyperparathyroidism ◽  
Real World ◽  
End Stage Renal Disease ◽  
Cox Regression ◽  
Electrolyte Imbalance ◽  
Research Database ◽  
Cox Regression Analysis ◽  
Stage Renal Disease ◽  
End Stage

AbstractPatients with end-stage renal disease (ESRD) may demonstrate secondary hyperparathyroidism (SHPT), characterized by parathyroid hormone oversecretion in response to electrolyte imbalance (e.g., hypocalcemia and hyperphosphatemia). Moreover, this electrolyte imbalance may affect vocal cord muscle contraction and lead to voice change. Here, we explored the effects of SHPT on the voices of patients with ESRD. We used data of 147,026 patients with ESRD from the registry for catastrophic illness patients, a sub-database of Taiwan National Health Insurance Research Database. We divided these patients into 2 groups based on whether they had hyperparathyroidism (HPT) and compared vocal dysfunction (VD) incidence among them. We also prospectively included 60 ESRD patients with SHPT; 45 of them underwent parathyroidectomy. Preoperatively and postoperatively, voice analysis was used to investigate changes in vocal parameters. In the real-world database analysis, the presence of HPT significantly increased VD incidence in patients with ESRD (p = 0.003): Cox regression analysis results indicated that patients with ESRD had an approximately 1.6-fold increased VD risk (p = 0.003). In the clinical analysis, the “jitter” and “shimmer” factors improved significantly after operation, whereas the aerodynamic factors remained unchanged. In conclusion, SHPT was an independent risk factor for VD in patients with ESRD, mainly affecting their acoustic factors.

MO757COMPARISON OF ANTI-COAGULATION AND NO ANTI-COAGULATION IN DIALYSIS PATIENTS WITH ATRIAL FIBRILLATION: A SINGLE CENTER RETROSPECTIVE STUDY

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Jun Young Lee ◽  
Jae Won Yang ◽  
Jae Seok Kim ◽  
Seong Ok Choi ◽  
Byoung Geun Han
Keyword(s):  
Atrial Fibrillation ◽  
Cox Regression ◽  
Dialysis Patients ◽  
Dialysis Therapy ◽  
Cox Regression Analysis ◽  
Significant Difference ◽  
Baseline Characteristics ◽  
Stage Renal Disease ◽  
End Stage ◽  
Risk And Benefit

Abstract Background and Aims Atrial fibrillation (AF) is common arrhythmia in end stage renal disease patients. Although, the need of anticoagulation to prevent stroke and thromboembolism is increasing, the efficacy of anticoagulation is not proven in most of study. We retrospectively analyzed the risk and benefit of anticoagulation in dialysis patients with AF. Method By using medical record, we retrospectively analyzed all data of 99 patients who received dialysis therapy and diagnosed AF. Results Among 99 patients who diagnosed AF with dialysis 36 patients received anticoagulation (17 coumadin, 19 apixaban 2.5mg bid), 63 patients received no anticoagulation. There was no significant difference of baseline characteristics between anticoagulation, and no anticoagulation patients. Although no anticoagulation group experienced more all-cause (39.7% vs 32.4%, p=0.572) and cardiovascular mortality (17.6% vs 10.8%, p=0.197) than anticoagulation group it was not statistically significant. Compared to apixaban 2.5mg bid patients, coumadin anticoagulation patients experienced more frequent mfig ajor adverse cardiovascular events (35.3% vs 15.8%, p=0.109) but it was not statistically significant in multi variate Cox regression analysis (Hazard ratio 1.143, 95% Confidence Interval 0.503-2.597). Conclusion Apixaban 2.5mg bid was not inferior than coumadin considering risk and benefit of anticoagulation in dialysis patients.

scholarly journals Clinicopathologic Features of Infection-Related Glomerulonephritis with IgA Deposits: a French Nationwide Study

2020 ◽  
Author(s):  
Elodie Miquelestorena-Standley ◽  
Charlotte Jaulerry ◽  
Marie-Christine Machet ◽  
Nolwenn Rabot ◽  
Christelle Barbet ◽  
...  
Keyword(s):  
Interstitial Fibrosis ◽  
Outcome Data ◽  
Renal Outcome ◽  
Tubular Atrophy ◽  
Short Delay ◽  
Adult Men ◽  
Staphylococcus Infections ◽  
Endocapillary Proliferative Glomerulonephritis ◽  
Stage Renal Disease ◽  
End Stage

Abstract Background: Infection-related glomerulonephritis with IgA deposits (IRGN-IgA) is a rare disease but it is increasingly reported in the literature. Data regarding epidemiology and outcome are lacking, especially in Europe. We aimed to assess the clinical, pathologic and outcome data of IRGN-IgA. Methods: Clinical and outcome data from patients from 11 French centers over the 2007-2017 period were collected retrospectively. We reviewed pathologic patterns and immunofluorescence of renal biopsies and evaluated C4d expression in IRGN-IgA. We analyzed the correlation between histological presentation and outcome. Results: Twenty-seven patients (23 men, mean age: 62±15 years) were included. Twenty-one (78%) had Staphylococcus aureus infection and twelve (44%) were diabetic. At the time of biopsy, 95.2% had haematuria, 48.1% had a serum creatinine level of >4 mg/dL, and 16% had hypocomplementemia. The most common pathologic presentation included mesangial (88.9%) and endocapillary proliferative glomerulonephritis (88.9%) with interstitial fibrosis and tubular atrophy (IF/TA) (85.1%). Diffuse and global glomerular C4d expression was found in 17.8%, mostly in biopsies with acute or subacute patterns, and was associated with a short delay between infection and renal biopsy compared to segmental and focal staining. After median follow-up of 13.2 months, 23.1% died, 46.2% had persistent renal dysfunction and 15.4% reached end-stage renal disease. Renal outcome was correlated to IF/TA severity. Conclusions: Infection-related glomerulonephritis with IgA deposits is usually associated with Staphylococcus infections and mainly affects adult men. This entity has a poor prognosis which is correlated to interstitial fibrosis and tubular atrophy severity.

scholarly journals Nonneoplastic Renal Cortical Scarring at Tumor Nephrectomy Predicts Decline in Kidney Function

2013 ◽  
Vol 137 (4) ◽  
pp. 531-540 ◽  
Author(s):  
Steven P. Salvatore ◽  
Eugene K. Cha ◽  
James S. Rosoff ◽  
Surya V. Seshan
Keyword(s):  
Diabetic Nephropathy ◽  
Renal Disease ◽  
Interstitial Fibrosis ◽  
Prognostic Significance ◽  
Preoperative Assessment ◽  
Tubular Atrophy ◽  
Hypertensive Nephropathy ◽  
Tumor Nephrectomy ◽  
End Stage

Context.—Evaluating nontumor portions of tumor nephrectomies is useful to diagnose nonneoplastic renal disease. Objective.—To determine the medical renal disease frequency and to assess the prognostic significance of the various renal pathologic variables with long-term follow-up in tumor nephrectomy patients. Design.—We reviewed nonneoplastic kidney sections of 456 consecutive cases from 1998 to 2008. Seventy-five cases were excluded (19 tumor compression, 25 no nonneoplastic tissue, 22 embolized kidneys, 9 end stage). Special staining, immunofluorescence, and/or electron microscopy was performed where appropriate. Vascular sclerosis was scored from mild to severe; interstitial fibrosis/tubular atrophy and global glomerulosclerosis (GS) were expressed as percentages. Follow-up, minimum 12 months, was evaluated in 156 cases. All renal pathologic variables were compared with regard to change in creatinine level from preoperative assessment to follow-up. Results.—Of 381 cases, 57 had additional medical renal disease (15%), most frequently diabetic nephropathy (28) and hypertensive nephropathy (11). Postoperative creatinine levels increased significantly in patients with severe arteriosclerosis or arteriolosclerosis, >5% GS, and >10% interstitial fibrosis/tubular atrophy. Seventy-four percent of cases with additional nonneoplastic diagnoses showed severe arteriolosclerosis. Higher corresponding GS was seen in the more affected vascular cases: mean, 5.56% GS for mild versus 23% GS for severe. Three patients progressed to renal failure 1 to 4 years after nephrectomy, 2 with hypertensive nephrosclerosis and 1 with diabetic nephropathy. Conclusions.—Medical renal disease was identified in 15% of tumor nephrectomy specimens. The degrees of vascular sclerosis, GS, and interstitial fibrosis/tubular atrophy are predictive of elevated creatinine levels in postnephrectomy patients. Prognostic implications of the nontumor pathology are important in nephrectomized patients.

scholarly journals Diabetic nephropathy: what should cardiologist remember

2021 ◽  
Vol 23 (1) ◽  
pp. 20-24
Author(s):  
Natalia P. Trubitsyna ◽  
◽  
Natalia V. Zaitseva ◽  
Anastasia S. Severinа ◽  
◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Diabetic Nephropathy ◽  
Renal Replacement Therapy ◽  
Renal Disease ◽  
Replacement Therapy ◽  
End Stage Renal Disease ◽  
Kidney Diseases ◽  
Renin Angiotensin Aldosterone System ◽  
Stage Renal Disease ◽  
End Stage

Prevalence of diabetes mellitus (DM) progressively increases around the world. Diabetic nephropathy (DN) is significant reason of end-stage renal disease and it is associated with high risk of cardiovascular disease and mortality. Necessity of expensive renal replacement therapy for patients with prominent vascular diabetic complications and end-stage renal disease has significant socio-economic impact. DM, as a one of leading causes of kidney diseases, competes for stricted resources of public health. Renal replacement therapy in patients with DM does not solve the whole problem, because survival of such patients is low, comparing with another kidney diseases, first of all because of cardiovascular diseases. Good control of glycaemia, blood pressure and cholesterol level and prescription of renin-angiotensin-aldosterone system inhibitors and statins decrease cardiovascular risk and slow down DN progression, as it was shown in many clinical trials. So patients with DM and DN should receive complex therapy for risk reduction of kidney disease and cardiovascular disorders progression. Keywords: diabetes mellitus type 2, diabetic nephropathy, nephroprotection, cardioprotection, SGLT-2 inhibitors, GLP-1 agonists, renin-angiotensin-aldosterone system For citation: Trubitsyna NP, Zaitseva NV, Severinа AS. Diabetic nephropathy: what should cardiologist remember. Consilium Medicum. 2021; 23 (1): 20–24. DOI: 10.26442/20751753.2021.1.200712

Clinical features and outcome of infection-related glomerulonephritis with IgA deposits

2020 ◽  
Author(s):  
Elodie Miquelestorena-Standley ◽  
Charlotte Jaulerry ◽  
Marie-Christine Machet ◽  
Nolwenn Rabot ◽  
Christelle Barbet ◽  
...  
Keyword(s):  
Interstitial Fibrosis ◽  
Outcome Data ◽  
Renal Outcome ◽  
Chi Square ◽  
Tubular Atrophy ◽  
Adult Men ◽  
Chi Square Test ◽  
Endocapillary Proliferative Glomerulonephritis ◽  
Stage Renal Disease ◽  
End Stage

Abstract Background Infection-related glomerulonephritis with IgA deposits (IRGN-IgA) is being more widely recognized but the precise epidemiology and outcome is lacking, particularly in Europe. We aimed to assess clinical, pathologic and outcome data of IRGN-IgA. Methods Clinical and outcome data from patients from 11 French centers over the 2007-2017 period were retrospectively collected. We reviewed pathologic patterns and immunofluorescence of renal biopsies and evaluated C4d expression in IRGN-IgA. We analyzed correlation between histological presentation and outcome using the Chi square test (qualitative data) and Kruskal-Wallis test (quantitative data). Results Twenty-seven patients (23 men, mean age: 62 ± 15 years) were included. Most of them had a Staphylococcus aureus infection (77.8%) and 44.4% were diabetic. At the time of biopsy, 95.2% had haematuria, 48.1% had a serum creatinine >4 mg/dL, and 16% had a hypocomplementemia. The most common pathologic presentation included mesangial (88.9%) and endocapillary proliferative glomerulonephritis (88.9%) with interstitial fibrosis with tubular atrophy (IF/TA) (85.1%). Diffuse and global glomerular C4d expression, found in 17.8% of the cases, was most frequently observed in biopsies with acute or subacute pattern and associated with a shorter delay between infection and renal biopsy compared to segmental and focal staining. After a median follow-up of 13.2 months, 23.1% died, 46.2% had persistent renal dysfunction and 15.4% reached end-stage renal disease. Renal outcome was correlated to IF/TA severity. Conclusions Infection-related glomerulonephritis with IgA deposits is usually associated with Staphyloccus infections and mainly affects adult men. This entity has a poor prognosis which is correlated to interstitial fibrosis and tubular atrophy severity.

A Pathological Scoring System to Predict Renal Outcome in Diabetic Nephropathy

2015 ◽  
Vol 41 (4-5) ◽  
pp. 337-344 ◽  
Author(s):  
Junichi Hoshino ◽  
Koki Mise ◽  
Toshiharu Ueno ◽  
Aya Imafuku ◽  
Masahiro Kawada ◽  
...  
Keyword(s):  
Diabetic Nephropathy ◽  
Renal Biopsy ◽  
Scoring System ◽  
Proportional Hazards ◽  
Interstitial Fibrosis ◽  
Predictive Ability ◽  
Cox Proportional Hazards ◽  
Renal Outcome ◽  
Tubular Atrophy ◽  
Stage Renal Disease

Background: With the association between diabetic nephropathy (DN) and renal outcome being increasingly clear, we aimed at creating a new DN pathological scoring system that could predict the renal outcome. Methods: We studied 205 patients with DN confirmed by renal biopsy, sometime between March 1985 and January 2010, who met the inclusion criteria. Renal biopsy included clinical parameters and Tervaert classifications. Hazard ratios (HRs) for death-censored end-stage renal disease (ESRD) were estimated by adjusted Cox proportional-hazards regression. The overall pathological risk score (D-score) was calculated by summing the products of beta coefficient and bootstrap-inclusion fractions, its predictive utility evaluated by Kaplan-Meier methods and c-statistics for a 10-year risk of ESRD. Results: The D-scores of glomerular classes 1, 2A, 2B, 3, and 4 were, respectively, 0, 3, 4, 6, and 6. Those of interstitial fibrosis and tubular atrophy classes 0, 1, 2, and 3 were 0, 7, 9, and 11, and those of interstitial inflammation classes 0, 1, and 2 were 0, 3, and 4, respectively. The D-score of hyalinosis class 2 was 3 and that of arteriosclerosis class 2 was 1. So, a patient's D-score could be 0-25. HRs for ESRD in patients with D-score ≤14, 15-18, 19-21, and 22-25 were, respectively, 1.00 (reference) 16.21 (95% confidence interval (CI), 1.86-140.90), 19.78 (95% CI, 2.15-182.40), and 45.46 (95% CI, 4.63-446.68) after adjusting for clinical factors. The c-statistics suggested a better predictive ability for a 10-year renal death with models that included the D-score. Conclusion: Prediction of DN patients' renal outcome was better with the D-score than without it. Patients with a D-score ≤14 had excellent renal prognosis.

scholarly journals Etiology of End-Stage Renal Disease and Arterial Stiffness among Hemodialysis Patients

2017 ◽  
Vol 2017 ◽  
pp. 1-6 ◽  
Author(s):  
Balsam El Ghoul ◽  
Yazan Daaboul ◽  
Serge Korjian ◽  
Andrew El Alam ◽  
Anthony Mansour ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Diabetic Nephropathy ◽  
Arterial Stiffness ◽  
Renal Disease ◽  
End Stage Renal Disease ◽  
Hemodialysis Patients ◽  
Cross Sectional ◽  
History Of ◽  
Stage Renal Disease ◽  
End Stage

Background. Prior studies have demonstrated that conventional and emerging CV risk factors are associated with worsening arterial stiffness among end-stage renal disease (ESRD) patients on hemodialysis. The present cross-sectional study evaluates the association between the etiology of ESRD and arterial stiffness among a cohort of hemodialysis patients.Methods. Etiology of ESRD was identified from patients’ medical records and classified as either vascular renal disease, diabetic nephropathy, nondiabetic glomerulopathy, tubular interstitial nephropathy, hereditary nephropathy, or ESRD of unconfirmed etiology.Results. A total of 82 subjects were enrolled. cfPWV was independently associated with the composite of either diabetic nephropathy or vascular renal disease (p=0.022), pulse pressure (p=0.001), and a history of CV events (p=0.025), but not history of hypertension or diabetes mellitus alone. The median cfPWVs in diabetic nephropathy and vascular renal disease were comparable and significantly higher than median cfPWVs in other etiologies of ESRD.Conclusion. The study suggests that the etiology of ESRD is independently associated with arterial stiffness among hemodialysis patients. Furthermore, arterial stiffness was higher among patients who developed renal sequelae of either diabetes mellitus or hypertension as compared with those who have a history of either diabetes mellitus or hypertension alone.

Sign in / Sign up

Export Citation Format

Share Document