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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_325"
                     title="MRI Reveals Risk for Kidney Failure in Diabetic Patients (CME/CE)"
                     score="0.007"
                     href="http://www.medpagetoday.com/Nephrology/Diabetes/tb/18195?impressionId=1265776525459"
                     
      So-called silent strokes, visible on cerebral MRI scans, predict kidney failure in patients with type 2 diabetes, Japanese researchers said.&lt;br&gt;
&lt;br&gt;After an average follow-up of 7.5 years, diabetic patients with evidence of small cerebral infarctions at baseline later suffered death or kidney failure at more than twice the rate seen in patients who had not had silent strokes, reported Takashi Uzu, MD, of Shiga University of Medical Sciences in Shiga, Japan, and colleagues.&lt;br&gt;
&lt;br&gt;Silent strokes are a consequence of cerebral microvascular disease and thus may logically accompany the development of similar abnormalities in renal blood vessels, ultimately leading to kidney failure, the researchers explained online in the &lt;em&gt;Journal of the American Society of Nephrology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;It is important to identify individuals who are at risk of progression of diabetic renal disease,&quot; Uzu and colleagues wrote.&lt;/p&gt;
&lt;p&gt;The current standard prognostic test is the albumin-creatinine ratio, but it is not entirely adequate for the purpose, they suggested: &quot;Recent clinical studies have shown that renal insufficiency can occur in the absence of microalbuminuria in patients with type 2 diabetes.&quot;&lt;/p&gt;
&lt;p&gt;But they acknowledged that brain MRI scans would be too expensive and inconvenient for routine prognostic testing.&lt;/p&gt;
&lt;p&gt;&quot;New strategies are needed to determine the presence of renal and/or extrarenal microvascular diseases,&quot; Uzu and colleagues wrote.&lt;/p&gt;
&lt;p&gt;Their study involved 608 patients with type 2 diabetes who had no clinical signs of cerebrovascular or cardiovascular disease or overt nephropathy. Their mean age at baseline was about 60 and the average glycated hemoglobin level was about 8.6%.&lt;/p&gt;
&lt;p&gt;Participants underwent cerebral MRI scans at baseline, with 177 showing evidence of silent cerebral infarctions, defined as focal lesions of at least 3 mm in diameter with low signal intensity on T1-weighted images and high intensity with T2 weighting. Dilated perivascular spaces were distinguished from infarcts with proton density scans. Patients with positive findings who had a history of stroke or transient ischemic attack were excluded.&lt;/p&gt;
&lt;p&gt;Those with silent infarctions at baseline differed significantly from other participants according to several parameters. Not surprisingly, patients with cerebral infarcts on average were somewhat older (63 versus 57), had had diabetes for a longer period of time (9.8 years versus 7.6), had higher blood pressure (146.8 mm Hg systolic versus 136.5 ), and were more likely to have a history of smoking (58% versus 46%). All differences were significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.01.&lt;/p&gt;
&lt;p&gt;On the other hand, baseline fasting plasma glucose and glycated hemoglobin levels were both significantly lower in the patients who&apos;d had silent infarctions: mean 163 mg/dL versus 176 for glucose and 8.3% versus 8.7% for HbA1c (&lt;em&gt;P&lt;/em&gt;&amp;#8804;0.01 for both).&lt;/p&gt;
&lt;p&gt;Patients were followed for up to 10 years, with a mean of 7.5. The primary outcome was end-stage renal disease or death, and Uzu and colleagues chose a secondary outcome combining dialysis with doubling of serum creatinine.&lt;/p&gt;
&lt;p&gt;Kaplan-Meier curves for the patients with and without silent infarctions at baseline indicated that the primary outcome occurred at equal rates through the first four years of follow-up, but then the curves diverged abruptly.&lt;/p&gt;
&lt;p&gt;At year eight, approximately 6% of the noninfarcted group had experienced the primary outcome, compared with 21% of those who&apos;d had silent strokes (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001), according to Uzu and colleagues.&lt;/p&gt;
&lt;p&gt;Curves for the secondary outcome began diverging by year three. At year eight, about 6% of the noninfarct participants had gone to dialysis or had serum creatinine levels double, whereas these endpoints occurred in nearly 30% of the infarct group (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001).&lt;/p&gt;
&lt;p&gt;Overall, the hazard ratio associated with baseline silent cerebral infarctions for the primary outcome during follow-up was 2.44 (95% CI 1.36 to 4.38).&lt;/p&gt;
&lt;p&gt;The hazard ratio for death alone was somewhat smaller (1.61, 95% CI 0.71 to 3.62), indicating that most of the risk measured by the primary outcome was actually in end-stage renal disease.&lt;/p&gt;
&lt;p&gt;For the secondary outcome, the hazard ratio was 4.79 (95% CI 2.72 to 8.46).&lt;/p&gt;
&lt;p&gt;All the hazard ratios reflected adjustments for age, sex, duration of diabetes, body mass index, smoking status, HbA1c, blood pressure, serum lipids, and standard lab indices of kidney function at baseline.&lt;/p&gt;
&lt;p&gt;Estimated glomerular filtration rate (eGFR) during follow-up also decreased faster in patients with silent strokes. After five years, mean eGFR had fallen by 8 ml/min/m&lt;sup&gt;2&lt;/sup&gt; in the patients without silent infarcts at baseline compared with 10.5 ml/min/m&lt;sup&gt;2&lt;/sup&gt; in those with cerebral microvascular disease.&lt;/p&gt;
&lt;p&gt;The researchers noted that the study was conducted at two clinical sites, which used somewhat different MRI procedures. But they also indicated that the prevalence of silent infarctions did not differ between the sites.&lt;/p&gt;
&lt;p&gt;Other limitations included use of an older creatinine assay, inclusion of larger silent infarcts which could reflect macrovascular disease, and more patients in the cerebral infarct group who were taking renin-angiotensin system blocking drugs, which have renal impairment as an adverse effect.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;External funding for the study was not reported.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_280"
                     title="Better Overall Diabetes Care Lowers Nephropathy Risk (CME/CE)"
                     score="0.004"
                     href="http://www.medpagetoday.com/Nephrology/Diabetes/tb/18136?impressionId=1265776525459"
                     
      &lt;p&gt;Simultaneously achieving tight glucose control and other targets in diabetes reduces the risk of kidney complications, researchers found.&lt;/p&gt;
&lt;p&gt;An aggressive multifactorial intervention appeared to delay diabetic nephropathy better when more targets were achieved (&lt;em&gt;P&lt;/em&gt;=0.002 for trend) in a longitudinal study of Chinese patients led by Ming-Chia Hsieh, MD, PhD, of Kaohsiung Medical University Hospital in Kaohsiung, Taiwan.&lt;/p&gt;
&lt;p&gt;The risk of new-onset microalbuminaria dropped 27.1% for those who met the American Diabetes Association-recommended goal of less than 7% glycosylated hemoglobin (&lt;em&gt;P&lt;/em&gt;=0.03), the researchers reported in the Jan. 25 &lt;em&gt;Archives of Internal Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Reaching the systolic blood pressure goal of less than 130 mm Hg reduced this risk 35.5% (&lt;em&gt;P&lt;/em&gt;=0.002). Achieving the HDL cholesterol goal  --  over 50 mg/dL for women and 40 mg/dL for men  --  reduced the risk by 28.5% (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;&quot;The control of microalbuminuria may halt progress to overt nephropathy and reduce occurrence of cardiovascular events in these patients,&quot; Hsieh&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;They suggested that this type of intensive intervention &quot;can be used at the very early stages of diabetic renal disease.&quot;&lt;/p&gt;
&lt;p&gt;Prior studies had suggested that intensive therapy could prevent nephropathy in patients who had already started showing signs of progression.&lt;/p&gt;
&lt;p&gt;So to see if starting earlier would be as effective, Hsieh and colleagues initiated a longitudinal cohort study of 1,290 patients with type 2 diabetes and normoalbuminuria in which participants received intensified treatment to meet ADA-recommended goals on glucose, blood pressure, cholesterol, and triglycerides.&lt;/p&gt;
&lt;p&gt;To this end, patients got the combined efforts of a physician, nurse, and dietitian working together on counseling and patient education to modify behavior.&lt;/p&gt;
&lt;p&gt;By the end of the intervention patients were more likely to have switched from single agent glucose-lowering treatment to insulin plus an oral hypoglycemic agent and to have gone on an antihypertensive (74% versus 48% baseline), statin (58.1% versus 28.0% baseline), and fibrate (14.0% versus 3.0% baseline).&lt;/p&gt;
&lt;p&gt;By the end of the study period, the mean glycosylated hemoglobin was 7.3%, while blood pressure averaged 129.3/74.4 mm Hg. Mean LDL cholesterol was 98.6 mg/dL, triglycerides were at 116.0 mg/dL, and mean HDL cholesterol was 53.6 mg/dL.&lt;/p&gt;
&lt;p&gt;Over the 4.5 years of follow-up, 16.4% of patients developed new-onset microalbuminuria.&lt;/p&gt;
&lt;p&gt;Unlike attainment of HDL cholesterol, glycosylated hemoglobin, and systolic blood pressure goals, reaching those for LDL cholesterol, diastolic blood pressure, and triglycerides appeared to have little impact on kidney function.&lt;/p&gt;
&lt;p&gt;But the more targets patients reached, the less likely they were to develop microalbuminuria (&lt;em&gt;P&lt;/em&gt;=0.002).&lt;/p&gt;
&lt;p&gt;The majority of participants in the study reached one or two of the treatment targets (71.4%) and 8.1% achieved three.&lt;/p&gt;
&lt;p&gt;Those who did reach two or three of the goals were at significantly lower risk of new-onset microalbuminuria than the 20.5% who didn&apos;t reach any of the goals (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Those who reached one target tended to be at lower risk as well, but the effect was not significant compared with reaching none of the goals (&lt;em&gt;P&lt;/em&gt;=0.35).&lt;/p&gt;
&lt;p&gt;One of the concerns with the tight glucose control goal has been hypoglycemia. In the study, 217 patients had at least one episode. Four cases involved major hypoglycemia, though without clinical morbidity or mortality.&lt;/p&gt;
&lt;p&gt;Overall, 37 patients died from any cause during the study period.&lt;/p&gt;
&lt;p&gt;A &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/13818&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/13818&quot; target=&quot;_blank&quot;&gt;review&lt;/a&gt; of recent large trials of aggressive glycemic control  --  U.K. Prospective Diabetes Study (UKPDS) and the U.S.-based ACCORD, ADVANCE, and VA Diabetes trials  --  suggested a two- to threefold increased risk of severe hypoglycemia without macrovascular benefits.&lt;/p&gt;
&lt;p&gt;In the recent &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/9739&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/9739&quot; target=&quot;_blank&quot;&gt;ACCORD&lt;/a&gt; trial, tight glucose control that brought hemoglobin A1c close to 6%, with a target of less than the standard 7.0%, resulted in 22% excess mortality risk.&lt;/p&gt;
&lt;p&gt;The search for a reason behind this risk has yet to turn up a culprit. &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/ADA/14635&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/ADA/14635&quot; target=&quot;_blank&quot;&gt;Analyses&lt;/a&gt; have suggested that hypoglycemia isn&apos;t to blame and that the lower A1c levels themselves aren&apos;t a problem.&lt;/p&gt;
&lt;p&gt;In the wake of the negative findings from ACCORD, ADVANCE, and the VA trials, leading diabetologists had suggested that pushing too hard in people who couldn&apos;t reach the targets might have been at fault.&lt;/p&gt;
&lt;p&gt;Rather than a one-size-fits all approach, the ADA guidelines suggest individualizing treatment targets.&lt;/p&gt;
&lt;p&gt;Hsieh&apos;s group acknowledged that &quot;even with close attention, not all our patients could achieve the ADA-recommended goals,&quot; but re-emphasized that for patients who could achieve targets, there were benefits.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that their study was limited by lack of a comparison group, no data on genetic factors, and use of potentially arbitrary treatment target cutoff points.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_2097"
                     title="ACE, ARB Slow Retinopathy but Not Nephropathy in Type 1 Diabetes"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Cardiology/Diabetes/tb/14938?impressionId=1265776525459"
                     
       SAN FRANCISCO, July 1 -- Type 1 diabetes patients who start on renin-angiotensin blockers early may slow development of retinopathy by up to 70%, a clinical trial revealed. 
              &lt;p&gt;&lt;p&gt;But neither an angiotensin-receptor blocker (ARB) nor an ACE inhibitor significantly slowed progression of nephropathy over five years by any measure, Michael Mauer, MD, of the University of Minnesota in Minneapolis, and colleagues reported in the July 2 issue of the &lt;em&gt;New England Journal of Medicine&lt;/em&gt;. 
              &lt;p&gt;These findings challenge the widely accepted belief that inhibition of the renin-angiotensin system in patients with diabetes counteracts both early and advanced stages of nephropathy, according to an accompanying editorial. 
              &lt;p&gt;Andrzej S. Krolewski, MD, PhD, of Harvard and the Joslin Diabetes Center in Boston, and colleagues commented in the editorial that numerous studies suggesting renal benefits were of short duration and focused primarily on urinary albumin excretion as a surrogate for kidney function. 
              &lt;p&gt;But Dr. Mauer&apos;s results shouldn&apos;t have been entirely unexpected, they said. 
              &lt;p&gt;Even the most influential trial supporting an effect on nephropathy -- the Collaborative Study Group&apos;s captopril (Capoten) trial -- showed an effect on creatinine doubling time in advanced nephropathy but not in those with creatinine levels of less than 1.5 mg/dL, the editorialists noted. 
              &lt;p&gt;So for a more rigorous look at renal effects of renin-angiotensin blockade in diabetes, Dr. Mauer&apos;s group conducted the Renin-Angiotensin System Study (RASS), which followed patients for progression of the early histologic lesions of diabetic nephropathy seen on biopsy. 
              &lt;p&gt;The trial included 285 patients with type 1 diabetes but normal albumin excretion and blood pressure levels. They were randomly assigned to receive losartan (Cozaar), enalapril (Vasotec), or placebo for five years. 
              &lt;p&gt;Midway through the trial, the 50-mg daily dose of losartan and 10-mg daily dose of enalapril were doubled based on data from another trial. 
              &lt;p&gt;For the primary endpoint, the change in mesangial fractional volume from baseline to five years was not significantly different for losartan or enalapril compared with placebo (+0.026 and +0.005 versus +0.016 units, &lt;em&gt;P&lt;/em&gt;=0.17 and &lt;em&gt;P&lt;/em&gt;=0.16, respectively). 
              &lt;p&gt;Other secondary measures of biopsy-assessed renal structural changes, such as interstitial fractional volume, showed generally similar results. 
              &lt;p&gt;The five-year cumulative incidence of microalbuminuria was actually higher with losartan than with placebo (17% versus 6%, &lt;em&gt;P&lt;/em&gt;=0.01), but was similar between enalapril and placebo (4% versus 6%, &lt;em&gt;P&lt;/em&gt;=0.96). 
              &lt;p&gt;This &quot;unexpected and unexplained&quot; increase in microalbuminuria incidence needs further confirmation in a randomized controlled trial, the researchers cautioned. 
              &lt;p&gt;&quot;Nonetheless, careful monitoring of the albumin excretion rate is recommended if ARBs are prescribed to such patients,&quot; they recommended. 
              &lt;p&gt;But there were no differences in kidney function between groups as assessed by the glomerular filtration rate over the five years (declines of 6.6 to 8.9 ml per minute, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.002 for all three versus baseline). 
              &lt;p&gt;For the retinopathy endpoint, progression of two or more steps on a 15-step diabetic retinopathy severity scale occurred in only 25% of patients who got enalapril and 21% of those who got losartan compared with 38% who got placebo (&lt;em&gt;P&lt;/em&gt;=0.02 and &lt;em&gt;P&lt;/em&gt;=0.008). 
              &lt;p&gt;This 65% risk reduction with enalapril (odds ratio 0.35 versus placebo, 95% confidence interval 0.14 to 0.85) and 70% risk reduction with losartan (odds ratio 0.30 versus placebo, 95% CI 0.12 to 0.73) appeared to be independent of blood pressure effects and glycemia. 
              &lt;p&gt;&quot;The benefits of enalapril and losartan on diabetic retinopathy in the present study may represent direct effects on the eye,&quot; the investigators posited, but noted, &quot;we cannot rule out effects of blood pressure on these diabetic retinopathy outcomes.&quot; 
              &lt;p&gt;The inconsistency in retinopathy effects in this trial compared with the DIRECT series of trials with the ARB candesartan (Atacand) might reflect differences in sample size and the drugs and doses administered, the editorialists said. (See &lt;a href=&quot;http://www.medpagetoday.com/Nephrology/Diabetes/11068&quot; target=&quot;blank&quot;&gt;ARB May Retard Diabetic Retinopathy for Some Patients&lt;/a&gt;) 
              &lt;p&gt;Dr. Mauer&apos;s group cautioned about extrapolating between early and advanced stages of diabetic nephropathy and between type 2 and type 1 diabetes, &quot;especially given the substantial differences in the relation of renal structure to albuminuria and the frequent presence of hypertension, obesity, and other risk factors for albuminuria in patients with type 2 diabetes.&quot; 
              &lt;p&gt;Likewise, the editorialists pointed to a variable strategy for these different populations: 
              &lt;ul type=&quot;disc&quot;&gt;
                &lt;li&gt;Inhibition of the renin-angiotensin system should not be considered for normotensive patients with type 1 diabetes and normoalbuminuria.
                &lt;li&gt;Use of ACE inhibitors and ARBs should be questioned for microalbuminuria in patients with type 1 or type 2 diabetes, &quot;since evidence of prevention of early decline in renal function is limited.&quot;
                &lt;li&gt;Recognition of little chance of retinopathy benefit for patients with type 1 diabetes who have established retinopathy or for those with type 2 diabetes regardless of retinopathy status.
              &lt;/ul&gt; 
              &lt;p&gt;Dr. Krolewski&apos;s group also cautioned that &quot;further work is required before the strategy is used for retinopathy prevention in clinical practice,&quot; including determination of the duration of therapy and subgroups that might not benefit.  
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt; The study was supported by grants from the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases, Merck, Merck Frosst, and the Canadian Institutes of Health Research. 
              &lt;p&gt;Dr. Mauer reported conflicts of interest with Genzyme and Merck. Co-authors reported conflicts of interest with Merck, AstraZeneca, Boehringer Ingelheim, Pfizer, Organon, Wyeth, Lilly, and Novartis. 
              &lt;p&gt;One of the editorialists reported conflicts of interest with Merck and Novartis. &lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3654"
                     title="Hemoglobin Levels Predict Diabetic Retinopathy (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Ophthalmology/GeneralOphthalmology/tb/16960?impressionId=1265776525459"
                     
      &lt;p&gt;An already routine blood test may identify juvenile-onset diabetic patients at heightened risk for proliferative retinopathy, researchers said.&lt;/p&gt;
&lt;p&gt;In a multivariate analysis, each increment of 1 g/dL in hemoglobin was associated with a linear 29% increase in risk for retinopathy in men with type 1 diabetes (95% CI 8% to 54%), and a quadratic 10% risk increase in women (95% CI 0% to 20%), reported Trevor Orchard, MD, of the University of Pittsburgh, and colleagues.&lt;/p&gt;
&lt;p&gt;&quot;This is the first study, to our knowledge, to show high hemoglobin levels to be predictive of the long-term incidence of proliferative diabetic retinopathy,&quot; the researchers wrote in the November issue of &lt;em&gt;Archives of Ophthalmology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Their study analyzed data on 426 participants in the Pittsburgh Epidemiology of Diabetes Complications Study, which began in the late 1980s. Some 18 years of follow-up were thus available.&lt;/p&gt;
&lt;p&gt;At enrollment, participants were about 25 years old on average, and had had diabetes for a mean of 17 years.&lt;/p&gt;
&lt;p&gt;During the study, 48% of both men and women were diagnosed with proliferative diabetic retinopathy.&lt;/p&gt;
&lt;p&gt;Mean hemoglobin levels were 16.5 g/dL in those who went on to develop retinopathy, compared with 16.1 g/dL in those who did not (&lt;em&gt;P&lt;/em&gt;=0.009).&lt;/p&gt;
&lt;p&gt;Other baseline factors that differed between the eventual retinopathy cases and those who remained free of the disorder included presence of overt nephropathy, albumin excretion rate, total and non-HDL cholesterol, diastolic (but not systolic) blood pressure, and glycated hemoglobin levels.&lt;/p&gt;
&lt;p&gt;Of those, only diastolic pressure and glycated hemoglobin were predictive of retinopathy in multivariate analysis for both sexes.&lt;/p&gt;
&lt;p&gt;The multivariate analysis controlled for all these factors as well as diabetes duration, body mass index, white blood cell count, fibrinogen, and hypertension medication.&lt;/p&gt;
&lt;p&gt;Each 1% increment in glycated hemoglobin was associated with a hazard ratio of 1.30 in men (95% CI 1.14 to 1.49) and 1.32 in women (95% CI 1.26 to 1.50).&lt;/p&gt;
&lt;p&gt;The hazard ratio for retinopathy associated with each 1 mm Hg in diastolic pressure was 1.03 in men (95% CI 1.00 to 1.05) and 2.28 in women (95% CI 1.02 to 5.07), Orchard and colleagues said.&lt;/p&gt;
&lt;p&gt;Systolic pressure predicted retinopathy in women (HR 1.03 per mm Hg) but not in men.&lt;/p&gt;
&lt;p&gt;Albumin excretion rate was a significant predictor in men (HR 1.34 per &amp;#956;g/min) but not in women.&lt;/p&gt;
&lt;p&gt;The researchers said that most attention to hemoglobin in the context of diabetes has focused on low levels  --  that is, anemia  --  in late-stage kidney disease.&lt;/p&gt;
&lt;p&gt;They said their findings on high hemoglobin levels and retinopathy &quot;may have important clinical relevance, as they may both identify new pathogenetic pathways to proliferative diabetic retinopathy and influence clinical treatment.&quot;&lt;/p&gt;
&lt;p&gt;Increased hemoglobin could be related to a number of factors potentially influencing retinopathy development, they said, such as testosterone levels, hypoxia, abnormalities in growth factors, and blood viscosity.&lt;/p&gt;
&lt;p&gt;The researchers noted that the difference in the nature of the relationship between hemoglobin and retinopathy risk between sexes  --  linear in men, quadratic in women  --  may just be a statistical fluke, arising from the small number of men with hemoglobin levels below 13.5 g/dL.&lt;/p&gt;
&lt;p&gt;A U-shaped relationship, indicating increased retinopathy risk for both low and high levels of hemoglobin, is likely to apply to both sexes, they said.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the National Institutes of Health.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_373"
                     title="Meta-Analysis Finds No Kidney Benefit for ACE-Inhibitors or ARBs"
                     score="-0.005"
                     href="