Microalbuminuria as predictor of increased mortality in elderly people.

OBJECTIVE--Correlation of the urinary albumin excretion rate and the risk of death among elderly subjects. DESIGN--216 Subjects aged 60-74 whose urinary albumin excretion rate had been determined were followed up 62-83 months later. SETTING--Municipality of Fredericia, Denmark. SUBJECTS--223 People who had been selected as control subjects for diabetics found during a systematic screening for diabetes of all people aged 60-74 living in the municipality of Fredericia, Denmark. Of these subjects, 216 had an extensive clinical and biochemical examination within a few weeks of selection. MAIN OUTCOME MEASURE--Death. RESULTS--The median urinary albumin excretion rate was 7.52 micrograms/min. Eight of those with a rate below the median died compared with 23 with a rate equal to or greater than the median (p = 0.0078). The median albumin excretion rate in the 31 who died was 15.00 micrograms/min. Cardiovascular disease was the most common cause of death in both groups. A multivariate regression analysis of survival data was performed using the proportional hazards model. Besides albumin excretion rate, male sex, serum creatinine concentration, and hypertension were found to be of prognostic value. CONCLUSIONS--The association between the albumin excretion rate and mortality that has been described in recent years in patients with diabetes mellitus may be present in elderly people in general, even when other known risk factors are taken into account.     

Urinary albumin in head-down bed rest

Previous studies reported low urinary albumin excretion in astronauts during space missions, suggesting an effect of microgravity on renal albumin handling. To test this hypothesis, urinary albumin excretion was investigated with use of head-down bed rest at -6 degrees (HDBR), an experimental model of microgravity. Eight healthy young men underwent two phases. Each phase included 2 days of dietary adaptation (run-in), 4 days of baseline (light activities and bed rest), and 6 days of experiment: HDBR 24h every day for intervention light activities and bed rest for control. The study was done in metabolic ward (DLR, Cologne, Germany). Urine were collected in days 3-4 of baseline and days 4-6 of experiment. Urinary albumin was measured by a double antibody radioimmunoassay, creatininuria by automated colourimetry. Data are expressed as albumin/creatinine ratio to control for timing and completeness of urine collection. Compared to baseline, albumin/creatinine ratio decreased by 9.3% during HDBR and increased by 14.9% during control. The difference in changes over baseline was significant between HDBR and control (p < 0.01 by paired comparison). The data support the hypothesis that low gravity reduces renal albumin excretion.     

The influence of work intensity on postexercise proteinuria

Fifteen men were studied during 100 m, 400 m and 3,000 m runs at maximal speed to determine total urinary protein and albumin excretion rates in relation to different distances of running. Venous blood lactate rose to 7.5 mmol.l-1 after the 100 m and 3,000 m events, while reaching 12 mmol.l-1 after the 400 m dash. Total urinary protein excretion increased to 330, 1640 and 565 micrograms.min-1 after the 100 m, 400 m and 3,000 m runs respectively, as compared with basal values (70 micrograms.min-1). In the meantime, albumin excretion increased respectively by 5, 25 and 18 fold of the resting values. The renal clearance of albumin increased to 0.84, 5.62 and 3.35 microliter.min-1 after the three runs, as compared with a mean value of 0.19 microliter.min-1 at rest. Exponential relationships (r = 0.85) were recorded between post-exercise venous lactate and albumin, and total protein excretion. The present work illustrates the major influence of the intensity of exercise (anaerobic glycolytic component), rather than its duration, on the excretion rate of urinary proteins.     

Microalbuminuria: associations with height and sex in non-diabetic subjects.

OBJECTIVES--To study the association(s) between microalbuminuria and cardiovascular risk factors in non-diabetic subjects. DESIGN--Patients aged 40-75 years were randomly selected from a general practice list and invited to participate. SETTING--Health centre in inner city London. SUBJECTS--Of those invited, 1046 out of 1671 (62.6%) attended. Subjects were excluded for the following reasons: not being white (44); urinary albumin excretion rate > 200 micrograms/min (3); having a urinary infection (5); taking penicillamine or angiotensin converting enzyme inhibitors (7); older than 75 (2); having diabetes (25); missing data on glucose concentration (1). MAIN OUTCOME MEASURES--Glucose tolerance test results, albumin excretion rate from overnight and timed morning collections of urine; blood pressure; height. RESULTS--Mean albumin excretion rate was significantly lower in women than men (mean ratio 0.8, 95% confidence interval (0.69 to 0.91)). Mean albumin excretion rate was significantly associated with age, blood pressure, and blood glucose concentration (fasting, 1 hour, and 2 hour) in men and inversely with height. Men who had microalbuminuria in both samples were significantly shorter (by 5 cm (1.3 to 9.3 cm)) than those who had no microalbuminuria in either sample when age was taken into account. In the case of women only systolic pressure was significantly associated with albumin excretion rate. CONCLUSIONS--Microalbuminuria and short stature in men are associated. Cardiovascular risk has been associated with both of these factors and with lower birth weight. The inverse association of microalbuminuria with height is compatible with the suggestion that factors operating in utero or early childhood are implicated in cardiovascular disease. The higher prevalence of microalbuminuria in men compared with women may indicate that sex differences in cardiovascular risk are reflected in differences in albumin excretion rate.     

Serum Gamma - Glutamyltransferase Is Associated with Albuminuria: A Population-Based Study

Background

Serum γ - glutamyltransferase (GGT) is implicated in the pathogenesis of endothelial dysfunction and atherosclerosis. Albuminuria is a marker of endothelial damage and correlated with structural and functional integrity of the vasculature. Our objective was to evaluate the association between serum GGT level and prevalence of albuminuria in a Chinese population.

Materials and Methods

We conducted a population-based cross-sectional study in 9,702 subjects aged 40 years or older. Increased urinary albumin excretion was defined according to the urinary albumin-to-creatinine ratio (ACR) ranges greater or equal than 30 mg/g. Low-grade albuminuria was defined according to the highest quartile of ACR in participants without increased urinary albumin excretion.

Results

The prevalence of low-grade albuminuria and increased urinary albumin excretion were respectively 23.4% and 6.6% in this population and gradually increased across the sex-specific serum GGT quartiles (all P for trend <0.05). In logistic regression analysis, compared with subjects in the lowest quartile of serum GGT level, the adjusted odds ratios (ORs) in the highest quartile was 1.22 [95% confidence interval (CI), 1.04–1.43] for low-grade albuminuria and 1.55 (95% CI, 1.18–2.04) for increased urinary albumin excretion. In subgroup analysis, significant relationship of serum GGT level with both low-grade albuminuria and increased urinary albumin excretion were detected in women, younger subjects, overweight subjects and in those with hypertension or glomerular filtration rate greater than 90 (all P <0.05).

Conclusion

Serum GGT level is associated with urinary albumin excretion in middle-aged and elderly Chinese.     

Urinary markers of renal inflammation in adolescents with Type 1 diabetes mellitus and normoalbuminuria

Diabet. Med. 29, 1297-1302 (2012) ABSTRACT: Aims Patients with the highest albumin:creatinine ratio within the normal range are at an increased risk for developing microalbuminuria. The mechanistic basis for this is unknown, but may be related to renal inflammation. Our goal was to characterize the urinary excretion of cytokines/chemokines in normoalbuminuric adolescents with Type?1 diabetes to determine whether higher range normoalbuminuria is associated with evidence of renal inflammation. Methods Forty-two urinary cytokines/chemokines were measured in subjects who were screened for the Adolescent Type?1 Diabetes Cardio-Renal Intervention Trial. Urinary cytokines/chemokines were compared across low (n?=?50), middle (n?=?50) or high (n?=?50) albumin:creatinine ratio tertile groups. Results At baseline, participants in the upper tertile were younger and had shorter diabetes duration compared with the other groups. Other clinical characteristics were similar. Urinary levels of interleukin?6, interleukin?8, platelet-derived growth factor-AA and RANTES differed across albumin:creatinine ratio tertiles, with higher values in patients in the middle and high tertiles compared with the lower tertile (ANCOVA P?≤?0.01). Conclusions Within the normal albumin:creatinine ratio range, higher urinary albumin excretion is associated with elevated urinary levels of inflammatory markers. Ultimately, this may provide mechanistic insights into disease pathophysiology and stratify the risk of nephropathy in Type?1 diabetes.     

Serum lipids and urinary albumin excretion in non insulin-dependent diabetics

The increase of urinary albumin excretion has a predictive value for cardiovascular disease in insulin-dependent and non insulin-dependent diabetics. To study the relationship between urinary albumin excretion and serum lipids, 380 non insulin-dependent diabetics, 40 to 75 yr old, with urinary albumin excretion from 0 to 200 mg/l, and normal serum creatinine (less than 150 µmol/1), were surveyed. Urinary albumin excretion, was related positively to age (r² = 0.014; p = 0.02), to systolic blood pressure (r² = 0.073, p = 0.0001) and diastolic blood pressure (r² = 0.052, p = 0.0001); a negative correlation existed with HDL-cholesterol (r² = 0.043, p = 0.0001) and Apoprotein A1 (r² = 0.044, p = 0.0001). A stepwise regression analysis was performed and resulted in three independently contributing variables related to urinary albumin excretion: First systolic blood pressure (F = 36), second Apoprotein A1 (F 24), third hemoglobin AlC (F = 6). The presence of hypertension or insulin therapy did not modify these findings. In conclusion, serum lipid seems an important determinant of urinary albumin excretion in non insulin-dependent diabetics.Abbreviations UAE Urinary Albumin Excretion - IDDs Insulin-Dependent Diabetics - NIDDs Non Insulin-Dependent Diabetics - ACE Angiotensin-converting-enzyme - HDL High Density Lipoproteins - VLDL Very Low Density Lipoproteins - LDL Low Density Lipoproteins     

Urinary albumin in space missions

Proteinuria was hypothesized for space mission but research data are missing. Urinary albumin, as index of proteinuria, was analyzed in frozen urine samples collected by astronauts during space missions onboard MIR station and on ground (control). Urinary albumin was measured by a double antibody radioimmunoassay. On average, 24h urinary albumin was 27.4% lower in space than on ground; the difference was statistically significant. Low urinary albumin excretion could be another effect of exposure to weightlessness (microgravity).     

Renal cortical albumin gene induction and urinary albumin excretion in response to acute kidney injury

This study evaluated the potential utility of albuminuria as a "biomarker" of acute kidney injury (AKI) and tested whether AKI induces renal expression of the normally silent albumin gene. Urine albumin concentrations were measured in mice with five different AKI models (maleate, ischemia-reperfusion, rhabdomyolysis, endotoxemia, ureteral obstruction). Albumin gene induction in renal cortex, and in antimycin A-injured cultured proximal tubular cells, was assessed (mRNA levels; RNA polymerase II binding to the albumin gene). Albumin's clinical performance as an AKI biomarker was also tested (29 APACHE II-matched intensive care unit patients with and without AKI). Results were contrasted to those obtained for neutrophil gelatinase-associated lipocalin (NGAL), an established "AKI biomarker" gene. The experimental and clinical assessments indicated albumin's equivalence to NGAL as an AKI biomarker (greater specificity in experimental AKI; slightly better receiver-operating curve in humans). Furthermore, experimental AKI markedly induced the albumin gene (mRNA/RNA polymerase II binding increases; comparable to those seen for NGAL). Albumin gene activation in patients with AKI was suggested by fivefold increases in RNA polymerase II binding to urinary fragments of the albumin gene (vs. AKI controls). Experimental AKI also increased renal cortical mRNA levels for α-fetoprotein (albumin's embryonic equivalent). A correlate in patients was increased urinary α-fetoprotein excretion. We conclude that AKI can unmask, in the kidney, the normally silent renal albumin and α-fetoprotein genes. In addition, the urinary protein data independently indicate that albuminuria, and perhaps α-fetoprotein, have substantial utility as biomarkers of acute tubular injury.     

Diet-induced nephrocalcinosis and urinary excretion of albumin in female rats

This study was carried out to test the hypothesis that diet-induced nephrocalcinosis causes enhanced loss of albumin in urine, irrespective of the composition of the nephrocalcinogenic diet. Female rats were fed various purified diets for 28 days. There was a control diet (0.5% Ca, 0.04% Mg, 0.4% P, 15.1% protein, wt/wt), a low Mg (0.01% Mg), a high protein (30.2% protein) and a high P diet (0.6% P). The low Mg and high P diet induced nephrocalcinosis as demonstrated histologically and by markedly increased concentrations of kidney Ca. In rats fed the high protein diet, nephrocalcinosis was essentially absent. Group mean values of urinary excretion of albumin and plasma concentrations of urea were increased in rats fed either the low Mg or high P diet. The high protein diet did not affect urinary albumin but caused lysozymuria which was not seen in the other groups. Plasma urea was increased in rats fed the high protein diet. In individual rats, the concentration of Ca in kidney and urinary albumin excretion were positively correlated. It is suggested that nephrocalcinosis in female rats induced by either low Mg or high P intake causes kidney damage which in turn leads to increased concentrations of albumin in urine and urea in plasma.     

阿霉素肾病大鼠尿液糖胺聚糖与尿液蛋白含量的相关性

目的探讨阿霉素肾病大鼠疾病进展过程中尿液糖胺聚糖含量的变化及其与尿蛋白的关系。方法采用一次性尾静脉注射阿霉素6mg/kg制作肾病综合征大鼠模型,第1、2、3、4、6周分别收集大鼠24h尿液测定尿糖胺聚糖和尿蛋白含量。43d后结束实验取血及肾脏,检测血生化,观察肾组织病理改变。结果第2、3、4、6周与正常对照组比较,阿霉素肾病大鼠24h尿蛋白排泄量呈进行性明显上升趋势;造模43d后模型组血清白蛋白含量显著下降,总胆固醇和甘油三酯含量显著升高,肾组织病理所见,模型组肾小球系膜区见中度至重度的系膜细胞增殖及基质增生。从第3周开始阿霉素肾病大鼠尿糖胺聚糖浓度显著高于正常组,且与24h尿蛋白排泄量呈正相关关系。第6周尿糖胺聚糖浓度与血清白蛋白浓度负相关,与甘油三酯浓度正相关。结论阿霉素肾病综合征大鼠尿液中糖胺聚糖浓度升高,并与24h尿蛋白排泄、血清白蛋白、甘油三酯浓度显著相关。     

Mechanism of hypoalbuminemia in rodents

Normal albumin loss from the plasma is thought to be minimized by a number of mechanisms, including charge repulsion with the capillary wall and an intracellular rescue pathway involving the major histocompatibility complex-related Fc receptor (FcRn)-mediated mechanism. This study investigates how these factors may influence the mechanism of hypoalbuminemia. Hypoalbuminemia in rats was induced by treatment with puromycin aminonucleoside (PA). To test the effects of PA on capillary wall permeability, plasma elimination rates were determined for tritium-labeled tracers of different-sized Ficolls, negatively charged Ficolls, and (14)C-labeled tracer of albumin in control and PA-treated Sprague-Dawley rats. Urinary excretion and tissue uptake were also measured. Hypoalbuminemia was also examined in two strains of FcRn-deficient mice: beta(2)-microglobulin (beta(2)M) knockout (KO) mice and FcRn alpha-chain KO mice. The excretion rates of albumin and albumin-derived fragments were measured. PA-induced hypoalbuminemia was associated with a 2.5-fold increase in the plasma elimination rate of albumin. This increase could be completely accounted for by the increase in urinary albumin excretion. Changes in the permeability of the capillary wall were not apparent, inasmuch as there was no comparable increase in the plasma elimination rate of 36- to 85-A Ficoll or negatively charged 50- to 80-A Ficoll. In contrast, hypoalbuminemic states in beta(2)M and FcRn KO mice were associated with decreases in excretion of albumin and albumin-derived fragments. This demonstrates that the mechanism of hypoalbuminemia consists of at least two distinct forms: one specifically associated with the renal handling of albumin and the other mediated by systemic processes.     

The measurement of leukotrienes in urine as diagnostic option in systemic mastocytosis

Clinical symptoms of patients with mastocytosis may include skin reactions, but also gastrointestinal symptoms with hyperacidity and dysmotility (e.g. ulcer, diarrhea, pain). They are mostly caused by mediators derived from activated mast cells. In order to investigate the impact of leukotrienes on the clinical symptoms excretion of leukotriene B4 (LTB4) and leukotrienes C4-D4-E4 (cysteinyl-leukotrienes) into urine was studied in 9 patients with indolent systemic mastocytosis divided into a group with high and low intensity of symptoms and in 11 healthy volunteers. Leukotriene excretion was determined by ELISA and correlated with methylhistamine excretion. Patients with systemic mastocytosis with high and low intense symptoms showed significantly higher urinary excretion of cysteinyl-leukotrienes than controls. There was a positive correlation of cysteinyl-leukotriene excretion and urinary methylhistamine excretion. LTB4 excretion was also significantly increased in patients with systemic mastocytosis compared to healthy volunteers. No correlation of urinary LTB4 excretion with urinary methylhistamine was observed. The present study demonstrates that urinary excretion of LTB4 and cysteinyl-leukotrienes LTC4-D4-E4 is clearly enhanced in indolent systemic mastocytosis Hence, determination of leukotriene excretion into urine can be used as a tool in the diagnostic and in the therapeutic monitoring of systemic mastocytosis.     

Renal protein excretion after exercise in man

Thirteen men were submitted to graded exhaustive cycle exercise to determine the kinetics of proteinuria in the recovery period. Venous blood samples were analysed for haematocrit, lactate, creatinine, total protein and albumin for 1 h following exercise. Urine samples were collected during a 3-h recovery period. Total protein, albumin, and creatinine levels were determined for these samples. Total protein and albumin urinary excretion increased to 581 and 315 micrograms min-1, respectively, at the end of the 1st h of recovery as compared to 42 and 15 micrograms.min-1 for resting values. Plasma volume returned to pre-exercise levels between 30 and 60 min after cessation of exercise, while urinary total protein and albumin content still remained above the resting values for the following 2 h. Both post-exercise urinary total protein and albumin excretion followed a logarithmic decline with the same half-life of 54 min, thus requiring about 4 h to regain resting values. The reduction of plasma volume and the degree of dehydration do not seem to be involved in the process. The present study indicates the delayed recovery of protein handling by the kidney, as compared with other biochemical parameters, and provides accurate information on the kinetics of post-exercise proteinuria.     

Liquid chromatography-based determination of urinary free and total N(epsilon)-(carboxymethyl)lysine excretion in normal and diabetic subjects

We propose a specific, reproducible and sensitive HPLC method for the determination of N(epsilon)-(carboxymethyl)lysine (CML) excreted in urine. Total CML was measured in acid hydrolysates of urine samples, while free CML was measured in acetonitrile-deproteinised urine samples using a RP-HPLC method with ortho-phtaldialdehyde (OPA)-derivatisation and fluorescence detection suited for automation. We compared the CML excretion of 51 non-proteinuric patients with diabetes mellitus (DM) (age 57+/-14 years, HbA1c 8.0+/-1.8%) to 42 non-diabetic controls (C) (age 45+/-17 years). The urinary excretion of total CML in diabetic patients was increased by approximately 30% (DM: 0.58+/-0.21; C: 0.45+/-0.14 microM/mmol creatinine; P<0.001). While urinary excretion of free CML was not significantly different, excretion of bound CML was increased (DM: 0.36+/-0.17; C: 0.27+/-0.14; P<0.05) in diabetic patients. CML excretion was correlated with protein and albumin excretion, but did not correlate with HbA1c, duration of DM or diabetic complications such as neuropathy or retinopathy. Furthermore, no age-dependent change of total CML excretion was found, while free CML excretion was lower in younger subjects. The specific and sensitive determination of CML by RP-HPLC of its OPA-derivative is well suited for automation and better than that of less defined glycoxidation products (AGEs).     

Transferrin and albumin excretion as a measure of glomerular function

Albumin and transferrin are relatively small protein molecules and highly negatively charged. Their levels in urine are a useful indicator of the integrity of membrane barriers of the kidney glomerular capillary wall. The present data shows that the excretion rates of albumin and transferrin and their kinetics of excretions are similar. Thus, their filtration mechanisms at the active site of the kidney membrane pores are similar. Total urinary protein/creatinine or albumin or transferrin/creatinine ratio were found to be linear and highly significant. Their measurement could indicate the degree of impaired glomerular permeability. Also, in the present study, a rapid biochemical method of measurement of the selectivity of proteinuria based on the transferrin/albumin ratios in random samples is reported. This method is particularly useful in the early stages of glomerular basement membrane damage.     

Sex differences in kidney mineral concentrations and urinary albumin excretion in rats given high-phosphorus feed

We examined sex differences in kidney mineral concentrations and urinary albumin excretion in rats given feed containing various phosphorus (P) levels. With feed that was 0.6%, 0.9%, 1.2%, and 1.5% P, kidney calcium and P concentrations were higher in female rats than in male rats. With 1.2% or 1.5% P, urinary albumin excretion was higher in the female rats. The sex of the animal affected the kidney mineral concentrations and urinary albumin excretion in rats with a high P intake.     

Treatment-Induced Changes in Plasma Adiponectin Do Not Reduce Urinary Albumin Excretion in the Diabetes Prevention Program Cohort

Background and Objectives

Molecular data suggests that adiponectin may directly regulate urinary albumin excretion. In the Diabetes Prevention Program (DPP) we measured adiponectin and albuminuria before and after intervention, and we previously reported increases in adiponectin with interventions. Here we have used the DPP dataset to test the hypothesis that treatment-related increases in adiponectin may reduce albuminuria in obesity.

Design, Setting, Participants and Methods

We evaluated cross-sectional correlations between plasma adiponectin and urinary albumin excretion at baseline, and the relationship of treatment-related changes in adiponectin and albuminuria. Baseline and follow-up urine albumin to creatinine ratios (ACR (albumin to creatinine ratio)) and plasma adiponectin concentration were available in 2553 subjects.

Results

Adjusting for age, sex and race/ethnicity, we observed a statistically significant but weak inverse relationship between adiponectin and ACR at baseline (conditional Spearman’s rho = (-) 0.04, p = 0.04). Although DPP treatments significantly increased plasma adiponectin, there were no treatment effects on ACR and no differences in ACR across treatment groups. There was a weak direct (not inverse) association between change in adiponectin and change in albuminuria (adjusted Spearman’s rho = (+) 0.04, p = 0.03).

Conclusions

In a large, well-characterized cohort of obese dysglycemic subjects we observed a weak inverse association between circulating adiponectin concentrations and urinary albumin excretion at baseline. Contrary to the hypothesized effect, treatment-related increases in plasma adiponectin were not associated with a reduction in ACR. The association of change in adiponectin with change in ACR should be assessed in populations with overt albuminuria before excluding a beneficial effect of increasing adiponectin to reduce ACR in obesity.     

Microtransferrinuria and microalbuminuria. I. In the diabetic human

We studied albumin, transferrin and total protein excretion in the urine of 110 diabetics visiting a family practice department. Of these patients 18.2% had an elevated total urinary protein above the reference range (greater than 200 mg/g creatinine). Of the remaining patients (normoproteinuria), 25.5% have elevated transferrin (greater than 0.9 mg/g creatinine) while 18.8% have elevated albumin (greater than 32 mg/g creatinine). The correlation coefficient between transferrin and albumin in urine when total urinary protein is normal was 0.77. Moderate exercise increased urinary transferrin in normal subjects 950%, while for albumin the increase was 440%. These data demonstrate the usefulness of microtransferrinuria, a potentially more sensitive indicator than microalbuminuria for diabetic nephropathy.     

Cohort study of predictive value of urinary albumin excretion for atherosclerotic vascular disease in patients with insulin dependent diabetes.

OBJECTIVE: To examine whether slightly elevated urinary albumin excretion precedes development of atherosclerotic vascular disease in patients with insulin dependent diabetes independently of conventional atherogenic risk factors and of diabetic nephropathy. DESIGN: Cohort study with 11 year follow up. SETTING: Diabetes centre in Denmark. SUBJECTS: 259 patients aged 19-51 with insulin dependent diabetes of 6-34 years'' duration and without atherosclerotic vascular disease or diabetic nephropathy at baseline. MAIN OUTCOME MEASURES: Baseline variables: urinary albumin excretion, blood pressure, smoking habits, and serum concentrations of total cholesterol, high density lipoprotein cholesterol, sialic acid, and von Willebrand factor. End point: atherosclerotic vascular disease assessed by death certificates, mailed questionnaires, and hospital records. RESULTS: Thirty patients developed atherosclerotic vascular disease during follow up of 2457 person year. Elevated urinary albumin excretion was significantly predictive of atherosclerotic vascular disease (hazard ratio 1.06 (95% confidence interval 1.02 to 1.18) per 5 mg increase in 24 hour urinary albumin excretion, P = 0.002). Predictive effect was independent of age; sex; blood pressure; smoking; serum concentrations of total cholesterol, high density lipoprotein cholesterol, sialic acid, and von Willebrand factor; level of haemoglobin A(lc); insulin dose, duration of diabetes, and diabetic nephropathy (hazard ratio 1.04 (1.01 to 1.08) per 5 mg increase