Observational Study to Evaluate the Relationship Between Ketonemia and Renal Function in the Diabetic Patient

Study Overview
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Brief Summary
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A multicentre real life study is proposed. The study has as its goal primary to compare the levels of ketonemia measured in patients with albuminuria and patients normo albuminurici to evaluate a possible correlation between ketone level and alteration of renal function in the diabetic patient, comparing the eGFR values of patients with ketonemia high and of patients with low ketonemia. In these patients, the lack of insulin causes one imbalance between ketogenesis and ketolysis, with increased production and reduced body clearance ketones. Several studies explore the effects of ketone bodies on cell function and lesions diabetic complications: ketonemia induces oxidative stress and increases the risk and the progression of complications, moreover, the increase in ketone levels may have pro-inflammatory effects. However, ketonemia levels between normal and DKA are poorly studied and their effects are still unknown. It is hypothesized that in diabetic patients with DKD the level of ketones may be high; Increased ketone levels may promote an alteration of renal function. We want to evaluate the relationship between ketone levels and renal function, because the kidneys, as well as the heart, are among the main organs in which the ketone bodies are oxidized to produce energy and DKD has a high morbidity and mortality in diabetes. The main objectives for being able to demonstrate the hypothesis in question are: Evaluate the level of ketones in albuminurate patients with diabetes and in patients with renal function altered; Evaluate the association between ketone level and decline of renal function in the diabetic patient e therefore the impact of ketonemia on the progression of renal function loss.

Detailed Description
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At the beginning and during the course of the study the glycemic and ketone index obtained by the homologous blood glucose monitoring will be evaluated. During the study, prognostic biomarkers (sP2X7R, KIM-1, sTNFR1, 11-dehydro-tromoxane B2 and 6-keto-prostaglandin-F-1a (PGF1α)), which are presumed to play an important role in inflammatory renal diseases, will also be measured in diabetic subject, in addition to the traditional marker that is the urinary albumin. Step 1. Visit Baseline: blood sampling and collection of a urinary sample, evaluation proteinuria, GFR and blood and urinary ketones Step 2. Visit at 6 months: blood collection and collection of a urinary sample, evaluation proteinuria, GFR and blood and urinary ketones Step 3. Visit at 12 months: blood collection and collection of a urinary sample, evaluation proteinuria, GFR and blood and urinary ketones. The study involves the enrollment of T1D and T2D subjects in diabetic nephropathy. The study involves the enrollment of T1D and T2D subjects in diabetic nephropathy A timetable will be prepared for the surgeries during the which the diabetic subject will be informed about the study protocol in question and will provide eventual informed consent to entry into the study, blood sampling and urinary sample collection. However, the analysis will be above all exploratory and will allow to foresee possible studies future properly sized.

Official Title
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Observational Study to Evaluate the Relationship Between Ketonemia and Renal Function in the Diabetic Patient

Conditions
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Diabetic Nephropathy Type 2

Intervention / Treatment
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* Other: Comparison of eGFR values and ketonemia in diabetic patients


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Presence of albuminuria (≥30 mg / 24h) Adult and male patients of age Diagnosis of type 1 or type 2 diabetes according to the ADA diagnostic criteria Presence of the disease for at least five years HbA1c≥7% Written informed consent of the patient and / or parents or legal guardian Exclusion Criteria: Chronic end-stage renal disease (CKD5) Current or previous treatments with immunosuppressants (with the exception of topical steroids ed inhalers) Participation in other clinical studies Significant disease other than diabetes found in the two weeks prior to the first visit Neurological or psychiatric diseases, hemoglobinopathies, liver diseases, cancer, cystic fibrosis, renal failure, malabsorption syndromes Abuse of alcohol and drugs HIV or hepatitis Pregnant or lactating women (β-HCG urinary should be evaluated before each visit) Presence of serious diseases or conditions of the patient considered unsuitable by the Investigator for be able to include it in the study Poor understanding by the patient of spoken and written Italian

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Patients with albuminuria<br>Comparison of eGFR values and ketonemia in diabetic patients | Other: Comparison of eGFR values and ketonemia in diabetic patients<br>* To verify if there is a correlation between the level of ketones and an alteration of the renal function in the diabetic patient, the values of the prognostic markers indicated in the protocol and the data downloaded by the glucometers will be evaluated in addition to the blood tests of the patients<br>|
| patients with normo albuminuria<br>Comparison of eGFR values and ketonemia in diabetic patients | Other: Comparison of eGFR values and ketonemia in diabetic patients<br>* To verify if there is a correlation between the level of ketones and an alteration of the renal function in the diabetic patient, the values of the prognostic markers indicated in the protocol and the data downloaded by the glucometers will be evaluated in addition to the blood tests of the patients<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Variations in albuminuria and albumin / creatinine ratio in urine (UACR) | immunoturbidimetric method | 12 months | 
| Variations of the eGFR (CKD-EPI formula) | CKD-EPI formula | 12 months | 
| Variations in ketone levels | monitoring ketones in capillary and urinary samples | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Variations of tubular function markers (sP2X7R, KIM-1, sTNFR1) | enzyme immunoassay (ELISA) | 12 months | 
| Variations of markers of glomerular function (11-dehydro-tromoxane B2 and 6-keto-prostaglandin- F-1a (PGF1α)) | enzyme immunoassay (ELISA) | 12 months | 
| Changes in glycated hemoglobin (HbA1c) | capillary electrophoresis | 12 months |