Insulin Sensitivity and Diabetic Kidney Disease in Children and Adolescents With Type 2 Diabetes: An Observational Analysis of Data From the TODAY Clinical Trial

Petter Bjornstad, Edward Nehus, Laure El ghormli, Fida Bacha, Ingrid M. Libman, Siripoom McKay, Steven M. Willi, Lori Laffel, Silva Arslanian, Kristen J. Nadeau, S. McKay, M. Haymond, B. Anderson, C. Bush, S. Gunn, H. Holden, S. M. Jones, G. Jeha, S. McGirk, S. ThamotharanL. Cuttler, E. Abrams, T. Casey, W. Dahms, C. Ievers-Landis, B. Kaminski, M. Koontz, S. MacLeish, P. McGuigan, S. Narasimhan, M. Geffner, V. Barraza, N. Chang, B. Conrad, D. Dreimane, S. Estrada, L. Fisher, E. Fleury-Milfort, S. Hernandez, B. Hollen, F. Kaufman, E. Law, V. Mansilla, D. Miller, C. Muñoz, R. Ortiz, A. Ward, K. Wexler, Y. K. Xu, P. Yasuda, L. Levitt Katz, R. Berkowitz, S. Boyd, B. Johnson, J. Kaplan, C. Keating, C. Lassiter, T. Lipman, G. McGinley, H. McKnight, B. Schwartzman, F. Bacha, S. Foster, B. Galvin, T. Hannon, A. Kriska, I. Libman, M. Marcus, K. Porter, T. Songer, E. Venditti, R. Goland, D. Gallagher, P. Kringas, N. Leibel, D. Ng, M. Ovalles, D. Seidman, L. Laffel, A. Goebel-Fabbri, M. Hall, L. Higgins, J. Keady, M. Malloy, K. Milaszewski, L. Rasbach, D. M. Nathan, A. Angelescu, L. Bissett, C. Ciccarelli, L. Delahanty, V. Goldman, O. Hardy, M. Larkin, L. Levitsky, R. McEachern, D. Norman, D. Nwosu, S. Park-Bennett, D. Richards, N. Sherry, B. Steiner, S. Tollefsen, S. Carnes, D. Dempsher, D. Flomo, T. Whelan, B. Wolff, R. Weinstock, D. Bowerman, S. Bristol, J. Bulger, J. Hartsig, R. Izquierdo, J. Kearns, R. Saletsky, P. Trief, P. Zeitler, N. Abramson, A. Bradhurst, N. Celona-Jacobs, J. Higgins, M. Kelsey, G. Klingensmith, K. Nadeau, T. Witten, K. Copeland, E. Boss, R. Brown, J. Chadwick, L. Chalmers, S. Chernausek, A. Hebensperger, C. Macha, R. Newgent, A. Nordyke, D. Olson, T. Poulsen, L. Pratt, J. Preske, J. Schanuel, S. Sternlof, J. Lynch, N. Amodei, R. Barajas, C. Cody, D. Hale, J. Hernandez, C. Ibarra, E. Morales, S. Rivera, G. Rupert, A. Wauters, N. White, A. Arbeláez, D. Flomo, J. Jones, T. Jones, M. Sadler, M. Tanner, A. Timpson, R. Welch, S. Caprio, M. Grey, C. Guandalini, S. Lavietes, P. Rose, A. Syme, W. Tamborlane, K. Hirst, S. Edelstein, P. Feit, N. Grover, C. Long, L. Pyle, B. Linder, S. M. Marcovina, J. Harting, J. Shepherd, B. Fan, L. Marquez, M. Sherman, J. Wang, M. Nichols, E. Mayer-Davis, Y. Liu, J. Lima, S. Gidding, J. Puccella, E. Ricketts, R. Danis, A. Domalpally, A. Goulding, S. Neill, P. Vargo, D. Wilfley, D. Aldrich-Rasche, K. Franklin, C. Massmann, D. O'Brien, J. Patterson, T. Tibbs, D. Van Buren, M. Palmert, R. Ratner, D. Dremaine, J. Silverstein

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53 Scopus citations


Background Diabetic kidney disease is a major cause of premature mortality in type 2 diabetes mellitus (T2DM). Worsening insulin sensitivity independent of glycemic control may contribute to the development of diabetic kidney disease. We investigated the longitudinal association of insulin sensitivity with hyperfiltration and increased albumin excretion in adolescents with T2DM. Study Design Observational prospective cohort study. Setting & Participants 532 TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) participants aged 12 to 17 years with T2DM duration less than 2 years at baseline. The TODAY Study was a multicenter randomized clinical trial that examined the efficacy of 3 treatment regimens (metformin monotherapy, metformin plus rosiglitazone, or metformin plus an intensive lifestyle intervention program) to achieve durable glycemic control. Predictors Natural log–transformed estimated insulin sensitivity (reciprocal of fasting insulin), hemoglobin A1c concentration, age, race-ethnicity, treatment group, body mass index, loss of glycemic control, and hypertension. Outcomes Hyperfiltration was defined as 99th percentile or higher of estimated glomerular filtration rate (≥140 mL/min/1.73 m2) when referenced to healthy adolescents (NHANES 1999-2002) and albumin-creatinine ratio ≥ 30 μg/mg at 3 consecutive annual visits. Results Hyperfiltration was observed in 7.0% of participants at baseline and in 13.3% by 5 years, with a cumulative incidence of 5.0% over 5 years. The prevalence of increased albumin excretion was 6% at baseline and 18% by 5 years, with a cumulative incidence of 13.4%. There was an 8% increase in risk for hyperfiltration per 10% lower estimated insulin sensitivity in unadjusted and adjusted models (P = 0.01). Increased albumin excretion was associated with hemoglobin A1c concentration, but not estimated insulin sensitivity. Limitations Longer follow-up is needed to capture the transition from hyperfiltration to rapid glomerular filtration rate decline in youth-onset T2DM. Conclusions Lower estimated insulin sensitivity was associated with risk for hyperfiltration over time, whereas increased albumin excretion was associated with hyperglycemia in youth-onset T2DM.

Original languageEnglish
Pages (from-to)65-74
Number of pages10
JournalAmerican Journal of Kidney Diseases
Issue number1
StatePublished - Jan 2018


  • Type 2 diabetes mellitus (T2DM)
  • adolescents
  • albumin-creatinine ratio (ACR)
  • children
  • creatinine
  • cystatin C
  • diabetic kidney disease (DKD)
  • disease progression
  • estimated glomerular filtration rate (eGFR)
  • hyperfiltration
  • increased albumin excretion
  • insulin sensitivity
  • kidney function
  • youth-onset T2DM


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