Association of soluble tumor necrosis factor receptors 1 and 2 with nephropathy, cardiovascular events, and total mortality in type 2 diabetes

AIMS/HYPOTHESIS: Soluble tumor necrosis factor receptors 1 and 2 (sTNFR1 and sTNFR2) contribute to experimental diabetic kidney disease, a condition with substantially increased cardiovascular risk when present in patients. Therefore, we aimed to explore the levels of sTNFRs, and their association with prevalent kidney disease, incident cardiovascular disease, and risk of mortality independently of baseline kidney function and microalbuminuria in a cohort of patients with type 2 diabetes. In pre-defined secondary analyses we also investigated whether the sTNFRs predict adverse outcome in the absence of diabetic kidney disease. METHODS: The CARDIPP study, a cohort study of 607 diabetes patients [mean age 61 years, 44 % women, 45 cardiovascular events (fatal/non-fatal myocardial infarction or stroke) and 44 deaths during follow-up (mean 7.6 years)] was used. RESULTS: Higher sTNFR1 and sTNFR2 were associated with higher odds of prevalent kidney disease [odd ratio (OR) per standard deviation (SD) increase 1.60, 95 % confidence interval (CI) 1.32-1.93, p < 0.001 and OR 1.54, 95 % CI 1.21-1.97, p = 0.001, respectively]. In Cox regression models adjusting for age, sex, glomerular filtration rate and urinary albumin/creatinine ratio, higher sTNFR1 and sTNFR2 predicted incident cardiovascular events [hazard ratio (HR) per SD increase, 1.66, 95 % CI 1.29-2.174, p < 0.001 and HR 1.47, 95 % CI 1.13-1.91, p = 0.004, respectively]. Results were similar in separate models with adjustments for inflammatory markers, HbA1c, or established cardiovascular risk factors, or when participants with diabetic kidney disease at baseline were excluded (p < 0.01 for all). Both sTNFRs were associated with mortality. CONCLUSIONS/INTERPRETATIONS: Higher circulating sTNFR1 and sTNFR2 are associated with diabetic kidney disease, and predicts incident cardiovascular disease and mortality independently of microalbuminuria and kidney function, even in those without kidney disease. Our findings support the clinical utility of sTNFRs as prognostic markers in type 2 diabetes.

La Reina de las Nieves. La moral y el inconsciente : Leonardo Villalba según Sigmund Freud y Carl Jung

Esta tesina trata sobre la moral y el inconsciente a partir del análisis del personaje Leonardo Villalba de la novela La Reina de las Nieves, escrita por Carmen Martín Gaite. El estudio se hace a partir de las siguientes teorías: inconsciente de Sigmund Freud; ello, yo y superyó de Sigmund Freud; inconsciente de Carl Jung. La información almacenada en el inconsciente de una persona es algo que ésta no puede contar ya que ella misma no sabe que tiene tal información. Así, al ser Leonardo narrador-protagonista en gran parte de la obra, se supone que éste sólo puede transmitir la información de la que él mismo es consciente. No obstante, Martín Gaite consigue que Leonardo transmita información que él parece desconocer, a través de su inconsciente reflejado en sueños y reflexiones que explican ideas abstractas. Esto será demostrado en el apartado de análisis. La complejidad del personaje hace que la novela no sea una simple narración de hechos, sino que parte importante de ella sean sueños, la imaginación de Leonardo, preguntas existenciales que él mismo se hace, o recuerdos de su infancia o adolescencia que son de una importancia trascendental. La Reina de las Nieves es en gran parte una reflexión sobre la moral que, unida al inconsciente, son las bases de la novela.