Viktor Rotbain Curovic

Objective: Diabetic foot ulcers (DFUs) affect up to 34% of people with diabetes and precede 80% of lower extremity amputations, yet no ulcer-level molecular biomarkers distinguish healing trajectories. We aimed to identify wound swab proteins associated with DFU healing time and characterize their prognostic potential. Research Design and Methods: LC-MS/MS proteomics was performed on wound swabs from 112 people with diabetes presenting with new DFUs, followed for up to 6 months. Participants were divided into fast-healers (180 days). Proteins associated with ″time to healing″ were identified using Firth−penalized Cox regression (FDR < 0.2; HR<1 indicated slow healing) and used to construct a cross-validated Protein Healing Score (PHS). Sensitivity and causal mediation analyses examined clinical variable effects on protein abundance, with independent dataset validation. Results: Participants had a mean (±SD) age of 67.5 (±12.3) years, and diabetes duration of 27.5 (±14.9) years. Twenty-seven proteins formed two clusters: a slow-healing cluster enriched in neutrophil granule and innate immune proteins (HR1). Triglyceride levels differed between healing groups (p=0.001); seven slow-healing proteins showed triglyceride-mediated effects (21−28%), suggesting a dyslipidaemia-innate immunity axis. The PHS significantly stratified prognosis (adjusted HR=1.47, 95%CI 1.14− 1.89; p=0.003), outperforming clinical variables alone (AUC-OVR 0.71 vs. 0.62). Transcriptomic validation confirmed directional concordance. Conclusions: Wound swab proteomics at DFU onset identified a 27−protein healing signature linked to neutrophil-innate immunity and triglyceride associated dyslipidaemia, offering a potential non-invasive prognostic tool.

Aim: Cardiovascular disease (CVD) is the leading cause of mortality in individuals with diabetes. Diabetic kidney disease, closely related to CVD risk, is prevalent in up to 40% of this population. Emerging evidence suggests ceramide lipids as accurate biomarkers for CVD. We assessed the effect of four albuminuria‐lowering drugs on CVD‐related ceramides in diabetes by post hoc analysis of the ROTATE trials. Materials and Methods: Twenty six adults with type 1 (T1D) as well as 37 with type 2 diabetes (T2D) with a urine albumin‐creatinine ratio (UACR) of 30–500 mg/g participated in a 4‐week 4‐time randomized crossover study with periods of telmisartan, empagliflozin, linagliptin and baricitinib treatment, each separated by a 4‐week washout period. Blood samples were collected at the beginning and end of each period and ceramide lipids (Cer16, Cer18, Cer20, Cer22, Cer24 and Cer24:1) were measured. The effect of each treatment was evaluated using linear mixed‐effect models. Results: At baseline, individuals with T2D had greater levels of Cer22 and Cer24 compared to the individuals with T1D. Among the treatments, linagliptin was the only drug that demonstrated a reduction of Cer22, Cer24 and Cer24:1 from baseline by 22.6% (95% CI: −33.58; −9.79, p = 0.001), 25.7% (95% CI: −38.94; −9.69, p = 0.003) and 19.6% (95% CI: −31.34; −5.95, p = 0.007), respectively. No changes in the ceramides were observed for the other drugs. Conclusion: Our exploratory findings suggest that certain albuminuria‐lowering drugs may affect ceramide levels as a secondary effect. However, further mechanistic investigations are needed.

Background and Hypothesis: Semaglutide is a glucagon-like peptide-1 receptor agonist widely used for its glucose-lowering effects in people with type 2 diabetes (T2D), as well as its cardiovascular and kidney-protective properties. However, it remains unclear whether semaglutide influences blood concentrations of endogenous filtration markers like creatinine, cystatin C, beta-trace protein (BTP), and beta-2 microglobulin (B2M). We investigated the effect of semaglutide on these filtration markers and the performance of estimated glomerular filtration rate (eGFR) equations compared with measured glomerular filtration rate (mGFR). Methods: Post hoc analysis of a randomized, double-blind, placebo-controlled clinical trial. Individuals with T2D and albuminuria were randomized in a 1:1 ratio to receive semaglutide 1 mg weekly or matching placebo for 26 weeks on top of empagliflozin. mGFR was determined by 99m-Tc-DTPA plasma clearance and eGFR was calculated using CKD-EPI equations based on plasma creatinine (eGFRcre), cystatin C (eGFRcys), their combination (eGFRcomb), or a panel of creatinine, cystatin C, BTP, and B2M (eGFRpanel). Outcomes included change in filtration marker concentration, mGFR, and eGFR from baseline to end-of-treatment, as well as eGFR performance compared to mGFR at each timepoint. Results: Among 48 participants (median age 70 years; 16.7% female), semaglutide treatment was associated with a small but significant increase in plasma creatinine and BTP compared with placebo, whereas there was no significant change in cystatin C or B2M. Semaglutide treatment was not associated with a significant change in mGFR (median [IQR] change of 0 [-7.5 to 10.3] mL/min/1.73 m2) compared with placebo (median [IQR] change of -2 [-11.3 to 3.0] mL/min/1.73 m2). Both eGFRcre and eGFRcys were consistently outperformed by eGFRcomb and eGFRpanel at baseline and end-of-treatment. Conclusion: Semaglutide treatment was associated with a small increase in plasma creatinine and BTP but not cystatin C or B2M, and eGFRcomb yielded the most reliable estimates of mGFR.

Aims: Kidney fibrosis, characterised by impaired extracellular matrix remodelling and excessive collagen deposition, is a hallmark of chronic kidney disease in diabetes. We investigated whether biomarkers reflecting collagen formation and degradation were associated with complications in type 1 diabetes. Methods: In this observational cohort study, markers of collagen type III (PRO‐C3), VII (PRO‐C7) and XXVIII (PRO‐C28) formation and collagen type III degradation (CTX‐III) were measured in serum by ELISA. Associations between baseline biomarker levels and a composite kidney endpoint, all‐cause mortality, albuminuria progression and cardiovascular events were tested using Cox proportional hazards models adjusted for traditional risk factors. Hazard ratios (HRs) are reported per 1‐SD increase in log ₂ ‐transformed biomarker levels. Results: Over a median follow‐up of 6.3 (IQR: 5.9–6.7) years, 125 of 662 participants experienced the composite kidney endpoint, 58 participants died, 102 progressed in albuminuria and 94 developed a cardiovascular event. Higher baseline levels of PRO‐C3 were associated with the development of the composite kidney endpoint (adjusted HR: 1.30, 95% CI 1.08–1.57, p < 0.01) and mortality (adjusted HR: 1.36, 95% CI 1.06–1.76, p = 0.016). No associations were found between PRO‐C3 and albuminuria progression or cardiovascular events. PRO‐C7, PRO‐C28 and CTX‐III were not associated with any of the endpoints. Conclusions: Higher baseline serum PRO‐C3, a marker of collagen type III formation and fibrogenesis, was associated with an increased risk of developing the composite kidney endpoint and all‐cause mortality in individuals with type 1 diabetes.

Introduction: Presence of albuminuria is associated with high risk of cardiovascular disease (CVD) and premature mortality in individuals with type 1 diabetes. We aimed to investigate carotid atherosclerosis in individuals with type 1 diabetes compared with healthy controls and assess the association between presence of albuminuria and carotid atherosclerosis in type 1 diabetes using three‐dimensional vascular ultrasound (3DVUS) and two‐dimensional vascular ultrasound (2DVUS). Materials & Methods: Cross‐sectional study including 350 individuals, 290 with type 1 diabetes and 60 healthy controls. Carotid total plaque volume (TPV) was measured using 3DVUS and carotid maximal plaque thickness (cPTmax) using 2DVUS. TPV and cPTmax were highly skewed and analysed in four categories using unadjusted and adjusted ordinal logistic regression models. Albuminuria categories were defined by the highest persistent urinary albumin‐creatinine ratio level recorded in each participant's medical history. Results: In the total cohort, 56% were men and mean (SD) age was 56 (14) years. Among the individuals with type 1 diabetes, 110 (38%) had normal‐, 124 (43%) moderately increased‐ and 56 (19%) severely increased albuminuria. Individuals with type 1 diabetes had higher median [IQR] TPV of 28 [0–144] mm ³ and cPTmax (14 [0–21] mm) compared to healthy controls (9 [0–54] mm ³ , 11 [0–17] mm). In adjusted ordinal logistic regression models, individuals with type 1 diabetes were more likely to be in a higher TPV category than healthy controls (0.82, 95% CI [0.16, 1.48], p = 0.015), whereas no difference was demonstrated for cPTmax. Among individuals with type 1 diabetes, presence of severely increased albuminuria was associated with being in a higher TPV category than normal albuminuria (1.40, 95% CI [0.61, 2.21], p < 0.001) after adjustment, whereas no difference was seen for cPTmax categories. Higher current albuminuria was associated with being in a higher TPV ( p = 0.002) and cPTmax ( p = 0.047) category after adjustment. Conclusion: Participants with type 1 diabetes had higher carotid TPV than healthy controls independent of other risk factors and higher levels of albuminuria were associated with higher carotid TPV and cPTmax in type 1 diabetes.

Key Points: A custom-made Joslin OLINK proteomics platform was developed to quantify 21 Joslin kidney panel (JKP) proteins in circulation to predict ESKD risk. Each JKP protein discriminated moderately/well ESKD risk in diabetes; optimal predictive model included three clinical markers and eight JKP proteins. In the type 2 diabetes subgroup from the Action to Control Cardiovascular Risk in Diabetes trial, three JKP proteins identified subjects in whom fenofibrate dramatically reduced risk of fast kidney decline. Background: To facilitate personalized treatment of diabetic kidney disease (DKD), we developed the Joslin kidney panel (JKP) of 21 circulating proteins associated with progression to ESKD. Prognostic models using baseline concentrations of JKP proteins in circulation and clinical markers were then developed to stratify individuals according to ESKD risk and according to response to fenofibrate, a potential renoprotective drug. Methods: The custom-made Joslin OLINK multipurpose proteomics platform was used to quantify JKP proteins. Association between baseline serum/plasma concentrations of these proteins and kidney outcomes was examined in five independent study groups. Results: In type 1 diabetes individuals from Joslin ( N =59), FinnDiane ( N =389), and Steno ( N =283), all JKP proteins were good discriminators of ESKD risk during a 10-year follow-up. Baseline concentrations of KIM-1 and WFDC2 performed the best, matching or outperforming the clinical markers. An optimal model to discriminate ESKD risk that included three clinical markers and eight JKP proteins (KIM1, TNF-R2, TNF-R3, TNF-R19L, PVRL4, WFDC2, DLL1, and SYND1) was developed using the FinnDiane cohort (C-index 0.868, SEM±0.019) and validated in the Steno cohort (C-index 0.913, SEM±0.104) and in type 2 diabetes Joslin study (C-index 0.807, SEM±0.036). In each of these studies, the optimal model performed better than models based solely on three clinical markers. In a subgroup of 450 individuals with type 2 diabetes from the Action to Control Cardiovascular Risk in Diabetes-Lipid trial, high levels of three JKP proteins (EFNA4, DLL1, IL-1RT1) predicted amelioration of fast kidney function decline during 4 years of follow-up in those treated with fenofibrate compared with placebo. Conclusions: Quantification of circulating JKP proteins using the Joslin OLINK platform discriminates ESKD risk in individuals with diabetes and their response to renoprotective drugs. The use of this multipurpose precision medicine tool should facilitate studies on the etiology of DKD and enable the development of effective personalized treatment protocols for individuals with DKD.

Aims: Individuals with type 1 diabetes are at high risk of cardiovascular disease (CVD) and chronic kidney disease (CKD) even with optimal glycaemic control. The Steno 1 study will test a strategy of intensified care based on multifactorial intervention (MFI) including treatment with semaglutide, sotagliflozin and finerenone in high‐risk individuals with type 1 diabetes. We hypothesize that this strategy will reduce major adverse cardiovascular endpoints (MACE), hospitalization for heart failure (HHF), progression of CKD and mortality. Materials and Methods: The study is a prospective, cluster‐randomized, open study with blinded endpoint evaluation. We will enrol 2000 high‐risk individuals with type 1 diabetes of >10 years duration. All five Steno Diabetes Centres and 11 partner hospitals in Denmark will participate, with the addition of the Steno Diabetes Centres in Greenland and the Faroe Islands. Sites will be randomized either to receive guideline‐recommended standard‐of‐care, or to receive the MFI. Eligible individuals with type 1 diabetes (≥40 years of age with presence of either CKD, CVD, HF, obesity or a >10% 5‐year CVD risk determined by the Steno T1 Risk Engine) will be included. For the MFI group, the intervention will comprise more ambitious treatment targets for blood pressure and lipid levels, and in addition, participants will be allocated to semaglutide, sotagliflozin and/or finerenone based on phenotype. Results and conclusions: The Steno 1 study will determine whether MFI is superior to standard care with respect to MACE, HHF progression of CKD, and mortality in individuals with type 1 diabetes and high risk of CVD.