Current status of type 2 (non-insulin-dependent) diabetic subjects on dialysis therapy in Japan

Tolvaptan alleviates excessive fluid retention of nephrotic diabetic renal failure unresponsive to furosemide

Patients with diabetic nephropathy develop nephrotic syndrome and may show limited response to conventional therapy. They often require earlier initiation of renal replacement therapy because they become refractory to diuretics, and experience excessive fluid retention. We aimed to investigate the efficacy of tolvaptan, an oral arginine vasopressin type 2 receptor antagonist, in a case series of 14 severe diabetic renal failure patients who were severely refractory to maximal doses of furosemide and had excessive fluid retention despite preserved cardiac function and residual renal function. All 14 patients experienced immediate and sustained water diuretic effects, resulting in alleviation of congestive heart failure. None required initiation of renal replacement therapy. Tolvaptan promptly increased urine volume and free water clearance, reversed progressive fluid retention, and alleviated congestive heart failure. Thus, tolvaptan could serve as a potential adjunct therapy for severe diabetic renal failure patients with excessive fluid retention and congestive heart failure.

Distinct biomarker roles for HbA1c and glycated albumin in patients with type 2 diabetes on hemodialysis

AIMS

HbA_1c and glycated albumin (GA) are used to monitor glycemia, but their accuracy to represent glycemic profiles in hemodialysis remains controversial.

METHODS

Continuous glucose monitoring in 97 patients with type 2 diabetes (41 on hemodialysis [HD] and 56 without nephropathy) was analyzed to evaluate whether HbA_1c and/or GA serve as appropriate glycemic profile markers.

RESULTS

The average glucose significantly correlated with HbA_1c in both HD group and group without nephropathy (r=0.59, P<0.0001; r=0.40, P<0.005). The slopes of linear regression lines were statistically indistinguishable (F=0.30, P=0.744), while the y-intercepts were significantly different (F=57.86, P<0.0001). GA showed strong correlation with the glycemic standard deviation (r=0.68, P<0.0001), and with the average glucose (r=0.42, P<0.001). Least square analysis revealed that only HbA_1c, but not GA, was significantly associated with the average glucose (F=10.20, P<0.0005; F=0.38, P=0.5427), while only GA was significantly associated with the glycemic variability in HD group.

CONCLUSIONS

In HD participants, HbA_1c correlates with the average glucose more than GA, but underestimates it, and a correction formula of HbA1c can be developed as an appreciable marker. GA value itself reflects the average glucose, but less accurately than HbA_1c, while it could serve as an indicator for hyperglycemia/hypoglycemia excursion.

Significant association of fracture of the lumbar spine with mortality in female hemodialysis patients: a prospective observational study

Prevalent fracture of the lumbar spine is established as a predictor of increased mortality in the general population. To examine whether this association is retained in hemodialysis patients, we conducted a single-center prospective observational study in 635 hemodialysis patients (60.3 + or - 12.0 years old, male/female 369/266). Patients were divided into two groups (with and without lumbar fracture, assessed by simple lateral radiograph), and survival was followed for an average of 53.8 months. Lumbar fracture was present in 62 patients (9.76%; male 9.76%, female 9.77%). During the follow-up period, there were 176 all-cause deaths (27.7%; male 27.6%, female 27.8%), of which 72 were from cardiovascular diseases. In Kaplan-Meier analysis, all-cause and noncardiovascular mortality rates, but not cardiovascular mortality, were significantly higher in patients with fracture than in those without (P < 0.0001). In multivariate Cox proportional hazard analysis, the presence of lumbar fracture was significantly associated with increased noncardiovascular mortality (HR = 2.035, 95% CI 1.135-3.652, P < 0.05) after adjustment for age, duration of hemodialysis, presence of diabetes, body mass index, and serum calcium, phosphate, and albumin. Significantly higher all-cause and noncardiovascular mortality rates were also evident for patients with fracture in separate analyses in males and females, but multivariate analysis showed a significant association of lumbar fracture with increased all-cause (HR = 2.151, 95% CI 1.033-4.478, P < 0.05) and noncardiovascular (HR = 2.637, 95% CI 1.014-6.858, P < 0.05) mortality rates only in females. In conclusion, lumbar fracture is significantly associated with all-cause mortality in female patients.

Glycemic control is a predictor of survival for diabetic patients on hemodialysis

OBJECTIVE

To investigate the impact of glycemic control on the survival of diabetic subjects with end-stage renal disease (ESRD) starting hemodialysis treatment.

RESEARCH DESIGN AND METHODS

This single-center prospective observational study enrolled 150 diabetic ESRD subjects (109 men and 41 women; age at hemodialysis initiation, 60.5 +/- 10.2 years) at start of hemodialysis between January 1989 and December 1997. The subjects were divided into groups according to their glycemic control level at inclusion as follows: good HbA1c <7.5%, n = 93 (group G), and poor HbA1c > or = 7.5%, n = 57 (group P); and survival was followed until December 1999, with a mean follow-up period of 2.7 years.

RESULTS

Group G had better survival than group P (the control group) (P = 0.008). At inclusion, there was no significant difference in age, sex, systolic blood pressure (SBP), BMI, cardio-to-thoracic ratio (CTR) on chest X-ray, and serum creatinine (Cre) or hemoglobin (Hb) levels between the two groups. After adjustment for age and sex, HbA1c was a significant predictor of survival (hazard ratio 1. 133 per 1.0% increment of HbA1c, 95% CI 1.028-1.249, P = 0.012), as were Cre and CTR.

CONCLUSIONS

Good glycemic control (HbA1c <7.5%) predicts better survival of diabetic ESRD patients starting hemodialysis treatment.

Attaining long-term survival when treating diabetic patients with ESRD by hemodialysis

Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD). The United States Renal Data System's report indicates that survival of diabetic patients has improved but continues to be reduced compared with that of nondiabetic patients. Several ways to decrease morbidity and mortality in diabetic patients are discussed: (1) Instructions and treatment in the predialysis period markedly influence compliance of patients, and this plays a determinant role in development and progression of diabetic complications before and during maintenance hemodialysis. (2) After the start of hemodialysis therapy, insulin therapy must be adjusted and respect impaired glucose use and prolongation of insulin half-life. (3) By avoiding of puncture of veins prospectively used for arteriovenous fistulae and timely installation of the fistulae, native arteriovenous fistulae can be achieved in more than 70% of diabetic patients. (4) Hypertension, left ventricular hypertrophy, and cardiovascular problems commonly found in diabetic patients require optimal removal of fluid overload. This is difficult to achieve in the presence of accelerated arteriosclerosis and autonomic polyneuropathy in diabetic patients and requires long and smooth dialysis procedures. (5) Infected necroses caused by diabetic polyneuropathy and peripheral vascular disease require appropriate therapy by experienced nephrologists and surgeons.

Prognostic factors in Brazilian diabetic patients starting dialysis: a 3.6-year follow-up study

The objective of this study was to analyze the prognostic factors of a cohort of diabetic patients starting dialysis. This prospective, 3. 6-year population-based cohort study included 111 diabetic patients starting dialysis in all 18 dialysis centers of the metropolitan area of Porto Alegre, Brazil, between July 1995 and October 1996. The survival rate was analyzed by Kaplan-Meier curves and prognostic factors for death by Cox's proportional-hazards model. During the study period, 685 patients started dialysis; 182 (26.5%) had diabetes and 111 patients were included. Eighty-four percent of the 111 patients were classified as type 2 diabetes (random C-peptide>0. 6 ng/ml), and these patients presented more coronary artery disease (60% vs. 29%; P<0.02) than type 1 patients. In type 2 patients, later diagnosis of diabetes was associated with a shorter interval until beginning of dialysis (r=0.67; P=0.001). Diabetic nephropathy was the primary renal disease in 61% of all patients. Overall median survival (26 months) was similar for types 1 and 2 diabetic patients. Survival in the first, second, and third year was 69%, 51%, and 28%, respectively. Cardiovascular disease was the most common cause (63%) of death. According to Cox's proportional-hazards model, history of stroke (HR: 4.53, CI: 2.09-9.86, P<0.0001), amputations (HR: 3.2, CI: 1.61-6.35, P<0.0009), and coronary artery disease (HR: 1.67, CI: 0.95-2.96, P<0.076) at baseline were significantly associated with mortality. In conclusion, macrovascular complications were the main predictors of mortality in this cohort of diabetic patients starting dialysis. Intensive treatment of cardiovascular risk factors during dialysis might reduce the mortality rate of diabetic patients.

Clinical and biochemical characteristics of type 2 diabetic patients on continuous ambulatory peritoneal dialysis: relationships with insulin requirement

Although glycemic control has an important impact on the clinical outcomes of patients with diabetes undergoing dialysis, there is a paucity of data on the relationship between glucose metabolism and clinical parameters in these patients. In this study, we compared a cohort of 48 patients with type II diabetes undergoing continuous ambulatory peritoneal dialysis (CAPD) with 84 age- and sex-matched patients with type II diabetes with similar disease duration but normal renal function. Compared with those with normal renal function, patients with type 2 diabetes undergoing CAPD had greater serum angiotensin-converting enzyme activity (median, 57.4 U/L; range, 33.5 to 100.0 U/L v 46.9 U/L; range, 11.6 to 111.2 U/L; P < 0.005), fasting C-peptide (median, 9.1 ng/mL; range, 0.9 to 30.0 ng/mL v 2.2 ng/mL; range, 0.2 to 20.3 ng/mL; P < 0.0001) and triglyceride levels, and lower serum albumin concentrations. Among the patients undergoing CAPD, there was a preponderance of men in the insulin-treated group. Insulin-treated patients also had greater plasma albumin levels and body weights and lower fasting serum C-peptide levels (2.81 +/- 1.77 v 3.12 +/- 2.04 ng/mL; analysis of variance, P = 0.007 adjusted for fasting glucose concentration). Multivariate analysis showed duration of diabetes, hemoglobin A(1c) (HbA(1c)) level, and body weight were independent determinants of insulin requirement in patients undergoing CAPD. The daily insulin dosage required was related to the duration of diabetes (r = 0.5; P = 0.007). In summary, among patients with end-stage renal failure, insulin-treated patients had greater body weights and plasma albumin levels but lower cholesterol levels. Plasma C-peptide concentration and duration of diabetes were the main determinants of insulin requirement, reflecting a decrease in beta-cell reserve, whereas the daily insulin dose correlated mainly with body weight, HbA(1c) level, and duration of diabetes. Kt/V had no effect on insulin resistance or insulin requirement of the patients.

Serum lipids status in patients with diabetic uremia on 10 years of maintenance hemodialysis

BACKGROUND

Dyslipidemia in patients with diabetic uremic patients remains unclear. We previously reported that lipid abnormalities in diabetic uremia on short-term (3 to 28 months) hemodialysis therapy were more severe than those in nondiabetic uremic patients. The object of this study is to investigate the serum lipid profiles in diabetic uremic patients on 10 years of maintenance hemodialysis treatment.

METHODS

Thirty diabetic uremic subjects and 40 age-matched nondiabetic subjects on long-term hemodialysis therapy were selected, and their clinical characteristics and serum concentrations of lipids, apolipoproteins, lecithin cholesterol acyltransferase (LCAT) activity, and apolipoprotein (apo) E phenotype were evaluated.

RESULTS

Patients with diabetic uremia had a higher prevalence of macrovascular complications, including ischemic heart diseases and cerebrovascular diseases. The mean levels of serum total cholesterol, triglyceride, and high-density lipoprotein cholesterol remained normal. Nondiabetic uremic patients exhibited a reduction in serum apo A-1 serum apo A-2, serum apo C-2, and LCAT activity and an increase in serum Apo C-3. Diabetic uremic patients showed a further reduction in serum apo A-1, serum apo A-2, serum apo E, and LCAT activity. Frequencies of apo E isoforms were not significantly different between two groups of uremic patients.

CONCLUSIONS

These results clearly indicate that lipid abnormalities in diabetic uremic patients on long-term hemodialysis therapy are more enhanced than those in nondiabetic uremic patients, suggesting that diabetic hemodialyzed patients are more prone to increase the individual risk for accelerated atherosclerosis to cause a higher incidence of cardiovascular diseases.

Association between a polymorphism in the angiotensin-converting enzyme gene and microvascular complications in Japanese patients with NIDDM

The relationship between diabetic nephropathy and an insertion (I)/deletion (D) polymorphism in intron 16 of the angiotensin-converting enzyme (ACE) gene is still under debate. The association of ACE gene polymorphism with nephropathy and retinopathy was therefore examined in 362 Japanese patients with non-insulin-dependent diabetes mellitus (NIDDM) and 105 healthy control subjects. Distribution of the ACE genotype did not differ between healthy control subjects and diabetic patients without complications. However, the frequency of the D allele was significantly higher in the diabetic subjects with nephropathy than in those without (0.32 in normoalbuminuric patients vs 0.44 in albuminuria patients with albuminuria) (chi 2 = 7.7; p = 0.006). There was no significant association between ACE genotype and retinopathy. These observations thus demonstrate a significant association of the ACE gene polymorphism with nephropathy, but not with retinopathy, in Japanese patients with NIDDM.

Diabetic nephropathy in Japan

According to a nation-wide survey of dialysis patients in Japan the number of diabetic patients with end-stage renal failure introduced to dialysis therapy has been increasing year by year, exceeding 6000 cases (28% of total cases) in 1991. A six-fold increase in numbers and a three-fold increase in percentages (DM/total) were observed in the past ten years. Although the medical technology and regimen in dialysis therapy have been greatly improved, the prognosis of those diabetic patients on maintenance dialysis has remained unsatisfactory. Their quality of life has been severely damaged mostly because of the impairment of visual acuity. The early detection and early introduction of effective therapy for diabetic nephropathy, therefore, may be the most imminent tasks necessary to prevent the various problems afflicting diabetic patients on end-stage renal failure.