Is there a "burnt-out diabetes" phenomenon in patients on hemodialysis?

Renal function is highly associated with podiatric risk in diabetic patients

Background

Chronic kidney disease (CKD) is correlated with the incidence of diabetic foot ulcer (DFU). Furthermore, the International Working Group on the Diabetic Foot (IWGDF) has proposed a classification of the risk factors for DFU. The purpose of this study was to investigate the relationship between the IWGDF risk classification and the glomerular filtration rate level estimated by the CKD Epidemiology Collaboration formula (eGFR).

Methods

We conducted a prospective multicentric study. Patients were recruited from either diabetology or nephrology departments. The secondary objectives were to determine this relationship after excluding people on dialysis and to identify the factors associated with podiatric risk.

Results

Four hundred and eighty-six patients were included, with a mean age of 64.2 years (±15.7) and a mean diabetes duration of 15.7 years (±12.1). Based on the IWGDF classification, 53.5% of the population were in podiatric stage 0, 11.7% in stage 1 and 34.8% in stage 2 or 3. The mean eGFR level was significantly lower in patients with podiatric risk ≥2 (36.8 ± 33.9 mL/min/1.73 m2 vs 71.9 ± 35.3 mL/min/1.73 m2, P < .0001) and a significant association was found between the eGFR and the podiatric risk. This association remained significant after the exclusion of the hemodialysis patients. After receiver operating characteristic analysis, a cutoff of 45 ± 11 mL/min/1.73 m2 (area under the curve 0.76) was found discriminant to define a group of CKD patients at higher risk for podiatric stage ≥2.

Conclusion

eGFR levels are linked to podiatric stages in diabetes mellitus. Patients with eGFR <45 mL/min/1.73 m2 and dialysis patients should be carefully managed in collaboration with diabetic foot specialized centers.

[Alternative strategies to the use of glycosylated hemoglobin in monitoring the glycemic status of diabetic patients with end-stage renal disease]

BACKGROUND

Diabetes mellitus (DM) is one of the leading causes of end-stage renal disease. Glycosylated hemoglobin (HbA1c) is the recommended glycemic marker to achieve an optimal glycemic control that is essential to prevent comorbidities associated with the disease. However, in patients on haemodialysis (HD) this marker has important limitations, this reason has led us to search alternative markers such as glycosylated albumin (AG), labile fraction of glycosylated hemoglobin (LHbA1c) or glycation indices.

PATIENTS AND METHODS

We enrolled 47 patients in HD, 23 with DM, obtaining samples for the determination of de AG, HbA1c y LHbA1c. Glycation indices, which allow estimated the HbA1c using glucose, AG or LHbA1c, were calculated including a control group composed of 75 diabetic patients without kidney disease.

RESULTS

Diabetic patients in HD had significantly higher mean values than patients without DM for glucose [160 (44) vs 96 (12)mg/dL], HbA1c [6,4 (1,0) vs 4,9 (0,3)%], AG [16,0 (5,1) vs 12,9 (1,6)%] and LHbA1c [2,0 (0,3) vs 1,7 (0,2)%]. HbA1c calculated using glycation indices was significantly higher than measured in all HD patients, regardless of the marker used for the estimation.

CONCLUSIONS

The glycemic markers evaluated (glucose, AG and LHbA1c), could reflect a possible underestimation of the real glycemic state by HbA1c because of the limitations of this marker in HD patients. The use of alternative markers, knowing their limitations, could improve the monitoring of patients on HD and, therefore, reduce the risk of developing DM2 complications.

Toward Revision of the ‘Best Practice for Diabetic Patients on Hemodialysis 2012’

Diabetic nephropathy is the leading cause of dialysis therapy worldwide. The number of diabetes patients on dialysis in clinical settings has been increasing in Japan. In 2013, the Japanese Society for Dialysis Therapy (JSDT) published the “Best Practice for Diabetic Patients on Hemodialysis 2012”. While glycated hemoglobin (HbA1c) is used mainly as a glycemic control index for dialysis patients overseas, Japan is the first country in the world to use glycated albumin (GA) for assessment. According to a survey conducted by the JSDT in 2018, the number of facilities measuring only HbA1c has decreased compared with 2013, while the number of facilities measuring GA or both has significantly increased. Ten years have passed since the publication of the first edition of the guidelines, and several clinical studies regarding the GA value and mortality of dialysis patients have been reported. In addition, novel antidiabetic agents have appeared, and continuous glucose monitoring of dialysis patients has been adopted. On the other hand, Japanese dialysis patients are rapidly aging, and the proportion of patients with malnutrition is increasing. Therefore, there is great variation among diabetes patients on dialysis with respect to their backgrounds and characteristics. This review covers the indices and targets of glycemic control, the treatment of hyperglycemia, and diet recommendations for dialysis patients with diabetes.

Prevalence of carbohydrate metabolism disorders in patients with end-stage renal disease on hemodialysis therapy

There are quite a lot of scientific works today dedicated to the role of disorders carbohydrate metabolism (DCM) in the development of end-stage renal disease (ESRD), at the same time, the influence of chronic kidney disease (CKD) on the development of carbohydrate disorders remains insufficiently studied, especially in patients on renal replacement therapy (RRT). The annual steady increase in the number of patients with ESRD without diabetes mellitus (DM) requiring dialysis therapy leads to increased interest and the need to study carbohydrate status in these patients. It is known that hyperglycemia in patients without DM on hemodialysis (HD) is a predisposing factor to the development of cardiovascular accidents that worsen the quality of life and also increase mortality. The peculiarities of glucose metabolism in patients receiving RRT do not always allow adequate assessment of carbohydrate status using glycated hemoglobin (HbA1c). The review provides up-to-date information on the prevalence of DCM in patients with ESRD without DM receiving HD RRT, touches upon the peculiarities of glucose metabolism, interpretation of HbA1c and glycated albumin values, and mortality risk in hemodialysis patients with various DCM.

The Nephrologist's Role in the Collaborative Multi-Specialist Network Taking Care of Patients with Diabetes on Maintenance Hemodialysis: An Overview

Diabetes mellitus is the leading cause of renal failure in incident dialysis patients in several countries around the world. The quality of life for patients with diabetes in maintenance hemodialysis (HD) treatment is in general poor due to disease complications. Nephrologists have to cope with all these problems because of the “total care model” and strive to improve their patients’ outcome. In this review, an updated overview of the aspects the nephrologist must face in the management of these patients is reported. The conventional marker of glycemic control, hemoglobin A1c (HbA1c), is unreliable. HD itself may be responsible for dangerous hypoglycemic events. New methods of glucose control could be used even during dialysis, such as a continuous glucose monitoring (CGM) device. The pharmacological control of diabetes is another complex topic. Because of the risk of hypoglycemia, insulin and other medications used to treat diabetes may need dose adjustment. The new class of antidiabetic drugs dipeptidyl peptidase 4 (DPP-4) inhibitors can safely be used in non-insulin-dependent end-stage renal disease (ESRD) patients. Nephrologists should take care to improve the hemodynamic tolerance to HD treatment, frequently compromised by the high level of ultrafiltration needed to counter high interdialytic weight gain. Kidney and pancreas transplantation, in selected patients with diabetes, is the best therapy and is the only approach able to free patients from both dialysis and insulin therapy.

Chronic Renal Failure and Cardiovascular Disease: A Comprehensive Appraisal

Coronary artery disease is highly prevalent in patients with chronic kidney disease. The concomitant renal disease often poses a major challenge in decision making as symptoms, cardiac biomarkers and noninvasive studies for evaluation of myocardial ischemia have different sensitivity and specificity thresholds in this specific population. Moreover, the effectiveness and safety of intervention and medical treatment in those patients is of great doubt as most clinical studies exclude patients with advance CKD. In the present paper, we discuss and review the literature in the diagnosis, treatment and prevention of CAD in the acute and chronic setting, in patients with CKD.

Super high-flux membrane dialyzers improve mortality in patients on hemodialysis: a 3-year nationwide cohort study

Introduction

In Japan, dialyzers are classified based on β₂-microglobulin clearance. Type I dialyzers are classified as low-flux dialyzers (<10 mL/min clearance), type II and III as high-flux dialyzers (≥10 to <30 mL/min and ≥30 to <50 mL/min clearance, respectively), and type IV and V as super high-flux dialyzers (≥50 to <70 mL/min and ≥70 mL/min clearance, respectively). Super high-flux dialyzers are commonly used, but their superiority over low-flux dialyzers is controversial.

Methods

In this nationwide prospective cohort study, we analyzed Japanese Society for Dialysis Therapy Renal Data Registry data collected at the end of 2008 and 2011. We enrolled 242,467 patients on maintenance hemodialysis and divided them into five groups by dialyzer type. We assessed the associations of each dialyzer type with 3-year all-cause mortality using Cox proportional hazards models and performed propensity score matching analysis, adjusting for potential confounders.

Results

By the end of 2011, 53,172 (21.9%) prevalent dialysis patients had died. Mortality significantly decreased according to dialyzer type. Hazard ratios (HRs) were significantly higher for type I, II and III compared with type IV (reference) after adjustment for basic factors and further adjustment for dialysis-related factors. HR was significantly higher for type I, but significantly lower for type V, after further adjustment for nutrition- and inflammation-related factors. These significant findings were also evident after propensity score matching.

Conclusions

Hemodialysis using super high-flux dialyzers might reduce mortality. Randomized controlled trials are warranted to clarify whether these type V dialyzers can improve prognosis.

Nutrition in Patients with Type 2 Diabetes: Present Knowledge and Remaining Challenges

Unhealthy behaviours, including diet and physical activity, coupled with genetic predisposition, drive type 2 diabetes (T2D) occurrence and severity; the present review aims to summarise the most recent nutritional approaches in T2D, outlining unmet needs. Guidelines consistently suggest reducing energy intake to counteract the obesity epidemic, frequently resulting in sarcopenic obesity, a condition associated with poorer metabolic control and cardiovascular disease. Various dietary approaches have been proposed with largely similar results, with a preference for the Mediterranean diet and the best practice being the diet that patients feel confident of maintaining in the long term based on individual preferences. Patient adherence is indeed the pivotal factor for weight loss and long-term maintenance, requiring intensive lifestyle intervention. The consumption of nutritional supplements continues to increase even if international societies do not support their systematic use. Inositols and vitamin D supplementation, as well as micronutrients (zinc, chromium, magnesium) and pre/probiotics, result in modest improvement in insulin sensitivity, but their use is not systematically suggested. To reach the desired goals, patients should be actively involved in the collaborative development of a personalised meal plan associated with habitual physical activity, aiming at normal body weight and metabolic control.

Continuous glucose monitoring in an end-stage renal disease patient with diabetes receiving hemodialysis

Diabetes is the leading cause of end-stage renal disease (ESRD) and contributes to heightened morbidity and mortality in dialysis patients. Given that ESRD patients are susceptible to hypoglycemia and hyperglycemia via multiple pathways, adequate glycemic monitoring and control is a cornerstone in diabetic kidney disease management. In ESRD, existing glycemic metrics such as glycated hemoglobin, self-monitored blood glucose, fructosamine, and glycated albumin have limitations in accuracy, convenience, and accessibility. In contrast, continuous glucose monitoring (CGM) provides automated, less invasive glucose measurements and more comprehensive glycemic data versus conventional metrics. Here, we report a 48-year-old male with ESRD due to diabetes receiving thrice-weekly hemodialysis who experienced decreased patient-burden, greater glucose monitoring adherence, improved glycemic parameters, and reduction in hypoglycemia after transitioning to CGM. Through this case, we discuss how CGM is a practical, convenient patient-centered tool that may improve metabolic outcomes and quality of life in ESRD patients with diabetes.

High-performance dialyzers and mortality in maintenance hemodialysis patients

Few data are available regarding the association of dialyzer type with prognosis. In Japan, dialyzers are classified as types I, II, III, IV, and V based on β₂-microglobulin clearance rates of < 10, < 30, < 50, < 70, and ≥ 70 mL/min, respectively. We investigated the relationship of the 5 dialyzer types with 1-year mortality. This nationwide cohort study used data collected at the end of 2008 and 2009 by the Japanese Society for Dialysis Therapy Renal Data Registry. We enrolled 203,008 patients on maintenance hemodialysis who underwent hemodialysis for at least 1 year and were managed with any of the 5 dialyzer types. To evaluate the association of dialyzer type with 1-year all-cause mortality, Cox proportional hazards models and propensity score-matched analyses were performed. After adjustment of the data with clinicodemographic factors, the type I, II, and III groups showed significantly higher hazard ratios (HRs) than the type IV dialyzers (reference). After adjustment for Kt/V and β₂-microglobulin levels, the HRs were significantly higher in the type I and II groups. After further adjustment for nutrition- and inflammation-related factors, the HRs were not significantly different between the type IV and type I and II groups. However, type V dialyzers consistently showed a significantly lower HR. With propensity score matching, the HR for the type V dialyzer group was significantly lower than that for the type IV dialyzer group. Additional long-term trials are required to determine whether type V dialyzers, which are high-performance dialyzers, can improve prognosis.

Glycated albumin and hemoglobin A1c levels and cause-specific mortality by patients' conditions among hemodialysis patients with diabetes: a 3-year nationwide cohort study

INTRODUCTION

Differences in mortality and cause-specific mortality rates according to glycated albumin (GA) and hemoglobin A1c (HbA1c) levels among dialysis patients with diabetes based on hypoglycemic agent use and malnutrition status remain unclear. Here, we examine these associations using a nationwide cohort.

RESEARCH DESIGN AND METHODS

We examined 40 417 dialysis patients with diabetes who met our inclusion criteria (female, 30.8%; mean age, 67.3±11.2 years; mean dialysis duration, 5.4±4.6 years). The Global Leadership Initiative on Malnutrition criteria were used to assess malnutrition. Adjusted HRs and 95% confidence limits were calculated for 3-year mortality after adjustment for 18 potential confounders. HRs and subdistribution HRs were used to explore cause-specific mortality.

RESULTS

We found a linear association between 3-year mortality and GA levels only in patients with GA ≥18% and not in patients with low GA levels, with a U-shaped association between HbA1c levels and the lowest morality at an HbA1c 6.0%-6.3%. This association differed based on patient conditions and hypoglycemic agent use. If patients using hypoglycemic agents were malnourished, mortality was increased with GA ≥24% and HbA1c ≥8%. In addition, patients with GA ≥22% and HbA1c ≥7.6% had significantly higher infectious or cardiovascular mortality rates. On the other hand, an inverse association was found between GA or HbA1c levels and cancer mortality. Patients with GA ≤15.8% had a higher risk of cancer mortality, especially those not using hypoglycemic agents (HR 1.63 (1.00-2.66)).

CONCLUSIONS

Target GA and HbA1c levels in dialysis patients may differ according to hypoglycemic agent use, nutritional status, and the presence of cancer. The levels may be higher in malnourished patients than in other patients, and a very low GA level in dialysis patients not taking hypoglycemic agents may be associated with a risk of cancer.

TRIAL REGISTRATION NUMBER

UMIN000018641.

Is HbA1c an ideal biomarker of well-controlled diabetes?

HbA1c is a biomarker with a central role in the diagnosis and follow-up of patients with diabetes, although not a perfect one. Common comorbidities encountered in patients with diabetes mellitus, such as renal insufficiency, high output states (iron deficiency anaemia, haemolytic anaemia, haemoglobinopathies and pregnancy) and intake of specific drugs could compromise the sensitivity and specificity of the biomarker. COVID-19 pandemic poses a pressing challenge for the diabetic population, since maintaining optimal blood glucose control is key to reduce morbidity and mortality rates. Alternative methods for diabetes management, such as fructosamine, glycosylated albumin and device-based continuous glucose monitoring, are discussed.

[Glycemic control in patients with diabetes mellitus on hemodialysis]

Achievement of stabilization of carbohydrate metabolism in patients with diabetes mellitus, receiving renal replacement therapy with hemodialysis, is a significant problem in endocrinology. It has to do with multiple factors of this cohort of patients, which affect the level of glycemia, pharmacokinetic of drugs, the efficiency of glycemic control. At the moment, the most efficiency method of glycemic control in patients with type 2 diabetes mellitus on hemodialysis is insulin therapy in the basis - bolus regime by analogues of human insulin. The use of oral hypoglycemic agents is significantly limited. The hemoglobin A1c (HbA1c) remains the main parameter of glycemic control. The simultaneous use of continuous glucose monitoring allows to reveal the true level of glucose of the blood and to carry out the timely correction of therapy in order to achieve targets for glycemic control and to decrease the risk of hypoglycemic episodes. At the moment other glycemic control markers such as glycated albumin and fructosamine are described. However, in routine practice at the moment these indicators are not used due to the lack of sufficient evidentiary base of their use in this cohort of patients.

Glycated albumin versus hemoglobin A1c and mortality in diabetic hemodialysis patients: a cohort study

Background

For glycemic control in diabetic patients on dialysis it was unclear what level of glycated albumin (GA) was associated with the lowest mortality and GA's utility. Accordingly, we examined the difference in association between GA and hemoglobin A1c (HbA1c) with 1-year mortality in a cohort of the Japanese Society for Dialysis Therapy.

Methods

We examined 84 282 patients with prevalent diabetes who were on maintenance hemodialysis (HD) (female 30.3%; mean age 67.3 ± 11.2 years; mean dialysis vintage 6.4 ± 4.5 years). Of them, 22 441 had both GA and HbA1c. We followed these for a year, 2013-14, using Cox regression to calculate adjusted hazard ratios (HRs) and 95% confidence limits for 1-year mortality after adjusting for potential confounders such as baseline age, sex, smoking and diabetes type.

Results

One-year mortality was lowest in diabetic HD patients who had GA levels of 15.6-18.2% and HbA1c levels of 5.8-6.3%. The associations were linear or J-shaped for GA and U-shaped for HbA1c. Adjusted HRs were significantly higher in patients with GA <12.5% and GA ≥22.9%. This trend flattened in elderly patients, those with higher hemoglobin or those with prior cardiovascular disease. In addition, the C-statistics, Harrell's C and category-free net reclassification improvement to predict 1-year mortality were better when GA was added to the model than when HbA1c was added.

Conclusions

There was a linear or J-shaped association between GA and 1-year mortality, with the lowest mortality at GA 15.6-18.2%. Furthermore, our analyses suggest the potential superiority of GA over HbA1c in predicting mortality.

Predictors of outcomes in patients on peritoneal dialysis: A 2-year nationwide cohort study

There has been no nationwide study of prognostic factors and outcomes in patients on peritoneal dialysis (PD) in Japan. We conducted a cohort study using data from the nationwide registry of the Japanese Society for Dialysis Therapy. We followed 8,954 prevalent PD patients for 2 years, 2014–2015. Cox proportional hazards regression analysis was used to determine factors that were independently associated with patient survival. Survival rates were compared between patients with and without diabetes after adjusting for potential confounders. During the 2-year study period, 893 (10.0%) of 8,954 patients died, 148 (1.6%) underwent kidney transplantation, and 2,637 (29.4%) were switched to hemodialysis; 5,276 (58.9%) patients were alive at the end of the study period. After multivariate adjustment, older age, longer duration of dialysis, presence of diabetes, cardiovascular comorbidity, use of 2.5% glucose dialysate, higher C-reactive protein and phosphate levels, and a lower serum albumin level were independently associated with increased hazard ratios for all-cause mortality. A combination of PD and hemodialysis was associated with a lower mortality rate. The new-onset cardiovascular event rate was significantly higher in the diabetes group than in the non-diabetes group (P < 0.0001). After adjusting for all variables, the hazard ratio was 1.509 (95% confidence interval 1.029–2.189, P = 0.036) in the diabetes group. Diabetes, older age, longer duration of dialysis, cardiovascular comorbidity, and inflammation were predictors of mortality in patients on PD.

Glycemic control and survival in peritoneal dialysis patients with diabetes: A 2-year nationwide cohort study

For glycemic control in patients with diabetes on peritoneal dialysis (PD), the level of glycated albumin (GA) associated with mortality is unclear. Accordingly, we examined the difference in the association of GA and glycated hemoglobin (HbA1c) with 2-year mortality in a Japanese Society for Dialysis Therapy cohort. We examined 1601 patients with prevalent diabetes who were on PD. Of these, 1282 had HbA1c (HbA1c cohort) and 725 had GA (GA cohort) measured. We followed them for 2 years from 2013 to 2015 and used Cox regression to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for 2-year mortality after adjusting for potential confounders in each cohort. No significant association was found between HbA1c levels and all-cause death HRs before and after adjustment for confounders in the HbA1c cohort. In contrast, the adjusted all-cause death HRs and 95% CIs for GAs < 12.0%, 12.0–13.9%, 16.0–17.9%, 18.0–19.9%, 20.0–21.9%, and ≥22.0%, compared with 14.0–15.9% (reference), were 1.56 (0.32–7.45), 1.24 (0.32–4.83), 1.32 (0.36–4.77), 2.02 (0.54–7.53), 4.36 (1.10–17.0), and 4.10 (1.20–14.0), respectively. In the GA cohort, GA ≥ 20.0% was significantly associated with a higher death HR compared with the reference GA. Thus, GA ≥ 20.0% appears to be associated with a decrease in survival in diabetic patients on PD. There were no associations between HbA1c levels and 2-year mortality in PD patients.

Association between End-Stage Renal Disease and Incident Diabetes Mellitus-A Nationwide Population-Based Cohort Study

Background: Glucose is one of the constituents in hemodialysates and peritoneal dialysates. How the dialysis associates with the incident diabetes mellitus (DM) remains to be assessed. Methods: The claim data of end-stage renal disease (ESRD) patients who initiated dialysis from and a cohort of matched non-dialysis individuals from 2000 to 2013 were retrieved from the Taiwan National Health Insurance Research Database to examine the risk of incident DM among patients on hemodialysis (HD) and peritoneal dialysis (PD). Predictors of incident DM were determined for HD and PD patients using Fine and Gray models to treat death as a competing event, respectively. Results: A total of 2228 patients on dialysis (2092 HD and 136 PD) and 8912 non-dialysis individuals were the study population. The PD and HD patients had 12 and 97 new-onset of DM (incidence rates of 15.98 and 8.69 per 1000 patient-years, respectively), while the comparison cohort had 869 DM events with the incidence rate of 15.88 per 1000 patient-years. The multivariable-adjusted Cox models of Fine and Gray method showed that the dialysis cohort was associated with an adjusted hazard ratio (HR) of 0.49 (95% CI 0.39–0.61, p value < 0.0001) for incident DM compared with the comparison cohort. The adjusted HR of incident DM was 0.46 (95% CI 0.37–0.58, p value < 0.0001) for HD and 0.84 (95% CI 0.47–1.51, p value = 0.56) for PD. Conclusions: ESRD patients were associated with a lower risk of incident DM. HD was associated with a lower risk of incident DM, whereas PD was not.

Rate of the "burnt-out diabetes" phenomenon in patients on peritoneal dialysis

AIMS

In some diabetes patients on dialysis, glycemic control improves spontaneously, leading to normal HbA1c levels; this phenomenon is known as "burnt-out diabetes." Glycated albumin (GA) might be a better indicator of glycemic control than HbA1c in hemodialysis patients, but it has not been assessed in peritoneal dialysis (PD) patients.

METHODS

This study involved diabetes patients on PD, with HbA1c level and antidiabetes therapy records. First, the "burnt-out diabetes" phenomenon was investigated in patients with HbA1c measurements alone (HbA1c cohort). Then, it was investigated in patients with both HbA1c and GA measurements (GA cohort).

RESULTS

A total of 1296 patients were included in the HbA1c cohort. When "burnt-out diabetes" was defined as HbA1c < 6.0% without treatment, it was noted in 269 patients (20.8%). A total of 413 patients were subsequently included in the GA cohort. "Burnt-out diabetes," using the same definition, was found in 73 patients (17.7%). However, when defined as HbA1c < 6.0% and GA < 16.0% without treatment, "burnt-out diabetes" was found in 45 patients (10.9%).

CONCLUSIONS

Although the "burnt-out diabetes" phenomenon was present in 17.7% of patients with diabetes on PD based on HbA1c, the rate was significantly decreased to 10.9% when taking GA into account.

Usefulness of glycated albumin as a biomarker for glucose control and prognostic factor in chronic kidney disease patients on dialysis (CKD-G5D)

In chronic kidney disease patients on dialysis (CKD-G5D) accurate assessment of glycemic control is vital to improve their outcome and survival. The best glycemic marker for glucose control in these patients is still debated because several clinical and pharmacological factors may affect the ability of the available biomarkers to reflect the patient's glycemic status properly. This review discusses the role of glycated albumin (GA) both as a biomarker for glucose control and as a prognostic factor in CKD-G5D; it also looks at the pros and cons of GA in comparison to the other markers and its usefulness in hemodialysis and peritoneal dialysis.