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Liu H, Xin X, Gan J, Huang J. The long-term effects of blood urea nitrogen levels on cardiovascular disease and all-cause mortality in diabetes: a prospective cohort study. BMC Cardiovasc Disord 2024; 24:256. [PMID: 38755538 PMCID: PMC11097526 DOI: 10.1186/s12872-024-03928-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 05/08/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND The long-term effects of blood urea nitrogen(BUN) in patients with diabetes remain unknown. Current studies reporting the target BUN level in patients with diabetes are also limited. Hence, this prospective study aimed to explore the relationship of BUN with all-cause and cardiovascular mortalities in patients with diabetes. METHODS In total, 10,507 participants with diabetes from the National Health and Nutrition Examination Survey (1999-2018) were enrolled. The causes and numbers of deaths were determined based on the National Death Index mortality data from the date of NHANES interview until follow-up (December 31, 2019). Multivariate Cox proportional hazard regression models were used to calculate the hazard ratios (HRs) and 95% confidence interval (CIs) of mortality. RESULTS Of the adult participants with diabetes, 4963 (47.2%) were female. The median (interquartile range) BUN level of participants was 5 (3.93-6.43) mmol/L. After 86,601 person-years of follow-up, 2,441 deaths were documented. After adjusting for variables, the HRs of cardiovascular disease (CVD) and all-cause mortality in the highest BUN level group were 1.52 and 1.35, respectively, compared with those in the lowest BUN level group. With a one-unit increment in BUN levels, the HRs of all-cause and CVD mortality rates were 1.07 and 1.08, respectively. The results remained robust when several sensitivity and stratified analyses were performed. Moreover, BUN showed a nonlinear association with all-cause and CVD mortality. Their curves all showed that the inflection points were close to the BUN level of 5 mmol/L. CONCLUSION BUN had a nonlinear association with all-cause and CVD mortality in patients with diabetes. The inflection point was at 5 mmol/L.
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Affiliation(s)
- Hongfang Liu
- Electrocardiography Department, Ganzhou Maternal and Child Health Hospital, Ganzhou, Jiangxi Province, 341000, China
| | - Xiaoqin Xin
- Department of Clinical Laboratory, Ganzhou People's Hospital, Ganzhou, Jiangxi Province, 341000, China
| | - Jinghui Gan
- Department of Medical Genetic, Ganzhou Maternal and Child Health Hospital, Ganzhou, Jiangxi Province, 341000, China
| | - Jungao Huang
- Department of Medical Genetic, Ganzhou Maternal and Child Health Hospital, Ganzhou, Jiangxi Province, 341000, China.
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2
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Kato K, Kageyama S, Nakashima K, Ito H, Ito Y, Miyake T. End-stage Renal Disease in Which Diazoxide Was Effective in Treating Hypoglycemia Caused by Late Dumping Syndrome after Gastrectomy. Intern Med 2024; 63:1421-1427. [PMID: 37813619 PMCID: PMC11157299 DOI: 10.2169/internalmedicine.1704-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 08/20/2023] [Indexed: 10/11/2023] Open
Abstract
We herein report a case in which diazoxide was effective in treating reactive hypoglycemia caused by late dumping syndrome in a patient with end-stage renal disease (ESRD). A 50-year-old man with ESRD and a history of gastrectomy underwent hemodialysis. Although he was administered voglibose to treat recurrent reactive hypoglycemia caused by late dumping syndrome, he had difficulty continuing treatment because of gastrointestinal side effects. When he began diazoxide treatment, the reactive hypoglycemia improved. The dose was gradually increased with no apparent side effects, and the hypoglycemic attacks disappeared one year after the start of treatment.
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Affiliation(s)
- Kosuke Kato
- Department of Internal Medicine, Meinan Hospital, Japan
| | | | | | - Harumi Ito
- Department of Internal Medicine, Meinan Hospital, Japan
| | - Yuji Ito
- Department of Internal Medicine, Meinan Hospital, Japan
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Kang DH, Streja E, You AS, Lee Y, Narasaki Y, Torres S, Novoa-Vargas A, Kovesdy CP, Kalantar-Zadeh K, Rhee CM. Hypoglycemia and Mortality Risk in Incident Hemodialysis Patients. J Ren Nutr 2024; 34:200-208. [PMID: 37918644 DOI: 10.1053/j.jrn.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/14/2023] [Accepted: 09/10/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVE Hypoglycemia is a frequent occurrence in chronic kidney disease patients due to alterations in glucose and insulin metabolism. However, there are sparse data examining the predictors and clinical implications of hypoglycemia including mortality risk among incident hemodialysis patients. DESIGN AND METHODS Among 58,304 incident hemodialysis patients receiving care from a large national dialysis organization over 2007-2011, we examined clinical characteristics associated with risk of hypoglycemia, defined as a blood glucose concentration <70 mg/dL, in the first year of dialysis using expanded case-mix + laboratory logistic regression models. We then examined the association between hypoglycemia during the first year of dialysis with all-cause mortality using expanded case-mix + laboratory Cox models. RESULTS In the first year of dialysis, hypoglycemia was observed among 16.8% of diabetic and 6.9% of nondiabetic incident hemodialysis patients. In adjusted logistic regression models, clinical characteristics associated with hypoglycemia included younger age, female sex, African-American race, presence of a central venous catheter, lower residual renal function, and longer dialysis session length. In the overall cohort, patients who experienced hypoglycemia had a higher risk of all-cause mortality risk (reference: absence of hypoglycemia): adjusted hazard ratio (95% confidence interval) 1.08 (1.04, 1.13). In stratified analyses, hypoglycemia was also associated with higher mortality risk in the diabetic and nondiabetic subgroups: adjusted hazard ratios (95% confidence interval's) 1.08 (1.04-1.13), and 1.17 (0.94-1.45), respectively. CONCLUSIONS Hypoglycemia was a frequent occurrence among both diabetic and nondiabetic hemodialysis patients and was associated with a higher mortality risk. Further studies are needed to identify approaches that reduce hypoglycemia risk in the hemodialysis population.
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Affiliation(s)
- Duk-Hee Kang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California; Division of Nephrology, Department of Internal Medicine, Ewha Womans University School of Medicine, Ewha Medical Research Center, Seoul, South Korea
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Amy S You
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California
| | - Yongkyu Lee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California; Nephrology Division, Department of Internal Medicine, NHIS Ilsan Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Yoko Narasaki
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California
| | - Silvina Torres
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California
| | - Alejandra Novoa-Vargas
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California.
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Miljuš G, Penezić A, Pažitná L, Gligorijević N, Baralić M, Vilotić A, Šunderić M, Robajac D, Dobrijević Z, Katrlík J, Nedić O. Glycosylation and Characterization of Human Transferrin in an End-Stage Kidney Disease. Int J Mol Sci 2024; 25:4625. [PMID: 38731843 PMCID: PMC11083005 DOI: 10.3390/ijms25094625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024] Open
Abstract
Chronic kidney disease (CKD) is a global health concern affecting approximately one billion individuals worldwide. End-stage kidney disease (ESKD), the most severe form of CKD, is often accompanied by anemia. Peritoneal dialysis (PD), a common treatment for ESKD, utilizes the peritoneum for solute transfer but is associated with complications including protein loss, including transferrin (Tf) a key protein involved in iron transport. This study investigated Tf characteristics in ESKD patients compared to healthy individuals using lectin microarray, spectroscopic techniques and immunocytochemical analysis to assess Tf interaction with transferrin receptors (TfRs). ESKD patients exhibited altered Tf glycosylation patterns, evidenced by significant changes in lectin reactivity compared to healthy controls. However, structural analyses revealed no significant differences in the Tf secondary or tertiary structures between the two groups. A functional analysis demonstrated comparable Tf-TfR interaction in both PD and healthy samples. Despite significant alterations in Tf glycosylation, structural integrity and Tf-TfR interaction remained preserved in PD patients. These findings suggest that while glycosylation changes may influence iron metabolism, they do not impair Tf function. The study highlights the importance of a glucose-free dialysis solutions in managing anemia exacerbation in PD patients with poorly controlled anemia, potentially offering a targeted therapeutic approach to improve patient outcomes.
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Affiliation(s)
- Goran Miljuš
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
| | - Ana Penezić
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
| | - Lucia Pažitná
- Institute of Chemistry, Slovak Academy of Sciences, 84538 Bratislava, Slovakia
| | - Nikola Gligorijević
- Institute of Chemistry, Technology and Metallurgy, Department of Chemistry, University of Belgrade, 11000 Belgrade, Serbia
| | - Marko Baralić
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Clinic of Nephrology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Aleksandra Vilotić
- Institute for the Application of Nuclear Energy (INEP), Department for Biology of Reproduction, University of Belgrade, 11000 Belgrade, Serbia
| | - Miloš Šunderić
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
| | - Dragana Robajac
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
| | - Zorana Dobrijević
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
| | - Jaroslav Katrlík
- Institute of Chemistry, Slovak Academy of Sciences, 84538 Bratislava, Slovakia
| | - Olgica Nedić
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
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Zhang J, Le Leu RK, Xu Q, Bennett P. The futility of post-haemodialysis blood glucose levels: A retrospective cohort study. J Ren Care 2024. [PMID: 38477224 DOI: 10.1111/jorc.12492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Frequent blood glucose tests are performed for people with diabetes receiving haemodialysis. OBJECTIVES To determine the rate of out-of-range post-haemodialysis blood glucose levels that are clinically acted upon, the intervention and outcome of each intervention, and the associations between post-haemodialysis blood glucose levels and relevant clinical predictors. DESIGN 12-month retrospective cohort medical record review in one Australian haemodialysis centre. Post-haemodialysis blood glucose levels, prehaemodialysis blood glucose levels, time of treatment, diabetes medications, intradialytic fluid removal, dialysate dextrose concentration, clinical actions, interventions, and outcomes on out-of-range blood glucose levels were retrieved. PARTICIPANTS 22 participants with a median time receiving dialysis 3.1 years (interquartile range 2.3-4.7). MEASUREMENTS AND RESULTS The proportion of out-of-range post-haemodialysis blood glucose levels was 87.3% (95% confidence interval, 86.1%-88.5%). No out-of-range post-haemodialysis blood glucose levels were clinically acted upon. Out-of-range post-haemodialysis blood glucose levels were 4.6 times more likely if a higher dextrose bath was used (95% confidence interval: 3.3; 6.3. p < 0.001). The odds of the post-haemodialysis blood glucose levels increased by each 1 mmol/L. Intradialytic fluid removal, dialysate dextrose concentration, sex, dialysis time, anti-hyperglycaemic agents were also associated with out-of-range post-haemodialysis blood glucose levels. CONCLUSION Routine post-haemodialysis blood glucose levels testing has limited clinical utility in care for people with diabetes receiving maintenance haemodialysis. Higher dextrose dialysate may require individual titration depending on prehaemodialysis blood glucose levels.
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Affiliation(s)
- Jing Zhang
- Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Richard K Le Leu
- Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Qunyan Xu
- Clinical & Health Sciences, University of South Australia, Adelaide, Australia
| | - Paul Bennett
- School of Nursing and Midwifery, Griffith Health, Griffith University, Brisbane, Queensland, Australia
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Ebert T, Sattar N, Greig M, Lamina C, Froissart M, Eckardt KU, Floege J, Kronenberg F, Stenvinkel P, Wheeler DC, Fotheringham J. Use of Analog and Human Insulin in a European Hemodialysis Cohort With Type 2 Diabetes: Associations With Mortality, Hospitalization, MACE, and Hypoglycemia. Am J Kidney Dis 2024; 83:18-27. [PMID: 37657634 DOI: 10.1053/j.ajkd.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 09/03/2023]
Abstract
RATIONALE & OBJECTIVE Poor glycemic control may contribute to the high mortality rate in patients with type 2 diabetes receiving hemodialysis. Insulin type may influence glycemic control, and its choice may be an opportunity to improve outcomes. This study assessed whether treatment with analog insulin compared with human insulin is associated with different outcomes in people with type 2 diabetes and kidney failure receiving hemodialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS People in the Analyzing Data, Recognizing Excellence and Optimizing Outcomes (AROii) study with kidney failure commencing hemodialysis and type 2 diabetes being treated with insulin within 288 dialysis facilities between 2007 and 2009 across 7 European countries. Study participants were followed for 3 years. People with type 1 diabetes were excluded using an established administrative data algorithm. EXPOSURE Treatment with an insulin analog or human insulin. OUTCOME All-cause mortality, major adverse cardiovascular events (MACE), all-cause hospitalization, and confirmed hypoglycemia (blood glucose<3.0mmol/L sampled during hemodialysis). ANALYTICAL APPROACH Inverse probability weighted Cox proportional hazards models to estimate hazard ratios for analog insulin compared with human insulin. RESULTS There were 713 insulin analog and 733 human insulin users. Significant variation in insulin type by country was observed. Comparing analog with human insulin at 3 years, the percentage of patients experiencing end points and adjusted hazard ratios (AHR) were 22.0% versus 31.4% (AHR, 0.808 [95% CI, 0.66-0.99], P=0.04) for all-cause mortality, 26.8% versus 35.9% (AHR, 0.817 [95% CI, 0.68-0.98], P=0.03) for MACE, and 58.2% versus 75.0% (AHR, 0.757 [95% CI, 0.67-0.86], P<0.001) for hospitalization. Hypoglycemia was comparable between insulin types at 14.1% versus 15.0% (AHR, 1.169 [95% CI, 0.80-1.72], P=0.4). Consistent strength and direction of the associations were observed across sensitivity analyses. LIMITATIONS Residual confounding, lack of more detailed glycemia data. CONCLUSIONS In this large multinational cohort of people with type 2 diabetes and kidney failure receiving maintenance hemodialysis, treatment with analog insulins was associated with better clinical outcomes when compared with human insulin. PLAIN-LANGUAGE SUMMARY People with diabetes who are receiving dialysis for kidney failure are at high risk of cardiovascular disease and death. This study uses information from 1,446 people with kidney failure from 7 European countries who are receiving dialysis, have type 2 diabetes, and are prescribed either insulin identical to that made in the body (human insulin) or insulins with engineered extra features (insulin analog). After 3 years, fewer participants receiving analog insulins had died, had been admitted to the hospital, or had a cardiovascular event (heart attack, stroke, heart failure, or peripheral vascular disease). These findings suggest that analog insulins should be further explored as a treatment leading to better outcomes for people with diabetes on dialysis.
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Affiliation(s)
- Thomas Ebert
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Medical Department III, Endocrinology, Nephrology, Rheumatology, University of Leipzig Medical Center, Leipzig, Germany
| | - Nosheen Sattar
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield
| | - Marni Greig
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield; Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield
| | - Claudia Lamina
- Medical University of Innsbruck, Institute of Genetic Epidemiology, Innsbruck, Austria
| | - Marc Froissart
- Centre de Recherche Clinique (CRC), Lausanne University Hospital, Lausanne, Switzerland
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH University of Aachen, Aachen, Germany
| | - Florian Kronenberg
- Medical University of Innsbruck, Institute of Genetic Epidemiology, Innsbruck, Austria
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield; Sheffield Kidney Institute, Northern General Hospital, Sheffield.
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Xie E, Ye Z, Wu Y, Zhao X, Li Y, Shen N, Gao Y, Zheng J. Predictive value of the stress hyperglycemia ratio in dialysis patients with acute coronary syndrome: insights from a multi-center observational study. Cardiovasc Diabetol 2023; 22:288. [PMID: 37891639 PMCID: PMC10612265 DOI: 10.1186/s12933-023-02036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Various studies have indicated that stress hyperglycemia ratio (SHR) can reflect true acute hyperglycemic status and is associated with poor outcomes in patients with acute coronary syndrome (ACS). However, data on dialysis patients with ACS are limited. The Global Registry of Acute Coronary Events (GRACE) risk score is a well-validated risk prediction tool for ACS patients, yet it underestimates the risk of major events in patients receiving dialysis. This study aimed to evaluate the association between SHR and adverse cardiovascular events in dialysis patients with ACS and explore the potential incremental prognostic value of incorporating SHR into the GRACE risk score. METHODS This study enrolled 714 dialysis patients with ACS from January 2015 to June 2021 at 30 tertiary medical centers in China. Patients were stratified into three groups based on the tertiles of SHR. The primary outcome was major adverse cardiovascular events (MACE), and the secondary outcomes were all-cause mortality and cardiovascular mortality. RESULTS After a median follow-up of 20.9 months, 345 (48.3%) MACE and 280 (39.2%) all-cause mortality occurred, comprising 205 cases of cardiovascular death. When the highest SHR tertile was compared to the second SHR tertile, a significantly increased risk of MACE (adjusted hazard ratio, 1.92; 95% CI, 1.48-2.49), all-cause mortality (adjusted hazard ratio, 2.19; 95% CI, 1.64-2.93), and cardiovascular mortality (adjusted hazard ratio, 2.70; 95% CI, 1.90-3.83) was identified in the multivariable Cox regression model. A similar association was observed in both diabetic and nondiabetic patients. Further restricted cubic spline analysis identified a J-shaped association between the SHR and primary and secondary outcomes, with hazard ratios for MACE and mortality significantly increasing when SHR was > 1.08. Furthermore, adding SHR to the GRACE score led to a significant improvement in its predictive accuracy for MACE and mortality, as measured by the C-statistic, net reclassification improvement, and integrated discrimination improvement, especially for those with diabetes. CONCLUSIONS In dialysis patients with ACS, SHR was independently associated with increased risks of MACE and mortality. Furthermore, SHR may aid in improving the predictive efficiency of the GRACE score, especially for those with diabetes. These results indicated that SHR might be a valuable tool for risk stratification and management of dialysis patients with ACS.
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Affiliation(s)
- Enmin Xie
- Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zixiang Ye
- Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yaxin Wu
- Department of Cardiology, Henan Provincial People's Hospital, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Xuecheng Zhao
- Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
| | - Yike Li
- Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
| | - Nan Shen
- Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
| | - Yanxiang Gao
- Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China.
| | - Jingang Zheng
- Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China.
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.
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Xie E, Ye Z, Wu Y, Zhao X, Li Y, Shen N, Gao Y, Zheng J. The triglyceride-glucose index predicts 1-year major adverse cardiovascular events in end-stage renal disease patients with coronary artery disease. Cardiovasc Diabetol 2023; 22:292. [PMID: 37891651 PMCID: PMC10612201 DOI: 10.1186/s12933-023-02028-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The triglyceride-glucose (TyG) index has been suggested as a dependable indicator for predicting major adverse cardiovascular events (MACE) in individuals with cardiovascular conditions. Nevertheless, there is insufficient data on the predictive significance of the TyG index in end-stage renal disease (ESRD) patients with coronary artery disease (CAD). METHODS This study, conducted at multiple centers in China, included 959 patients diagnosed with dialysis and CAD from January 2015 to June 2021. Based on the TyG index, the participants were categorized into three distinct groups. The study's primary endpoint was the combination of MACE occurring within one year of follow-up, including death from any cause, non-fatal myocardial infarction, and non-fatal stroke. We assessed the association between the TyG index and MACE using Cox proportional hazard models and restricted cubic spline analysis. The TyG index value was evaluated for prediction incrementally using C-statistics, continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI). RESULTS The three groups showed notable variations in the risk of MACE (16.3% in tertile 1, 23.5% in tertile 2, and 27.2% in tertile 3; log-rank P = 0.003). Following complete adjustment, patients with the highest TyG index exhibited a notably elevated risk of MACE in comparison to those in the lowest tertile (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.14-2.35, P = 0.007). Likewise, each unit increase in the TyG index correlated with a 1.37-fold higher risk of MACE (HR 1.37, 95% CI 1.13-1.66, P = 0.001). Restricted cubic spline analysis revealed a connection between the TyG index and MACE (P for nonlinearity > 0.05). Furthermore, incorporating the TyG index to the Global Registry of Acute Coronary Events risk score or baseline risk model with fully adjusted factors considerably enhanced the forecast of MACE, as demonstrated by the C-statistic, continuous NRI, and IDI. CONCLUSIONS The TyG index might serve as a valuable and dependable indicator of MACE risk in individuals with dialysis and CAD, indicating its potential significance in enhancing risk categorization in clinical settings.
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Affiliation(s)
- Enmin Xie
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zixiang Ye
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yaxin Wu
- Department of Cardiology, Henan Provincial People's Hospital, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Xuecheng Zhao
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yike Li
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Nan Shen
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yanxiang Gao
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Jingang Zheng
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China.
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.
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Zhang RT, Liu Y, Lin KK, Jia WN, Wu QY, Wang J, Bai XY. Development of a clinical automatic calculation of hypoglycemia during hemodialysis risk in patients with diabetic nephropathy. Diabetol Metab Syndr 2023; 15:199. [PMID: 37833779 PMCID: PMC10571353 DOI: 10.1186/s13098-023-01177-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 10/01/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Hypoglycemia is one of the most common complications in patients with DN during hemodialysis. The purpose of the study is to construct a clinical automatic calculation to predict risk of hypoglycemia during hemodialysis for patients with diabetic nephropathy. METHODS In this cross-sectional study, patients provided information for the questionnaire and received blood glucose tests during hemodialysis. The data were analyzed with logistic regression and then an automated calculator for risk prediction was constructed based on the results. From May to November 2022, 207 hemodialysis patients with diabetes nephropathy were recruited. Patients were recruited at blood purifying facilities at two hospitals in Beijing and Inner Mongolia province, China. Hypoglycemia is defined according to the standards of medical care in diabetes issued by ADA (2021). The blood glucose meter was used uniformly for blood glucose tests 15 minutes before the end of hemodialysis or when the patient did not feel well during hemodialysis. RESULTS The incidence of hypoglycemia during hemodialysis was 50.2% (104/207). The risk prediction model included 6 predictors, and was constructed as follows: Logit (P) = 1.505×hemodialysis duration 8~15 years (OR = 4.506, 3 points) + 1.616×hemodialysis duration 16~21 years (OR = 5.032, 3 points) + 1.504×having hypotension during last hemodialysis (OR = 4.501, 3 points) + 0.788×having hyperglycemia during the latest hemodialysis night (OR = 2.199, 2 points) + 0.91×disturbance of potassium metabolism (OR = 2.484, 2 points) + 2.636×serum albumin<35 g/L (OR = 13.963, 5 points)-4.314. The AUC of the prediction model was 0.866, with Matthews correlation coefficient (MCC) of 0.633, and Hosmer-Lemeshow χ2 of 4.447(P = 0.815). The automatic calculation has a total of 18 points and four risk levels. CONCLUSIONS The incidence of hypoglycemia during hemodialysis is high in patients with DN. The risk prediction model in this study had a good prediction outcome. The hypoglycemia prediction automatic calculation that was developed using this model can be used to predict the risk of hypoglycemia in DN patients during hemodialysis and also help identify those with a high risk of hypoglycemia during hemodialysis.
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Affiliation(s)
- Rui-Ting Zhang
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Yu Liu
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China.
| | - Ke-Ke Lin
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Wan-Ning Jia
- Blood Purification Center of China-Japan Friendship Hospital, Beijing, China
| | - Quan-Ying Wu
- Nursing Department, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Wang
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Xiao-Yan Bai
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
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10
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Horne C, Cranston I, Amos M, Flowers K. Accuracy of Continuous Glucose Monitoring in an Insulin-Treated Population Requiring Haemodialysis. J Diabetes Sci Technol 2023; 17:971-975. [PMID: 37148160 PMCID: PMC10347996 DOI: 10.1177/19322968231173447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Continuous glucose monitoring (CGM) is revolutionizing diabetes care by giving both patients and the healthcare professionals unprecedented insights into glucose variability and patterns. It is established in National Institute for Health and Care Excellence (NICE) guidance as a standard of care for type 1 diabetes and diabetes in pregnancy under certain conditions. Diabetes mellitus (DM) is recognized as an important risk factor for chronic kidney disease (CKD). Around a third of patients receiving in-center haemodialysis as renal replacement therapy (RRT) have diabetes, either as a direct cause of renal failure or as an additional co-morbidity. Evidence of poor compliance with the current standard of care (self-monitoring of blood glucose [SMBG]) and overall greater morbidity and mortality, suggests this patient population as an ideal target group for CGM. However, there exists no strong published evidence showing the validity of CGM devices in insulin-treated diabetes patients requiring haemodialysis. METHODS We applied a Freestyle Libre Pro sensor to 69 insulin-treated diabetes haemodialysis (HD) patients on a dialysis day. Interstitial glucose levels were obtained, and time matched within 7 minutes to capillary blood glucose testing and any plasma blood glucose levels sent. Data cleansing techniques were applied to account for rapidly correcting hypoglycaemia and poor SMBG technique. RESULTS Clarke-error grid analysis showed 97.9% of glucose values in an acceptable range of agreement (97.3% on dialysis days and 99.1% on non-dialysis days). CONCLUSIONS We conclude that the Freestyle Libre sensor is accurate in measuring glucose levels when compared to glucose as measured by capillary SMBG testing and laboratory obtained serum glucose in patients on HD.
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Affiliation(s)
- Christopher Horne
- Department of Diabetes and Endocrinology, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Iain Cranston
- Department of Diabetes and Endocrinology, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Mark Amos
- Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Katey Flowers
- Wessex Kidney Centre, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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11
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Takao N, Maruyama T, Kobayashi H, Kitai M, Yoshida Y, Takashima H, Abe M. Kinetics of Glucoregulatory Peptide Hormones during Hemodialysis with Cellulose Triacetate and Polysulfone Dialyzers in Patients with Diabetes and End-Stage Kidney Disease. Int J Mol Sci 2023; 24:10604. [PMID: 37445782 DOI: 10.3390/ijms241310604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023] Open
Abstract
The mechanisms behind reported decreases in plasma insulin and glucagon during hemodialysis (HD) are not clear. Here, we investigated these mechanisms during HD treatment and the characteristics of insulin and glucagon removal when using two super high-flux membranes. In an experimental study, clearance, adsorption rates, and reduction rates of insulin and glucagon were investigated when using cellulose triacetate (CTA) and polysulfone (PS) membranes in a closed circuit using bovine blood. In a clinical study, 20 diabetes patients with end-stage kidney disease who were stable on HD were randomly selected for two HD sessions with two different membranes. At 1 h after the initiation of HD, insulin and glucagon clearance were measured, and the reduction rates were also investigated. In the experimental study, the PS membrane showed significantly higher clearance, adsorption rates, and reduction rates of insulin and glucagon compared with the CTA membrane. Although glucagon was detected in the ultrafiltration fluids in both membranes, insulin was absent in the PS membrane. In the clinical study, both membranes showed significant reductions in plasma insulin and glucagon at each time point. The PS membrane showed significantly higher insulin clearance and reduction rates compared with the CTA membrane. The two membranes showed no significant difference in glucagon clearance, but the glucagon reduction rate was significantly higher with the PS membrane. Our findings show that HD with the two super high-flux membranes used removes significant amounts of glucoregulatory peptide hormones from plasma in patients with diabetes and end-stage kidney disease, potentially affecting their glucose metabolism.
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Affiliation(s)
- Nobuteru Takao
- Division of Nephrology, Hypertension and Endocrinology, Department of Medicine, Nihon University School of Medicine, Itabashi City, Tokyo 173-8610, Japan
| | - Takashi Maruyama
- Division of Nephrology, Hypertension and Endocrinology, Department of Medicine, Nihon University School of Medicine, Itabashi City, Tokyo 173-8610, Japan
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Department of Medicine, Nihon University School of Medicine, Itabashi City, Tokyo 173-8610, Japan
| | - Maki Kitai
- Division of Nephrology, Hypertension and Endocrinology, Department of Medicine, Nihon University School of Medicine, Itabashi City, Tokyo 173-8610, Japan
| | - Yoshinori Yoshida
- Division of Nephrology, Hypertension and Endocrinology, Department of Medicine, Nihon University School of Medicine, Itabashi City, Tokyo 173-8610, Japan
| | - Hiroyuki Takashima
- Division of Nephrology, Hypertension and Endocrinology, Department of Medicine, Nihon University School of Medicine, Itabashi City, Tokyo 173-8610, Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Medicine, Nihon University School of Medicine, Itabashi City, Tokyo 173-8610, Japan
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12
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Lu JC, Lee P, Ierino F, MacIsaac RJ, Ekinci E, O'Neal D. Challenges of Glycemic Control in People With Diabetes and Advanced Kidney Disease and the Potential of Automated Insulin Delivery. J Diabetes Sci Technol 2023:19322968231174040. [PMID: 37162092 DOI: 10.1177/19322968231174040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Diabetes is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease in the world. It is known that maintaining optimal glycemic control can slow the progression of CKD. However, the failing kidney impacts glucose and insulin metabolism and contributes to increased glucose variability. Conventional methods of insulin delivery are not well equipped to adapt to this increased glycemic lability. Automated insulin delivery (AID) has been established as an effective treatment in patients with type 1 diabetes mellitus, and there is emerging evidence for their use in type 2 diabetes mellitus. However, few studies have examined their role in diabetes with concurrent advanced CKD. We discuss the potential benefits and challenges of AID use in patients with diabetes and advanced CKD, including those on dialysis.
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Affiliation(s)
- Jean C Lu
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, VIC, Australia
| | - Petrova Lee
- Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Francesco Ierino
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
- Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
- St Vincent's Institute of Medical Research, Fitzroy, VIC, Australia
| | - Richard J MacIsaac
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, VIC, Australia
| | - Elif Ekinci
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, VIC, Australia
- Department of Endocrinology and Diabetes, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, Austin Hospital, The University of Melbourne, Heidelberg, VIC, Australia
| | - David O'Neal
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, VIC, Australia
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13
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Avari P, Tang W, Jugnee N, Hersi I, Al-Balah A, Tan T, Frankel A, Oliver N, Reddy M. The Accuracy of Continuous Glucose Sensors in People with Diabetes Undergoing Haemodialysis (ALPHA Study). Diabetes Technol Ther 2023. [PMID: 36961385 DOI: 10.1089/dia.2023.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
OBJECTIVES Real-time and intermittently scanned continuous glucose monitoring are increasingly used for glucose monitoring in people with diabetes requiring renal replacement therapy, with limited data reporting their accuracy in this cohort. We evaluated the accuracy of Dexcom G6 and Abbott Freestyle Libre 1 glucose monitoring systems in people with diabetes undergoing haemodialysis. METHODS Participants on haemodialysis with diabetes (on insulin or sulfonylureas) were recruited. Paired sensor glucose from Dexcom G6 and Freestyle Libre 1 were recorded with plasma glucose analysed using the YSI (Yellow Springs Instrument) method at frequent intervals during haemodialysis. Analysis of accuracy metrics included mean absolute relative difference (MARD), Clarke Error Grid (CEG) analysis and proportion of CGM values within 15 and 20% or 15 and 20mg/dL of YSI reference values for blood glucose >100 mg/dL or ≤100 mg/dL, respectively (% 15/15, % 20/20). RESULTS Forty adults (median age 64.7 (60.2-74.4) years) were recruited. Overall MARD for Dexcom G6 was 22.7% (2,656 matched glucose pairs), and 11.3% for Libre 1 (n=2,785). The proportions of readings meeting %15/15 and %20/20 were 29.1% and 45.4% for Dexcom G6, respectively, and 73.5% and 85.6% for Libre 1. CEG analysis showed 98.9% of all values in zones A and B for Dexcom G6 and 99.8% for Libre 1. CONCLUSIONS Our results indicate Freestyle Libre 1 is a reliable tool for glucose monitoring in adults on haemodialysis. Further studies are required to evaluate Dexcom G6 accuracy in people on haemodialysis. Small molecule interferents may affect electrochemical glucose sensors in end-stage kidney disease.
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Affiliation(s)
- Parizad Avari
- Imperial College London, 4615, Department of Metabolism, Digestion and Reproduction, London, United Kingdom of Great Britain and Northern Ireland;
| | - Wenxi Tang
- Imperial College London, 4615, Department of Metabolism, Digestion and Reproduction, London, United Kingdom of Great Britain and Northern Ireland;
| | - Narvada Jugnee
- Imperial College London, 4615, Department of Metabolism, Digestion and Reproduction, London, London, United Kingdom of Great Britain and Northern Ireland;
| | - Ibrahim Hersi
- Imperial College London, 4615, Department of Metabolism, Digestion and Reproduction, London, United Kingdom of Great Britain and Northern Ireland;
| | - Amer Al-Balah
- Imperial College London, 4615, Department of Metabolism, Digestion and Reproduction, London, United Kingdom of Great Britain and Northern Ireland;
| | - Tricia Tan
- Imperial College London, 4615, Department of Metabolism, Digestion and Reproduction, London, United Kingdom of Great Britain and Northern Ireland;
| | - Andrew Frankel
- Imperial College London, 4615, Department of Metabolism, Digestion and Reproduction, London, United Kingdom of Great Britain and Northern Ireland;
| | - Nick Oliver
- Imperial College London, 4615, Department of Metabolism, Digestion and Reproduction, London, United Kingdom of Great Britain and Northern Ireland;
| | - Monika Reddy
- Imperial College London, 4615, Department of Metabolism, Digestion and Reproduction, London, United Kingdom of Great Britain and Northern Ireland;
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14
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Hayashi A, Shimizu N, Suzuki A, Fujishima R, Matoba K, Moriguchi I, Kobayashi N, Miyatsuka T. Novel clinical relationships between time in range and microangiopathies in people with type 2 diabetes mellitus on hemodialysis. J Diabetes Complications 2023; 37:108470. [PMID: 37043984 DOI: 10.1016/j.jdiacomp.2023.108470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/07/2023] [Accepted: 03/25/2023] [Indexed: 04/03/2023]
Abstract
AIMS/HYPOTHESIS We investigated associations among glucose time in range (TIR, 70-180 mg/dL), glycemic markers and prevalence of diabetic microangiopathy in people with diabetes undergoing hemodialysis (HD). METHODS A total of 107 people with type 2 diabetes undergoing HD (HbA1c 6.4 %; glycated albumin [GA] 20.6 %) using continuous glucose monitoring were analyzed in this observational and cross-sectional study. RESULTS HbA1c and GA levels significantly negatively correlated with TIR, and positively correlated with time rate of hyperglycemia, but not with time rate of hypoglycemia. TIR of 70 % corresponded to HbA1c of 6.5 % and GA of 21.2 %. The estimated HbA1c level corresponding to TIR of 70 % in this study was lower than that previously reported in people with diabetes without HD. The prevalence of diabetic neuropathy was not significantly different between people with TIR ≥ 70 % and those with TIR < 70 % (P = 0.1925), but the prevalence of diabetic retinopathy in people with TIR ≥ 70 % was significantly lower than in those with TIR < 70 % (P = 0.0071). CONCLUSION/INTERPRETATION TIR correlated with HbA1c and GA levels in people with type 2 diabetes on HD. Additionally, a higher TIR resulted in a lower rate of diabetic retinopathy. RESEARCH IN CONTEXT What is already known about this subject? What is the key question? What are the new findings? How might this impact on clinical practice in the foreseeable future?
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15
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Zanchi A, Jehle AW, Lamine F, Vogt B, Czerlau C, Bilz S, Seeger H, de Seigneux S. Diabetic kidney disease in type 2 diabetes: a consensus statement from the Swiss Societies of Diabetes and Nephrology. Swiss Med Wkly 2023; 153:40004. [PMID: 36652726 DOI: 10.57187/smw.2023.40004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Diabetic kidney disease is highly prevalent in patients with type 2 diabetes and is a major cause of end-stage renal disease in Switzerland. Patients with diabetic kidney disease are among the most complex patients in diabetes care. They require a multifactorial and multidisciplinary approach with the goal to slow the decline in glomerular filtration rate (GFR) and cardiovascular morbidity. With this consensus we propose an evidence-based guidance to health care providers involved in the care of type 2 diabetic patients with diabetic kidney disease.First, there is a need to increase physician awareness and improve screening for diabetic kidney disease as early intervention may improve clinical outcomes and the financial burden. Evaluation of estimated GFR (eGFR) and spot urine albumin/creatinine ratio is recommended at least annually. Once it is diagnosed, glucose control and optimisation of blood pressure control with renin-angiotensin system blockers have been recommended as mainstay management of diabetic kidney disease for more than 20 years. Recent, high quality randomised controlled trials have shown that sodium-glucose cotransporter-2 (SGLT2) inhibition slows eGFR decline and cardiovascular events beyond glucose control. Likewise, mineralocorticoid receptor antagonism with finerenone has cardiorenal protective effects in diabetic kidney disease. Glucagon-like peptide-1 (GLP1) receptor agonists improve weight loss if needed, and decrease albuminuria and cardiovascular morbidity. Lipid control is also important to decrease cardiovascular events. All these therapies are included in the treatment algorithms proposed in this consensus. With advancing kidney failure, other challenges may rise, such as hyperkalaemia, anaemia and metabolic acidosis, as well as chronic kidney disease-mineral and bone disorder. These different topics and treatment strategies are discussed in this consensus. Finally, an update on diabetes management in renal replacement therapy such as haemodialysis, peritoneal dialysis and renal transplantation is provided. With the recent developments of efficient therapies for diabetic kidney disease, it has become evident that a consensus document is necessary. We are optimistic that it will significantly contribute to a high-quality care for patients with diabetic kidney disease in Switzerland in the future.
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Affiliation(s)
- Anne Zanchi
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Service of Endocrinology, Diabetes and Metabolism, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Andreas W Jehle
- Department of Internal Medicine, Hirslanden Klinik St. Anna, Lucerne, Switzerland.,Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Faiza Lamine
- Service of Endocrinology, Diabetes and Metabolism, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Unit of Diabetes and Endocrinology, Department of Internal Medicine, Riviera-Chablais Hospital (HRC), Rennaz, Switzerland
| | - Bruno Vogt
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Cecilia Czerlau
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Stefan Bilz
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, Switzerland
| | - Harald Seeger
- Division of Nephrology, University Hospital Zurich, Switzerland
| | - Sophie de Seigneux
- Service of Nephrology and Hypertension, Department of Medicine, Geneva University Hospital, Switzerland
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16
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Li M, Li Y, Lv J, Xu H, Wu X, Wen W, Wang W, Yang H. The effects of glucose-free and glucose-containing dialysate during dialysis in MHD patients: a prospective cross-over study. Perfusion 2023; 38:178-185. [PMID: 34541941 DOI: 10.1177/02676591211042726] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To investigate the effects of glucose-free and glucose-containing dialysates during dialysis in maintenance hemodialysis (MHD) patients by the prospective cross-over study, and detect glucose control methods in MHD patients. METHODS A total of 66 MHD 18-75 years old patients in our hospital from Nov. 2019 to Mar. 2020 were recruited. All patients underwent HD with 4 hours per time, three times per week. Glucose-free dialysate (glucose-free group) and then 5.55 mmol/L glucose-containing dialysate (glucose-5.55 group) were used alternately in dialysis. The demographics and parameters of pre- and post-dialysis were recorded. RESULTS A total of 60 patients were analyzed, and 28 patients among them had type 2 diabetes. Serum glucose pre and post dialysis were 8.64 ± 4.18 mmol/L versus 5.74 ± 1.82 mmol/L (p < 0.01) in glucose-free dialysate, and 9.31 ± 4.89 mmol/L versus 7.80 ± 2.59 mmol/L (p < 0.01) in glucose-5.55 dialysate. The post-dialysis blood glucose of glucose-free group was lower than glucose-5.55 group (5.74 ± 1.82 vs 7.80 ± 2.59, p < 0.01). About 18 (30.00%) patients in glucose-free group and 1 patient (1.67%) in glucose-5.55 group whose blood glucose was lower than 4.44 mmol/L (p < 0.01). About 29 patients (48.33%) in glucose-free group and 17 patients (28.33%; p = 0.02) in glucose-5.55 group have hunger feeling. Serum sodium level in the glucose-free group was higher than that in Glucose-5.55 group (137.92 ± 1.64 vs 136.70 ± 1.64, p < 0.01). Post-dialysis blood glucose had no significant differences between patients not using diabetes-related medication (13 patients) and patients using diabetes-related medication (15 patients) in glucose-free group (7.13 ± 1.78 mmol/L vs 6.08 ± 2.84 mmol/L, p = 0.23) and glucose-5.55 group (9.22 ± 2.59 mmol/L vs 9.35 ± 2.88 mmol/L, p = 0.90). CONCLUSIONS Glucose-free and glucose-5.55 dialysate both decrease the blood glucose post-dialysis. Dialysates containing 5.55 mmol/L glucose can reduce the incidence of hypoglycemia and lower serum sodium, but have no effect on blood pressure during dialysis. Stopping insulin and oral anti-diabetic drugs once before dialysis may not affect the control of blood glucose.
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Affiliation(s)
- Minxia Li
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Yuehong Li
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Jiaxuan Lv
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Huiying Xu
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Xianglan Wu
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Wen Wen
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Wei Wang
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Hua Yang
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
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Galindo RJ, de Boer IH, Neumiller JJ, Tuttle KR. Continuous Glucose Monitoring to Optimize Management of Diabetes in Patients with Advanced CKD. Clin J Am Soc Nephrol 2023; 18:130-145. [PMID: 36719162 PMCID: PMC10101590 DOI: 10.2215/cjn.04510422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Treatment of patients with diabetes and CKD includes optimizing glycemic control using lifestyle modifications and drugs that safely control glycemia and improve clinical kidney and cardiovascular disease outcomes. However, patients with advanced CKD, defined as eGFR <30 ml/min per 1.73 m2 or kidney disease treated with dialysis, have limitations to the use of some preferred glucose-lowering medications, are often treated with insulin, and experience high rates of severe hypoglycemia. Moreover, hemoglobin A1c accuracy decreases as GFR deteriorates. Hence, there is a need for better glycemic monitoring tools. Continuous glucose monitoring allows for 24-hour glycemic monitoring to understand patterns and the effects of lifestyle and medications. Real-time continuous glucose monitoring can be used to guide the administration of insulin and noninsulin therapies. Continuous glucose monitoring can overcome the limitations of self-monitored capillary glucose testing and hemoglobin A1c and has been shown to prevent hypoglycemic excursions in some populations. More data are needed to understand whether similar benefits can be obtained for patients with diabetes and advanced CKD. This review provides an updated approach to management of glycemia in advanced CKD, focusing on the role of continuous glucose monitoring in this high-risk population.
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Affiliation(s)
- Rodolfo J. Galindo
- Division of Endocrinology, Emory University School of Medicine, Atlanta, Georgia
| | - Ian H. de Boer
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington
| | - Joshua J. Neumiller
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington
| | - Katherine R. Tuttle
- Nephrology Division, Kidney Research Institute and Institute of Translational Health Sciences, University of Washington, Seattle, Washington
- Providence Medical Research Center, Providence Health Care, Spokane, Washington
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Maganeva IS, Eremkina AK, Miliutina AP, Martynov SA, Severina AS, Salimkhanov RH, Evloeva MI, Shamkhalova MS, Shestakova MV, Mokrysheva NG. The structure of mineral and bone disorders in patients with сhronic kidney disease of the 5th dialysis stage, taking into account the presence or absence of a diagnosis of type 1 diabetes mellitus. DIABETES MELLITUS 2022. [DOI: 10.14341/dm12958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND: In patients with end-stage CKD, receiving renal replacement therapy (RRT) with programmed hemodialysis (HD), the severity of complications is associated with metabolic disturbances: accumulation of uremic toxins, nephrogenic anemia, secondary hyperparathyroidism (SHPT), extraskeletal calcification, impaired clearance and rhythm of hormone secretion.AIM: To evaluate the main biochemical and hormonal parameters, and manifestations of mineral bone disease (MBD) in patients receiving RRT with HD, before and after hemodialysis, taking into account the presence or absence of diabetes mellitus.MATERIALS AND METHODS: We divided all patients receiving RRT with HD in two groups: #1 (n=24) — patients with DM, #2 (n=16) — patients without DM. All of them had their blood analyzed before and immediately after the HD. Data analysis was performed with the Statistica 13 (StatSoft, USA). A prognostically significant model was considered at p<0.05.RESULTS: The level of iPTH, both at baseline and after HD, was lower in group #1 (p<0.001). The level of alkaline phosphatase (AP) was significantly higher in group #2 (p=0.012). In both groups before HD, a high incidence of hypocalcemia was detected (according to albumin-corrected calcium in group #1 in 58.3%, in group #2 in 43.7% of cases, p = 0.366) and hyperphosphatemia (in 66.7% and in 43 .7% of cases, respectively, p=0.151). Hypocalcemia after HD in group #1 persisted in 14%, in group #2 — in 20% of cases (p>0.05); hyperphosphatemia in group #1 was completely leveled, in group #2 it persisted in 7% of cases (p=0.417). Prior to the HD session, group #1 had significantly higher levels of RAGE, glucagon, immunoreactive insulin (IRI), cortisol, and glucose than after the HD session (p<0.05). In group #2, after HD, the levels of glucagon, IRI and cortisol significantly decreased (p<0.05), and the level of 3-nitrotyrosine (3-HT) increased significantly (p=0.026). In group #1, fibrocalcinosis of the heart valves according to ECHO and calcification of the arteries of the lower extremities according to ultrasonic doplerography were more common than in group #2 (42% vs 25%, p<0.001 and 75% vs 37.5%, p=0.018, respectively). (χ2)). Compression fractures occurred with the same frequency in both groups (60%). A decrease in bone mineral density (BMD) to the level of osteopenia was noted more often in group #1 (50% vs 18.8%), and osteoporosis was more common in group #2 (68.8% vs 33.3%) (p<0.001, χ2).CONCLUSION: The low level of PTH in group #1 may reflect the effect of diabetes on calcium-phosphorus metabolism. Patients with DM have an increased risk of renal osteodystrophy with a low bone turnover because of a number of metabolic factors inherent in diabetes. At the same time, the dynamics of phosphorus and calcium indicators during the HD procedure were similar.
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Affiliation(s)
| | | | - A. P. Miliutina
- Endocrinology Research Centre; Pirogov Russian National Research Medical University
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Dialysis as a Novel Adjuvant Treatment for Malignant Cancers. Cancers (Basel) 2022; 14:cancers14205054. [PMID: 36291840 PMCID: PMC9600214 DOI: 10.3390/cancers14205054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary There is a clear need for new cancer therapies as many cancers have a very short long-term survival rate. For most advanced cancers, therapy resistance limits the benefit of any single-agent chemotherapy, radiotherapy, or immunotherapy. Cancer cells show a greater dependence on glucose and glutamine as fuel than healthy cells do. In this article, we propose using 4- to 8-h dialysis treatments to change the blood composition, i.e., lowering glucose and glutamine levels, and elevating ketone levels—thereby disrupting major metabolic pathways important for cancer cell survival. The dialysis’ impact on cancer cells include not only metabolic effects, but also redox balance, immunological, and epigenetic effects. These pleiotropic effects could potentially enhance the effectiveness of traditional cancer treatments, such as radiotherapies, chemotherapies, and immunotherapies—resulting in improved outcomes and longer survival rates for cancer patients. Abstract Cancer metabolism is characterized by an increased utilization of fermentable fuels, such as glucose and glutamine, which support cancer cell survival by increasing resistance to both oxidative stress and the inherent immune system in humans. Dialysis has the power to shift the patient from a state dependent on glucose and glutamine to a ketogenic condition (KC) combined with low glutamine levels—thereby forcing ATP production through the Krebs cycle. By the force of dialysis, the cancer cells will be deprived of their preferred fermentable fuels, disrupting major metabolic pathways important for the ability of the cancer cells to survive. Dialysis has the potential to reduce glucose levels below physiological levels, concurrently increase blood ketone body levels and reduce glutamine levels, which may further reinforce the impact of the KC. Importantly, ketones also induce epigenetic changes imposed by histone deacetylates (HDAC) activity (Class I and Class IIa) known to play an important role in cancer metabolism. Thus, dialysis could be an impactful and safe adjuvant treatment, sensitizing cancer cells to traditional cancer treatments (TCTs), potentially making these significantly more efficient.
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Alicic RZ, Neumiller JJ, Galindo RJ, Tuttle KR. Use of Glucose-Lowering Agents in Diabetes and CKD. Kidney Int Rep 2022; 7:2589-2607. [PMID: 36506243 PMCID: PMC9727535 DOI: 10.1016/j.ekir.2022.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/31/2022] [Accepted: 09/19/2022] [Indexed: 12/15/2022] Open
Abstract
Diabetes is the most common cause of kidney failure worldwide. Patients with diabetes and chronic kidney disease (CKD) are also at markedly higher risk of cardiovascular disease, particularly heart failure (HF), and death. Through the processes of gluconeogenesis and glucose reabsorption, the kidney plays a central role in glucose homeostasis. Insulin resistance is an early alteration observed in CKD, worsened by the frequent presence of hypertension, obesity, and ongoing chronic inflammation, and oxidative stress. Management of diabetes in moderate to severe CKD warrants special consideration because of changes in glucose and insulin homeostasis and altered metabolism of glucose-lowering therapies. Kidney failure and initiation of kidney replacement therapy by dialysis adds to management complexity by further limiting therapeutic options, and predisposing individuals to hypoglycemia and hyperglycemia. Glycemic goals should be individualized, considering CKD severity, presence of macrovascular and microvascular complications, and life expectancy. A general hemoglobin A1c (HbA1c) goal of approximately 7% may be appropriate in earlier stages of CKD, with more relaxed targets often appropriate in later stages. Use of sodium glucose cotransporter2 (SGLT2) inhibitors and glucagon like peptide-1 receptor agonists (GLP-1RAs) meaningfully improves kidney and heart outcomes for patients with diabetes and CKD, irrespective of HbA1c targets, and are now part of guideline-directed medical therapy in this high-risk population. Delivery of optimal care for patients with diabetes and CKD will require collaboration across health care specialties and disciplines.
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Affiliation(s)
- Radica Z. Alicic
- Providence Medical Research Center, Providence Health Care, Spokane, Washington, USA
- Department of Medicine, University of Washington School of Medicine, Spokane and Seattle, Washington, USA
- Correspondence: Radica Z. Alicic, Providence Medical Research Center, 105 West 8th Avenue, Suite 250E, Spokane, Washington 99204, USA.
| | - Joshua J. Neumiller
- Providence Medical Research Center, Providence Health Care, Spokane, Washington, USA
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington, USA
| | - Rodolfo J. Galindo
- Department of Medicine, Division of Endocrinology, Emory University School of Medicine
| | - Katherine R. Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, Washington, USA
- Department of Medicine, University of Washington School of Medicine, Spokane and Seattle, Washington, USA
- Nephrology Division, Kidney Research Institute and Institute of Translational Health Sciences, University of Washington, Spokane and Seattle, Washington, USA
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Evaluation of the relationship between hemodialysis-related glycemic variability and hormonal profiles in patients with type 2 diabetes on hemodialysis: a pilot study. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00429-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The number of dialysis patients with diabetes is currently increasing in Japan and a similar proportion worldwide. It was suggested that approximately 20% of these patients had hypoglycemia after dialysis session and most of these hypoglycemia were unconscious. Furthermore, it was suggested that glucose variabilities induced by hemodialysis may be related to insulin and insulin-counter hormones, such as glucagon, adrenocorticotropic hormone (ACTH), and cortisol and growth hormone, but conclusive evidence has not still been obtained.
Methods
We investigated in detail the glucose and hormonal profiles in 7 patients with type 2 diabetes on hemodialysis (all male, HbA1c 6.8 ± 2.1%, glycated albumin 24.7 ± 10.2%). All participants were attached continuous glucose monitoring (iPro2®). Blood glucose level, C-peptide immunoreactivity, plasma glucagon, ACTH, cortisol and growth hormone were measured by 7 points blood tests at before breakfast, after breakfast (predialysis), 2 h and 4 h after starting dialysis, after lunch and before/after dinner on the dialysis day and 6 points at before/after each meal on the non-dialysis day, and these relationship with blood glucose dynamics were examined. The meal contents were set to the indicated energy amount, and the same menu was served daily for breakfast, lunch, and dinner on dialysis and non-dialysis days of this study period. In addition, the start time of lunch on non-dialysis day was the same as the start time of lunch on the dialysis day.
Results
Serum C-peptide level was significantly increased by taking breakfast and lunch on the hemodialysis day, significantly decreased during hemodialysis, and was significantly lower before and after lunch on the hemodialysis day than on the non-hemodialysis day. Plasma glucagon level significantly decreased during hemodialysis and that before lunch on hemodialysis day was significantly lower than on non-hemodialysis day. ACTH, cortisol, and growth hormone did not show any changes related to hemodialysis.
Conclusions
It was suggested that C-peptide and glucagon play an important role in hemodialysis-related glycemic variabilities in patients with type 2 diabetic hemodialysis.
Trial registration UMIN Clinical Trial Registry (Registration Number UMIN000018707). Registered 18 August 2015, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&language=J&recptno=R000021647.
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Shah N, Gada JV, Billa VS, Kothari JP, Bichu SD, Usulumarty DH, Khaire SS, Varthakavi PK, Bhagwat NM. Targeting Predialysis Glucose up to 180 mg/dl Reduces Glycemic Variability in End Stage Diabetic Nephropathy. Indian J Endocrinol Metab 2022; 26:439-445. [PMID: 36618515 PMCID: PMC9815189 DOI: 10.4103/ijem.ijem_157_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/15/2022] [Accepted: 08/26/2022] [Indexed: 11/19/2022] Open
Abstract
Context Glycemic variability plays a major role in the development as well as the progression of cardiovascular disease in diabetes. Aims We compared the mean plasma glucose and glycemic variability (GV) parameters on and off hemodialysis (HD) in patients with End-Stage Diabetic Nephropathy (ESDN) and End-Stage Renal Disease (ESRD). Settings and Design Cross-sectional study. Methods and Material We included 23 ESDN and 6 ESRD patients who underwent continuous glucose monitoring (CGM) (iPro2) for 6 days and a glucose-free dialysate for 4 hours thrice weekly. EasyGV software was used to calculate the variability parameters {mean glucose, Time in range (TIR), Time above and below range (TAR/TBR), CV (Coefficient of Variation) and MAGE}. Statistical Analysis Used The quantitative data variables were expressed by using mean and SD. Unpaired t-test was used to compare the two groups. P value <0.05 was considered significant. Results In the ESDN group, TIR was significantly lower whereas TAR and TBR were significantly higher on HD day. MAGE (101.88 ± 40.5 v/s 89.46 ± 30.0, P < 0.007) and CV (29.41% v/s 21.67%) were higher on HD day. Subjects with pre-HD glucose values ≥180 mg/dl (Group B, n = 24) had a rapid drop with a delayed higher rise in glucose values than those with pre-HD glucose values <180 mg/dl (Group A, n = 27). Ten patients had 13 episodes of hypoglycemia. The CGM parameters were not different in the ESRD group. Conclusions Targeting a pre- HD glucose value <180 mg/dl could be a good strategy to prevent larger fluctuation during and post HD.
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Affiliation(s)
- Nikita Shah
- Department of Endocrinology, Room No. 419, 4 Floor, College Building, Topiwala National Medical College and BYL Nair Charitable Hospital, A.L. Nair Road, Mumbai Central, Mumbai, Maharashtra, India
| | - Jugal V. Gada
- Department of Endocrinology, Room No. 419, 4 Floor, College Building, Topiwala National Medical College and BYL Nair Charitable Hospital, A.L. Nair Road, Mumbai Central, Mumbai, Maharashtra, India
| | - Vishwanath S. Billa
- Department of Nephrology, Sushrut Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Jatin Piyush Kothari
- Department of Nephrology, P.D. Hinduja Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Shrirang D. Bichu
- Department of Nephrology, Head of Nephrology, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Deepa H. Usulumarty
- Department of Nephrology, Sushrut Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Suhas S. Khaire
- Department of Endocrinology, Room No. 419, 4 Floor, College Building, Topiwala National Medical College and BYL Nair Charitable Hospital, A.L. Nair Road, Mumbai Central, Mumbai, Maharashtra, India
| | - Premlata K. Varthakavi
- Department of Endocrinology, Room No. 419, 4 Floor, College Building, Topiwala National Medical College and BYL Nair Charitable Hospital, A.L. Nair Road, Mumbai Central, Mumbai, Maharashtra, India
| | - Nikhil M. Bhagwat
- Department of Endocrinology, Room No. 419, 4 Floor, College Building, Topiwala National Medical College and BYL Nair Charitable Hospital, A.L. Nair Road, Mumbai Central, Mumbai, Maharashtra, India
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WANG F, WANG D, LU XL, SUN XM, DUAN BH. Continuous glucose monitoring in diabetes patients with chronic kidney disease on dialysis: a meta-analysis. Minerva Endocrinol (Torino) 2022; 47:325-333. [DOI: 10.23736/s2724-6507.20.03284-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Markova TN, Yavorskaya VO. Prevalence of carbohydrate metabolism disorders in patients with end-stage renal disease on hemodialysis therapy. DIABETES MELLITUS 2022. [DOI: 10.14341/dm12920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- T. N. Markova
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov;
Moscow City Hospital 52
| | - V. O. Yavorskaya
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
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Fujiwara M, Ando I, Shishido Y, Imai Y, Terawaki H. Amino acid availability enhanced through glucose coadministration of amino acid supplementation during hemodiafiltration: two case reports. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00417-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Intravenous administration of amino acid (AA) formulation (IVAA) as intradialytic parenteral nutrition is widely used for malnourished patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) or hemodiafiltration (HDF). Although various therapy recipes such as AA compositions or simultaneous administration of glucose and/or lipids have been attempted, the specific effects of each recipe on AA behaviors and metabolic consequences have not been well investigated. To clarify the effect of simultaneous glucose administration with IVAA, we investigated the behavior of AAs, insulin as a metabolic hormone, and energy-related metabolites during an HDF session in two patients.
Case presentation
We aimed to determine the effect of IVAA with or without simultaneous glucose administration. The plasma levels of AAs, branched-chain AAs (leucine, isoleucine, and valine), major nonessential AAs (alanine and glutamine with glutamate), insulin, glucose, and ketone bodies were measured before HDF and at the second hour (prior to the meal in the HDF session). Lost AAs in the spent dialysate were also measured for the first two hours during the HDF session.
Conclusion
In the absence of glucose administration, plasma AA levels and the loss of AAs in the dialysate increased owing to IVAA, with the increase in plasma levels in ketone bodies occurring because of scarce secretion of plasma insulin. In the presence of glucose administration, plasma levels and the loss of AA decreased even when the same amount of AAs was injected, possibly because of the profound secretion of insulin with a decrease in ketone bodies. The present findings suggest that the metabolic effects of simultaneous glucose administration on IVAAs enhanced AA uptake into the body during HDF sessions, which might increase the effectiveness of IVAAs.
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García-Maset R, Bover J, Segura de la Morena J, Goicoechea Diezhandino M, Cebollada Del Hoyo J, Escalada San Martin J, Fácila Rubio L, Gamarra Ortiz J, García-Donaire JA, García-Matarín L, Gràcia Garcia S, Isabel Gutiérrez Pérez M, Hernández Moreno J, Mazón Ramos P, Montañés Bermudez R, Muñoz Torres M, de Pablos-Velasco P, Pérez-Maraver M, Suárez Fernández C, Tranche Iparraguirre S, Luis Górriz J. Information and consensus document for the detection and management of chronic kidney disease. Nefrologia 2022; 42:233-264. [PMID: 36210616 DOI: 10.1016/j.nefroe.2022.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 06/16/2023] Open
Abstract
Chronic kidney disease (CKD) is a major public health problem worldwide that affects more than 10% of the Spanish population. CKD is associated with high comorbidity rates, poor prognosis and major consumption of health system resources. Since the publication of the last consensus document on CKD seven years ago, little evidence has emerged and few clinical trials on new diagnostic and treatment strategies in CKD have been conducted, apart from new trials in diabetic kidney disease. Therefore, CKD international guidelines have not been recently updated. The rigidity and conservative attitude of the guidelines should not prevent the publication of updates in knowledge about certain matters that may be key in detecting CKD and managing patients with this disease. This document, also prepared by 10 scientific associations, provides an update on concepts, clarifications, diagnostic criteria, remission strategies and new treatment options. The evidence and the main studies published on these aspects of CKD have been reviewed. This should be considered more as an information document on CKD. It includes an update on CKD detection, risk factors and screening; a definition of renal progression; an update of remission criteria with new suggestions in the older population; CKD monitoring and prevention strategies; management of associated comorbidities, particularly in diabetes mellitus; roles of the Primary Care physician in CKD management; and what not to do in Nephrology. The aim of the document is to serve as an aid in the multidisciplinary management of the patient with CKD based on current recommendations and knowledge.
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Affiliation(s)
| | | | - Julián Segura de la Morena
- Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA)
| | | | | | | | | | | | - Jose A García-Donaire
- Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA)
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Documento de información y consenso para la detección y manejo de la enfermedad renal crónica. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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28
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Canaud B, Kooman JP, Selby NM, Taal M, Maierhofer A, Kopperschmidt P, Francis S, Collins A, Kotanko P. Hidden risks associated with conventional short intermittent hemodialysis: A call for action to mitigate cardiovascular risk and morbidity. World J Nephrol 2022; 11:39-57. [PMID: 35433339 PMCID: PMC8968472 DOI: 10.5527/wjn.v11.i2.39] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/30/2021] [Accepted: 03/23/2022] [Indexed: 02/06/2023] Open
Abstract
The development of maintenance hemodialysis (HD) for end stage kidney disease patients is a success story that continues to save many lives. Nevertheless, intermittent renal replacement therapy is also a source of recurrent stress for patients. Conventional thrice weekly short HD is an imperfect treatment that only partially corrects uremic abnormalities, increases cardiovascular risk, and exacerbates disease burden. Altering cycles of fluid loading associated with cardiac stretching (interdialytic phase) and then fluid unloading (intradialytic phase) likely contribute to cardiac and vascular damage. This unphysiologic treatment profile combined with cyclic disturbances including osmotic and electrolytic shifts may contribute to morbidity in dialysis patients and augment the health burden of treatment. As such, HD patients are exposed to multiple stressors including cardiocirculatory, inflammatory, biologic, hypoxemic, and nutritional. This cascade of events can be termed the dialysis stress storm and sickness syndrome. Mitigating cardiovascular risk and morbidity associated with conventional intermittent HD appears to be a priority for improving patient experience and reducing disease burden. In this in-depth review, we summarize the hidden effects of intermittent HD therapy, and call for action to improve delivered HD and develop treatment schedules that are better tolerated and associated with fewer adverse effects.
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Affiliation(s)
- Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
- Department of Nephrology, Montpellier University, Montpellier 34000, France
| | - Jeroen P Kooman
- Department of Internal Medicine, Maastricht University, Maastricht 6229 HX, Netherlands
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Maarten Taal
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Andreas Maierhofer
- Global Research Development, Fresenius Medical Care, Schweinfurt 97424, Germany
| | | | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
| | - Peter Kotanko
- Renal Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10065, United States
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Cavallari G, Mancini E. The Nephrologist's Role in the Collaborative Multi-Specialist Network Taking Care of Patients with Diabetes on Maintenance Hemodialysis: An Overview. J Clin Med 2022; 11:jcm11061521. [PMID: 35329847 PMCID: PMC8949004 DOI: 10.3390/jcm11061521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 12/22/2022] Open
Abstract
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.
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Davenport A. Peri-dialytic hypoglycaemia with haemodialysis and on-line post-dilutional haemodiafiltration. Ther Apher Dial 2022; 26:1148-1155. [PMID: 35261192 DOI: 10.1111/1744-9987.13835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We wished to determine whether peri-dialytic hypoglycaemia is a clinical risk in contemporary dialysis patients using glucose containing dialysate. METHODS We measured blood glucose pre- and post-haemodialysis or haemodiafiltration, using 5.5 mmol/L glucose dialysate, and body composition by bioimpedance. RESULTS 239 patients were studied, mean age 65±15.4 years, 59.4% male, 46.4% diabetes, 81.6% treated by haemodiafiltration, Five haemodiafiltration patients (2.1%) had hypoglycaemia, with 82 (33%) a blood glucose <5.5 mmol/L, with fewer diabetics (19.8 vs 74.7%, p=0.001, and %body fat 27.7(20.6-32.6) vs 34.7(26.6-42.8)%, p=0.001. Low post-dialysis blood glucose was negatively associated with glycated haemoglobin (OR 0.94 (0.84-0.97), p=0.004), weight (OR 0.94 (0.89-0.98), p=0.009), and % body fat (OR 0.92 (0.86-0.98), p=0.013). CONCLUSIONS Although hypoglycaemia occurred in 2%, 33% had a blood glucose below dialysate glucose. Low post-dialysis glucose was associated with lower glycated haemoglobin and body fat, suggesting nutritional status is important in determining the risk of peri-dialytic hypoglycaemia.
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Affiliation(s)
- Andrew Davenport
- UCL Department of Renal Medicine Royal Free Hospital University College London Rowland Hill Street London NW3 2PF
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Fujiwara M, Ando I, Shishido Y, Imai Y, Terawaki H. An increase in circulating levels of branched-chain amino acids during hemodialysis with regard to protein breakdown: three case reports. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-021-00391-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hemodialysis (HD) is a protein catabolic event. However, the amino acid (AA) kinetics during HD sessions involved in protein breakdown have not been well investigated in patients with and without diabetes mellitus (DM).
Case presentation
Three patients (two patients with DM and one patient without DM) underwent fasting HD. Plasma levels of branched-chain AAs (BCAA; leucine, isoleucine, and valine), major non-essential AAs (alanine and glutamine, including glutamate), insulin, and ketone bodies were measured every hour during each HD session. After the start of the HD session, the plasma levels of insulin and all BCAAs dropped simultaneously. There was a significant subsequent increase in the plasma level of leucine and isoleucine levels, while valine levels remained constant. However, the recovery in levels of BCAAs during HD indicated a profound amount of BCAAs entering the blood from body tissues such as muscles. BCAAs may have surpassed their removal by HD. Ketone body levels increased continuously from the start of the sessions and reached high values in patients with DM. Synchronous changes in insulin depletion and an increase in the levels of ketone bodies may indicate disruption of energy metabolism.
Conclusions
This is the first report to demonstrate the time course of the changes in circulating levels of BCAAs and related metabolites in energy homeostasis during HD. An increase in BCAA levels during HD was found to be due to their transfer from the body tissue which suggested protein breakdown.
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Kalantar-Zadeh K, Lockwood MB, Rhee CM, Tantisattamo E, Andreoli S, Balducci A, Laffin P, Harris T, Knight R, Kumaraswami L, Liakopoulos V, Lui SF, Kumar S, Ng M, Saadi G, Ulasi I, Tong A, Li PKT. Patient-centred approaches for the management of unpleasant symptoms in kidney disease. Nat Rev Nephrol 2022; 18:185-198. [PMID: 34980890 DOI: 10.1038/s41581-021-00518-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 12/22/2022]
Abstract
Patients with chronic kidney disease (CKD) frequently experience unpleasant symptoms. These can be gastrointestinal (constipation, nausea, vomiting and diarrhoea), psychological (anxiety and sadness), neurological (lightheadedness, headache and numbness), cardiopulmonary (shortness of breath and oedema), dermatological (pruritus and dry skin), painful (muscle cramps, chest pain and abdominal pain) or involve sexual dysfunction, sleep disorders and fatigue. These symptoms often occur in clusters, with one of them as the lead symptom and others as secondary symptoms. Uraemic toxins (also called uremic toxins) are often considered to be the main cause of CKD-associated symptom burden, but treatment of uraemia by dialysis often fails to resolve them and can engender additional symptoms. Indeed, symptoms can be exacerbated by comorbid conditions, pharmacotherapies, lifestyle and dietary regimens, kidney replacement therapy and ageing. Patients with kidney disease, including those who depend on dialysis or transplantation, should feel actively supported in their symptom management through the identification and targeting of unpleasant symptoms via a tailored palliative care approach. Such an approach may help minimize the burden and consequences of kidney disease, and lead to improved patient outcomes including health-related quality of life and better life participation.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- The International Federation of Kidney Foundation - World Kidney Alliance (IFKF-WKA), Mexico City, Mexico. .,Division of Nephrology and Hypertension and Kidney Transplantation, University of California, Irvine, Irvine, CA, USA.
| | - Mark B Lockwood
- Department of Behavioral Health Science, University of Illinois at Chicago, College of Nursing, Chicago, IL, USA
| | - Connie M Rhee
- Division of Nephrology and Hypertension and Kidney Transplantation, University of California, Irvine, Irvine, CA, USA
| | - Ekamol Tantisattamo
- Division of Nephrology and Hypertension and Kidney Transplantation, University of California, Irvine, Irvine, CA, USA
| | - Sharon Andreoli
- James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - Tess Harris
- Polycystic Kidney Disease Charity, London, UK
| | | | | | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Siu-Fai Lui
- The International Federation of Kidney Foundation - World Kidney Alliance (IFKF-WKA), Mexico City, Mexico.,Hong Kong Kidney Foundation, Hong Kong, China
| | | | - Maggie Ng
- The International Federation of Kidney Foundation - World Kidney Alliance (IFKF-WKA), Mexico City, Mexico.,Hong Kong Kidney Foundation, Hong Kong, China
| | - Gamal Saadi
- Nephrology Unit, Department of Internal Medicine, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ifeoma Ulasi
- Renal Unit, Department of Medicine, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Carol & Richard Yu PD Research Centre, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China.
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Ling J, Ng JKC, Chan JCN, Chow E. Use of Continuous Glucose Monitoring in the Assessment and Management of Patients With Diabetes and Chronic Kidney Disease. Front Endocrinol (Lausanne) 2022; 13:869899. [PMID: 35528010 PMCID: PMC9074296 DOI: 10.3389/fendo.2022.869899] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
In developed countries, diabetes is the leading cause of chronic kidney disease (CKD) and accounts for 50% of incidence of end stage kidney disease. Despite declining prevalence of micro- and macrovascular complications, there are rising trends in renal replacement therapy in diabetes. Optimal glycemic control may reduce risk of progression of CKD and related death. However, assessing glycemic control in patients with advanced CKD and on dialysis (G4-5) can be challenging. Laboratory biomarkers, such as glycated haemoglobin (HbA1c), may be biased by abnormalities in blood haemoglobin, use of iron therapy and erythropoiesis-stimulating agents and chronic inflammation due to uraemia. Similarly, glycated albumin and fructosamine may be biased by abnormal protein turnover. Patients with advanced CKD exhibited heterogeneity in glycemic control ranging from severe insulin resistance to 'burnt-out' beta-cell function. They also had high risk of hypoglycaemia due to reduced renal gluconeogenesis, frequent use of insulin and dysregulation of counterregulatory hormones. Continuous glucose monitoring (CGM) systems measure glucose in interstitial fluid every few minutes and provide an alternative and more reliable method of glycemic assessment, including asymptomatic hypoglycaemia and hyperglycaemic excursions. Recent international guidelines recommended use of CGM-derived Glucose Management Index (GMI) in patients with advanced CKD although data are scarce in this population. Using CGM, patients with CKD were found to experience marked glycemic fluctuations with hypoglycemia due to loss of glucose and insulin during haemodialysis (HD) followed by hyperglycemia in the post-HD period. On the other hand, during peritoneal dialysis, patients may experience glycemic excursions with influx of glucose from dialysate solutions. These undesirable glucose exposure and variability may accelerate decline of residual renal function. Although CGM may improve the quality of glycemic monitoring and control in populations with CKD, further studies are needed to confirm the accuracy, optimal mode and frequency of CGM as well as their cost-effectiveness and user-acceptability in patients with advanced CKD and dialysis.
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Affiliation(s)
- James Ling
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, Hong Kong SAR, China
| | - Jack K. C. Ng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, Hong Kong SAR, China
| | - Juliana C. N. Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Elaine Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, Hong Kong SAR, China
- *Correspondence: Elaine Chow,
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Rhee CM, Kalantar-Zadeh K, Tuttle KR. Novel approaches to hypoglycemia and burnt-out diabetes in chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:72-81. [PMID: 34750332 PMCID: PMC8684381 DOI: 10.1097/mnh.0000000000000756] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Diabetes mellitus is a leading cause of chronic kidney disease (CKD) that confers faster kidney disease progression, higher mortality, and various metabolic derangements including hypoglycemia. RECENT FINDINGS Even in the absence of diabetes mellitus, growing research demonstrates that CKD patients are at heightened risk for hypoglycemia via multiple pathways. In CKD patients transitioning to end-stage renal disease (ESRD), spontaneous resolution of hyperglycemia and frequent hypoglycemia resulting in reduction and/or cessation of glucose-lowering medications are frequently observed in a phenomenon described as 'burnt-out diabetes'. In non-CKD patients, it is well established that hypoglycemia is causally associated with mortality, with pathways including arrhythmias, sudden cardiac death, stroke, and seizures. Increasing evidence shows that, in CKD and ESRD patients with and without diabetes mellitus, hypoglycemia is associated with cardiovascular complications and mortality risk. SUMMARY Given the high prevalence of hypoglycemia in CKD patients and the morbidity and mortality associated with this metabolic complication, a multimodal strategy is needed to prevent dysglycemia, including individualization of glycemic targets, selection of glucose-lowering medications less likely to induce hypoglycemia, medical nutrition therapy administered by trained dietitians, and accurate and precise hypoglycemia detection methods, such as self-monitored blood glucose or continuous glucose monitoring including during dialysis treatment.
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Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, California
| | - Katherine R. Tuttle
- Providence Health Care, Spokane, Washington
- Nephrology Division and Kidney Research Institute, University of Washington, Seattle, Washington
- Institute of Translational Health Sciences, University of Washington, Seattle, Washington
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35
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Genua I, Sánchez-Hernandez J, Martínez MJ, Pujol I, Places J, González C, Martinez E, Díaz JM, Chico A. Accuracy of Flash Glucose Monitoring in Patients with Diabetes Mellitus on Hemodialysis and Its Relationship with Hydration Status. J Diabetes Sci Technol 2021; 15:1308-1312. [PMID: 33251824 PMCID: PMC8655287 DOI: 10.1177/1932296820975057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The use of flash-glucose monitoring system FreeStyle Libre (FSL) has demonstrated benefits in metabolic control and quality of life in different populations with diabetes mellitus (DM), being funded in many countries. Due to this, DM subjects on hemodialysis (HD) are using FSL despite the accuracy in this population being unclear. The aims of the present study are to assess the accuracy of FSL in DM subjects on HD, its relationship to hydration status, and patient satisfaction. MATERIAL AND METHODS A prospective study in 16 patients with DM in a chronic HD program was conducted. Interstitial glucose values from FSL during a 14-day period were compared to capillary glucose measurements obtained at the same time. Hydration status was measured via bioimpedance spectroscopy. Satisfaction with FSL was obtained from an ad hoc satisfaction questionnaire. RESULTS A total of 766 paired interstitial and capillary glucose levels were analyzed. A correlation coefficient of 0.936 was determined and a mean absolute relative difference (MARD) value of 23%, increasing to 29% during HD. MARD was not related to hydration status. Interstitial glucose values were lower during HD (100.1 ± 17 mg/dL) than within the 12 hours after (125.1 ± 39 mg/dL; P = .012) and the days without HD (134.2 ± 32 mg/dL; P = .001). Subjects showed high satisfaction with FSL. CONCLUSION The accuracy of FSL in DM patients on HD is lower than in other populations, especially during HD sessions and is not related with the hydration status. Despite this, the degree of patient satisfaction with FSL is very high.
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Affiliation(s)
- Idoia Genua
- Endocrinology and Nutrition Department,
Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Joan Sánchez-Hernandez
- Endocrinology and Nutrition Department,
Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Medicine Department, Universitat
Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Maria José Martínez
- Endocrinology and Nutrition Department,
Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Isabel Pujol
- Endocrinology and Nutrition Department,
Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jaume Places
- Nephrology Department, Fundació
Puigvert, Barcelona, Spain
| | | | | | - Juan Manuel Díaz
- Nephrology Department, Fundació
Puigvert, Barcelona, Spain
- Medicine Department, Universitat de Vic
– Universitat Central de Catalunya (UVic-UCC), Vic, Spain
- Juan Manuel Díaz, MD, Nephrology Department,
Fundació Puigvert, C/Cartagena, 340-350, Barcelona, Spain.
| | - Ana Chico
- Endocrinology and Nutrition Department,
Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Medicine Department, Universitat
Autònoma de Barcelona (UAB), Barcelona, Spain
- CIBER-BBN, Spain
- Ana I. Chico, MD, Hospital de la Santa Creu
i Sant Pau, Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain.
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Abstract
Uremic encephalopathy encompasses a wide range of central nervous system abnormalities associated with poor kidney function occurring with either progressive chronic kidney disease or acute kidney injury. The syndrome is likely caused by retention of uremic solutes, alterations in hormonal metabolism, changes in electrolyte and acid-base homeostasis, as well as changes in vascular reactivity, blood-brain barrier transport, and inflammation. There are no defining clinical, laboratory, or imaging findings, and the diagnosis is often made retrospectively when symptoms improve after dialysis or transplantation. The diagnosis is also made difficult because of the many confounding and overlapping conditions seen in patients with chronic kidney disease and acute kidney injury. Thus, institution of kidney replacement therapy should be considered as a trial to improve symptoms in the right clinical context. Neurological symptoms that do not improve after improvement in clearance should prompt a search for other explanations. Further knowledge linking possible uremic retention solutes with neurological symptoms is needed to better understand this syndrome as well as to develop more tailored treatments that aim to improve cognitive function.
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37
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Watha K, Davenport A, Tangvoraphonkchai K. Changes in blood glucose and lactate concentrations with hemodialysis. Artif Organs 2021; 46:138-145. [PMID: 34695248 DOI: 10.1111/aor.14097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 09/22/2021] [Accepted: 10/21/2021] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Blood glucose concentrations are recognized to vary during hemodialysis (HD), with hypoglycemia reported with glucose-free dialysates. As glucose can be converted to lactate, and conversely lactate to glucose, we wished to study factors associated with peri-dialytic changes in blood glucose. METHODS We prospectively collected data including patient profile, dialysis prescription, hemodynamic parameters, medications, dialysis adequacy and monthly blood tests for three consecutive months. All patients used a 100 mg/dl glucose dialysate. Linear mixed model, general estimated equation and binary logistic regression were used for analysis. RESULTS We studied 157 sessions in 55 patients, median age 67.1 (58.5-72.6) years, 67% male, 71% diabetic, 40% prescribed insulin, dialysis vintage 20.4 (10.7-57.7) months. Mean single pool Kt/Vurea and normalized protein nitrogen appearance rate (nPNA) were 1.70 ± 0.34 and 1.01 ± 0.30 g/kg/day respectively. Hypoglycemia (<70 mg/dl) occurred during 10 sessions (6.4%). 25% of non-diabetes experienced hypoglycemia. The % change in peri-dialytic blood glucose was associated with the % change in lactate (estimate of fixed effect = 0.23 p < 0.001) and pre-HD glucose (estimate of fixed effect = 0.09, p < 0.001). The fall in glucose was not associated with urea clearance, consumption of food, administration of insulin or antidiabetic medications, nPNA, body mass index, or pyridoxine concentrations. CONCLUSIONS Peri-dialytic hypoglycemia cannot simply be explained by dialyzer clearance, as the corresponding fall in lactate would potentially suggest increased gluconeogenesis. Despite using a glucose containing dialysate, asymptomatic hypoglycemia occurred in 6.4% of sessions, suggesting a role for peri-dialytic blood glucose monitoring and avoiding fasting during dialysis.
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Affiliation(s)
- Kanchana Watha
- Department of Renal Medicine, Suddhavej Hospital, Mahasarakham University, Mahasarakham, Thailand
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
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Zhou X, Shi H, Zhu S, Wang H, Sun S. Dipeptidyl peptidase-4 inhibitor and insulin combination treatment in type 2 diabetes and chronic kidney disease: A meta-analysis. J Diabetes Investig 2021; 13:468-477. [PMID: 34551206 PMCID: PMC8902402 DOI: 10.1111/jdi.13675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/07/2021] [Accepted: 09/18/2021] [Indexed: 12/18/2022] Open
Abstract
Aims/Introduction The union of dipeptidyl peptidase‐4 inhibitors and insulin in patients with type 2 diabetes and chronic kidney disease provides satisfactory glucose management without increasing adverse events (AEs). This research appraised the therapeutic effect and safety of combination therapy in patients with type 2 diabetes and chronic kidney disease. Materials and Methods We carried out a meta‐analysis of randomized controlled trials to analyze AEs, hypoglycemia, serious AEs, severe hypoglycemia, estimated glomerular filtration rate, fasting plasma glucose, glycated hemoglobin, insulin dose, low‐density lipoprotein cholesterol, uric acid and weight between combination treatment groups and control groups by searching the Cochrane Library, Excerpta Medica Database (Embase), PubMed and Web of Science databanks until October 2020. Results Five studies (6 trials, 1,278 participants) met the inclusion criteria. The evidence quality ranged from moderate to high. Glycated hemoglobin (standardized mean difference −0.29, 95% confidence interval −0.44 to −0.14) and insulin dose (standardized mean difference −0.16, 95% confidence interval −0.29 to −0.02) were obviously smaller in the combination cure patients than in the control patients. Compared with the control groups, combination treatment did not increase AEs, hypoglycemia, serious AEs or severe hypoglycemia. Conclusions This study showed the effectiveness and safety of dipeptidyl peptidase‐4 inhibitors bonded with insulin in patients with type 2 diabetes and chronic kidney disease, but the protective actions of this cure on kidney and cardiovascular outcomes, as well as the functions of other dipeptidyl peptidase‐4 inhibitors, need to be affirmed by more good‐quality randomized controlled trials.
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Affiliation(s)
- Xianling Zhou
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Heng Shi
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shiping Zhu
- Department of Traditional Chinese Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Haixia Wang
- Department of Traditional Chinese Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shengyun Sun
- Department of Traditional Chinese Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, China
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Yoshizawa Y, Hosojima M, Kabasawa H, Tanabe N, Miyachi A, Hamajima H, Mieno E, Kobayashi M, Kitamura T, Narita I, Saito A. Measurement of Plasma Glucagon Levels Using Mass Spectrometry in Patients with Type 2 Diabetes on Maintenance Hemodialysis. Kidney Blood Press Res 2021; 46:652-656. [PMID: 34515141 DOI: 10.1159/000518027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/21/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recently, attention has been focused on the effect of glucagon on blood glucose variability. The dynamics of glucagon have attracted attention as a new target in the treatment of diabetes patients. However, the dynamics of glucagon in hemodialysis (HD) patients with type 2 diabetes mellitus (T2DM) remain unclear. OBJECTIVES The aim of this study was to assess the dynamics of glucagon in HD patients with T2DM. MATERIALS AND METHODS We measured plasma glucagon in HD patients with T2DM by liquid chromatography-high-resolution mass spectrometry (LC-HRMS), sandwich enzyme-linked immunosorbent assay (ELISA), and radioimmunoassay (RIA). The glucagon levels measured by each method were compared. We used the glucagon levels determined by our developed LC-HRMS method as the standard in this study. RESULTS Plasma glucagon levels measured by LC-HRMS before HD were significantly higher than those measured after HD. Plasma glucagon levels measured using sandwich ELISA had a significantly higher correlation with those measured using LC-HRMS compared with RIA. CONCLUSIONS This was the first study to assess glucagon levels in HD patients with T2DM using LC-HRMS, which is considered a highly accurate method. Sandwich ELISA was shown to measure glucagon levels accurately as well.
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Affiliation(s)
- Yuta Yoshizawa
- Department of Applied Molecular Medicine, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.,Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Michihiro Hosojima
- Department of Clinical Nutrition Science, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hideyuki Kabasawa
- Department of Clinical Nutrition Science, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Naohito Tanabe
- Department of Health and Nutrition, Faculty of Human Life Studies, University of Niigata Prefecture, Niigata, Japan
| | - Atsushi Miyachi
- Radioisotope and Chemical Analysis Center, Sanwa Kagaku Kenkyusho Co., Ltd., Mie, Japan
| | - Hitoshi Hamajima
- Radioisotope and Chemical Analysis Center, Sanwa Kagaku Kenkyusho Co., Ltd., Mie, Japan
| | - Eri Mieno
- Radioisotope and Chemical Analysis Center, Sanwa Kagaku Kenkyusho Co., Ltd., Mie, Japan
| | - Masaki Kobayashi
- Metabolic Signal Research Center, Institute for Molecular and Cellular Regulation, Gunma University, Gunma, Japan
| | - Tadahiro Kitamura
- Metabolic Signal Research Center, Institute for Molecular and Cellular Regulation, Gunma University, Gunma, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Akihiko Saito
- Department of Applied Molecular Medicine, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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40
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Narasaki Y, Park E, You AS, Daza A, Peralta RA, Guerrero Y, Novoa A, Amin AN, Nguyen DV, Price D, Kalantar-Zadeh K, Rhee CM. Continuous glucose monitoring in an end-stage renal disease patient with diabetes receiving hemodialysis. Semin Dial 2021; 34:388-393. [PMID: 34378258 DOI: 10.1111/sdi.13009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/05/2021] [Accepted: 07/18/2021] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Elisa Park
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Amy S You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Andrea Daza
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Rene Amel Peralta
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Yalitzi Guerrero
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Alejandra Novoa
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Alpesh N Amin
- Department of Medicine, University of California Irvine School of Medicine, Orange, California, USA
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine School of Medicine, Orange, California, USA
| | | | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
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41
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Fully automated closed-loop glucose control compared with standard insulin therapy in adults with type 2 diabetes requiring dialysis: an open-label, randomized crossover trial. Nat Med 2021; 27:1471-1476. [PMID: 34349267 PMCID: PMC8363503 DOI: 10.1038/s41591-021-01453-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/28/2021] [Indexed: 12/18/2022]
Abstract
We evaluated the safety and efficacy of fully closed-loop insulin therapy compared with standard insulin therapy in adults with type 2 diabetes requiring dialysis. In an open-label, multinational, two-center, randomized crossover trial, 26 adults with type 2 diabetes requiring dialysis (17 men, 9 women, average age 68 ± 11 years (mean ± s.d.), diabetes duration of 20 ± 10 years) underwent two 20-day periods of unrestricted living, comparing the Cambridge fully closed-loop system using faster insulin aspart (‘closed-loop’) with standard insulin therapy and a masked continuous glucose monitor (‘control’) in random order. The primary endpoint was time in target glucose range (5.6–10.0 mmol l−1). Thirteen participants received closed-loop first and thirteen received control therapy first. The proportion of time in target glucose range (5.6–10.0 mmol l−1; primary endpoint) was 52.8 ± 12.5% with closed-loop versus 37.7 ± 20.5% with control; mean difference, 15.1 percentage points (95% CI 8.0–22.2; P < 0.001). Mean glucose was lower with closed-loop than control (10.1 ± 1.3 versus 11.6 ± 2.8 mmol l−1; P = 0.003). Time in hypoglycemia (<3.9 mmol l−1) was reduced with closed-loop versus control (median (IQR) 0.1 (0.0–0.4%) versus 0.2 (0.0–0.9%); P = 0.040). No severe hypoglycemia events occurred during the control period, whereas one severe hypoglycemic event occurred during the closed-loop period, but not during closed-loop operation. Fully closed-loop improved glucose control and reduced hypoglycemia compared with standard insulin therapy in adult outpatients with type 2 diabetes requiring dialysis. The trial registration number is NCT04025775. A new randomized, crossover clinical trial testing rapid-acting insulin aspart delivered in a closed-loop system compared with standard care demonstrates increased time in range in patients with type 2 diabetes who require dialysis in the outpatient setting.
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Yusof Khan AHK, Zakaria NF, Zainal Abidin MA, Kamaruddin NA. Prevalence of glycemic variability and factors associated with the glycemic arrays among end-stage kidney disease patients on chronic hemodialysis. Medicine (Baltimore) 2021; 100:e26729. [PMID: 34397709 PMCID: PMC8322551 DOI: 10.1097/md.0000000000026729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 06/29/2021] [Indexed: 01/04/2023] Open
Abstract
Glycemic variability (GV) confers a significantly higher risk of diabetic-related complications, especially cardiovascular. Despite extensive research in this area, data on end-stage kidney disease (ESKD) patients on chronic hemodialysis are scarce. This study aims to determine the magnitude of GV among ESKD (diabetic vs nondiabetic) patients and its associated factors on hemodialysis days (HDD) and non-hemodialysis days (NHDD) where postulation of a higher GV observed among diabetic on HDD.We recruited 150 patients on hemodialysis, 93 patients with type 2 diabetic (DM-ESKD), and 57 with nondiabetic (NDM-ESKD). The GV indices (standard deviation [SD] and percentage coefficient variant [%CV]) were obtained from 11-point and 7-point self-monitoring blood glucose (fasting to post-meal) (SMBG) profiles on HDD and NHDD. The GV indices and its associated factors of both DM-ESKD and NDM-ESKD were analyzed to compare HDD vs NHDD.Mean blood glucose on HDD was 9.33 [SD 2.7, %CV 30.6%] mmol/L in DM-ESKD compared with 6.07 [SD 0.85, %CV 21.3%] mmol/L in NDM-ESKD (P = <.01). The DM-ESKD group experienced significantly above target GV indices compared to NDM-ESKD on both HDD and NHDD, particularly in the subgroup with HbA1c 8-10% (P = <.01). Presence of diabetes, older age, hyperlipidemia, HbA1c, ferritin levels, and albumin were identified as factors associated with GV.DM-ESKD patients have above-target GV indices, especially on HDD, therefore increasing their risk of developing future complications. We identified high HbA1c, older age group, presence of hyperlipidemia, ferritin levels, and albumin as factors associated with GV indices that may be used as surrogate markers for GV. Since these groups of patients are vulnerable to CVD mortality, urgent attention is needed to rectify it.
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Affiliation(s)
- Abdul Hanif Khan Yusof Khan
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (UPM), Serdang, Selangor, Malaysia
| | - Nor Fadhlina Zakaria
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (UPM), Serdang, Selangor, Malaysia
| | - Muhammad Adil Zainal Abidin
- Kuliyyah of Medicine, International Islamic University Malaysia (IIUM), Jalan Hospital Campus, Kuantan, Pahang, Malaysia
| | - Nor Azmi Kamaruddin
- Department of Medicine, The National University of Malaysia (HUKM), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Wilayah Persekutuan Kuala Lumpur, Malaysia
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Mambelli E, Cristino S, Mosconi G, Göbl C, Tura A. Flash Glucose Monitoring to Assess Glycemic Control and Variability in Hemodialysis Patients: The GIOTTO Study. Front Med (Lausanne) 2021; 8:617891. [PMID: 34395456 PMCID: PMC8360859 DOI: 10.3389/fmed.2021.617891] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 06/28/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Flash glucose monitoring (FGM) is a technology with considerable differences compared to continuous glucose monitoring (CGM), but it has been scarcely studied in hemodialysis patients. Thus, we aimed assessing the performance of FGM in such patients by comparison to self-monitoring of blood glucose (SMBG). We will also focus on estimation of glycemic control and variability, and their relationships with parameters of glucose homeostasis. Methods: Thirty-one patients (20 with type 2 diabetes, T2DM, 11 diabetes-free, NODM) collected readings by FGM and SMBG for about 12 days on average. Readings by FGM and SMBG were compared by linear regression, Clarke error grid, and Bland-Altman analyses. Several indices of glycemic control and variability were computed. Ten patients also underwent oral glucose tolerance test (OGTT) for assessment of insulin sensitivity/resistance and insulin secretion/beta-cell function. Results: Flash glucose monitoring and SMBG readings showed very good agreement in both T2DM and NODM (on average, 97 and 99% of readings during hemodialysis in A+B Clarke regions, respectively). Some glycemic control and variability indices were similar by FGM and SMBG (p = 0.06–0.9), whereas others were different (p = 0.0001–0.03). The majority of control and variability indices were higher in T2DM than in NODM, according to both FGM and SMBG (p = 0.0005–0.03). OGTT-based insulin secretion was inversely related to some variability indices according to FGM (R < −0.72, p < 0.02). Conclusions: Based on our dataset, FGM appeared acceptable for glucose monitoring in hemodialysis patients, though partial disagreement with SMBG in glycemic control/variability assessment needs further investigations.
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Affiliation(s)
- Emanuele Mambelli
- Nephrology and Dialysis, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Stefania Cristino
- Nephrology and Dialysis, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Giovanni Mosconi
- Nephrology and Dialysis, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Christian Göbl
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Andrea Tura
- CNR Institute of Neuroscience, Padova, Italy
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Martino FG, Vitillo M, Pieri M, Marrone G, Gangeri F, Ansali F, Dessì M, Bernardini S, Di Daniele N, Noce A. Biomarkers of Glyco-Metabolic Control in Hemodialysis Patients: Glycated Hemoglobin vs. Glycated Albumin. ACTA ACUST UNITED AC 2021; 57:medicina57070712. [PMID: 34356993 PMCID: PMC8307856 DOI: 10.3390/medicina57070712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 12/18/2022]
Abstract
Background and Objectives: Glycated hemoglobin (HbA1c) dosage is considered the gold standard in glycol-metabolic monitoring, but it presents limits, which can underestimate the glycemia trend. In this regard, it was introduced the glycated albumin (GA). The aim of the study is to verify the predictivity of the GA compared to HbA1c in identifying glyco-metabolic alterations in non-diabetic and diabetic hemodialysis (HD) patients. Materials and Methods: For this purpose, we conducted a multicenter study involving one analysis laboratory and six dialysis centers in the Lazio region (Rome, Italy). Both diabetic and non-diabetic HD patients represent the study population, and the protocol included five time points. Results: The analyzed data highlighted the ability of GA to predict changes in glycemic metabolism in HD patients, and GA values are not significantly influenced, like HbA1c, by dialysis therapy itself and by comorbidities of the uremic state, such as normochromic and normocytic anemia. Thus, GA seems to reflect early glyco-metabolic alterations, both in patients with a previous diagnosis of diabetes and in subjects without diabetes mellitus. As part of this study, we analyzed two HD patients (one diabetic and one non-diabetic) in which GA was more predictive of glycol-metabolic alterations compared to HbA1c. Our study confirms the need to compare classical biomarkers used for the monitoring of glyco-metabolic alterations with new ones, likely more reliable and effective in specific subgroups of patients in which the classic biomarkers can be influenced by the preexisting pathological conditions. Conclusions: In conclusion, our evidence highlights that in uremic patients, GA shows a better ability to predict glyco-metabolic alterations allowing both an earlier diagnosis of DM and a prompt modulation of the hypoglycemic therapy, thus improving the clinical management of these patients.
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Affiliation(s)
- Francesca Gabriela Martino
- UOC Clinical Pathology, Hospital San Filippo Neri Laboratory HUB, ASL Roma 1, 00135 Rome, Italy; (F.G.M.); (M.V.)
| | - Marina Vitillo
- UOC Clinical Pathology, Hospital San Filippo Neri Laboratory HUB, ASL Roma 1, 00135 Rome, Italy; (F.G.M.); (M.V.)
| | - Massimo Pieri
- Department of Experimental Medicine, Clinical Biochemistry, University of Rome Tor Vergata, 00133 Rome, Italy; (M.P.); (M.D.); (S.B.)
| | - Giulia Marrone
- UOC of Internal Medicine—Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata Via Montpellier, 00133 Rome, Italy; (G.M.); (N.D.D.)
- PhD School of Applied Medical, Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Fabio Gangeri
- UOC Nephrology and Dialysis, Santo Spirito Hospital, ASL Roma 1, 00193 Rome, Italy;
| | - Ferruccio Ansali
- UOC Nephrology and Dialysis, San Paolo Hospital, ASL Roma 4, 00053 Civitavecchia, Italy;
- UDD Nephrology and Dialysis, Padre Pio Hospital, ASL Roma 4, 00062 Bracciano, Italy
| | - Mariarita Dessì
- Department of Experimental Medicine, Clinical Biochemistry, University of Rome Tor Vergata, 00133 Rome, Italy; (M.P.); (M.D.); (S.B.)
| | - Sergio Bernardini
- Department of Experimental Medicine, Clinical Biochemistry, University of Rome Tor Vergata, 00133 Rome, Italy; (M.P.); (M.D.); (S.B.)
| | - Nicola Di Daniele
- UOC of Internal Medicine—Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata Via Montpellier, 00133 Rome, Italy; (G.M.); (N.D.D.)
| | - Annalisa Noce
- UOC of Internal Medicine—Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata Via Montpellier, 00133 Rome, Italy; (G.M.); (N.D.D.)
- Correspondence: ; Tel./Fax: +39-06-20902188
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Applying Proteomics and Integrative "Omics" Strategies to Decipher the Chronic Kidney Disease-Related Atherosclerosis. Int J Mol Sci 2021; 22:ijms22147492. [PMID: 34299112 PMCID: PMC8305100 DOI: 10.3390/ijms22147492] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 02/07/2023] Open
Abstract
Patients with chronic kidney disease (CKD) are at increased risk of atherosclerosis and premature mortality, mainly due to cardiovascular events. However, well-known risk factors, which promote “classical” atherosclerosis are alone insufficient to explain the high prevalence of atherosclerosis-related to CKD (CKD-A). The complexity of the molecular mechanisms underlying the acceleration of CKD-A is still to be defied. To obtain a holistic picture of these changes, comprehensive proteomic approaches have been developed including global protein profiling followed by functional bioinformatics analyses of dysregulated pathways. Furthermore, proteomics surveys in combination with other “omics” techniques, i.e., transcriptomics and metabolomics as well as physiological assays provide a solid ground for interpretation of observed phenomena in the context of disease pathology. This review discusses the comprehensive application of various “omics” approaches, with emphasis on proteomics, to tackle the molecular mechanisms underlying CKD-A progression. We summarize here the recent findings derived from global proteomic approaches and underline the potential of utilizing integrative systems biology, to gain a deeper insight into the pathogenesis of CKD-A and other disorders.
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Hayashi A, Shimizu N, Suzuki A, Matoba K, Momozono A, Masaki T, Ogawa A, Moriguchi I, Takano K, Kobayashi N, Shichiri M. Hemodialysis-Related Glycemic Disarray Proven by Continuous Glucose Monitoring; Glycemic Markers and Hypoglycemia. Diabetes Care 2021; 44:1647-1656. [PMID: 34045240 DOI: 10.2337/dc21-0269] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/03/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE There is a high risk of asymptomatic hypoglycemia associated with hemodialysis (HD) using glucose-free dialysate; therefore, the inclusion of glucose in the dialysate is believed to prevent intradialytic hypoglycemia. However, the exact glycemic fluctuation profiles and frequency of asymptomatic hypoglycemia using dialysates containing >100 mg/dL glucose have not been determined. RESEARCH DESIGN AND METHODS We evaluated the glycemic profiles of 98 patients, 68 of whom were men, with type 2 diabetes undergoing HD (HbA1c 6.4 ± 1.2%; glycated albumin 20.8 ± 6.8%) with a dialysate containing 100, 125, or 150 mg/dL glucose using continuous glucose monitoring. RESULTS Sensor glucose level (SGL) showed a sustained decrease during HD, irrespective of the dialysate glucose concentration, and reached a nadir that was lower than the dialysate glucose concentration in 49 participants (50%). Twenty-one participants (21%) presented with HD-related hypoglycemia, defined by an SGL <70 mg/dL during HD and/or between the end of HD and their next meal. All these hypoglycemic episodes were asymptomatic. Measures of glycemic variability calculated using the SGL data (SD, coefficient of variation, and range of SGL) were higher and time below range (<70 mg/dL) was lower in participants who experienced HD-related hypoglycemia than in those who did not, whereas time in range between 70 and 180 mg/dL, time above range (>180 mg/dL), HbA1c, and glycated albumin of the two groups were similar. CONCLUSIONS Despite the use of dialysate containing 100-150 mg/dL glucose, patients with diabetes undergoing HD experienced HD-related hypoglycemia unawareness frequently. SGL may fall well below the dialysate glucose concentration toward the end of HD.
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Affiliation(s)
- Akinori Hayashi
- Department of Laboratory Medicine, Kitasato University School of Medicine, Kanagawa, Japan .,Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
| | - Naoya Shimizu
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
| | - Agena Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kenta Matoba
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
| | - Akari Momozono
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tsuguto Masaki
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
| | - Akifumi Ogawa
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
| | | | - Koji Takano
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
| | | | - Masayoshi Shichiri
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
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Buades JM, Craver L, Del Pino MD, Prieto-Velasco M, Ruiz JC, Salgueira M, de Sequera P, Vega N. Management of Kidney Failure in Patients with Diabetes Mellitus: What Are the Best Options? J Clin Med 2021; 10:2943. [PMID: 34209083 PMCID: PMC8268456 DOI: 10.3390/jcm10132943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/22/2021] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
Diabetic kidney disease (DKD) is the most frequent cause of kidney failure (KF). There are large variations in the incidence rates of kidney replacement therapy (KRT). Late referral to nephrology services has been associated with an increased risk of adverse outcomes. In many countries, when patients reach severely reduced glomerular filtration rate (GFR), they are managed by multidisciplinary teams led by nephrologists. In these clinics, efforts will continue to halt chronic kidney disease (CKD) progression and to prevent cardiovascular mortality and morbidity. In patients with diabetes and severely reduced GFR and KF, treating hyperglycemia is a challenge, since some drugs are contraindicated and most of them require dose adjustments. Even more, a decision-making process will help in deciding whether the patient would prefer comprehensive conservative care or KRT. On many occasions, this decision will be conditioned by diabetes mellitus itself. Effective education should cover the necessary information for the patient and family to answer these questions: 1. Should I go for KRT or not? 2. If the answer is KRT, dialysis and/or transplantation? 3. Dialysis at home or in center? 4. If dialysis at home, peritoneal dialysis or home hemodialysis? 5. If transplantation is desired, discuss the options of whether the donation would be from a living or deceased donor. This review addresses the determinant factors with an impact on DKD, aiming to shed light on the specific needs that arise in the management and recommendations on how to achieve a comprehensive approach to the diabetic patient with chronic kidney disease.
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Affiliation(s)
- Juan M. Buades
- Department of Nephrology, Hospital Universitario Son Llàtzer, Balearic Islands, 07198 Palma de Mallorca, Spain
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma de Mallorca, Spain
| | - Lourdes Craver
- Department of Nephrology, Hospital Universitario Arnau de Vilanova, 25198 Lleida, Spain;
| | - Maria Dolores Del Pino
- Department of Nephrology, Complejo Hospitalario Torrecárdenas de Almería, 04009 Almería, Spain;
| | - Mario Prieto-Velasco
- Department of Nephrology, Complejo Asistencial Universitario de Leon, 24001 León, Spain;
| | - Juan C. Ruiz
- Department of Nephrology, Valdecilla Hospital, University of Cantabria, 39008 Santander, Spain;
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain
| | - Mercedes Salgueira
- Department of Nephrology, Hospital Universitario Virgen Macarena, 41009 Seville, Spain;
- Biomedical Engineering Group, Medicine Department, University of Seville, 41092 Seville, Spain
- Center for Biomedical Research Network in Bioengineering Biomaterials and Nanomedicina (CIBER-BBN), 28029 Madrid, Spain
| | - Patricia de Sequera
- Department of Nephrology, Hospital Universitario Infanta Leonor, 28031 Madrid, Spain;
- Medicine Department, Universidad Complutense de Madrid, 28031 Madrid, Spain
| | - Nicanor Vega
- Department of Nephrology, Hospital Universitario de Gran Canaria Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain;
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Takashima H, Maruyama T, Abe M. Significance of Levocarnitine Treatment in Dialysis Patients. Nutrients 2021; 13:1219. [PMID: 33917145 PMCID: PMC8067828 DOI: 10.3390/nu13041219] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/01/2021] [Accepted: 04/04/2021] [Indexed: 01/04/2023] Open
Abstract
Carnitine is a naturally occurring amino acid derivative that is involved in the transport of long-chain fatty acids to the mitochondrial matrix. There, these substrates undergo β-oxidation, producing energy. The major sources of carnitine are dietary intake, although carnitine is also endogenously synthesized in the liver and kidney. However, in patients on dialysis, serum carnitine levels progressively fall due to restricted dietary intake and deprivation of endogenous synthesis in the kidney. Furthermore, serum-free carnitine is removed by hemodialysis treatment because the molecular weight of carnitine is small (161 Da) and its protein binding rates are very low. Therefore, the dialysis procedure is a major cause of carnitine deficiency in patients undergoing hemodialysis. This deficiency may contribute to several clinical disorders in such patients. Symptoms of dialysis-related carnitine deficiency include erythropoiesis-stimulating agent-resistant anemia, myopathy, muscle weakness, and intradialytic muscle cramps and hypotension. However, levocarnitine administration might replenish the free carnitine and help to increase carnitine levels in muscle. This article reviews the previous research into levocarnitine therapy in patients on maintenance dialysis for the treatment of renal anemia, cardiac dysfunction, dyslipidemia, and muscle and dialytic symptoms, and it examines the efficacy of the therapeutic approach and related issues.
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Affiliation(s)
| | | | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, Tokyo 173-8610, Japan; (H.T.); (T.M.)
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Hu K, Peng H, Ma Y, Li X, Bai R, Wang J, Xu J, Fu L, Liu J, Bai J, Wu H, Wang H, Jiang H. Analysis of Glycemic Improvement in Hemodialysis Patients Based on Time in Range, Assessed by Flash Glucose Monitoring. Blood Purif 2021; 50:883-890. [PMID: 33774625 DOI: 10.1159/000513162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This study aimed to investigate the application value of "time in ranges (TIRs)" in dialysis patients with diabetes and summarize the experience of optimizing glycemic control by flash glucose monitoring (FGM) system. METHODS In this monocentric 2-week pilot study, FGM was applied for 14 days in 57 type 2 diabetes mellitus medically stable patients under maintenance hemodialysis to determine their glycemic improvement. The diagnostic value of TIR versus HbA1c in detecting glucose fluctuations and levels was evaluated using receiver operating characteristic analysis. RESULTS Average glucose exhibited stronger association with TIR (r = -0.785, p < 0.001) than HbA1c (r = 0.644, p < 0.001), and mean amplitude of glycemic excursion (MAGE) had the same conclusion (r = -0.568, p < 0.001 for TIR vs. r = 0.423, p = 0.016 for HbA1c). TIR exhibited a higher area under curve than HbA1c in detecting significant derangements in glucose fluctuation, using a 14-day average FGM-derived coefficient of variation >36% as the reference standard (difference between areas: 0.237; 95% CI 0.092-0.383, p = 0.001). We found a significant improvement in TIR (58.38 ± 19.42 vs. 46.45 ± 24.42 mmol/L, p < 0.001) and a significant decline in MAGE (median 5.64 vs.7.42 mmol/L, p < 0.001) compared to the baseline without deterioration of time spent in hypoglycemia. CONCLUSION TIR seems to be feasible and clinically useful for AGP analysis in dialysis patients with diabetes, and FGM can be used to improve glycemic control.
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Affiliation(s)
- Keyan Hu
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.,Luoyang Clinical Medicine Research Center of Endocrine and Metabolic Diseases, Luoyang, China
| | - Huifang Peng
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.,Luoyang Clinical Medicine Research Center of Endocrine and Metabolic Diseases, Luoyang, China
| | - Yujin Ma
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.,Luoyang Clinical Medicine Research Center of Endocrine and Metabolic Diseases, Luoyang, China
| | - Xuefeng Li
- The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | | | - Junxia Wang
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Jiayun Xu
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Liujun Fu
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.,Luoyang Clinical Medicine Research Center of Endocrine and Metabolic Diseases, Luoyang, China
| | - Jing Liu
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.,Luoyang Clinical Medicine Research Center of Endocrine and Metabolic Diseases, Luoyang, China
| | - Jinlei Bai
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.,Luoyang Clinical Medicine Research Center of Endocrine and Metabolic Diseases, Luoyang, China
| | - Hongli Wu
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.,Luoyang Clinical Medicine Research Center of Endocrine and Metabolic Diseases, Luoyang, China
| | - Hongyun Wang
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Hongwei Jiang
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.,Luoyang Clinical Medicine Research Center of Endocrine and Metabolic Diseases, Luoyang, China
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Abstract
Chronic kidney disease (CKD) is among the most prevalent and dire complications of diabetes mellitus in adults across the world. Diabetes substantially contributes to the burden of kidney disease, such that one third to one half of CKD in the United States and many other countries is attributable to diabetic kidney disease (DKD). As DKD progresses to end-stage renal disease (ESRD), patients are at heightened risk for atypical glycemic complications, including the development of burnt-out diabetes, manifested by hypoglycemic bouts and poor outcomes. Furthermore, even in the absence of diabetes, hypoglycemia is a frequent occurrence in CKD patients that may contribute to their high burden of cardiovascular disease and death. Extrapolation of data from clinical trials in high-cardiovascular-risk populations and observational studies in patients with non-dialysis-dependent (NDD) CKD and ESRD suggest that moderate glycemic targets defined by glycated hemoglobin levels of 6% to 8% and glucose levels of 100 to 150 mg/dL are associated with better survival in DKD patients. However, given the imprecision of glycated hemoglobin levels in kidney disease, further research is needed to determine the optimal glycemic metric and target in diabetic NDD-CKD and ESRD patients. Given their exceedingly high cardiovascular morbidity and mortality, there is a compelling need for further investigation of how to optimally manage dysglycemia in the NDD-CKD and ESRD populations.
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