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

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

In-patient outcomes of patients with diabetic ketoacidosis and concurrent protein energy malnutrition: A national database study from 2016 to 2017

Introduction:Patients often present to the hospital with a well-known complication of diabetes mellitus, namely diabetic ketoacidosis (DKA). In this study, we assess the clinical outcomes of DKA hospitalizations with and without protein-energy malnutrition (PEM).Methods:This was a population-based, retrospective observational study using data gathered from the Nationwide Inpatient Sample (NIS) for 2016 and 2017. Hospitalizations of adults >/ = 18 years old with a principal diagnosis of DKA were obtained using ICD-10 codes and divided into groups based on a secondary diagnosis of PEM. The primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), total hospital charges (THC), and system-based complications.Results:Patients with PEM had a statistically significant difference in the adjusted odds for in-hospital mortality compared to patients without PEM (aOR 1.73, 95% CI: 1.20-2.49, p = 0.004). Patients with DKA and PEM had an increased risk of developing sepsis (aOR 2.99, 95% CI: 2.49-3.58, p < 0.001), septic shock (aOR 3.37, 95% CI: 2.31-4.91, p < 0.001), acute kidney failure (aOR 1.27, 95% CI: 1.17-1.37, p < 0.001), acute respiratory failure (aOR 2.23, 95% CI: 1.83-2.73, p < 0.001), deep vein thrombosis (aOR 1.91, 95% CI: 1.43-2.54, p < 0.001), and pulmonary embolism (aOR 2.36, 95% CI: 1.42-3.94, p = 0.001). Patients with DKA and PEM also had an increased mean THC (aOR 19,200, 95% CI 16,000-22,400, p < 0.001) in US dollars and increased LOS (aOR 2.26, 95% CI 1.96-2.57, p < 0.001) in days when compared to patients without PEM.Conclusion:Patients hospitalized for DKA with a secondary diagnosis of PEM within the same admission had a statistically significantly higher in-hospital mortality.

Ketoanalogue supplements reduce mortality in patients with pre-dialysis advanced diabetic kidney disease: A nationwide population-based study

BACKGROUND & AIMS

Metabolism dysregulation and protein energy wasting occur in patients with chronic kidney disease (CKD) and are associated with poor survival, especially in patients prior to starting dialysis. Accumulating evidence indicates that dietary supplementation with ketoanalogues (KAs, a mixture of branched-chain amino acids) exerts a variety of beneficial effects for patients with CKD. However, the role of KAs in diabetic kidney disease (DKD), one of the major causes of CKD, is still controversial. The aim of this study was to explore the impact of KA supplements on survival in patients with stage 5 DKD who have not yet started dialysis (DKD-5-ND).

METHODS

We analyzed a nationwide cohort retrieved from the National Health Insurance Research Database in Taiwan to study the long-term impact of KA supplements in patients with DKD-5-ND. We enrolled 15,782 incident pre-dialysis DKD patients between January 1, 2004 and December 31, 2007. Landmark analysis was used to eliminate immortal bias, and overlap weighting was used to balance differences between the KA users and nonusers in the beginning. The primary study endpoint was all-cause mortality, and the occurrence of permanent dialysis (presenting the end-stage renal disease, ESRD) and major adverse cardiovascular events (MACEs) was also evaluated. All patients were followed for five years or until death.

RESULTS

The prevalence of KA usage in the DKD-5-ND patients was 6.3%. The 5-year all-cause mortality rate in the KA users was lower than that in the nonusers (34.7% vs 42.7%). After adjusting for known covariates, the KA users still had a lower risk of mortality (adjusted hazard ratio [aHR]: 0.73, 95% confidence interval [CI]: 0.66-0.82). In addition, the incidence of ESRD was also slightly lower among the KA users (90.9% for users vs 91.2% for nonusers, adjusted cause-specific hazard ratio [aCSHR]: 0.65, 95% CI: 0.61-0.69), and the occurrence of MACEs was lower (adjusted incidence rate ratios [aIRR]: 0.76, 95% CI: 0.67-0.86). Although the all-cause mortality was higher among patientsolder than 70 years (60.5% for KA users vs 46.5% for nonusers) the risk reduction seemed prominent among older patients (aHR: 0.65, 95% CI: 0.56-0.76 for patients aged ≥70 years; aHR: 0.82, 95% CI: 0.71-0.96 for patients aged < 70 years). The reduction in risks of mortality was consistent in subgroup analysis and sensitivity tests.

CONCLUSIONS

The use of KA supplements seemed to be beneficial for patients with DKD-5-ND; further in-depth analysis of using KA for these patients is warranted.

Angiotensin II receptor blockade is associated with preserved muscle strength in chronic hemodialysis patients

BACKGROUND

Sarcopenia, defined as low muscle mass and strength, is highly prevalent in patients undergoing chronic hemodialysis (HD). However, muscle function and muscle mass do not share the same clinical relevance. In fact, muscle strength was more closely associated with the risk of mortality in chronic HD patients than was muscle mass. Therefore, to identify the risk factors of muscle weakness is vital. Angiotensin II overexpression had been recognized to impair skeletal muscle strength. Accordingly, angiotensin II receptor blockers (ARBs) potentially possess a muscle protective effect. This cross-sectional study aimed to identify the factors associated with low muscle strength and to explore the relationship between ARB use and muscle strength in chronic HD patients.

METHODS

A total of 120 chronic HD patients, aged 63.3 ± 13.2 years, were included in this study. Basic characteristics, handgrip strength (HGS), body composition, and nutritional status were assessed, and blood samples for biochemical tests were obtained. We divided these participants into normal- and low HGS groups according to the consensus of the European Working Group on Sarcopenia in Older People (EWGSOP).

RESULTS

We observed that 78 (65.0%) patients had low HGS. In our cohort, we found that height (r = 0.653; P <  0.001), weight (r = 0.496; P <  0.001), body mass index (r = 0.215; P = 0.020), skeletal muscle index (r = 0.562; P <  0.001), albumin (r = 0.197; P = 0.032), and serum creatinine (r = 0.544; P <  0.001) were positively and age (r = - 0.506; P <  0.001), subjective global assessment (SGA) score (r = - 0.392; P <  0.001), fractional clearance index for urea (Kt/V) (r = - 0.404; P <  0.001) and urea reduction ratio (URR) (r = - 0.459; P <  0.001) were negatively correlated with HGS. According to our analysis, age (Odds ratio, OR = 1.11, 95% confidence interval, 95% CI = 1.05-1.17, P <  0.001), HD duration (OR = 1.01, 95% CI = 1.00-1.02, P = 0.010), diabetes (OR = 13.33, 95% CI = 3.45-51.53, P <  0.001), Kt/V (OR = 1.61, 95% CI = 1.06-2.46, P = 0.027), and SGA score (OR = 1.19, 95% CI = 1.03-1.38, P = 0.017) were regarded as independent predictors of low HGS. In contrast, ARB use (OR = 0.25, 95% CI = 0.07-0.93, P = 0.039) was independently associated with preserved HGS in chronic HD patients, after adjustment for multiple confounding factors.

CONCLUSIONS

Our study is the first report in chronic HD patients to indicate a potentially protective effect of ARB on muscle strength. However, further longitudinal follow-up and intervention studies are needed to confirm this finding.

The effect of dulaglutide on body composition in type 2 diabetes mellitus patients on hemodialysis

AIMS

To evaluate the effect of dulaglutide on body composition in type 2 diabetes mellitus (T2DM) patients undergoing hemodialysis (HD).

METHODS

Twenty-one T2DM patients on HD, who had been treated with insulin and newly added teneligliptin (N = 10) or dulaglutide (N = 11), were enrolled. Body composition changes, such as fat mass (FM) and skeletal muscle mass (SMM), glycated albumin (GA), and insulin doses were compared before and after six months of treatment with teneligliptin or dulaglutide.

RESULTS

The percentage changes of GA and insulin doses were comparable between the teneliglipin and dulaglutide groups. Conversely, although FM and SMM did not change in the teneligliptin group (from 15.7 kg to 14.1 kg, P = 0.63 and 18.6 kg to 18.9 kg, P = 0.16, respectively), those in the dulaglutide group significantly decreased (from 21.9 kg to 18.9 kg, P = 0.037 and 21.0 kg to 20.2 kg, P = 0.011, respectively).

CONCLUSIONS

Six months of dulaglutide treatment significantly reduced not only FM but also SMM, although changes in GA and insulin doses were comparable with those in the teneligliptin group. Dulaglutide may have the effect of promoting sarcopenia; therefore, it may be carefully used in T2DM patients on HD.

Comparison of Muscle Mass Indices Using Computed Tomography or Dual X-Ray Absorptiometry for Predicting Physical Performance in Hemodialysis Patients

BACKGROUND/AIMS

Our study aims to evaluate the association between thigh muscle cross-sectional area (TMA) using computed tomography (CT), or appendicular skeletal muscle mass (ASM) using dual energy X-ray absorptiometry (DEXA), and physical performance levels in hemodialysis (HD) patients.

METHODS

Patients were included if they were on HD for ≥6 months (n = 84). ASM and TMA were adjusted to body weight (BW, kg) or height2 (Ht2, m2). Each participant performed a short physical performance battery test (SPPB), a sit-to-stand for 30 second test (STS30), a 6-minute walk test (6-MWT), a timed up and go test (TUG), and hand grip strength (HGS) test.

RESULTS

Correlation coefficients for SPPB, GS, 5STS, STS30, 6-MWT, and TUG were highest in TMA/BW. Results from partial correlation or linear regression analyses displayed similar trends to those derived from Pearson's correlation analyses. An increase in TMA/BW or TMA/Ht2 was associated with a decreased odds ratio of low SPPB, GS, or HGS in multivariate analyses. Indices using DEXA were associated with a decreased odds ratio of a low HGS only in multivariate analysis.

CONCLUSION

TMA indices using CT may be more valuable in predicting physical performance or strength in HD patients.

A prospective cohort study of risk prediction in simultaneous pancreas and kidney transplantation

INTRODUCTION

Current risk prediction scoring systems in pancreas transplantation are limited to organ factors and are specific to predicting graft outcome. They do not consider recipient factors or inform regarding recipient morbidity. The aim of this study was to assess the utility of commonly used general surgical risk prediction models (P-POSSUM [Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity], MODS [multiple organ dysfunction score], Charlson co-morbidity index, revised cardiac risk index, ASA [American Society of Anesthesiologists] grade and Waterlow score), and to correlate them with total length of hospital stay (LOS) and critical care unit (CCU) LOS, important surrogate markers of patient outcome.

METHODS

All risk prediction scores were calculated prospectively for all simultaneous pancreas and kidney (SPK) transplant recipients from November 2011 to October 2013, and correlated with outcome measures.

RESULTS

Overall, 57 SPK transplant recipients were analysed. The mean age was 42.0 years (standard deviation [SD]: 7.60 years), 27 (52%) were male and the mean body mass index was 25.43kg/m(2) (SD: 3.11kg/m(2)). The mean pancreas and kidney cold ischaemic times were 703 minutes (SD: 182 minutes) and 850 minutes (SD: 192 minutes) respectively. The median total LOS and mean CCU LOS was 17 days (range: 8-79 days) and 7 days (SD: 4.04 days) respectively. When correlated with risk prediction scores, Waterlow score was the only significant predictor of total LOS and CCU LOS (p<0.001 [Spearman's correlation] and p=0.001 [Pearson's correlation] respectively).

CONCLUSIONS

Preoperative risk prediction plays an important part in planning perioperative care. To date, no validated risk prediction scoring system exists for SPK transplantation. This prospective study indicates that Waterlow score identifies high risk individuals and has value in the prediction of outcome following SPK transplantation.

Metabolic effects of sulforaphane oral treatment in streptozotocin-diabetic rats

Diabetes has reached epidemic levels in the whole world, and the use of bioactive compounds that may have the capacity to prevent and treat diabetes is of great interest. Sulforaphane (SFN) is a compound which is found in cruciferous vegetables and that acts as both a potent antioxidant and regulator of gene expression. The aim of this study was to evaluate the effect of SFN in diabetes induced by streptozotocin (STZ). Male Wistar rats were gavaged with water or 0.1, 0.25, or 0.5 mg/kg of SFN before an injection of STZ (80 mg/kg). Animals treated with SFN showed fasting glycemia, insulin sensitivity, and hepatic glycogen concentrations, similar to the control group (nondiabetic), and different from the diabetic group. Diabetic animals also presented elevated levels of serum triacylglycerols (TAG), urea, and creatinine, and all SFN doses were able to reverse these alterations. However, the same doses of SFN accentuated alterations in total cholesterol, alanine, and aspartate aminotransferase levels, and had no effect on hepatic TAG, HDL cholesterol, and uptake of 2-deoxy glucose in adipose tissue and soleum muscle. Based on the effects inferred by the present data, SFN presented some positive effects against diabetes induction, although the impairment of hepatic function and cholesterol levels were aggravated after treatment with the compound.

Transthyretin predicts cardiovascular outcome in hemodialysis patients with type 2 diabetes

OBJECTIVE

BMI and albumin are commonly accepted parameters to recognize wasting in dialysis patients and are powerful predictors of morbidity and mortality. However, both parameters reveal limitations and may not cover the entire range of patients with wasting. The visceral protein transthyretin (TTR) may be helpful in overcoming the diagnostic and prognostic gap. Therefore, the aim of this study was to assess the association of TTR with morbidity and mortality in hemodialysis patients.

RESEARCH DESIGN AND METHODS

The TTR concentration was determined in plasma samples of 1,177 hemodialysis patients with type 2 diabetes. Cox regression analyses were used to determine hazard ratios (HRs) for the risk of cardiovascular end points (CVEs) and mortality according to quartiles of TTR concentration for the total study cohort and the subgroups BMI ≥23 kg/m(2), albumin concentration ≥3.8 g/dL, and a combination of both.

RESULTS

A low TTR concentration was associated with an increased risk for CVE for the total study cohort (HR 1.65 [95% CI 1.27-2.14]), patients with BMI ≥23 kg/m(2) (1.70 [1.22-2.37]), albumin ≥3.8 g/dL (1.68 [1.17-2.42]), and the combination of both (1.69 [1.13-2.53]). Additionally, a low TTR concentration predicted mortality for the total study cohort (1.79 [1.43-2.24]) and patients with BMI ≥23 kg/m(2) (1.46 [1.09-1.95]).

CONCLUSIONS

The current study demonstrated that TTR is a useful predictor for cardiovascular outcome and mortality in diabetic hemodialysis patients. TTR was particularly useful in patients who were not identified to be at risk by BMI or albumin status.

Comparison of markers of appetite and inflammation between hemodialysis patients with and without failed renal transplants

OBJECTIVE

The survival of patients returning to hemodialysis (HD) following kidney transplant failure is unfavorable. However, the factors responsible for this poor outcome are largely unknown; chronic inflammation due to failed allograft and malnutrition may contribute to morbidity and mortality. We aim to compare the markers of appetite and malnutrition, and their relation with inflammation in HD patients with and without previous kidney transplantation.

METHODS

Fifty-six patients with failed renal allografts at least 3 months on dialysis (31 men, 25 women; mean age, 46 ± 9 years) and 77 HD patients who never underwent a transplant (43 men, 34 women; mean age, 50 ± 15 years) were included in the study. The appetite and diet assessment tool (ADAT) was used to determine the self reported appetite of patients. Serum concentrations of ghrelin, leptin, insulin like growth factor 1 (IGF-1), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high-sensitivity C-reactive protein (hs-CRP) were measured. Associations among these variables were analyzed.

RESULTS

There were no significant differences considering age, gender or duration of renal replacement therapy between the 2 groups. The scores from Appetite and Diet Assessment Tool were significantly higher in the failed-transplant group. Serum ghrelin levels were significantly higher and serum albumin levels were significantly lower in the failed-transplant group. Serum leptin levels were similar between 2 groups. In addition, hs-CRP, IL-6, and TNF-α levels, which were used as inflammatory parameters, were significantly higher in the failed-transplant group.

CONCLUSIONS

Elevated serum ghrelin levels and inflammation may cause diminished appetite and malnutrition in patients with failed renal allografts, and higher levels of this hormone seem to be associated with inflammation caused by retained failed allografts.