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Öberg CM, Sternby J, Nilsson A, Storr M, Flieg R, Harenski K, Roos V, Källquist L, Hobro S. Experimental hemodialysis in diet-induced ketosis and the potential use of dialysis as an adjuvant cancer treatment. Sci Rep 2023; 13:19476. [PMID: 37945638 PMCID: PMC10636042 DOI: 10.1038/s41598-023-46715-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 11/03/2023] [Indexed: 11/12/2023] Open
Abstract
Numerous in vivo studies on the ketogenic diet, a diet that can induce metabolic conditions resembling those following extended starvation, demonstrate strong outcomes on cancer survival, particularly when combined with chemo-, radio- or immunological treatments. However, the therapeutic application of ketogenic diets requires strict dietary adherence from well-informed and motivated patients, and it has recently been proposed that hemodialysis might be utilized to boost ketosis and further destabilize the environment for cancer cells. Yet, plasma ketones may be lost in the dialysate-lowering blood ketone levels. Here we performed a single 180-min experimental hemodialysis (HD) session in six anesthetized Sprague-Dawley rats given ketogenic diet for five days. Median blood ketone levels pre-dialysis were 3.5 mmol/L (IQR 2.2 to 5.6) and 3.8 mmol/L (IQR 2.2 to 5.1) after 180 min HD, p = 0.54 (95% CI - 0.6 to 1.2). Plasma glucose levels were reduced by 36% (- 4.5 mmol/L), p < 0.05 (95% CI - 6.7 to - 2.5). Standard base excess was increased from - 3.5 mmol/L (IQR - 4 to - 2) to 0.5 mmol/L (IQR - 1 to 3), p < 0.01 (95% CI 2.0 to 5.0). A theoretical model was applied confirming that intra-dialytic glucose levels decrease, and ketone levels slightly increase since hepatic ketone production far exceeds dialytic removal. Our experimental data and in-silico modeling indicate that elevated blood ketone levels during ketosis are maintained during hemodialysis despite dialytic removal.
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Affiliation(s)
- Carl M Öberg
- Department of Clinical Sciences Lund, Skåne University Hospital, Njurmottagningen SUS Lund, Barngatan 2a, 221 85, Lund, Sweden.
| | - Jan Sternby
- Baxter International Inc., Magistratsvägen 10, 22643, Lund, Sweden
| | - Anders Nilsson
- Baxter International Inc., Magistratsvägen 10, 22643, Lund, Sweden
| | - Markus Storr
- Baxter International Inc., 72379, Hechingen, Germany
| | - Ralf Flieg
- Baxter International Inc., 72379, Hechingen, Germany
| | - Kai Harenski
- Baxter Deutschland GmbH., 85 716, Unterschleissheim, Germany
| | - Viktoria Roos
- Baxter International Inc., Magistratsvägen 10, 22643, Lund, Sweden.
| | - Linda Källquist
- Baxter International Inc., Magistratsvägen 10, 22643, Lund, Sweden
| | - Sture Hobro
- Baxter International Inc., Magistratsvägen 10, 22643, Lund, Sweden
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Fačkovcová L, Pongrac Barlovic D, Brož J. Glucose variability in maintenance hemodialysis patients with type 2 diabetes. Hemodial Int 2023; 27:475-476. [PMID: 37474300 DOI: 10.1111/hdi.13089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/05/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Lucia Fačkovcová
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Drazenka Pongrac Barlovic
- Department of Endocrinology, Diabetes and Metabolic Diseases, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Jan Brož
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic
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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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Bomholt T, Rix M, Almdal T, Knop FK, Rosthøj S, Jørgensen MB, Feldt-Rasmussen B, Hornum M. Glucose variability in maintenance hemodialysis patients with type 2 diabetes: Comparison of dialysis and nondialysis days. Hemodial Int 2023; 27:126-133. [PMID: 36760179 DOI: 10.1111/hdi.13073] [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: 02/09/2022] [Revised: 12/09/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Hemodialysis (HD) induces several physiological changes that can affect plasma glucose levels in patients with diabetes and in turn their glycemic control. Studies using continuous glucose monitoring (CGM) to assess glucose variations on dialysis days compared with nondialysis days report conflicting results. Here, we used CGM to examine glucose variations induced by HD in patients with type 2 diabetes. METHODS Patients with type 2 diabetes undergoing maintenance HD were included. CGM (Ipro2®, Medtronic) was performed at baseline and Week 4, 8, 12, and 16 for up to 7 days at each visit. CGM profiles on days where participants received HD were compared with days without HD using a linear mixed model. FINDINGS Twenty-seven patients were included. The median number of CGM days performed was 8 (interquartile range [IQR] 6-10) for dialysis days and 16 (IQR 12-17) for nondialysis days. The median sensor glucose was 9.4 (95% confidence interval [CI] 8.8-10.2) mmol/L on dialysis days compared with 9.5 (95% CI 8.9-10.2) mmol/L on nondialysis days (p = 0.58). Nocturnal mean sensor glucose was higher on dialysis days compared with nondialysis days: 8.8 (95% CI 8.0-9.6) mmol/L versus 8.4 (95% CI 7.7-9.2) mmol/L (p = 0.029). DISCUSSION Similar median sensor glucose values were found for days on and off HD. Nocturnal glucose levels were modestly increased on dialysis days. Our findings indicate that antidiabetic treatment does not need to be differentiated on dialysis versus nondialysis days in patients with type 2 diabetes undergoing maintenance HD.
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Affiliation(s)
- Tobias Bomholt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Almdal
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Filip K Knop
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Susanne Rosthøj
- Section of Biostatistics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten B Jørgensen
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Bo Feldt-Rasmussen
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mads Hornum
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Williams ME, Steenkamp D, Wolpert H. Making sense of glucose sensors in end-stage kidney disease: A review. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:1025328. [PMID: 36992784 PMCID: PMC10012164 DOI: 10.3389/fcdhc.2022.1025328] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022]
Abstract
Diabetes mellitus remains the leading cause of end-stage kidney disease worldwide. Inadequate glucose monitoring has been identified as one of the gaps in care for hemodialysis patients with diabetes, and lack of reliable methods to assess glycemia has contributed to uncertainty regarding the benefit of glycemic control in these individuals. Hemoglobin A1c, the standard metric to evaluate glycemic control, is inaccurate in patients with kidney failure, and does not capture the full range of glucose values for patients with diabetes. Recent advances in continuous glucose monitoring have established this technology as the new gold standard for glucose management in diabetes. Glucose fluctuations are uniquely challenging in patients dependent on intermittent hemodialysis, and lead to clinically significant glycemic variability. This review evaluates continuous glucose monitoring technology, its validity in the setting of kidney failure, and interpretation of glucose monitoring results for the nephrologist. Continuous glucose monitoring targets for patients on dialysis have yet to be established. While continuous glucose monitoring provides a more complete picture of the glycemic profile than hemoglobin A1c and can mitigate high-risk hypoglycemia and hyperglycemia in the context of the hemodialysis procedure itself, whether the technology can improve clinical outcomes merits further investigation.
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Affiliation(s)
- Mark E. Williams
- Renal Unit, Joslin Diabetes Center, Boston MA, United States
- *Correspondence: Mark E. Williams,
| | - Devin Steenkamp
- Section of Endocrinology, Diabetes, and Nutrition, Department of Medicine, Boston Medical Center, Boston, MA, United States
| | - Howard Wolpert
- Boston University School of Medicine, Boston, MA, United States
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Rigon FA, Ronsoni MF, Vianna AGD, de Lucca Schiavon L, Hohl A, van de Sande-Lee S. Flash glucose monitoring system in special situations. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:883-894. [PMID: 35657123 PMCID: PMC10118756 DOI: 10.20945/2359-3997000000479] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 02/04/2022] [Indexed: 02/08/2023]
Abstract
The management of diabetes mellitus (DM) requires maintaining glycemic control, and patients must keep their blood glucose levels close to the normal range to reduce the risk of microvascular complications and cardiovascular events. While glycated hemoglobin (A1C) is currently the primary measure for glucose management and a key marker for long-term complications, it does not provide information on acute glycemic excursions and overall glycemic variability. These limitations may even be higher in some special situations, thereby compromising A1C accuracy, especially when wider glycemic variability is expected and/or when the glycemic goal is more stringent. To attain adequate glycemic control, continuous glucose monitoring (CGM) is more useful than self-monitoring of blood glucose (SMBG), as it is more convenient and provides a greater amount of data. Flash Glucose Monitoring (isCGM /FGM) is a widely accepted option of CGM for measuring interstitial glucose levels in individuals with DM. However, its application under special conditions, such as pregnancy, patients on hemodialysis, patients with cirrhosis, during hospitalization in the intensive care unit and during physical exercise has not yet been fully validated. This review addresses some of these specific situations in which hypoglycemia should be avoided, or in pregnancy, where strict glycemic control is essential, and the application of isCGM/FGM could alleviate the shortcomings associated with poor glucose control or high glycemic variability, thereby contributing to high-quality care.
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Affiliation(s)
- Fernanda Augustini Rigon
- Programa de Pós-graduação em Ciências Médicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil,
| | - Marcelo Fernando Ronsoni
- Departamento de Clínica Médica, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
| | - André Gustavo Daher Vianna
- Centro de Diabetes de Curitiba, Departamento de Doenças Endócrinas, Hospital Nossa Senhora das Graças, Curitiba, PR, Brasil
| | | | - Alexandre Hohl
- Departamento de Clínica Médica, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
| | - Simone van de Sande-Lee
- Departamento de Clínica Médica, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
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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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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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10
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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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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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Phillips J, Chen JHC, Ooi E, Prunster J, Lim WH. Global Epidemiology, Health Outcomes, and Treatment Options for Patients With Type 2 Diabetes and Kidney Failure. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2021; 2:731574. [PMID: 36994340 PMCID: PMC10012134 DOI: 10.3389/fcdhc.2021.731574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/29/2021] [Indexed: 12/15/2022]
Abstract
The burden of type 2 diabetes and related complications has steadily increased over the last few decades and is one of the foremost global public health threats in the 21st century. Diabetes is one of the leading causes of chronic kidney disease and kidney failure and is an important contributor to the cardiovascular morbidity and mortality in this population. In addition, up to one in three patients who have received kidney transplants develop post-transplant diabetes, but the management of this common complication continues to pose a significant challenge for clinicians. In this review, we will describe the global prevalence and temporal trend of kidney failure attributed to diabetes mellitus in both developing and developed countries. We will examine the survival differences between treated kidney failure patients with and without type 2 diabetes, focusing on the survival differences in those on maintenance dialysis or have received kidney transplants. With the increased availability of novel hypoglycemic agents, we will address the potential impacts of these novel agents in patients with diabetes and kidney failure and in those who have developed post-transplant diabetes.
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Affiliation(s)
- Jessica Phillips
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- *Correspondence: Jessica Phillips,
| | - Jenny H. C. Chen
- School of Medicine, University of Wollongong, Wollongong, NSW, Australia
- Depatment of Nephrology, Wollongong Hospital, Wollongong, NSW, Australia
| | - Esther Ooi
- School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia
| | - Janelle Prunster
- Department of Renal Medicine, Cairns Hospital, Cairns, QLD, Australia
| | - Wai H. Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Medical School, University of Western Australia, Perth, WA, Australia
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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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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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Schneditz D, Niemczyk L, Niemczyk S. Modeling of insulin secretion and insulin mass balance during hemodialysis in patients with and without type 2 diabetes. Biocybern Biomed Eng 2021. [DOI: 10.1016/j.bbe.2021.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Niemczyk L, Schneditz D, Wojtecka A, Szamotulska K, Smoszna J, Niemczyk S. Glucose tolerance in patients with and without type 2 diabetes mellitus during hemodialysis. Diabetes Res Clin Pract 2021; 173:108694. [PMID: 33571598 DOI: 10.1016/j.diabres.2021.108694] [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] [Received: 03/04/2020] [Revised: 10/12/2020] [Accepted: 01/28/2021] [Indexed: 02/06/2023]
Abstract
AIMS The disposal of a glucose bolus was studied to identify glucose metabolism in patients with and without type 2 diabetes mellitus (T2DM) during their regular hemodialysis (HD) treatment. METHODS Plasma glucose, insulin, and c-peptide concentrations were measured during a 60 min observation phase following a rapid glucose infusion (0.5 g/kg dry weight). Glucose disposition and elimination rates were determined from kinetic analysis, and insulinogenic index was calculated. Insulin resistance (RHOMA) was determined by homeostatic model assessment (HOMA). RESULTS 35 HD patients (14 with T2DM) distinguished by a higher age (median: 70 vs. 55 y, p < 0.01) in T2DM patients were studied. Glucose kinetic data showed only small differences between patients with or without T2DM, but as RHOMA measured in all patients increased, a larger fraction of glucose was removed by the extracorporeal system (r = 0.430, p = 0.01). One hour after glucose bolus injection the glucose level was not different from that before HD also in patients with T2DM (p = 0.115). CONCLUSIONS The larger glucose amount recovered in dialysate in patients with increasing RHOMA indicates that impaired glucose disposal could be measured during HD using a non-invasive dialysis quantification approach without blood sampling. Glucose infusion during HD is safe also in patients with T2DM.
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Affiliation(s)
- Longin Niemczyk
- Dept. of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, ul. Banacha 1a, 02-097 Warsaw, Poland.
| | - Daniel Schneditz
- Otto Loewi Research Center, Div. of Physiology, Medical University of Graz, Neue Stiftingtalstrasse 6/V, 8010 Graz, Austria.
| | - Anna Wojtecka
- Dept. of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, ul. Szaserów 128, 04-141 Warsaw, Poland.
| | - Katarzyna Szamotulska
- Dept. of Epidemiology and Biostatistics, National Research Institute of Mother and Child, ul. Kasprzaka 17a, 01-211 Warsaw, Poland.
| | - Jerzy Smoszna
- Dept. of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, ul. Szaserów 128, 04-141 Warsaw, Poland.
| | - Stanisław Niemczyk
- Dept. of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, ul. Szaserów 128, 04-141 Warsaw, Poland.
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Kato R, Nishimura A, Matsumura K, Kikuno S, Nagasawa K, Mori Y. Successful treatment of adult-onset nesidioblastosis by continuous subcutaneous octreotide infusion in a patient on hemodialysis. Clin Case Rep 2021; 9:278-281. [PMID: 33489173 PMCID: PMC7813030 DOI: 10.1002/ccr3.3514] [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: 08/25/2020] [Accepted: 10/19/2020] [Indexed: 11/09/2022] Open
Abstract
Octreotide may be useful in noninsulinoma pancreatogenous hypoglycemia syndrome with nesidioblastosis patients who was on hemodialysis. Continuous octreotide subcutaneous infusion can reduce side-effects and stabilize plasma glucose levels.
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Affiliation(s)
- Rina Kato
- Department of Endocrinology and MetabolismToranomon HospitalMinato‐kuJapan
| | - Akihiro Nishimura
- Department of Endocrinology and MetabolismToranomon HospitalMinato‐kuJapan
| | - Kimio Matsumura
- Department of Endocrinology and MetabolismToranomon HospitalMinato‐kuJapan
| | - Shota Kikuno
- Department of Endocrinology and MetabolismToranomon HospitalMinato‐kuJapan
| | - Kaoru Nagasawa
- Department of Endocrinology and MetabolismToranomon HospitalMinato‐kuJapan
| | - Yasumichi Mori
- Department of Endocrinology and MetabolismToranomon HospitalMinato‐kuJapan
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Crespo JCL, Gomes VR, Barbosa RL, Padilha KG, Secoli SR. Haemodialysis, nutritional disorders and hypoglycaemia in critical care. ACTA ACUST UNITED AC 2017; 26:281-286. [PMID: 28328262 DOI: 10.12968/bjon.2017.26.5.281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This study aimed to determine hypoglycemia incidence and associated factors in critically ill patients. It looked at a retrospective cohort with 106 critically ill adult patients with 48 hours of glycaemic control and 72 hours of follow up. The dependent variable, hypoglycaemia (≤70 mg/dl), was assessed with respect to independent variables: age, diet, insulin, catecholamines, haemodialysis, nursing workload and the Simplified Acute Physiology Score. Statistical analysis was performed using Student's t-test, Fisher's exact test and logistic regression at 5% significance level. Incidence of hypoglycaemia was 14.2%. Hypoglycaemia was higher in the group of patients on catecholamines (p=0.040), with higher glycaemic variability (p<0.001) and death in the intensive care unit (p=0.008). Risk factors were identified as absence of oral diet (OR 5.11; 95% CI 1.04-25.10) and haemodialysis (OR 4.28; 95% CI 1.16-15.76). Patients on haemodialysis and with no oral diet should have their glycaemic control intensified in order to prevent and/or manage hypoglycaemic episodes.
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Affiliation(s)
- Jeiel Carlos Lamonica Crespo
- Nursing Department, Instituto do Coração (Heart Institute), Hospital das Clínicas da Escola de Medicina da Universidade de São Paulo, Brazi
| | - Vanessa Rossato Gomes
- Nursing Department, Instituto do Coração (Heart Institute), Hospital das Clínicas da Escola de Medicina da Universidade de São Paulo, Brazil
| | | | - Katia Grillo Padilha
- Medical-Surgical Nursing Department, Escola de Enfermagem da Universidade de São Paulo, Brazil
| | - Silvia Regina Secoli
- Medical-Surgical Nursing Department, Escola de Enfermagem da Universidade de São Paulo, Brazil
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Sudha MJ, Salam HS, Viveka S, Udupa AL. Assessment of changes in insulin requirement in patients of type 2 diabetes mellitus on maintenance hemodialysis. J Nat Sci Biol Med 2017; 8:64-68. [PMID: 28250677 PMCID: PMC5320826 DOI: 10.4103/0976-9668.198348] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Hemodialysis improves insulin sensitivity. Currently, there is no recommendation for the adjustment of insulin dose on dialysis day and nondialysis day in diabetic patients. This study was undertaken to determine the variations in insulin requirement based on blood glucose levels on dialysis days and nondialysis days in type 2 diabetic patients with chronic kidney disease on maintenance hemodialysis. METHODOLOGY Twenty-eight diabetic patients on hemodialysis were recruited into the study after obtaining written informed consent and approval from Azeezia Ethics Committee. Capillary blood glucose levels, just before dialysis and 2 h after dialysis, were checked and compared with fasting and postprandial glucose levels on-off dialysis days. RESULTS Mean age of the patients was 59.5 (±2.3) years. The average duration of dialysis was 20.2 months. There was significant (35.8%) decrease in blood glucose levels 2 h after dialysis in comparison to predialysis levels (from mean level of 258-165 mg/dl). The decrease in the blood glucose levels from predialysis level to 2 h postdialysis level was statistically significant (P < 0.001). Both sets of data showed "strong" positive correlation with r = 0.657 and 0.849. The blood glucose levels on the day of dialysis were significantly lower than the off-day values. CONCLUSIONS Diabetic patients with end-stage renal disease on hemodialysis have lower capillary blood glucose levels postdialysis. This has to be addressed clinically to prevent hypoglycemic episodes by reducing exogenous insulin administration on the day of dialysis.
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Affiliation(s)
- M. J. Sudha
- Department of Pharmacology, Azeezia Institute of Medical Sciences, Kollam, Kerala, India
| | - Halma S. Salam
- Department of Medical Undergraduate Student, Azeezia Institute of Medical Sciences, Kollam, Kerala, India
| | - S. Viveka
- Department of Anatomy, Azeezia Institute of Medical Sciences, Kollam, Kerala, India
| | - A. L. Udupa
- Department of Pharmacology, Azeezia Institute of Medical Sciences, Kollam, Kerala, India
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20
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Jamaludin UK, Docherty PD, Chase JG, Shaw GM. Impact of haemodialysis on insulin sensitivity of acute renal failure (ARF) patients with sepsis in critical care. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2013:3503-6. [PMID: 24110484 DOI: 10.1109/embc.2013.6610297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Critically ill patients often develop renal failure in addition to their primary diagnosis. However, the effect and impact of haemodialysis (HD) on insulin sensitivity n critically ill patients remains unclear. Specifically, this study investigates insulin sensitivity of acute renal failure (ARF) patients with sepsis who underwent HD and glycaemic control. Model-based insulin sensitivity (SI) profiles were identified for 20 critically ill ARF patients on Specialized Relative Insulin Nutrition Titration (SPRINT) glycaemic control during intervals onto HD (OFF/ON), and after HD (ON/OFF). Patients exhibited a median -18% (IQR -36% to -5% p<0.05) reduction in measured SI after the OFF/ON dialysis transition, and a median 9% (IQR -5% to 37%, p<0.05) rise after the ON/OFF transition. Almost 80% of patients exhibited decreased SI at the OFF/ON interval, and 60% exhibited increased SI at the ON/OFF transition. Results indicate that HD commencement has significant effect on insulin pharmacokinetics at a cohort and per-patient level. These results provide the data to design conclusive studies of HD effects on SI, and to inform glycaemic control protocol development and implementation for this specific group of critically ill patients with ARF-sepsis.
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Abstract
In patients with diabetes receiving chronic haemodialysis, both very high and low glucose levels are associated with poor outcomes, including mortality. Conditions that are associated with an increased risk of hypoglycaemia in these patients include decreased gluconeogenesis in the remnant kidneys, deranged metabolic pathways, inadequate nutrition, decreased insulin clearance, glucose loss to the dialysate and diffusion of glucose into erythrocytes during haemodialysis. Haemodialysis-induced hypoglycaemia is common during treatments with glucose-free dialysate, which engenders a catabolic status similar to fasting; this state can also occur with 5.55 mmol/l glucose-containing dialysate. Haemodialysis-induced hypoglycaemia occurs more frequently in patients with diabetes than in those without. Insulin therapy and oral hypoglycaemic agents should, therefore, be used with caution in patients on dialysis. Several hours after completion of haemodialysis treatment a paradoxical rebound hyperglycaemia may occur via a similar mechanism as the Somogyi effect, together with insulin resistance. Appropriate glycaemic control tailored for patients on haemodialysis is needed to avoid haemodialysis-induced hypoglycaemia and other glycaemic disarrays. In this Review we summarize the pathophysiology and current management of glycaemic disarrays in patients on haemodialysis.
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Affiliation(s)
- Masanori Abe
- Divisions of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-chou, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine, 101 The City Drive South, Orange, CA 92868, USA
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Li T, Vijayan A. Insulin for the treatment of hyperkalemia: a double-edged sword? Clin Kidney J 2015; 7:239-41. [PMID: 25852882 PMCID: PMC4377764 DOI: 10.1093/ckj/sfu049] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 05/02/2014] [Indexed: 12/16/2022] Open
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Nakao T, Inaba M, Abe M, Kaizu K, Shima K, Babazono T, Tomo T, Hirakata H, Akizawa T. Best Practice for Diabetic Patients on Hemodialysis 2012. Ther Apher Dial 2015; 19 Suppl 1:40-66. [DOI: 10.1111/1744-9987.12299] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
| | | | - Masanori Abe
- Japanese Society for Dialysis Therapy; Tokyo Japan
| | - Kazo Kaizu
- Japanese Society for Dialysis Therapy; Tokyo Japan
| | - Kenji Shima
- Japanese Society for Dialysis Therapy; Tokyo Japan
| | | | - Tadashi Tomo
- Japanese Society for Dialysis Therapy; Tokyo Japan
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Jamaludin UK, Docherty PD, Geoffrey Chase J, Shaw GM. Impact of Haemodialysis on Insulin Kinetics of Acute Kidney Injury Patients in Critical Care. J Med Biol Eng 2015; 35:125-133. [PMID: 25750607 PMCID: PMC4342528 DOI: 10.1007/s40846-015-0015-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 05/02/2014] [Indexed: 01/04/2023]
Abstract
Critically ill patients are occasionally associated with an abrupt decline in renal function secondary to their primary diagnosis. The effect and impact of haemodialysis (HD) on insulin kinetics and endogenous insulin secretion in critically ill patients remains unclear. This study investigates the insulin kinetics of patients with severe acute kidney injury (AKI) who required HD treatment and glycaemic control (GC). Evidence shows that tight GC benefits the onset and progression of renal involvement in precocious phases of diabetic nephropathy for type 2 diabetes. The main objective of GC is to reduce hyperglycaemia while determining insulin sensitivity. Insulin sensitivity (SI) is defined as the body response to the effects of insulin by lowering blood glucose levels. Particularly, this study used SI to track changes in insulin levels during HD therapy. Model-based insulin sensitivity profiles were identified for 51 critically ill patients with severe AKI on specialized relative insulin nutrition titration GC during intervals on HD (OFF/ON) and after HD (ON/OFF). The metabolic effects of HD were observed through changes in SI over the ON/OFF and OFF/ON transitions. Changes in model-based SI at the OFF/ON and ON/OFF transitions indicate changes in endogenous insulin secretion and/or changes in effective insulin clearance. Patients exhibited a median reduction of −29 % (interquartile range (IQR): [−58, 6 %], p = 0.02) in measured SI after the OFF/ON dialysis transition, and a median increase of +9 % (IQR −15 to 28 %, p = 0.7) after the ON/OFF transition. Almost 90 % of patients exhibited decreased SI at the OFF/ON transition, and 55 % exhibited increased SI at the ON/OFF transition. Results indicate that HD commencement has a significant effect on insulin pharmacokinetics at a cohort and per-patient level. These changes in metabolic behaviour are most likely caused by changes in insulin clearance or/and endogenous insulin secretion.
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Affiliation(s)
- Ummu K. Jamaludin
- Faculty of Mechanical Engineering, Universiti Malaysia Pahang, 26600 Pekan, Pahang Malaysia
| | - Paul D. Docherty
- Department of Mechanical Engineering, Centre of Bioengineering, University of Canterbury, Private Bag 4800, Christchurch, 8140 New Zealand
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, Centre of Bioengineering, University of Canterbury, Private Bag 4800, Christchurch, 8140 New Zealand
| | - Geoffrey M. Shaw
- Department of Intensive Care Christchurch School of Medicine and Health Science, PO Box 4345, Christchurch, 8140 New Zealand
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Sarathy H, Pramanik V, Kahn J, Abramowitz MK, Meier K, Kishore P, Melamed ML. The effects of short-term vitamin D supplementation on glucose metabolism in dialysis patients: a systematic review and meta-analysis. Int Urol Nephrol 2015; 47:537-49. [PMID: 25636811 DOI: 10.1007/s11255-015-0909-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/02/2015] [Indexed: 12/26/2022]
Abstract
PURPOSE We tested whether short-term vitamin D supplementation improves insulin resistance in patients with kidney disease, a condition with little intrinsic vitamin D activity. METHODS PubMed, EMBASE and CENTRAL were searched for relevant observational studies and randomized clinical trials (RCTs). Random-effects models were employed for meta-analysis, and effect sizes were summarized as standardized mean difference (SMD) with 95% confidence intervals. Separate analyses were done for RCTs and non-randomized intervention studies (NRIS). RESULTS Seventeen studies (5 RCTs and 12 NRIS) were included. The meta-analysis population (n = 131) was mostly middle aged (40-50 years), male and non-diabetic, and on hemodialysis. The duration (4-12 weeks) and type of supplementation varied between studies. Among RCTs, compared to placebo, vitamin D supplementation was associated with significant decrease in fasting glucose [SMD -1.13, (-2.11 to -0.11)] and PTH levels [SMD -1.50, (-2.95 to -0.04)] but no difference in fasting insulin levels [SMD 1.32, (-0.15 to 2.79)]. Among NRIS, there was only a significant decrease in PTH levels [SMD -1.68, (-2.55 to -0.82)] between pre- and post-vitamin D treatment levels. CONCLUSIONS Short-term (4-12 weeks) supplementation with vitamin D is associated with lower fasting glucose levels in ESRD with no change in fasting insulin levels. However, the findings from this study are limited by the studies that were used in the meta-analysis, which were mostly small, used multiple different vitamin D compounds and dosing regimens, and had large heterogeneity, and funnel plots showed that there was a dearth of studies with null or negative finding. Therefore, larger RCTs need to be performed to answer this important clinical question.
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Affiliation(s)
- Harini Sarathy
- Department of Internal Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, NY, USA
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Shimizu M, Suzuki K, Tsuchida K, Kojima M, Hiraishi H, Aso Y. Insulinoma in a patient with chronic renal failure due to type 2 diabetes mellitus treated effectively with diazoxide. Intern Med 2015; 54:621-5. [PMID: 25786453 DOI: 10.2169/internalmedicine.54.3621] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 63-year-old man was diagnosed with diabetes mellitus at 42 years of age. He subsequently exhibited poor blood glucose control for a prolonged period, and his renal failure worsened. He therefore underwent hemodialysis and abdominal magnetic resonance imaging, which revealed a mass in the pancreatic tail. The immunoreactive insulin and C-peptide immunoreactivity levels were significantly elevated, and the results of a fasting test led to a diagnosis of insulinoma. The patient received treatment with oral diazoxide and continuous glucose monitoring (CGM), which resulted in the resolution of the hypoglycemia. This is a rare case of renal failure in which the CGM findings showed improvements in the blood glucose level after diazoxide administration.
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Affiliation(s)
- Masanori Shimizu
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Japan
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Jorgensen MB, Idorn T, Knop FK, Holst JJ, Hornum M, Feldt-Rasmussen B. Clearance of glucoregulatory peptide hormones during haemodialysis and haemodiafiltration in non-diabetic end-stage renal disease patients. Nephrol Dial Transplant 2014; 30:513-20. [DOI: 10.1093/ndt/gfu327] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Gai M, Merlo I, Dellepiane S, Cantaluppi V, Leonardi G, Fop F, Guarena C, Grassi G, Biancone L. Glycemic pattern in diabetic patients on hemodialysis: continuous glucose monitoring (CGM) analysis. Blood Purif 2014; 38:68-73. [PMID: 25300368 DOI: 10.1159/000362863] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/12/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Recent evidences suggest that hemodialysis (HD) induces glycemic variations in diabetic patients. Continuous glucose monitoring (CGM) devices measure interstitial glucose in a 'Holter-like' manner thereby improving the glycemic control assessment method. METHODS A CGM device (Medtronic iPRO) was used on 12 diabetic patients with chronic HD for 6 days to assess intra- and extra-dialytic interstitial glucose. RESULTS In all enrolled patients, HD was associated with a decrease of interstitial glucose values. Intradialytic glucose nadir was 79 mg/dl and it was reached at the third hour after the beginning of the session. At the end of HD, interstitial glucose increased in all patients and a glycemic peak (187 mg/dl) occurred after an average time of 2.5 h. No episodes of nocturnal hypoglycemia occurred. CONCLUSION HD is associated with significant intradialytic reduction of glycemia and postdialytic hyperglycemia. CGM devices result in better monitoring of glycemic trends in diabetic patients on chronic HD and could improve insulin management.
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Affiliation(s)
- Massimo Gai
- SCU Nephrology, Dialysis and Transplantation, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Presidio 'Molinette', Torino, Italy
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Senda M, Ogawa S, Nako K, Okamura M, Sakamoto T, Ito S. The strong relation between post-hemodialysis blood methylglyoxal levels and post-hemodialysis blood glucose concentration rise. Clin Exp Nephrol 2014; 19:527-33. [DOI: 10.1007/s10157-014-1018-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
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Garlich FM, Goldfarb DS. Have advances in extracorporeal removal techniques changed the indications for their use in poisonings? Adv Chronic Kidney Dis 2011; 18:172-9. [PMID: 21531323 DOI: 10.1053/j.ackd.2011.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 01/13/2011] [Accepted: 01/20/2011] [Indexed: 11/11/2022]
Abstract
During the past 25 years, numerous changes have taken place in the use of hemodialysis as a therapeutic modality. Advances in technologies and a progression in our collective understanding of the pharmacokinetics of certain xenobiotics have resulted in alterations in the indications, effectiveness, and safety of hemodialysis. However, these changes have not necessarily been reflected in the current published data regarding treatment of intoxications. Reported clearance rates often reflect what was achievable in the 1970s and 1980s, and more recent reports are frequently lacking. Our goal in this review is to summarize the changes in hemodialysis and in other extracorporeal removal technologies and highlight the effects of these changes on the current indications for hemodialysis of the poisoned patient. Changes in dialysis performance that are reviewed in this article include the use of high-efficiency and high-flux dialysis membranes, improved hemodynamic stability because of ultrafiltration control, and the use of bicarbonate as a source of base. We review the indications for hemodialysis for removal of specific toxins, including vancomycin, methotrexate, carbamazepine, and valproic acid.
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Vos FE, Manning PJ, Sutherland WHF, Schollum JB, Walker RJ. Anti-inflammatory effect of an insulin infusion in patients on maintenance haemodialysis: a randomized controlled pilot study. Nephrology (Carlton) 2011; 16:68-75. [PMID: 21175981 DOI: 10.1111/j.1440-1797.2010.01329.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM A pilot study to investigate the anti-inflammatory effect of insulin in patients on maintenance haemodialysis. BACKGROUND Elevated concentrations of pro-inflammatory and oxidative mediators are thought to contribute to the increased cardiovascular risk in haemodialysis. Insulin has been demonstrated to have anti-inflammatory properties and a continuous low-dose insulin infusion in critically ill patients is associated with improved outcomes. The anti-inflammatory effects of insulin in haemodialysis have not been investigated. METHODS In a single-blind cross-over study, 11 stable, non-diabetic, haemodialysis patients received a continuous insulin infusion (Actrapid 2 IU/h) during a dialysis of 4 h or a conventional dialysis in random order. Normoglycaemia was maintained by a modified glucose dialysate and glucose infusion. Blood samples were collected at baseline, 1, 4, 6 and 24 h. C-reactive protein (CRP), tumour necrosis factor-α, interleukin-6, neopterin, vascular cell adhesion molecule 1, protein thiols, dityrosine and peroxides were measured. RESULTS Insulin produced a significant reduction in median CRP over the immediate dialysis phase (confidence interval) by 6% (2-9% (95% CI), P=0.006) and an even greater decline at 24 h (19% (8-28%, 95% CI), P=0.001) compared with values of the conventional dialysis. No significant changes were observed in the other markers. Median glucose levels were comparable during both dialysis sessions. CONCLUSIONS During haemodialysis, insulin may have a modest anti-inflammatory effect as evident by a reduction in CRP that appears to have a persistent effect over the next 24 h post dialysis. More studies are required to examine longer-term benefits as well as the potential role in more high-risk individuals.
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Affiliation(s)
- Frederiek E Vos
- Department of Medical and Surgical Sciences, Dunedin School of Medicine, University of Otago, and Department of Nephrology, Dunedin Hospital, Dunedin, New Zealand.
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Abe M, Okada K, Ikeda K, Matsumoto S, Soma M, Matsumoto K. Characterization of Insulin Adsorption Behavior of Dialyzer Membranes Used in Hemodialysis. Artif Organs 2011; 35:398-403. [DOI: 10.1111/j.1525-1594.2010.01112.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Biesenbach G, Bodlaj G, Ebner S, Biesenbach P, Pieringer H. Metabolic control and vascular diseases under oral antidiabetic drug versus insulin therapy and/or diet alone during the first year of hemodialysis in type 2 diabetic patients with ESRD. Int Urol Nephrol 2010; 43:1155-60. [PMID: 20640938 DOI: 10.1007/s11255-010-9804-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 07/02/2010] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Uremic type 2 diabetic patients on hemodialysis need various types of antidiabetic therapies. The aim of the present study was to identify differences between patients on oral antidiabetic drug therapy or insulin substitution or diet therapy alone during their first year of hemodialysis. PATIENTS AND METHODS Sixty-four type 2 diabetic patients who had started hemodialysis (HD) at our dialysis center between 2003 and 2007 were included in the study. Kidney-transplanted patients (n = 1) and those with chronic infectious or malignant diseases (n = 4) were excluded. Patients were divided into three groups according to their antidiabetic therapy: group 1 consisted of patients on oral antidiabetic drug therapy (n = 12), group 2 of those on insulin therapy (n = 42), and group 3 of those being treated with diet alone (n = 10). At the start of HD and 12 months later, we measured fasting plasma glucose (FPG), HbA1c, the incidence of hypoglycemia (n/patient/month), cholesterol, triglycerides, body weight, and insulin requirements in the insulin-treated group. C-peptide was only measured at the start of dialysis. We evaluated changes in antidiabetic therapy during the first year on dialysis, and the prevalence of vascular disease in each group at the start of HD. RESULTS FPG and HbA1c values were similar in all groups at the start of HD and after 1 year. Hypoglycemia occurred more frequently in insulin-treated patients; however, the difference was not significant. Cholesterol levels were similar in all groups, whereas triglycerides were significantly lower in insulin-treated patients (138 ± 28 vs. 176 ± 46 mg/dl; P < 0.05). Body weight was similar in all groups. No significant change in body weight was observed in any group after 12 months on dialysis. At the start of HD, C-peptide levels were lower in insulin-treated patients than in the other groups (1.8 ± 0.9 ng/ml vs. 2.2 ± 1.1 and 2.4 ± 1.1 ng/ml; P < 0.05). During the first 12 months on HD, two patients from group 1 were shifted to group 3 (diet alone), while four patients could reduce their drug dosage (33%). However, two subjects became insulin-dependent. In group 2, insulin therapy could be terminated in two cases, while the insulin dose could be reduced in 20 patients (48%). In group 3, one patient was switched to oral antidiabetic therapy. The prevalence of vascular disease was slightly higher in group 3 (NS). CONCLUSION Within 1 year after the start of HD, the dose of sulfonylurea as well as insulin could be reduced in a large majority of patients. Metabolic control was similar in all groups. Only triglycerides were significantly lower in group 2. The frequency of hypoglycemia and the prevalence of vascular disease were just slightly higher in the group on insulin therapy.
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Affiliation(s)
- Georg Biesenbach
- 2nd Department of Medicine, General Hospital Linz, Bismarckstrasse 7, 4020 Linz, Austria.
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Ivarsen P, Chen JW, Tietze I, Christiansen JS, Flyvbjerg A, Frystyk J. Marked reductions in bioactive insulin-like growth factor I (IGF-I) during hemodialysis. Growth Horm IGF Res 2010; 20:156-161. [PMID: 20044291 DOI: 10.1016/j.ghir.2009.12.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 11/29/2009] [Accepted: 12/01/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Hemodialysis (HD) patients lose lean body mass, even when they are adequately dialysed. One reason may be a decreased activity of the IGF-system. However, data on changes in bioactive IGF-I during HD are sparse. DESIGN Ten stable, non-diabetic HD patients were studied with 30 min intervals during a scheduled HD, with blood sampling before (-15 and 0 min), during (4 h) and after (1 h) the session. Patients were fasted for at least 6 h before and during the study. Arterial and venous blood was sampled for determination of IGF-I bioactivity, free and total IGF-I and IGF-II, IGF binding protein-1 (IGFBP-1), IGFBP-1 complexed IGF-I and IGFBP-2. RESULTS Total IGF-I and -II decreased marginally (<12%) at the very end of the study (P<0.05). By contrast, at 3 h free and bioactive IGF-I had declined by approximately 35% and 50%, respectively, and levels remained suppressed for the rest of the study (P<0.05). Concomitantly, IGFBP-1 and IGFBP-1:IGF-I complex formation increased 5.0-fold and 2.6-fold, respectively (P<0.05). By contrast, IGFBP-2 did not increase as a result of HD. No major differences between arterial and venous concentrations were observed. CONCLUSION Despite marginal reductions in total IGF-I and -II, bioactive and free IGF-I declined markedly during and after HD. This is likely a consequence of the increase in IGFBP-1, sequestering free IGF-I, and reducing bioactive IGF-I. Based on the present data we hypothesize that the catabolism induced by HD is in part related to the observed reductions in bioactive IGF-I.
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Affiliation(s)
- Per Ivarsen
- Department of Renal Medicine C, Aarhus University Hospital, Skejby Sygehus, Aarhus N, Denmark.
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Riveline JP, Teynie J, Belmouaz S, Franc S, Dardari D, Bauwens M, Caudwell V, Ragot S, Bridoux F, Charpentier G, Marechaud R, Hadjadj S. Glycaemic control in type 2 diabetic patients on chronic haemodialysis: use of a continuous glucose monitoring system. Nephrol Dial Transplant 2009; 24:2866-71. [PMID: 19389864 DOI: 10.1093/ndt/gfp181] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The proportion of diabetic patients undergoing haemodialysis is rapidly increasing. Glucose control among such patients is difficult to assess. We aimed to evaluate the clinical performance of a continuous glucose monitoring system (CGMS) in type 2 diabetic patients on chronic haemodialysis. METHODS We used a 4-day CGMS to monitor glucose levels in 19 haemodialysed type 2 diabetic patients (HD T2) including 2 days with and 2 days without dialysis session, and 39 non-HD T2 in a double-centre study. RESULTS The glucose concentration according to the glucose meter and CGMS were correlated in HD T2 patients (r = 0.90, P < 0.0001) and in non-HD T2 patients (r = 0.81, P < 0.0001). The relative absolute difference (RAD) between glucose determined by a glucose meter and glucose determined by the CGMS did not differ between HD T2 and non-HD T2 patients (9.2 +/- 10.5 vs. 8.2 +/- 7.6%; P = 0.165). Glycated haemoglobin (A1c) and mean glucose concentration were strongly correlated in non-HD T2 patients (r = 0.71; P < 0.0001) but weakly correlated in HD T2 patients (r = 0.47; P = 0.042). Fructosamine was correlated with the mean glucose concentration in non-HD T2 (r = 0.67; P < 0.0001) but not in HD T2 patients (r = 0.04; P = 0.88). CONCLUSION CGM is a validated marker of glycaemic control in HD diabetic patients. This tool showed that A1c and fructosamine, despite being good markers of glycaemic control in non-HD diabetic patients, are of poor value in HD diabetic patients.
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