Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome after renal transplantation in the United States

Serum Levels of Selected Elements in Patients with Beta Thalassemia Major

β-thalassemia major is a significant health problem in the world that obliges patient to repeated blood transfusions. Frequent transfusions cause toxic iron overload and the association between serum iron levels and β-thalassemia major have been extensively studied in literature. Nonetheless, data on trace elements is still limited. The aim of this work was to study the relationship between some trace element levels in serum and β-thalassemia major. The quantifications of Al, K, Sn, Sb, Ni, Cr, Cd, Ba, Co, As and Se elements were carried out by Inductively Coupled Plasma - Mass Spectrometry system. Mann Whitney U test is performed in order to test the statistical difference between patient and control groups in terms of their element concentrations. Significant differences were observed for the concentrations of Al, K, Sn and Sb elements and for the correlation between concentrations of K-Sb elements. The study indicates higher levels of Al and Sb, and lower levels of K and Sn elements of patients when compared to control group. These findings reveal the altered profile of serum trace element concentrations and so, further studies are required to evaluate the potential of trace elements as biomarkers and/or to administrate their levels in blood to reduce the related complications.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) in kidney transplant recipients: what is the evidence?

Several recent randomized controlled trials (RCTs) have demonstrated the wide clinical application of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in improving kidney and cardiovascular outcomes in patients with native kidney disease. In April 2021, Dapagliflozin became the first SGLT2 inhibitor to be approved by the Food and Drug Administration (FDA) for the treatment of chronic kidney disease (CKD) regardless of diabetic status. However, while these agents have drawn much acclaim for their cardiovascular and nephroprotective effects among patients with native kidney disease, little is known about the safety and efficacy of SGLT2i in the kidney transplant setting. Many of the mechanisms by which SGLT2i exert their benefit stand to prove equally as efficacious or more so among kidney transplant recipients as they have in patients with CKD. However, safety concerns have excluded transplant recipients from all large RCTs, and clinicians and patients alike are left to wonder if the benefits of these amazing drugs outweigh the risks. In this review, we will discuss the known mechanisms SGLT2i exploit to provide their beneficial effects, the potential benefits, and risks of these agents in the context of kidney transplantation, and finally, we will discuss current findings of the published literature for SGLT2i use in kidney transplant recipients and propose potential directions for future research.

Correlation of Transferrin Saturation and Serum Ferritin with Bone Mass Density in Adult Transfusion Dependent Beta-Thalassemia Patients

BACKGROUND

The use of regular blood transfusions and iron chelation therapy to treat thalassemia has improved survival and increased the incidence of osteoporosis. Moreover, iron toxicity is one of the contributing factors that reduce bone mass density in adult transfusion-dependent beta-thalassemia patients. Therefore, this study aims to determine the proportion of low bone mass density in adult thalassemia patients and transferrin saturation, as well as serum ferritin, which correlates to the skeletal condition.

METHODS

This is a cross-sectional study conducted in Thalassemia and Hematology Medical Oncology Clinics of Cipto Mangunkusumo Hospital in March 2016. The anthropometric data and hemoglobin levels were obtained before transfusion. Subsequently, the average ferritin levels, bone mineral density, and radiographic results were obtained.

RESULTS

The percentage of adult thalassemia major and intermedia patients with low bone mass density was 68%. Also, there was a weak inverse correlation between bone mass density and transferrin saturation (r = -0.329, p = 0.01), while no correlation was shown between bone mass density and ferritin (r = -0.088, p = 0.504). The transferrin saturation cutoff point value used to distinguish the incidence of low and normal bone density in patients with transfusion-dependent beta-thalassemia was 89.5%. In addition, there was weak correlation between Singh index and bone mass density (r = 0.273, p = 0.038).

CONCLUSION

Among the transfusion-dependent beta-thalassemia patients, 68% had low bone mass density, which inversely correlated to transferrin saturation. Furthermore, the cutoff value of transferrin saturation to differentiate the incidence of low and normal bone density in thalassemia major compared to thalassemia intermedia was 89.5%. Singh Index correlates weakly with bone mass density and might be used to detect low bone mass density in remote healthcare facilities.

Diabetic Ketoacidosis in Patients with End-stage Kidney Disease: A Review

Diabetes mellitus is a highly prevalent disease. Chronic kidney disease is one of its chronic complications, and diabetic ketoacidosis is one of the most dreaded acute complications. The increasing prevalence of diabetes mellitus and renal failure has resulted in physicians increasingly encountering diabetic ketoacidosis in this complicated subgroup of patients. This review discusses the pathophysiologic understanding of diabetic ketoacidosis in patients with renal failure, its varying clinical presentation, and management and prevention. We have also highlighted the role of patient weight and proximity to dialysis as tools to assess and manage fluid status in this challenging group of patients.

Posttransplant Tacrolimus-Induced Diabetic Ketoacidosis: Review of the Literature

Diabetic ketoacidosis (DKA) in patients receiving tacrolimus as part of their immunosuppressive regimen is a rarely reported adverse event. We report a patient with autosomal dominant polycystic kidney disease (ADPKD) and no known history of diabetes mellitus who presented with DKA, 3 months after kidney transplantation.

Correlates of poor glycemic control among patients with diabetes initiating hemodialysis for end-stage renal disease

Background

Maintaining tight glycemic control is important for prevention of diabetes-related outcomes in end-stage renal disease patients with diabetes, especially in light of their poor prognosis. This study aimed to determine factors associated with poor glycemic control among U.S. patients with diabetes mellitus initiating hemodialysis for end-stage renal disease.

Methods

Using data from the U.S. Renal Data System, electronic health records of a large national dialysis provider, and U.S. Census data, we performed a cross-sectional multivariable Poisson regression analysis to characterize risk factors associated with poor glycemic control, defined as glycated hemoglobin (HbA1c) >7 vs. ≤7 %, in adult patients with diabetes who initiated hemodialysis at an outpatient facility between 2006 and 2011.

Results

Of 16,297 patients with diabetes, 21.2 % had HbA1c >7 %. In multivariable analysis, younger patients, patients of Native American race, and those of Hispanic ethnicity had higher prevalence of poor glycemic control. Independent correlates of poor glycemic control further included higher platelet count, white blood cell count, and ferritin; higher body mass index, systolic blood pressure, total cholesterol and triglyceride concentrations; lower HDL and albumin concentrations; lower normalized protein catabolic rate; and higher estimated glomerular filtration rate at initiation of dialysis (all P < 0.05). No independent associations were found with area-level socioeconomic indicators. Occurrence of diabetes in patients <40 years of age, a proxy for type 1 diabetes, was associated with poor HbA1c control compared with that in patients ≥40 years of age, which was classified as type 2 diabetes. These findings were robust to the different outcome definitions of HbA1c >7.5 % and >8 %.

Conclusion

In this cohort of incident end-stage renal disease patients with diabetes, poor glycemic control was independently associated with younger age, Native American race, Hispanic ethnicity, higher body mass index, and clinical risk factors including atherogenic lipoprotein profile, hypertension, inflammation, and markers indicative of malnutrition and a more serious systemic disease.

Prospective study of cytomegalovirus seropositivity and risk of mortality from diabetes

Cytomegalovirus (CMV) infects 40 % of the world population and has been suggested to be associated with diabetes; however, no prospective study has ever examined diabetes mortality associated with the infection. A cohort of 14,404 non-diabetic adult participants aged 17-90 years from the Third National Health and Nutrition Examination Survey (1988-1994) was prospectively followed for mortality through 2006. CMV immunoglobulin G was measured by enzyme-linked immunosorbent assay and immunofluorescence assay. Diabetes death was assessed with death records from the National Death Index. Cox proportional hazards modeling was used to determine diabetes mortality risk associated with CMV infection, adjusting for socio-demographics, diabetes risk factors, and comorbidities. At baseline, 76.8 % of subjects were CMV seropositive, and after an average follow-up of 13.7 years, diabetes mortality rate per 10,000 person-years was 6.8 (95 % CI 5.7, 8.0). Among seropositive participants, the diabetes death rate (8.4, 95 % CI 7.0, 9.9) was more than four times the rate in seronegative ones (2.0, 95 % CI 1.1, 3.6) (P value for the difference <0.001). In the adjusted Cox proportional hazards analysis, CMV seropositivity more than doubled the risk of diabetes mortality (HR 2.06, 95 % CI 1.05, 4.06). CMV infection may thus predict future mortality from diabetes in non-diabetic people.

Combination therapy of mycophenolate mofetil and tacrolimus in lupus nephritis

Since most lupus nephritis patients have an incomplete response to mycophenolate mofetil, combination regimens may improve outcomes. Tacrolimus (FK506) has shown some benefit in lupus nephritis in small trials, and combined with mycophenolate mofetil is standard immunosuppression in transplant patients. We investigate the addition of FK506 to mycophenolate mofetil, in patients who were mycophenolate mofetil failures. All patients were part of a prospective cohort, but evaluated retrospectively. Seven lupus nephritis patients (mean age 27.1, 100% female, 42% Caucasian and 42% African American) were evaluated. Three patients had combined ISN class III and V, two ISN class IV, one ISN class V and II and one ISN class IV and V. Six were taking an ACE-inhibitor or angiotensin receptor blocker, 6 hydroxychloroquine and 5 prednisone (mean dose 11.5 mg; range 0-30 mg). Mean mycophenolate mofetil dose at time of tacrolimus addition was 2.8 g (range 2-3 g). Mean tacrolimus dose was 3.4 mg (range 2-8 mg) titrated to a mean level of 4.67 ng/dl (range 2.2-11.8 ng/dl) for a mean of duration of 16 months (range 2-54 months). Two patients continued both therapies, while five discontinued therapy. One patient achieved a complete renal remission, while three achieved partial remission with 82.9%, 77.1%, 55.3% reductions in proteinuria. Toxicity limited the use of combination therapy: diabetic ketoacidosis (one patient), pneumonia (two) and muscle pain (two). These data suggest that adding tacrolimus in patients refractory to mycophenolate mofetil might have some benefit, although complete responses were rare. Unfortunately, tacrolimus toxicity appeared to be prevalent in these systemic lupus erythematosus patients, limiting its long term use.

Prediction of Inpatient Survival and Graft Loss in Rehospitalized Kidney Recipients

INTRODUCTION

Despite a sizeable amount of research conducted hitherto into predictors of renal transplantation outcomes, there are scarce, data on predictors of in-hospital outcomes of post-kidney transplant rehospitalization. This study sought to provide a user-friendly prediction model for inpatient mortality and graft loss among rehospitalized kidney recipients.

METHOD

This retrospective review of 424 consecutive kidney recipients rehospitalized after kidney transplantation between the years 2000 and 2005 used multiple logistic regression analysis to evaluate predictors of hospitalization outcomes.

RESULTS

Multivariate analysis showed that age at admission, diabetes mellitus as the cause of end-stage renal disease (ESRD), admission due to cerebrovascular accident (CVA), surgical complications were predictors of in-hospital death; age at transplantation, surgical complications, and rejection were predictors of graft loss. Equation for prediction of in-hospital death was Logit(death) -0.304 * age at transplantation (year) + 0.284 age at admission (year) + 1.621 admission for surgical complication + 4.001 admission for CVA-ischemic heart disease + 2.312 diabetes as cause of ESRD. Equation for prediction of in-hospital death was Logit(graft loss) = 0.041 age at transplantation (year) + 1.184 admission for graft rejection + 1.798 admission for surgical complication.

CONCLUSIONS

Our prediction equations, using simple demographic and clinical variables, estimated the probability of inpatient mortality and graft loss among re-hospitalized kidney recipients.

Review article: hepatitis C virus infection and type-2 diabetes mellitus in renal diseases and transplantation

A link between hepatitis C virus infection and development of diabetes mellitus has been suggested by many investigators; however, this remains controversial. The mechanisms underlying the association between hepatitis C virus and diabetes mellitus are unclear but a great majority of clinical surveys have found a significant and independent relationship between hepatitis C virus and diabetes mellitus after renal transplantation and orthotopic liver transplantation. We have systematically reviewed the scientific literature to explore the association between hepatitis C virus and diabetes mellitus in end-stage renal disease; in addition, data on patients undergoing orthotopic liver transplantation were also analysed. The unadjusted odds ratio for developing post-transplant diabetes mellitus in hepatitis C virus-infected renal transplant recipients ranged between 1.58 and 16.5 across the published studies. The rate of anti-hepatitis C virus antibody in serum was higher among dialysis patients having diabetes mellitus (odds ratio 9.9; 95% confidence interval 2.663-32.924). Patients with type-2 diabetes-related glomerulonephritis had the highest anti-hepatitis C virus prevalence [19.5% (24/123) vs. 3.2% (73/2247); P < 0.001] in a large cohort of Japanese patients who underwent renal biopsy. The link between hepatitis C virus and diabetes mellitus may explain, in part, the detrimental role of hepatitis C virus on patient and graft survival after orthotopic liver transplantation and/or renal transplantation. Preliminary evidence suggests that anti-viral therapies prior to renal transplantation and novel immunosuppressive regimens may lower the occurrence of diabetes mellitus in hepatitis C virus-infected patients after renal transplantation. Clinical trials are under way to assess if the hepatitis C virus-linked predisposition to new onset diabetes mellitus after renal transplantation may be reduced by newer immunosuppressive medications.

Diabetic ketoacidosis following development of de novo diabetes in renal transplant recipient associated with tacrolimus

Although drugs used in renal transplant recipients such as steroids, cyclosporine, and particularly, tacrolimus have diabetogenic potential, diabetic ketoacidosis is uncommon. There are few data concerning the long-term follow-up of these patients. Diabetic ketoacidosis occurred in a renal transplant recipient following de novo development associated with tacrolimus.

Hepatitis C virus is independently associated with increased insulin resistance after liver transplantation

BACKGROUND AND AIMS

There is a strong epidemiologic association between diabetes mellitus (DM) and hepatitis C virus (HCV) infection. However, the pathogenetic basis for this association has not been established. We sought to evaluate the association between insulin resistance (IR), beta-cell dysfunction, and HCV among orthotopic liver transplant (OLT) recipients.

METHODS

We performed a cross sectional analysis comparing 39 HCV(+) with 60 HCV(-) OLT recipients. IR and beta-cell function were calculated using validated measures and were correlated with clinical variables.

RESULTS

By multivariate analysis of the entire cohort, HCV infection and body mass index (BMI) were independent predictors of IR (P =0.04 and 0.0006, respectively). HCV infection was associated with 35% increase in IR. Because the model used to calculate IR was derived from nondiabetic subjects, we performed additional analysis of patients who did not meet criteria for diabetes at the time of their study evaluation. In this analysis, HCV(+) subjects had greater fasting insulin and homeostasis model assessment (HOMA) IR (15.3 mu U/mL and 3.8) compared with HCV(-) patients (10.7 mu U/mL and 2.5) (P =0.03, 0.03). There was no difference in beta-cell function or hepatic insulin extraction between the HCV (+) and (-) groups. HCV (P =0.0005), BMI (P <0.0001), and high high-density lipoprotein (P =0.039) were the only independent predictors of IR. The presence of HCV infection and a 10-fold increase in HCV RNA were associated with a 62% and 8% increase in IR, respectively.

CONCLUSIONS

HCV is independently associated with increased IR after OLT. These findings provide a possible pathogenetic basis for the association of DM with HCV.