Evidence-based guideline: Treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation

OBJECTIVE

To develop a scientifically sound and clinically relevant evidence-based guideline for the treatment of painful diabetic neuropathy (PDN).

METHODS

We performed a systematic review of the literature from 1960 to August 2008 and classified the studies according to the American Academy of Neurology classification of evidence scheme for a therapeutic article, and recommendations were linked to the strength of the evidence. The basic question asked was: "What is the efficacy of a given treatment (pharmacological: anticonvulsants, antidepressants, opioids, others; and non-pharmacological: electrical stimulation, magnetic field treatment, low-intensity laser treatment, Reiki massage, others) to reduce pain and improve physical function and quality of life (QOL) in patients with PDN?"

RESULTS AND RECOMMENDATIONS

Pregabalin is established as effective and should be offered for relief of PDN (Level A). Venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids (morphine sulphate, tramadol, and oxycodone controlled-release), and capsaicin are probably effective and should be considered for treatment of PDN (Level B). Other treatments have less robust evidence or the evidence is negative. Effective treatments for PDN are available, but many have side effects that limit their usefulness, and few studies have sufficient information on treatment effects on function and QOL.

Comparable outcomes in type 2 diabetic patients with diabetic or vascular nephropathy treated by hemodialysis

AIM

The aim of the present study was to find out any differences in the progression of macroangiopathic diseases and patient survival in diabetic patients with diabetic nephropathy (DN) or diabetic renal vasculopathy (DV) under hemodialysis therapy.

METHODS

We compared 24 type 2 diabetic patients under hemodialysis with DV and 102 type 2 diabetic patients under hemodialysis with DN. Observation period was the first 3 years after initiating dialysis therapy.

RESULTS

Patients with DN were younger and their diabetes duration was longer (p < 0.05) than in the DV patients. The prevalence of vascular diseases at the start of dialysis treatment as well as after 3 years was not significantly different between both groups. The 3-year mortality was 50% in the DN group and 46% in the DV patients.

CONCLUSION

Patients with DN and DV show a similar poor outcome during the first 3 years of hemodialysis therapy.

The kidney in diabetes: dynamic pathways of injury and repair. The Camillo Golgi Lecture 2007

Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD). The natural history of diabetic nephropathy has changed over the last decades, as a consequence of better metabolic and blood pressure management. Thus, it may now be possible to delay or halt the progression towards ESRD in patients with overt diabetic nephropathy, and the decline of renal function is not always inexorable and unavoidable. Also, the rate of progression from microalbuminuria to overt nephropathy is much lower than originally estimated in the early 80s. Furthermore, there is now evidence that it is possible, in humans, to obtain reversal of the established lesions of diabetic nephropathy. This review focuses on the contribution of kidney biopsy studies to the understanding of the pathogenesis and natural history of diabetic nephropathy and the identification of patients at high risk of progression to ESRD. The classic lesions of diabetic nephropathy and the well-established structural-functional relationships in type 1 diabetes will be briefly summarised and the renal lesions leading to renal dysfunction in type 2 diabetes will be described. The relevance of these biopsy studies to diabetic nephropathy pathogenesis will be outlined. Finally, the evidence and the possible significance of reversibility of diabetic renal lesions will be discussed, as well as future directions for research in this field.

Adiponectin is associated with brain natriuretic peptide and left ventricular hypertrophy in hemodialysis patients with type 2 diabetes mellitus

BACKGROUND

Adiponectin, an adipocyte-derived hormone, has been shown to prevent the progression of left ventricular hypertrophy (LVH). However, recent studies have demonstrated increased levels of adiponectin according to the severity of chronic heart failure. We therefore investigated the relationships between adiponectin, brain natriuretic peptide (BNP), and LVH in type 2 diabetic patients on hemodialysis.

METHODS

The study population comprised 41 type 2 diabetic patients on hemodialysis. Left ventricular mass index (LVMI) and criteria for LVH were determined on the basis of echocardiographic findings. Serum adiponectin and plasma BNP levels were assayed with a commercially available kit.

RESULTS

Serum adiponectin levels significantly correlated with BMI (r = -0.49, p < 0.01), HDL-C (r = 0.36, p < 0.05) and TG (r = -0.49, p < 0.01). In addition, serum adiponectin levels correlated significantly and positively with plasma BNP levels (r = 0.36, p < 0.05). This relationship remained significant after adjustment for age, gender, and BMI (r = 0.34, p < 0.05). Serum adiponectin levels as well as plasma BNP levels were significantly higher than in patients without LVH (p < 0.05; p < 0.01, respectively), accompanied by a positive correlation between these levels and LVMI (r = 0.42, p < 0.01; r = 0.32, p < 0.05, respectively).

CONCLUSION

Increased levels of adiponectin were associated with elevated BNP levels and LVH in hemodialysis patients with type 2 diabetes mellitus. It is speculated that adiponectin levels may be modulated by chronic hypervolemic state in this population.

Long-term evaluation of a structured outpatient education programme for intensified insulin therapy in patients with Type 1 diabetes: a 12-year follow-up

AIMS/HYPOTHESIS

This study was conducted to evaluate the long-term outcome of a structured outpatient diabetes teaching and treatment programme (DTTP) for intensified insulin therapy in patients with Type 1 diabetes, which aims to improve metabolic control without increasing the risk of severe hypoglycaemia.

METHODS

All 123 diabetic outpatients (age 41+/-14 years; 64 women; BMI 23.5+/-3.1; diabetes duration 17+/-11 years; HbA1c 7.9+/-1.6%; 32 patients with a history of severe hypoglycaemia; 18 with overt nephropathy; 22 with proliferative retinopathy) who participated in the DTTP between June 1989 and June 1990 were invited for follow-up visits after 3, 6 and 12 years.

RESULTS

Out of the 123 patients, 11 died during the follow-up period, two were lost for follow-up, and one was not willing to participate in re-evaluation after 12 years. Mean HbA1c levels decreased from 7.9+/-1.6% to 7.1+/-1.2% (p<0.01) after 3 years, and were 7.8+/-1.5% (NS) and 7.8+/-1.2% (NS) after 6 and 12 years respectively. Frequency of hypoglycaemia decreased from 0.49 episodes per patient per year to 0.14 after 3 years (p<0.01), 0.19 after 6 years (p<0.01) and 0.16 after 12 years (p<0.01). Of the participants, 41% were able to lower HbA1c levels without episodes of severe hypoglycaemia and to maintain this improvement at all follow-up visits over the 12-year period. At follow-up, intensified insulin therapy was carried out by 94% of the patients.

CONCLUSIONS/INTERPRETATION

A sustained reduction of the incidence of severe hypoglycaemia was observed in patients with Type 1 diabetes after participation in a structured outpatient DTTP over a 12-year period.

Geriatric rehabilitation. 3. Physical medicine and rehabilitation interventions for common disabling disorders1∗1No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated.∗Key references

This self-directed learning module highlights physical medicine and rehabilitation (PM and R) interventions for common disorders that cause disability in older adults. It is part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in PM and R and geriatric medicine. This article specifically focuses on PM and R interventions for arthritides, fractures, cardiovascular disorders, peripheral vascular disease, amputations, pulmonary disorders, cancer, stroke, traumatic brain injury, Parkinson's disease, spinal cord injury, peripheral neuropathies, and diabetic complications.

OVERALL ARTICLE OBJECTIVE

To summarize the physical medicine and rehabilitation interventions for commonly disabling conditions of older adults.

Nutrition interventions in early diabetic renal disease

Education and nutritional intervention play an important role in preventing and delaying the progression of renal disease in persons with diabetes. We need to identify those patients at risk or who have renal disease early, when interventions are most effective. Patients should visit a dietitian with expertise in diabetes to obtain an individual meal plan that focuses on those aspects that have the greatest impact on the disease: blood pressure control, blood glucose control, and moderate protein restriction.

Dismal rehabilitation in predominantly type II diabetics on dialysis in Inner-City Brooklyn

AIM

In order to define their demographics and medical conditions, 218 diabetic patients undergoing hemodialysis in Brooklyn were interviewed and their charts reviewed.

METHODS

Patient rehabilitation was assessed with the Karnofsky score, and the urea reduction rate as well as serum albumin and hematocrit levels evaluated adequacy of hemodialysis.

RESULTS

The majority of patients (167) were African-American, 25 were Whites, 19 patients were Hispanic and 6 were Asian. One patient was a Native American. The mean age was 60.5 years (range 16-88), and the majority, 52%, were women. Rehabilitation was poor, the mean Karnofsky score being 65.1+/-20.8, and only 6% of patients were working. By linear regression, there was no difference in the Karnofsky score according to gender, age, race, type of diabetes, education, family income or hematocrit level. Only the patients' self-perception of their psyche function, or how well they thought they were doing, was significant.

CONCLUSION

Further work is needed to examine the reasons for the poor rehabilitation of diabetics on dialysis in Brooklyn.

Grip strength in end stage renal disease

The grip strength of 110 patients with end stage renal disease was measured. Their grip strength tended to be low compared with published norms. Significant correlations were found between the patients' grip strength and their gender, height, weight, and diabetic status. A regression equation including gender, height, and diabetic status as independent variables explained more than 40% of the variance in patients' grip strength.

Quality of life after successful pancreas-kidney transplantation

Quality of life assessment has emerged as an important approach to evaluate the effect of pancreas transplantation in diabetic patients with end-stage renal failure (ESRD). The aim of this study was to evaluate the impact of the ESRD treatment modality on the quality of life in patients with Type I (insulin-dependent) diabetes mellitus. Thirty-two patients of similar age, sex and diabetes duration, treated for more than 1 year with simultaneous kidney and pancreas transplantation (Group 1, n = 12), or kidney transplantation (Group 2, n = 10), or hemodialysis (Group 3, n = 10) were studied. Quality of life was assessed using a questionnaire (34 questions with 103 possible answers) including social (sickness pension, working capacity) and subjective (general health perception), index of Spizer and index of reintegration to normal life of Wood Dauphine) quality of life indicators, working capacity, as well as physical ability (Karnofsky index), sports training and sexual activity. Patients in Group 1 showed highest scores on general health perception (p = 0.012), Karnofsky index (p = 0.076) and sexual activity (p = 0.026). There were no significant differences between groups on social index, as well as index of Spizer, index of reintegration to normal life and sport activity. Patients on hemodialysis treatment presented the lowest scores in all the items evaluated. In conclusion, in our experience simultaneous pancreas and kidney transplantation is the treatment modality that offers better quality of life to diabetic patients with ESRD; however, this does not translate into a higher socio-labor yield.

[Principles and general practice of goal-oriented planning of training in patients with diabetic nephropathy and in dialysis patients]

Uremic patients on hemodialysis suffer from marked reduction of physical exercise capacity. This reduction cannot solely be explained by the underlying disease and co-existing anemia. We wondered, whether reduced exercise capacity in these patients might be due to lack of physical exercise and whether anaerobic exercise training (AET) would lead to improved work capacity. 8 patients were enrolled in this study. At the beginning and at the end of the training period, which lasted 4 to 6 weeks, a symptom-limited incremental bicycle-spiroergometry was performed. AET led to a significant increase in exercise capacity without any changes in the renal status and hematocrit as well as hemoglobin values. From these data we conclude, that decreased exercise capacity in uremic patients on dialysis is due to inadequate exercise performance of these patients and that AET is able to improve exercise capacity.

Assessment of rehabilitation outcomes among chronic dialysis patients

The physical status of 137 chronic dialysis patients was assessed by both objective and subjective measures; education and employment statuses were also determined. Below normal grip strength characterized the majority of patients; slowed nerve conduction and subjective fatigue were also observed among a subset of patients. However, patients demonstrated good to normal muscle strength and relatively normal pinch strength, and activities of daily living presented no problems for the large majority of patients. Employment probability was directly related to educational status. Despite dialysis requirements and other employment disincentives, 42% of non-diabetic men aged 21-59 were employed.

Physical activity and employment status of patients on maintenance dialysis

Existing data on the clinical outcome of maintenance dialysis for end-stage kidney disease focus mainly on the duration of life. We surveyed 18 dialysis centers to gain a broader overview of the current status of 2481 patients on dialysis, irrespective of the type or location of dialysis. The results suggest that 12 per cent of dialysis patients are diabetics and that 53 per cent are 50 years of age or older. There was considerable variation among centers in the degree of rehabilitation; nevertheless, only 60 per cent of the nondiabetic patients and 23 per cent of the diabetic patients were capable of a level of physical activity beyond that of caring for themselves. Only one quarter of the patients worked outside the home, whereas one third worked at home. These results suggest that a larger proportion of dialysis patients than previously suspected are severely debilitated. There is a need for improved data on the quality and length of life of patients on maintenance dialysis.

Long-term rehabilitation of transplant patients

In conclusion, 148 patients transplanted between 1970-3 have been evaluated in terms of quality of life. Nondiabetic long-term transplant patients showed high levels of improvement and rehabilitation among multiple dimensions. While diabetic patients also showed improvement, many problems remain for this group.

End-stage renal failure in juvenile diabetes mellitus: a 5-year follow-up of treatment

A group of 43 juvenile diabetic patients accepted for renal transplantation and followed up for as long as 5 years was studied. The cumulative survivial of the group was 66% at 1 year and 58% at 5 years. The 1-year survival of those receiving cadaveric renal allografts (65%) or of those on dialysis alone (55%) was less than the survival of those after living related donor transplantation (88%). The major morbid sequelae included retinopathy, neuropathy, and peripheral vascular disease. While patients were on dialysis, blindness increased, with 44% of the bilateral blindness and 27% of the unilateral blindness representing new cases. After transplantation, permanent unilateral or bilateral blindness developed in an additional 12% of the patients. Severe neuropathy progressed rapidly in patients on dialysis and improved after transplantation in all. Fifty percent of the patients who survived transplantation 1 year or more required amputation of one or more extremities. Only 25% of the patients who survived 1 year after transplantation were without blindness, severe peripheral vascular problems, or both.