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Agarwal S, Mader JK, Arevalo G, Avula S, Chavez E, Sloan LA, Galindo RJ. Diabetes and Glucose Management in People on Hemodialysis. Diabetes Spectr 2025; 38:7-18. [PMID: 39959530 PMCID: PMC11825408 DOI: 10.2337/dsi24-0015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2025]
Abstract
Diabetes is a major cause of end-stage kidney disease (ESKD). Glycemic management is challenging in this population, and A1C, commonly used for monitoring glycemic control, is unreliable. Continuous glucose monitoring indices can be used for glycemic monitoring in people with ESKD. Dipeptidyl peptidase 4 inhibitors, incretin mimetic agents (glucagon-like peptide 1 and glucose-dependent insulinotropic peptide receptor agonists), and insulin using an automated insulin delivery system are preferred to manage diabetes in people with ESKD on hemodialysis.
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Affiliation(s)
- Shubham Agarwal
- Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Julia K. Mader
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Giuliana Arevalo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Sreekant Avula
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Efren Chavez
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | - Lance A. Sloan
- Department of Clinical Metabolism, Texas Institute for Kidney and Endocrine Disorders, Lufkin, TX
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
- College of Osteopathic Medicine, Sam Houston State University, Conroe, TX
| | - Rodolfo J. Galindo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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Klein KR, Lingvay I, Tuttle KR, Flythe JE. Glycemic Management and Individualized Diabetes Care in Dialysis-Dependent Kidney Failure. Diabetes Care 2025; 48:164-176. [PMID: 39693267 PMCID: PMC11770169 DOI: 10.2337/dci24-0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2024] [Accepted: 11/22/2024] [Indexed: 12/20/2024]
Abstract
Of the nearly 600,000 people in the U.S. who receive dialysis for chronic kidney failure, >60% have diabetes. People receiving dialysis who have diabetes have worse overall and cardiovascular survival rates than those without diabetes. Diabetes care in the dialysis setting is complicated by kidney failure-related factors that render extrapolation of glycated hemoglobin (HbA1c) targets to the dialysis population unreliable and may change the risk-benefit profiles of glucose-lowering and disease-modifying therapies. No prospective studies have established the optimal glycemic targets in the dialysis population, and few randomized clinical trials of glucose-lowering medications included individuals receiving dialysis. Observational data suggest that both lower and higher HbA1c are associated with mortality in the dialysis population. Existing data suggest the potential for safety and effectiveness of some glucose-lowering medications in the dialysis population, but firm conclusions are hindered by limitations in study design and sample size. While population-specific knowledge gaps about optimal glycemic targets and diabetes medication safety and effectiveness preclude the extension of all general population diabetes guidelines to the dialysis-dependent diabetes population, these uncertainties should not detract from the importance of providing person-centered diabetes care to people receiving dialysis. Diabetes care for individuals with and without dialysis-dependent kidney failure should be holistic, based on individual preferences and prognoses, and tailored to integrate established treatment approaches with proven benefits for glycemic control and cardiovascular risk reduction. Additional research is needed to inform how recent pharmacologic and technological advances can be applied to support such individualized care for people receiving maintenance dialysis.
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Affiliation(s)
- Klara R. Klein
- Division of Endocrinology and Metabolism, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Ildiko Lingvay
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
- Peter O’Donnel Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine R. Tuttle
- Division of Nephrology, University of Washington School of Medicine, Seattle, WA
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA
| | - Jennifer E. Flythe
- Division of Nephrology and Hypertension, University of North Carolina School of Medicine, Chapel Hill, NC
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
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Chowdhury TA, Mukuba D, Casabar M, Byrne C, Yaqoob MM. Management of diabetes in people with advanced chronic kidney disease. Diabet Med 2025; 42:e15402. [PMID: 38992927 DOI: 10.1111/dme.15402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/28/2024] [Accepted: 06/24/2024] [Indexed: 07/13/2024]
Abstract
Diabetes is the commonest cause of end stage kidney disease globally, accounting for almost 40% of new cases requiring renal replacement therapy. Management of diabetes in people with advanced kidney disease on renal replacement therapy is challenging due to some unique aspects of assessment and treatment in this group of patients. Standard glycaemic assessment using glycated haemoglobin may not be valid in such patients due to altered red blood cell turnover or iron/erythropoietin deficiency, leading to changed red blood cell longevity. Therefore, use of continuous glucose monitoring may be beneficial to enable more focussed glycaemic assessment and improved adjustment of therapy. People with advanced kidney disease may be at higher risk of hypoglycaemia due to a number of physiological mechanisms, and in addition, therapeutic options are limited in such patients due to lack of experience or license. Insulin therapy is the basis of treatment of people with diabetes with advanced kidney disease due to many other drugs classes being contraindicated. Targets for glycaemic control should be adjusted according to co-morbidity and frailty, and continuous glucose monitoring should be used in people on dialysis to ensure low risk of hypoglycaemia. Post-transplant diabetes is common amongst people undergoing solid organ transplantation and confers a greater risk of mortality and morbidity in kidney transplant recipients. It should be actively screened for and managed in the post-transplant setting.
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Affiliation(s)
| | - Dorcas Mukuba
- Department of Diabetes, The Royal London Hospital, London, UK
| | - Mahalia Casabar
- Department of Nephrology, The Royal London Hospital, London, UK
| | - Conor Byrne
- Department of Nephrology, The Royal London Hospital, London, UK
| | - M Magdi Yaqoob
- Barts and the London School of Medicine and Dentistry, London, UK
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Yu Y, Vangaveti VN, Schnetler RJ, Crowley BJ, Mallett AJ. Hyperkalaemia among hospital admissions: prevalence, risk factors, treatment and impact on length of stay. BMC Nephrol 2024; 25:454. [PMID: 39696056 DOI: 10.1186/s12882-024-03863-w] [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: 07/31/2024] [Accepted: 11/15/2024] [Indexed: 12/20/2024] Open
Abstract
BACKGROUND Hyperkalaemia is one of the common electrolyte disorders among hospital patients, affected by many risk factors including medications and medical conditions. Prompt treatment is important given its impact on patient mortality and morbidity, which can lead to negative patient outcomes and healthcare resource utilisation. This study aims to describe the prevalence, characteristics, and treatment of patients admitted to hospitals with hyperkalaemia and compare findings between patients with kidney failure on maintenance haemodialysis therapy and patients without kidney failure. It also aims to identify associations between hyperkalaemia and hospital length of stay. METHODS We undertook a retrospective cohort study on adult patients admitted to Townsville University Hospital between 1st January 2018 and 31st December 2022 (n = 99,047). Patients were included if they had a serum potassium result of 5.1 mmol/L and above during their admission/s. Statistical analysis was conducted using several methods. A Welch's t test and Chi-square test were employed to assess differences between groups of patients with kidney failure on maintenance haemodialysis therapy and those without kidney failure. For comparison among multiple groups with varying severities of hyperkalaemia, the Kruskal-Wallis test with Mann-Whitney U test and logistic regression were used. RESULTS 8,775 hyperkalaemic patients were included in the study, with a mean age of 64.7 years. The prevalence of hyperkalaemia was 8.9% of patients. Risk factors for hyperkalaemia were highly prevalent among those who had the condition during their admissions. Patients with kidney failure on haemodialysis who had hyperkalaemia were, on average, 6 years younger, more often Indigenous, and experienced more severe hyperkalaemia compared to other patients without kidney failure. There was a notable difference in hyperkalaemia treatment between groups with varying degrees of hyperkalaemia severity. Hyperkalaemia was not found to be associated with prolonged hospital stay. CONCLUSION Hyperkalaemia is common among hospital admissions. Patients with kidney failure on haemodialysis are at higher risk of developing severe hyperkalaemia. Treatment for hyperkalaemia was variable and likely insufficient. Timely detection and treatment of hyperkalaemia is recommended.
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Affiliation(s)
- Yalin Yu
- Department of Internal Medicine, Townsville University Hospital, Douglas, QLD, Australia
| | - Venkat N Vangaveti
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Douglas, QLD, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia
| | - Rudolf J Schnetler
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Douglas, QLD, Australia
| | - Benjamin J Crowley
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Douglas, QLD, Australia
| | - Andrew J Mallett
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Douglas, QLD, Australia.
- Department of Renal Medicine, Townsville University Hospital, Douglas, QLD, 4029, Australia.
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia.
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, QLD, Australia.
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Galindo RJ, Soliman D, Cherñavvsky D, Rhee CM. Diabetes technology in people with diabetes and advanced chronic kidney disease. Diabetologia 2024; 67:2129-2142. [PMID: 39112642 PMCID: PMC11446991 DOI: 10.1007/s00125-024-06244-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/03/2024] [Indexed: 09/07/2024]
Abstract
Diabetes is the leading cause and a common comorbidity of advanced chronic kidney disease. Glycaemic management in this population is challenging and characterised by frequent excursions of hypoglycaemia and hyperglycaemia. Current glucose monitoring tools, such as HbA1c, fructosamine and glycated albumin, have biases in this population and provide information only on mean glucose exposure. Revolutionary developments in glucose sensing and insulin delivery technology have occurred in the last decade. Newer factory-calibrated continuous glucose monitors provide real-time glucose data, with predictive alarms, allowing improved assessment of glucose excursions and preventive measures, particularly during and between dialysis sessions. Furthermore, integration of continuous glucose monitors and their predictive alerts with automated insulin delivery systems enables insulin administration to be decreased or stopped proactively, leading to improved glycaemic management and diminishing glycaemic fluctuations. While awaiting regulatory approval, emerging studies, expert real-world experience and clinical guidelines support the use of diabetes technology devices in people with diabetes and advanced chronic kidney disease.
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Affiliation(s)
| | - Diana Soliman
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Daniel Cherñavvsky
- University of Virginia Center for Diabetes Technology, Charlottesville, VA, USA
| | - Connie M Rhee
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Yoon SY, Kim JS, Ko GJ, Choi YJ, Moon JY, Jeong K, Hwang HS. Fasting blood glucose and the risk of all-cause mortality in patients with diabetes mellitus undergoing hemodialysis. Kidney Res Clin Pract 2024; 43:680-689. [PMID: 38325864 PMCID: PMC11467367 DOI: 10.23876/j.krcp.23.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 11/17/2023] [Accepted: 01/15/2023] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Glycemic control is particularly important in hemodialysis (HD) patients with diabetes mellitus (DM). Although fasting blood glucose (FBG) level is an important indicator of glycemic control, a clear target for reducing mortality in HD patients with DM is lacking. METHODS A total of 26,162 maintenance HD patients with DM were recruited from the National Health Insurance Database of Korea between 2002 and 2018. We analyzed the association of FBG levels at the baseline health examination with the risk of all-cause and cause-specific mortality. RESULTS Patients with FBG 80-100 mg/dL showed a higher survival rate compared with that of other FBG categories (p < 0.001). The risk of all-cause mortality increased with the increase in FBG levels, and adjusted hazard ratios (HRs) were 1.10 (95% confidence interval [CI], 1.04-1.17), 1.21 (95% CI, 1.13-1.29), 1.36 (95% CI, 1.26-1.46), and 1.61 (95% CI, 1.51-1.72) for patients with FBG 100-125, 125-150, 150-180, and ≥180 mg/dL, respectively. The HR for mortality was also significantly increased in patients with FBG <80 mg/dL (adjusted HR, 1.14; 95% CI, 1.05-1.23). The analysis of cause-specific mortality also revealed a J-shaped curve between FBG levels and the risk of cardiovascular deaths. However, the risk of infection or malignancy-related deaths was not linearly increased as FBG levels increased. CONCLUSION A J-shaped association was observed between FBG levels and the risk of all-cause mortality, with the lowest risk at FBG 80-100 mg/dL in HD patients with DM.
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Affiliation(s)
- Soo-Young Yoon
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Jin Sug Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Gang Jee Ko
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yun Jin Choi
- Biomedical Research Institute, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Ju Young Moon
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Kyunghwan Jeong
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Hyeon Seok Hwang
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
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Zhang N, Chen C, Han P, Wang B, Yang J, Guo Q, Cao P. Short-physical performance battery: complete mediator of cognitive depressive symptoms and diabetes mellitus in hemodialysis patients. BMC Public Health 2024; 24:2318. [PMID: 39187805 PMCID: PMC11348770 DOI: 10.1186/s12889-024-19857-0] [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: 12/21/2023] [Accepted: 08/22/2024] [Indexed: 08/28/2024] Open
Abstract
OBJECTIVE This study aimed to examine the relationship between different dimensions of depressive symptoms and the presence of diabetes mellitus in hemodialysis patients. Additionally, the study sought to elucidate the mediating effect of physical performance on this association. METHODS This was a cross-sectional multicenter study conducted between July 2020 and March 2023, involving 1024 patients from eight hemodialysis centers in Shanghai. Diabetes mellitus was based on a documented physician diagnosis and blood glucose tests. Physical performance and depressive symptoms were assessed using short-physical performance battery (SPPB) and the patient health questionnaire-9, respectively. Regression and mediation analysis were applied to statistical analysis. RESULTS Among the 1024 participants, 39.26% (n = 402) were found to have coexisting diabetes mellitus. Diminished SPPB scores (OR = 0.843, 95% CI = 0.792-0.897) and cognitive depressive symptoms (OR = 1.068, 95% CI = 1.011-1.129) exhibited significant associations with diabetes mellitus, while somatic depressive symptoms did not show a significant correlation. Notably, SPPB emerged as a complete mediator in the relationship between cognitive depressive symptoms and diabetes mellitus. The observed indirect effect of SPPB on this relationship was estimated at 0.038 (95% CI: 0.021-0.057). CONCLUSION This study showed an association between diabetes mellitus and cognitive depressive symptoms in patients undergoing hemodialysis, with physical performance appearing to mediate the relationship between diabetes mellitus and depressive symptoms.
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Affiliation(s)
- Ningning Zhang
- The Cardiovascular Center, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, No. 68 Gehu Middle Road, Changzhou, 213164, Jiangsu, China
| | - Cheng Chen
- The School of Health , Fujian Medical University, Fuzhou, 350122, Fujian, China
| | - PeiPei Han
- College of Rehabilitation Sciences, Shanghai University of Medicine and Health Sciences, 279 Zhouzhu Highway, Pudong New Area, Shanghai, 201318, China
| | - Bojian Wang
- School of Nursing, Jilin University, 965 Xinjiang Street, Changchun, 130021, Jilin, China
| | - Jinting Yang
- School of Nursing, Jilin University, 965 Xinjiang Street, Changchun, 130021, Jilin, China
| | - Qi Guo
- College of Rehabilitation Sciences, Shanghai University of Medicine and Health Sciences, 279 Zhouzhu Highway, Pudong New Area, Shanghai, 201318, China.
| | - Pengyu Cao
- The Cardiovascular Center, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, No. 68 Gehu Middle Road, Changzhou, 213164, Jiangsu, China.
- Changzhou Medical Center, Nanjing Medical University, Changzhou, 213004, Jiangsu, China.
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Zeidalkilani JM, Milhem YA, Shorafa RN, Taha S, Koni AA, Al-Jabi SW, Zyoud SH. Factors associated with patient activation among patients with diabetes on hemodialysis: a multicenter cross-sectional study from a developing country. BMC Nephrol 2024; 25:232. [PMID: 39033115 PMCID: PMC11265049 DOI: 10.1186/s12882-024-03674-z] [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: 08/12/2023] [Accepted: 07/15/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND Diabetes mellitus (DM) is a major public health concern with considerable morbidity and mortality. DM affects patients' quality of life and can lead to multiple complications, including chronic kidney disease (CKD) and the need for dialysis. Higher patient activation can improve health outcomes in hemodialysis patients with DM. This study aimed to explore the factors associated with higher patient activation and health-related quality of life (HRQoL) among hemodialysis patients with DM. METHODS This was a cross-sectional, questionnaire-based study conducted on hemodialysis patients with DM in Palestine. The quota sampling method was utilized to draw samples from six dialysis centers. The questionnaire consists of three sections. The first section includes demographic, socioeconomic and clinical questions. The second section utilizes the patient activation measure-13 (PAM-13) to measure patient activation, while the third section assesses HRQoL using the EQ-5D-5 L tool and the visual analog scale (VAS). Mann‒Whitney and Kruskal‒Wallis tests were employed to examine the relationships between variables at the bivariate level, and multiple regression analysis was employed at the multivariate level. RESULTS Of the 200 patients who were approached, 158 were included. The median PAM, EQ-5D index, and VAS score were low at 51.0, 0.58, and 60.0, respectively. A higher PAM score was independently associated with a higher household income level and taking medications independently. A higher EQ-5D index was associated with taking more than eight medications, taking medications independently, living with fewer than three comorbid conditions, and having a higher PAM. A higher VAS score was associated with being married, and receiving less than 3.5 hours of hemodialysis. CONCLUSIONS A higher patient activation level was associated with a higher income level and independence in taking medications. Interventions designed to improve patient activation, such as medication management programs, should address these factors among the target population. Longitudinal studies are needed to assess the time effect and direction of causation between health status and patient activation.
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Affiliation(s)
- Jehad M Zeidalkilani
- Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
| | - Yazan A Milhem
- Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
| | - Reem N Shorafa
- Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
| | - Sari Taha
- An-Najah Global Health Institute (GHI), An-Najah National University, Nablus, 44839, Palestine
- Department of Public Health, Faculty of Medicine and Health Sciences, An-Najah National University, P.O. Box 7, Nablus, Palestine
- Department of Anatomy, Biochemistry and Genetics, An-Najah National University, Nablus, 44839, Palestine
| | - Amer A Koni
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
- Division of Clinical Pharmacy, Department of Hematology and Oncology, An-Najah National University Hospital, Nablus, 44839, Palestine
| | - Samah W Al-Jabi
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
| | - Sa'ed H Zyoud
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine.
- Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine.
- Clinical Research Centre, An-Najah National University Hospital, Nablus, 44839, Palestine.
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Mallappallil M, Sasidharan S, Sabu J, John S. Treatment of Type 2 Diabetes Mellitus in Advanced Chronic Kidney Disease for the Primary Care Physician. Cureus 2024; 16:e64663. [PMID: 39149651 PMCID: PMC11326530 DOI: 10.7759/cureus.64663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 08/17/2024] Open
Abstract
Diabetes mellitus (DM) is a common cause of chronic kidney disease (CKD), leading to the need for renal replacement therapy (RRT). RRT includes hemodialysis (HD), peritoneal dialysis (PD), kidney transplantation (KT), and medical management. As CKD advances, the management of DM may change as medication clearance, effectiveness, and side effects can be altered due to decreasing renal clearance. Medications like metformin that were safe to use early in CKD may build up toxic levels of metabolites in advanced CKD. Other medications, like sodium-glucose co-transporter 2 inhibitors, which work by excreting glucose in the urine, may not be able to work effectively in advanced CKD due to fewer working nephrons. Insulin breakdown may take longer, and both formulation and dosing may need to be changed to avoid hypoglycemia. While DM control contributes to CKD progression, effective DM control continues to be important even after patients have been placed on RRT. Patients on RRT are frequently taken care of by a team of providers, including the primary care physician, both in and outside the hospital. Non-nephrologists who are involved with the care of a patient treated with RRT need to be adept at managing DM in this population. This paper aims to outline the management of type 2 DM in advanced CKD.
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Affiliation(s)
- Mary Mallappallil
- Internal Medicine and Nephrology, New York City (NYC) Health + Hospitals/Kings County Hospital Center, Brooklyn, USA
- Internal Medicine and Nephrology, State University of New York (SUNY) Downstate University of Health Sciences, Brooklyn, USA
| | - Sandeep Sasidharan
- Internal Medicine and Nephrology, State University of New York (SUNY) Downstate University of Health Sciences, Brooklyn, USA
- Internal Medicine and Nephrology, New York City (NYC) Health + Hospitals/Kings County Hospital Center, Brooklyn, USA
| | - Jacob Sabu
- Internal Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Sabu John
- Internal Medicine and Cardiology, New York City (NYC) Health + Hospitals/Kings County Hospital Center, Brooklyn, USA
- Internal Medicine and Cardiology, State University of New York (SUNY) Downstate University of Health Sciences, Brooklyn, USA
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Tsai CH, Shih DH, Tu JH, Wu TW, Tsai MG, Shih MH. Analyzing Monthly Blood Test Data to Forecast 30-Day Hospital Readmissions among Maintenance Hemodialysis Patients. J Clin Med 2024; 13:2283. [PMID: 38673554 PMCID: PMC11051209 DOI: 10.3390/jcm13082283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 03/27/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Background: The increase in the global population of hemodialysis patients is linked to aging demographics and the prevalence of conditions such as arterial hypertension and diabetes mellitus. While previous research in hemodialysis has mainly focused on mortality predictions, there is a gap in studies targeting short-term hospitalization predictions using detailed, monthly blood test data. Methods: This study employs advanced data preprocessing and machine learning techniques to predict hospitalizations within a 30-day period among hemodialysis patients. Initial steps include employing K-Nearest Neighbor (KNN) imputation to address missing data and using the Synthesized Minority Oversampling Technique (SMOTE) to ensure data balance. The study then applies a Support Vector Machine (SVM) algorithm for the predictive analysis, with an additional enhancement through ensemble learning techniques, in order to improve prediction accuracy. Results: The application of SVM in predicting hospitalizations within a 30-day period among hemodialysis patients resulted in an impressive accuracy rate of 93%. This accuracy rate further improved to 96% upon incorporating ensemble learning methods, demonstrating the efficacy of the chosen machine learning approach in this context. Conclusions: This study highlights the potential of utilizing machine learning to predict hospital readmissions within a 30-day period among hemodialysis patients based on monthly blood test data. It represents a significant leap towards precision medicine and personalized healthcare for this patient group, suggesting a paradigm shift in patient care through the proactive identification of hospitalization risks.
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Affiliation(s)
- Cheng-Han Tsai
- Department of Information Management and Institute of Healthcare Information Management, National Chung Cheng University, Chiayi City 62102, Taiwan or
- Department of Emergency Medicine, Chiayi Branch, Taichung Veteran’s General Hospital, Chiayi City 60090, Taiwan
| | - Dong-Her Shih
- Department of Information Management, National Yunlin University of Science and Technology, Douliu 64002, Taiwan;
| | - Jue-Hong Tu
- Department of Nephrology, St. Joseph’s Hospital, Yunlin 63241, Taiwan; (J.-H.T.); (M.-G.T.)
| | - Ting-Wei Wu
- Department of Information Management, National Yunlin University of Science and Technology, Douliu 64002, Taiwan;
| | - Ming-Guei Tsai
- Department of Nephrology, St. Joseph’s Hospital, Yunlin 63241, Taiwan; (J.-H.T.); (M.-G.T.)
| | - Ming-Hung Shih
- Department of Electrical and Computer Engineering, Iowa State University, 2520 Osborn Drive, Ames, IA 50011, USA;
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11
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Xie E, Ye Z, Wu Y, Zhao X, Li Y, Shen N, Gao Y, Zheng J. The triglyceride-glucose index predicts 1-year major adverse cardiovascular events in end-stage renal disease patients with coronary artery disease. Cardiovasc Diabetol 2023; 22:292. [PMID: 37891651 PMCID: PMC10612201 DOI: 10.1186/s12933-023-02028-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The triglyceride-glucose (TyG) index has been suggested as a dependable indicator for predicting major adverse cardiovascular events (MACE) in individuals with cardiovascular conditions. Nevertheless, there is insufficient data on the predictive significance of the TyG index in end-stage renal disease (ESRD) patients with coronary artery disease (CAD). METHODS This study, conducted at multiple centers in China, included 959 patients diagnosed with dialysis and CAD from January 2015 to June 2021. Based on the TyG index, the participants were categorized into three distinct groups. The study's primary endpoint was the combination of MACE occurring within one year of follow-up, including death from any cause, non-fatal myocardial infarction, and non-fatal stroke. We assessed the association between the TyG index and MACE using Cox proportional hazard models and restricted cubic spline analysis. The TyG index value was evaluated for prediction incrementally using C-statistics, continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI). RESULTS The three groups showed notable variations in the risk of MACE (16.3% in tertile 1, 23.5% in tertile 2, and 27.2% in tertile 3; log-rank P = 0.003). Following complete adjustment, patients with the highest TyG index exhibited a notably elevated risk of MACE in comparison to those in the lowest tertile (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.14-2.35, P = 0.007). Likewise, each unit increase in the TyG index correlated with a 1.37-fold higher risk of MACE (HR 1.37, 95% CI 1.13-1.66, P = 0.001). Restricted cubic spline analysis revealed a connection between the TyG index and MACE (P for nonlinearity > 0.05). Furthermore, incorporating the TyG index to the Global Registry of Acute Coronary Events risk score or baseline risk model with fully adjusted factors considerably enhanced the forecast of MACE, as demonstrated by the C-statistic, continuous NRI, and IDI. CONCLUSIONS The TyG index might serve as a valuable and dependable indicator of MACE risk in individuals with dialysis and CAD, indicating its potential significance in enhancing risk categorization in clinical settings.
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Affiliation(s)
- Enmin Xie
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zixiang Ye
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yaxin Wu
- Department of Cardiology, Henan Provincial People's Hospital, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Xuecheng Zhao
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yike Li
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Nan Shen
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yanxiang Gao
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Jingang Zheng
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China.
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.
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Hayashi A, Shimizu N, Suzuki A, Fujishima R, Matoba K, Moriguchi I, Kobayashi N, Miyatsuka T. Novel clinical relationships between time in range and microangiopathies in people with type 2 diabetes mellitus on hemodialysis. J Diabetes Complications 2023; 37:108470. [PMID: 37043984 DOI: 10.1016/j.jdiacomp.2023.108470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/07/2023] [Accepted: 03/25/2023] [Indexed: 04/03/2023]
Abstract
AIMS/HYPOTHESIS We investigated associations among glucose time in range (TIR, 70-180 mg/dL), glycemic markers and prevalence of diabetic microangiopathy in people with diabetes undergoing hemodialysis (HD). METHODS A total of 107 people with type 2 diabetes undergoing HD (HbA1c 6.4 %; glycated albumin [GA] 20.6 %) using continuous glucose monitoring were analyzed in this observational and cross-sectional study. RESULTS HbA1c and GA levels significantly negatively correlated with TIR, and positively correlated with time rate of hyperglycemia, but not with time rate of hypoglycemia. TIR of 70 % corresponded to HbA1c of 6.5 % and GA of 21.2 %. The estimated HbA1c level corresponding to TIR of 70 % in this study was lower than that previously reported in people with diabetes without HD. The prevalence of diabetic neuropathy was not significantly different between people with TIR ≥ 70 % and those with TIR < 70 % (P = 0.1925), but the prevalence of diabetic retinopathy in people with TIR ≥ 70 % was significantly lower than in those with TIR < 70 % (P = 0.0071). CONCLUSION/INTERPRETATION TIR correlated with HbA1c and GA levels in people with type 2 diabetes on HD. Additionally, a higher TIR resulted in a lower rate of diabetic retinopathy. RESEARCH IN CONTEXT What is already known about this subject? What is the key question? What are the new findings? How might this impact on clinical practice in the foreseeable future?
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13
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Wijewickrama P, Williams J, Bain S, Dasgupta I, Chowdhury TA, Wahba M, Frankel AH, Lambie M, Karalliedde J. Narrative Review of glycaemic management in people with diabetes on peritoneal dialysis. Kidney Int Rep 2023; 8:700-714. [PMID: 37069983 PMCID: PMC10105084 DOI: 10.1016/j.ekir.2023.01.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/09/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
There is an increasing number of people with diabetes on peritoneal dialysis (PD) worldwide. However, there is a lack of guidelines and clinical recommendations for managing glucose control in people with diabetes on PD. The aim of this review is to provide a summary of the relevant literature and highlight key clinical considerations with practical aspects in the management of diabetes in people undergoing PD. A formal systematic review was not conducted because of the lack of sufficient and suitable clinical studies. A literature search was performed using PubMed, MEDLINE, Central, Google Scholar and ClinicalTrials.gov., from 1980 through February 2022. The search was limited to publications in English. This narrative review and related guidance have been developed jointly by diabetologists and nephrologists, who reviewed all available current global evidence regarding the management of diabetes in people on PD.We focus on the importance of individualized care for people with diabetes on PD, the burden of hypoglycemia, glycemic variability in the context of PD and treatment choices for optimizing glucose control. In this review, we have summarized the clinical considerations to guide and inform clinicians providing care for people with diabetes on PD.
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Affiliation(s)
- Piyumi Wijewickrama
- Department of Diabetes and Endocrinology, University College London Hospital, London, UK
| | - Jennifer Williams
- Department of Renal Medicine, Royal Devon and Exeter Hospital, Exeter, UK
| | - Steve Bain
- Diabetes Research Unit, Swansea University, Swansea, UK
| | - Indranil Dasgupta
- Department of Renal Medicine, Heartlands Hospital Birmingham, Brimingham, UK
| | | | - Mona Wahba
- Department of Renal Medicine, St. Helier Hospital, Carshalton, UK
| | - Andrew H. Frankel
- Department of Renal Medicine, Imperial College Healthcare, London, UK
| | - Mark Lambie
- Department of Renal Medicine, Keele University, Keele, UK
| | - Janaka Karalliedde
- School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London, London, UK
- Correspondence: Janaka Karalliedde, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London SE1 9NH, UK.
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Li M, Li Y, Lv J, Xu H, Wu X, Wen W, Wang W, Yang H. The effects of glucose-free and glucose-containing dialysate during dialysis in MHD patients: a prospective cross-over study. Perfusion 2023; 38:178-185. [PMID: 34541941 DOI: 10.1177/02676591211042726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To investigate the effects of glucose-free and glucose-containing dialysates during dialysis in maintenance hemodialysis (MHD) patients by the prospective cross-over study, and detect glucose control methods in MHD patients. METHODS A total of 66 MHD 18-75 years old patients in our hospital from Nov. 2019 to Mar. 2020 were recruited. All patients underwent HD with 4 hours per time, three times per week. Glucose-free dialysate (glucose-free group) and then 5.55 mmol/L glucose-containing dialysate (glucose-5.55 group) were used alternately in dialysis. The demographics and parameters of pre- and post-dialysis were recorded. RESULTS A total of 60 patients were analyzed, and 28 patients among them had type 2 diabetes. Serum glucose pre and post dialysis were 8.64 ± 4.18 mmol/L versus 5.74 ± 1.82 mmol/L (p < 0.01) in glucose-free dialysate, and 9.31 ± 4.89 mmol/L versus 7.80 ± 2.59 mmol/L (p < 0.01) in glucose-5.55 dialysate. The post-dialysis blood glucose of glucose-free group was lower than glucose-5.55 group (5.74 ± 1.82 vs 7.80 ± 2.59, p < 0.01). About 18 (30.00%) patients in glucose-free group and 1 patient (1.67%) in glucose-5.55 group whose blood glucose was lower than 4.44 mmol/L (p < 0.01). About 29 patients (48.33%) in glucose-free group and 17 patients (28.33%; p = 0.02) in glucose-5.55 group have hunger feeling. Serum sodium level in the glucose-free group was higher than that in Glucose-5.55 group (137.92 ± 1.64 vs 136.70 ± 1.64, p < 0.01). Post-dialysis blood glucose had no significant differences between patients not using diabetes-related medication (13 patients) and patients using diabetes-related medication (15 patients) in glucose-free group (7.13 ± 1.78 mmol/L vs 6.08 ± 2.84 mmol/L, p = 0.23) and glucose-5.55 group (9.22 ± 2.59 mmol/L vs 9.35 ± 2.88 mmol/L, p = 0.90). CONCLUSIONS Glucose-free and glucose-5.55 dialysate both decrease the blood glucose post-dialysis. Dialysates containing 5.55 mmol/L glucose can reduce the incidence of hypoglycemia and lower serum sodium, but have no effect on blood pressure during dialysis. Stopping insulin and oral anti-diabetic drugs once before dialysis may not affect the control of blood glucose.
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Affiliation(s)
- Minxia Li
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Yuehong Li
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Jiaxuan Lv
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Huiying Xu
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Xianglan Wu
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Wen Wen
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Wei Wang
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Hua Yang
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
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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: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [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)
| | - 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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16
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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: 10] [Impact Index Per Article: 3.3] [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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Afghahi H, Nasic S, Rydell H, Svensson J, Peters B. The association between long-term glycemic control and all-cause mortality is different among older versus younger patients with diabetes mellitus and maintenance hemodialysis treatment. Diabetes Res Clin Pract 2022; 191:110033. [PMID: 35940301 DOI: 10.1016/j.diabres.2022.110033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022]
Abstract
AIMS Knowledge about association between glycated hemoglobin (HbA1c) and risk of all-cause mortality in patients with diabetes mellitus on maintenance hemodialysis (HD)-treatment is sparse. The study aims to investigate association between HbA1c and all-cause mortality in patients with diabetes and maintenance HD-treatment, separately for two age groups- above and below 75 years. METHODS 2487 patients (mean age 66 years, 66 % men) were separated in two age groups: ≤75 years (n = 1810) and > 75 years (n = 677) and followed up between 2008 and 2018. Hazard ratios (HR) and 95 % confidence intervals (CI) for associations between HbA1c and all-cause mortality were calculated using Cox-regression-models. RESULTS 1295 (52 %) patients died and 473 (70 %) among the patients above 75 years old. In the multivariate analysis, HbA1c5-6 % was used as reference. In patients ≤ 75 years old, only increased HbA1c > 9.7 %, HR2.03(CI1.43-2.89) was associated with increased risk of all-cause mortality. In patients > 75 years, HbA1c ≤ 5 %, HR1.67(CI1.16-2.40); HbA1c6.9-7.8 %, HR1.41(CI1.03-1.93) and HbA1c8.7-9.7 %, HR1.79 (CI1.08-2.96) were associated with increased risk of all-cause mortality. CONCLUSIONS We found a J-shaped association between HbA1c and mortality only in diabetic HD-patients > 75 years. This probably indicates that in an old population of diabetic HD-patients, both intensive glucose control and hyperglycemia could be harmful and associated with higher risk of death.
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Affiliation(s)
- Hanri Afghahi
- Department of Nephrology, Skaraborg Hospital, Skövde, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Salmir Nasic
- Research and Development Centre at Skaraborg Hospital, Skövde, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Helena Rydell
- Karolinska University Hospital, Stockholm Division of Renal Medicine, CLINTEC, Karolinska Institutet, Sweden
| | - Johan Svensson
- Research and Development Centre at Skaraborg Hospital, Skövde, Sweden; Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Björn Peters
- Department of Nephrology, Skaraborg Hospital, Skövde, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
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Kim DK, Ko GJ, Choi YJ, Jeong KH, Moon JY, Lee SH, Hwang HS. Glycated hemoglobin levels and risk of all-cause and cause-specific mortality in hemodialysis patients with diabetes. Diabetes Res Clin Pract 2022; 190:110016. [PMID: 35870571 DOI: 10.1016/j.diabres.2022.110016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/04/2022] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
AIM Adequate glycemic control is fundamental for improving clinical outcomes in hemodialysis patients with diabetes. However, the target for glycated hemoglobin (HbA1c) level and whether cause-specific mortality differs based on HbA1c levels remain unclear. METHODS A total of 24,243 HD patients with diabetes were enrolled from a multicenter, nationwide registry. We examined the association between HbA1c levels and the risk of all-cause and cause-specific mortality. RESULTS Compared to patients with HbA1c 6.5%-7.5%, patients with HbA1c 8.5-9.5% and ≥9.5% were associated with a 1.26-fold (95% CI, 1.12-1.42) and 1.56-fold (95% CI, 1.37-1.77) risk for all-cause mortality. The risk of all-cause mortality did not increase in patients with HbA1c < 5.5%. In cause-specific mortality, the risk of cardiovascular deaths significantly increased from small increase of HbA1c levels. However, the risk of other causes of death increased only in patients with HbA1c > 9.5%. The slope of HR increase with increasing HbA1c levels was significantly faster for cardiovascular causes than for other causes. CONCLUSIONS There was a linear relationship between HbA1c levels and risk of all-cause mortality in hemodialysis patients, and the risk of cardiovascular death increased earlier and more rapidly, with increasing HbA1c levels, compared with other causes of death.
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Affiliation(s)
- Dae Kyu Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Gang Jee Ko
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yun Jin Choi
- Biomedical Research Institute, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hwan Jeong
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Ju Young Moon
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang Ho Lee
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Hyeon Seok Hwang
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea.
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de Sá JR, Rangel EB, Canani LH, Bauer AC, Escott GM, Zelmanovitz T, Bertoluci MC, Silveiro SP. The 2021-2022 position of Brazilian Diabetes Society on diabetic kidney disease (DKD) management: an evidence-based guideline to clinical practice. Screening and treatment of hyperglycemia, arterial hypertension, and dyslipidemia in the patient with DKD. Diabetol Metab Syndr 2022; 14:81. [PMID: 35690830 PMCID: PMC9188192 DOI: 10.1186/s13098-022-00843-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetic kidney disease is the leading cause of end-stage renal disease and is associated with increased morbidity and mortality. This review is an authorized literal translation of part of the Brazilian Diabetes Society (SBD) Guidelines 2021-2022. This evidence-based guideline provides guidance on the correct management of Diabetic Kidney Disease (DKD) in clinical practice. METHODS The methodology was published elsewhere in previous SBD guidelines and was approved by the internal institutional Steering Committee for publication. Briefly, the Brazilian Diabetes Society indicated 14 experts to constitute the Central Committee, designed to regulate methodology, review the manuscripts, and make judgments on degrees of recommendations and levels of evidence. SBD Renal Disease Department drafted the manuscript selecting key clinical questions to make a narrative review using MEDLINE via PubMed, with the best evidence available including high-quality clinical trials, metanalysis, and large observational studies related to DKD diagnosis and treatment, by using the MeSH terms [diabetes], [type 2 diabetes], [type 1 diabetes] and [chronic kidney disease]. RESULTS The extensive review of the literature made by the 14 members of the Central Committee defined 24 recommendations. Three levels of evidence were considered: A. Data from more than 1 randomized clinical trial or 1 metanalysis of randomized clinical trials with low heterogeneity (I2 < 40%). B. Data from metanalysis, including large observational studies, a single randomized clinical trial, or a pre-specified subgroup analysis. C: Data from small or non-randomized studies, exploratory analyses, or consensus of expert opinion. The degree of recommendation was obtained based on a poll sent to the panelists, using the following criteria: Grade I: when more than 90% of agreement; Grade IIa 75-89% of agreement; IIb 50-74% of agreement, and III, when most of the panelist recommends against a defined treatment. CONCLUSIONS To prevent or at least postpone the advanced stages of DKD with the associated cardiovascular complications, intensive glycemic and blood pressure control are required, as well as the use of renin-angiotensin-aldosterone system blocker agents such as ARB, ACEI, and MRA. Recently, SGLT2 inhibitors and GLP1 receptor agonists have been added to the therapeutic arsenal, with well-proven benefits regarding kidney protection and patients' survival.
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Affiliation(s)
- João Roberto de Sá
- Endocrinology Division, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil
| | - Erika Bevilaqua Rangel
- Nephrology Division, UNIFESP, São Paulo, Brazil
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luis Henrique Canani
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Andrea Carla Bauer
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Gustavo Monteiro Escott
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Themis Zelmanovitz
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Marcello Casaccia Bertoluci
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Sandra Pinho Silveiro
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil.
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Al-Ghamdi SM, Bieber B, AlRukhaimi M, AlSahow A, Al Salmi I, Al Ali F, Al Aradi A, Pecoits-Filho R, Robinson BM, Pisoni RL. Diabetes Prevalence, Treatment, Control, and Outcomes Among Hemodialysis Patients in the Gulf Cooperation Council Countries. Kidney Int Rep 2022; 7:1093-1102. [PMID: 35570992 PMCID: PMC9091610 DOI: 10.1016/j.ekir.2022.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Diabetes mellitus (DM) is a leading cause of end-stage kidney disease (ESKD). We provide the first description of DM prevalence, related outcomes, and the hemoglobin A1c (HbA1c)/mortality relationship in national hemodialysis (HD) patient samples across the Gulf Cooperation Council (GCC) countries. METHODS We analyzed data from the prospective Dialysis Outcomes and Practice Patterns Study (DOPPS) in the GCC (2012-2018, N = 2274 HD patients ≥18 years old). Descriptive statistics were calculated, and all-cause mortality was analyzed for patients with DM versus without DM and by HbA1c levels in patients with DM by Cox regression with progressive confounder adjustments. RESULTS DM in the GCC ranged from 45% to 74% in patients with HD by country. Patients with DM were 13 years older (59.9 vs. 46.7 years) and had greater body mass index (BMI), shorter median years on dialysis (1.5 vs. 3.0 years), and higher comorbidity burden. In patients with DM, insulin use was 26% to 50% across countries, with variable oral antidiabetic drug use (2%-32%); median HbA1c levels were 6.1% to 7.5% across countries. Patients with DM (vs. without DM) had higher crude death rates (15.6 vs. 6.2 deaths per 100 patient-years, mean follow-up 1.3 years) and adjusted mortality (hazard ratio [HR] = 1.72 [95% CI 1.23-2.39]). In patients with DM, mortality was lowest at HbA1c 6.5% to 7.5%, with mortality particularly elevated at high HbA1c >9% (HR = 2.13 [95% CI 1.10-4.10]). CONCLUSION Patients with DM in the GCC have high comorbidity burden and mortality rates despite a relatively young mean age. In GCC countries, a holistic strategy for improving diabetes care and outcomes for HD patients is needed at the primary, secondary, and tertiary levels.
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Affiliation(s)
- Saeed M.G. Al-Ghamdi
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Mona AlRukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Ali AlSahow
- Division of Nephrology, Jahra Hospital, Jahra, Kuwait
| | - Issa Al Salmi
- Department of Nephrology, The Royal Hospital, Ministry of Health, Muscat, Oman
| | - Fadwa Al Ali
- Department of Nephrology, Hamad General Hospital, Doha, Qatar
| | - Ali Al Aradi
- Nephrology, Salmaniya Medical Complex, Manama, Bahrain
| | - Roberto Pecoits-Filho
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bruce M. Robinson
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ronald L. Pisoni
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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21
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Ben-David E, Hull R, Banerjee D. Diabetes mellitus in dialysis and renal transplantation. Ther Adv Endocrinol Metab 2021; 12:20420188211048663. [PMID: 34631007 PMCID: PMC8495524 DOI: 10.1177/20420188211048663] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/29/2021] [Indexed: 12/31/2022] Open
Abstract
Diabetes mellitus is the commonest cause of end-stage kidney failure worldwide and is a proven and significant risk factor for the development of cardiovascular disease. Renal impairment has a significant impact on the physiology of glucose homeostasis as it reduces tissue sensitivity to insulin and reduces insulin clearance. Renal replacement therapy itself affects glucose control: peritoneal dialysis may induce hyperglycaemia due to glucose-rich dialysate and haemodialysis often causes hypoglycaemia due to the relatively low concentration of glucose in the dialysate. Autonomic neuropathy which is common in chronic kidney disease (CKD) and diabetes increases the risk for asymptomatic hypoglycaemia. Pharmacological options for improving glycaemic control are limited due to alterations to drug metabolism. Impaired glucose tolerance and diabetes are also common in the post-kidney-transplant setting and increase the risk of graft failure and mortality. This review seeks to summarise the literature and tackle the intricacies of glycaemic management in patients with CKD who are either on maintenance haemodialysis or have received a kidney transplant. It outlines changes to glycaemic targets, monitoring of glycaemic control, the use of oral hypoglycaemic agents, the management of severe hyperglycaemia in dialysis and kidney transplantation patients.
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Affiliation(s)
- Eyal Ben-David
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Richard Hull
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, Room G2.113, Second Floor, Grosvenor Wing, Blackshaw Road, Tooting, London SW17 0QT, UK
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22
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Lambie M, Bonomini M, Davies SJ, Accili D, Arduini A, Zammit V. Insulin resistance in cardiovascular disease, uremia, and peritoneal dialysis. Trends Endocrinol Metab 2021; 32:721-730. [PMID: 34266706 PMCID: PMC8893168 DOI: 10.1016/j.tem.2021.06.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/03/2021] [Accepted: 06/15/2021] [Indexed: 02/09/2023]
Abstract
Diabetic nephropathy is highly correlated with the occurrence of other complications of type 1 diabetes (T1D) and type 2 diabetes (T2D) mellitus; for example, hypertension with cardiovascular disease (CVD) being the most frequent cause of death in patients with end-stage renal disease and undergoing renal dialysis. Hyperglycemia and insulin resistance (IR) are responsible for the micro- and macrovascular complications of diabetes through different mechanisms. In particular, IR plays a key role in the etiology of atherosclerosis in both diabetic and non-diabetic patients. IR - exacerbated by organ-level selectivity - is more important than glycemic control per se in determining cardiovascular outcomes. This may be exacerbated by the fact that IR is organ and pathway specific due to the only selective loss of sensitivity to insulin action of specific pathways/processes. Therefore, it is counterintuitive that the use of peritoneal dialysis (PD) in (frequently) diabetic renal disease patients should involve their exposure to high daily doses of glucose peritoneally. In view of the controversy about the causal association between glucose load and CVD in PD patients, we discuss the role that selective IR may play in the progression of CVD in diabetic renal end-stage patients. In discussing these associations, we propose that reducing glucose exposure in PD solutions may be beneficial especially if coupled with strategies that address IR directly, and the avoidance of excessive use of insulin treatment in T2D.
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Affiliation(s)
- Mark Lambie
- Faculty of Medicine and Health Sciences, Keele University, Keele ST5 5BG, UK
| | - Mario Bonomini
- Department of Medicine, G. d'Annunzio University, Chieti 66100, Italy
| | - Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele ST5 5BG, UK
| | - Domenico Accili
- Columbia University College of Physicians and Surgeons, Department of Medicine, New York, NY 10032, USA
| | | | - Victor Zammit
- Translational & Experimental Medicine, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK.
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23
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Fully automated closed-loop glucose control compared with standard insulin therapy in adults with type 2 diabetes requiring dialysis: an open-label, randomized crossover trial. Nat Med 2021; 27:1471-1476. [PMID: 34349267 PMCID: PMC8363503 DOI: 10.1038/s41591-021-01453-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/28/2021] [Indexed: 12/18/2022]
Abstract
We evaluated the safety and efficacy of fully closed-loop insulin therapy compared with standard insulin therapy in adults with type 2 diabetes requiring dialysis. In an open-label, multinational, two-center, randomized crossover trial, 26 adults with type 2 diabetes requiring dialysis (17 men, 9 women, average age 68 ± 11 years (mean ± s.d.), diabetes duration of 20 ± 10 years) underwent two 20-day periods of unrestricted living, comparing the Cambridge fully closed-loop system using faster insulin aspart (‘closed-loop’) with standard insulin therapy and a masked continuous glucose monitor (‘control’) in random order. The primary endpoint was time in target glucose range (5.6–10.0 mmol l−1). Thirteen participants received closed-loop first and thirteen received control therapy first. The proportion of time in target glucose range (5.6–10.0 mmol l−1; primary endpoint) was 52.8 ± 12.5% with closed-loop versus 37.7 ± 20.5% with control; mean difference, 15.1 percentage points (95% CI 8.0–22.2; P < 0.001). Mean glucose was lower with closed-loop than control (10.1 ± 1.3 versus 11.6 ± 2.8 mmol l−1; P = 0.003). Time in hypoglycemia (<3.9 mmol l−1) was reduced with closed-loop versus control (median (IQR) 0.1 (0.0–0.4%) versus 0.2 (0.0–0.9%); P = 0.040). No severe hypoglycemia events occurred during the control period, whereas one severe hypoglycemic event occurred during the closed-loop period, but not during closed-loop operation. Fully closed-loop improved glucose control and reduced hypoglycemia compared with standard insulin therapy in adult outpatients with type 2 diabetes requiring dialysis. The trial registration number is NCT04025775. A new randomized, crossover clinical trial testing rapid-acting insulin aspart delivered in a closed-loop system compared with standard care demonstrates increased time in range in patients with type 2 diabetes who require dialysis in the outpatient setting.
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24
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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: 17] [Impact Index Per Article: 4.3] [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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25
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Urina-Jassir M, Herrera-Parra LJ, Hernández Vargas JA, Valbuena-García AM, Acuña-Merchán L, Urina-Triana M. The effect of comorbidities on glycemic control among Colombian adults with diabetes mellitus: a longitudinal approach with real-world data. BMC Endocr Disord 2021; 21:128. [PMID: 34174843 PMCID: PMC8235812 DOI: 10.1186/s12902-021-00791-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/08/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Achieving an optimal glycemic control has been described to reduce the incidence of diabetes mellitus (DM) related complications. The association between comorbidities and glycemic control remains unclear. Our aim is to evaluate the effect of comorbidities on glycemic control in people living with DM. METHODS A retrospective longitudinal study on data from the National Registry of Chronic Kidney Disease from 2014 to 2019 in Colombia. The outcome was poor glycemic control (PGC = HbA1c ≥7.0%). The association between each comorbidity (hypertension (HTN), chronic kidney disease (CKD) or obesity) and PGC was evaluated through multivariate mixed effects logistic regression models. The measures of effect were odds ratios (OR) and their 95% confidence intervals (CI). We also evaluated the main associations stratified by gender, insurance, and early onset diabetes as well as statistical interaction between each comorbidity and ethnicity. RESULTS From 969,531 people at baseline, 85% had at least one comorbidity; they were older and mostly female. In people living with DM and CKD, the odds of having a PGC were 78% (OR: 1.78, CI 95%: 1.55-2.05) higher than those without CKD. Same pattern was observed in obese for whom the odds were 52% (OR: 1.52, CI 95%: 1.31-1.75) higher than in non-obese. Non-significant association was found between HTN and PGC. We found statistical interaction between comorbidities and ethnicity (afro descendant) as well as effect modification by health insurance and early onset DM. CONCLUSIONS Prevalence of comorbidities was high in adults living with DM. Patients with concomitant CKD or obesity had significantly higher odds of having a PGC.
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Affiliation(s)
- Manuel Urina-Jassir
- Fundación del Caribe para la Investigación Biomédica, Carrera 50 # 80 - 216 Office 201, Barranquilla, Atlántico, Colombia
| | - Lina Johana Herrera-Parra
- Cuenta de Alto Costo, Fondo Colombiano de Enfermedades de Alto Costo, Carrera 45 # 103 - 34, Bogotá, D.C, Colombia
| | | | - Ana María Valbuena-García
- Cuenta de Alto Costo, Fondo Colombiano de Enfermedades de Alto Costo, Carrera 45 # 103 - 34, Bogotá, D.C, Colombia
| | - Lizbeth Acuña-Merchán
- Cuenta de Alto Costo, Fondo Colombiano de Enfermedades de Alto Costo, Carrera 45 # 103 - 34, Bogotá, D.C, Colombia
| | - Miguel Urina-Triana
- Fundación del Caribe para la Investigación Biomédica, Carrera 50 # 80 - 216 Office 201, Barranquilla, Atlántico, Colombia.
- Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Carrera 59 # 59 - 65, Barranquilla, 080002, Colombia.
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26
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Alalawi F, Bashier A. Management of diabetes mellitus in dialysis patients: Obstacles and challenges. Diabetes Metab Syndr 2021; 15:1025-1036. [PMID: 34000713 DOI: 10.1016/j.dsx.2021.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Diabetic kidney disease (DKD) is a major health issue that is associated with an increased risk of morbidity and mortality. The treatment of DKD is challenging given changes in blood glucose homeostasis, unclear accuracy of glucose metrics, and altered kinetics of the blood glucose-lowering medications. There is uncertainty surrounding the optimal glycemic target in this population although recent epidemiologic data suggest that HbA1c ranges of 6-8%, as well as 7-9%, are associated with increased survival rates among diabetic dialysis patients. Furthermore, the treatment of diabetes in patients maintained on dialysis is challenging, and many blood glucose-lowering medications are renally metabolized and excreted hence requiring dose adjustment or avoidance in dialysis patients. METHOD ology: PubMed, Google Scholar, and Medline were searched for all literature discussing the management of diabetes in dialysis patients. RESULTS The literature was discussed under many subheadings providing the latest evidence in the treatment of diabetes in dialysis patients. CONCLUSION The management of diabetes in dialysis is very complex requiring a multi-disciplinary team involving endocrinologists and nephrologists to achieve targets and reduce morbidity and mortality.
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Affiliation(s)
- Fakhriya Alalawi
- Nephrology Department, Dubai Hospital. Dubai Health Authority, United Arab Emirates
| | - Alaaeldin Bashier
- Endocrine Department, Dubai Hospital. Dubai Health Authority, United Arab Emirates.
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27
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Abstract
Chronic kidney disease (CKD) is among the most prevalent and dire complications of diabetes mellitus in adults across the world. Diabetes substantially contributes to the burden of kidney disease, such that one third to one half of CKD in the United States and many other countries is attributable to diabetic kidney disease (DKD). As DKD progresses to end-stage renal disease (ESRD), patients are at heightened risk for atypical glycemic complications, including the development of burnt-out diabetes, manifested by hypoglycemic bouts and poor outcomes. Furthermore, even in the absence of diabetes, hypoglycemia is a frequent occurrence in CKD patients that may contribute to their high burden of cardiovascular disease and death. Extrapolation of data from clinical trials in high-cardiovascular-risk populations and observational studies in patients with non-dialysis-dependent (NDD) CKD and ESRD suggest that moderate glycemic targets defined by glycated hemoglobin levels of 6% to 8% and glucose levels of 100 to 150 mg/dL are associated with better survival in DKD patients. However, given the imprecision of glycated hemoglobin levels in kidney disease, further research is needed to determine the optimal glycemic metric and target in diabetic NDD-CKD and ESRD patients. Given their exceedingly high cardiovascular morbidity and mortality, there is a compelling need for further investigation of how to optimally manage dysglycemia in the NDD-CKD and ESRD populations.
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28
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Escott GM, da Silveira LG, Cancelier VDA, Dall'Agnol A, Silveiro SP. Monitoring and management of hyperglycemia in patients with advanced diabetic kidney disease. J Diabetes Complications 2021; 35:107774. [PMID: 33168397 DOI: 10.1016/j.jdiacomp.2020.107774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/10/2020] [Accepted: 10/10/2020] [Indexed: 11/19/2022]
Abstract
Diabetes mellitus is the leading cause of end-stage renal disease, and uncontrolled hyperglycemia is directly related to the increased mortality in this setting. As kidney function decreases, it becomes more challenging to control blood glucose since the risk of hypoglycemia increases. Decreased appetite, changes in glycaemia homeostasis, along with reduced renal excretion of anti-hyperglycemic drugs tend to facilitate the occurrence of hypoglycemia, despite the paradoxical occurrence of insulin resistance in advanced kidney disease. Thus, in patients using insulin and/or oral anti-hyperglycemic agents, dynamic adjustments with drug dose reduction or drug switching are often necessary. Furthermore, in addition to consider these pharmacokinetics alterations, it is of utmost importance to choose drugs with proven cardio-renal benefits in this setting, such as sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists. In this review, we summarize the indications and contraindications, titration of doses and side effects of the available anti-hyperglycemic agents in the presence of advanced diabetic kidney disease (DKD) and dialysis, highlighting the risks and benefits of the different agents. Additionally, basic renal function assessment and monitoring of glycemic control in DKD will be evaluated in order to guide the use of drugs and define the glycemic targets to be achieved.
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Affiliation(s)
- Gustavo Monteiro Escott
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil
| | | | | | - Angélica Dall'Agnol
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil
| | - Sandra Pinho Silveiro
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil; Endocrine Unit, Hospital de Clínicas de Porto Alegre, RS, Brazil.
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29
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Guthoff M, Merker L. Therapie des Diabetes bei chronischer Niereninsuffizienz. DIABETOL STOFFWECHS 2021. [DOI: 10.1055/a-1156-9957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Copur S, Onal EM, Afsar B, Ortiz A, van Raalte DH, Cherney DZ, Rossing P, Kanbay M. Diabetes mellitus in chronic kidney disease: Biomarkers beyond HbA1c to estimate glycemic control and diabetes-dependent morbidity and mortality. J Diabetes Complications 2020; 34:107707. [PMID: 32861562 DOI: 10.1016/j.jdiacomp.2020.107707] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 12/13/2022]
Abstract
Diabetes mellitus (DM) is the leading cause of chronic kidney disease (CKD). Optimal glycemic control contributes to improved outcomes in patients with DM, particularly for microvascular damage, but blood glucose levels are too variable to provide an accurate assessment and instead markers averaging long-term glycemic load are used. The most established glycemic biomarker of long-term glycemic control is HbA1c. Nevertheless, HbA1c has pitfalls that limit its accuracy to estimate glycemic control, including the presence of altered red blood cell survival, hemoglobin glycation and suboptimal performance of HbA1c assays. Alternative methods to evaluate glycemic control in patients with DM include glycated albumin, fructosamine, 1-5 anhydroglucitol, continuous glucose measurement, self-monitoring of blood glucose and random blood glucose concentration measurements. Accordingly, our aim was to review the advantages and pitfalls of these methods in the context of CKD.
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Affiliation(s)
- Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Emine M Onal
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Baris Afsar
- Department of Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Alberto Ortiz
- Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Avd. Reyes Católicos 2, 28040 Madrid, Spain
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, location VUMC, Amsterdam, the Netherlands
| | - David Z Cherney
- Toronto General Hospital Research Institute, UHN, Toronto, Canada; Departments of Physiology and Pharmacology and Toxicology, University of Toronto, Ontario, Canada
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey.
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Galindo RJ, Beck RW, Scioscia MF, Umpierrez GE, Tuttle KR. Glycemic Monitoring and Management in Advanced Chronic Kidney Disease. Endocr Rev 2020; 41:5846208. [PMID: 32455432 PMCID: PMC7366347 DOI: 10.1210/endrev/bnaa017] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/19/2020] [Indexed: 02/06/2023]
Abstract
Glucose and insulin metabolism in patients with diabetes are profoundly altered by advanced chronic kidney disease (CKD). Risk of hypoglycemia is increased by failure of kidney gluconeogenesis, impaired insulin clearance by the kidney, defective insulin degradation due to uremia, increased erythrocyte glucose uptake during hemodialysis, impaired counterregulatory hormone responses (cortisol, growth hormone), nutritional deprivation, and variability of exposure to oral antihyperglycemic agents and exogenous insulin. Patients with end-stage kidney disease frequently experience wide glycemic excursions, with common occurrences of both hypoglycemia and hyperglycemia. Assessment of glycemia by glycated hemoglobin (HbA1c) is hampered by a variety of CKD-associated conditions that can bias the measure either to the low or high range. Alternative glycemic biomarkers, such as glycated albumin or fructosamine, are not fully validated. Therefore, HbA1c remains the preferred glycemic biomarker despite its limitations. Based on observational data for associations with mortality and risks of hypoglycemia with intensive glycemic control regimens in advanced CKD, an HbA1c range of 7% to 8% appears to be the most favorable. Emerging data on the use of continuous glucose monitoring in this population suggest promise for more precise monitoring and treatment adjustments to permit fine-tuning of glycemic management in patients with diabetes and advanced CKD.
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Affiliation(s)
- Rodolfo J Galindo
- Emory University School of Medicine, Division of Endocrinology, Atlanta, Georgia
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida
| | - Maria F Scioscia
- Emory University School of Medicine, Division of Endocrinology, Atlanta, Georgia
| | | | - Katherine R Tuttle
- University of Washington, Division of Nephrology, Kidney Research Institute, and Institute of Translational Health Sciences, Seattle, Washington.,Providence Medical Research Center, Providence Health Care, Spokane, Washington
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32
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Glucose Levels During Dialysis with Glucose-Free Versus Glucose-Rich Dialysate Fluid. ACTA ACUST UNITED AC 2019; 40:41-46. [PMID: 32109218 DOI: 10.2478/prilozi-2020-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Asymptomatic hypoglycaemia has been reported in both diabetic and non-diabetic patients on haemodialysis. Uremic symptoms as inadequate appetite, nausea and vomiting worsen the risk of hypoglycaemia at dialysis initiation. As a standard therapeutic approach for decreasing this risk and dis-equilibrium syndrome at our dialysis unit, a continuous venous 5% glucose solution is applied during the glucose-free dialysate (GFD) dialysis. In this interventional study we sought to assess the glycaemic control during standard initiating dialysis protocol versus novel approach with glucose-rich dialysis fluid (GRD). MATERIAL AND METHODS Twenty-one dialysis patients with chronic renal failure were dialyzed alternatively using GRD (5.6 mmol/l) and GFD fluid. They were not taking any hypoglycaemic medication prior and food during dialysis session. Blood was sampled at regular intervals during dialysis. The dialysis prescription consisted of ultrafiltration (UF) of up to 1 L, membrane surface (MS) up to 1.4 square meters and duration time of 2-2.5 hours. Intra-patient glycaemic variability was defined by Coefficient of variation (CV). In paired analysis t-test was used to determine the glucose control differences in both therapeutic approaches in each patient. For the whole group t-test was used to assess the glucose variability as CV. RESULTS The mean age of study participants was 62.95±11.73 years; 7 (33%) had diabetes. The two dialysis approaches did not differ in respect of initial blood pressure, UF and MS. Only two episodes of hypoglycaemia occurred in both types of dialysis. The mean glucose level was higher during GRD (8.15±1.89 vs. 6.29±1.33, p=0.001), respectively. The glucose CV was lower in GRD dialysis when pared t-test was applied, without significant difference (16.97± 8.86 vs. 21.05±11.99, p=0.151). When only diabetic patients were analysed, there was no significant glucose CV difference as well (p=0.151). For the whole cohort glucose variability was significantly higher in glucose-free dialysate dialysis (p=0.0001). CONCLUSION The GRD approach for initiating dialysis sessions is non-inferior to standard GFD care. Dialysate rich in glucose obtains better glucose control during dialysis compared to glucose-free dialysate.
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Yarragudi R, Gessl A, Vychytil A. New-Onset Diabetes Mellitus in Peritoneal Dialysis and Hemodialysis Patients: Frequency, Risk Factors, and Prognosis-A Review. Ther Apher Dial 2019; 23:497-506. [PMID: 30854792 PMCID: PMC6916572 DOI: 10.1111/1744-9987.12800] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 02/03/2019] [Accepted: 03/08/2019] [Indexed: 12/23/2022]
Abstract
New-onset diabetes mellitus (NODM) is observed in both hemodialysis (HD) and peritoneal dialysis (PD) patients. The prevalence of NODM in dialysis patients is slightly higher compared to subjects of the general population. Based on currently published data there is no convincing evidence that the risk of NODM is different between HD and PD patients. Data on the effect of glucose load on risk of NODM in dialysis patients remain controversial. PD modality (automated or continuous ambulatory PD) has no significant influence on NODM incidence. Chronic inflammation is associated with NODM in dialysis patients. Reported differences in NODM between PD and HD patients are possibly also influenced by differences in demographic factors between these patient groups. Mortality in NODM patients is lower than mortality in patients with preexisting DM. This may be partly explained by the younger age and lower number of comorbidities in patients with NODM.
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Affiliation(s)
- Rajashri Yarragudi
- Clinical Division of Nephrology and Dialysis, Department of Medicine IIIMedical University of ViennaViennaAustria
| | - Alois Gessl
- Clinical Division of Endocrinology and Metabolism, Department of Medicine IIIMedical University of ViennaViennaAustria
| | - Andreas Vychytil
- Clinical Division of Nephrology and Dialysis, Department of Medicine IIIMedical University of ViennaViennaAustria
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Niezen S, Diaz del Castillo H, Mendez Castaner LA, Fornoni A. Safety and efficacy of antihyperglycaemic agents in diabetic kidney disease. Endocrinol Diabetes Metab 2019; 2:e00072. [PMID: 31294086 PMCID: PMC6613230 DOI: 10.1002/edm2.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/11/2019] [Accepted: 04/22/2019] [Indexed: 12/24/2022] Open
Abstract
Diabetic kidney disease (DKD) is the major contributor to the mortality and the financial burden of diabetes, accounting for approximately 50% of the cases of end-stage renal disease (ESRD) in the developed world. Several studies have already demonstrated that achieving blood pressure targets in DKD with agents blocking the renin-angiotensin system confer superior renoprotection when compared to other agents. However, the effects on renal outcomes of antihyperglycaemic agents in these patients have not been reported or studied broadly until recent years. The intent of this article is to review the available data on safety, efficacy, impact on renal outcomes and pathophysiology implications of the most utilized antihyperglycaemic agents in DKD/ESRD.
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Affiliation(s)
| | | | | | - Alessia Fornoni
- Katz Family Division of Nephrology and HypertensionUniversity of MiamiMiamiFlorida
- Peggy and Harold Katz Family Drug Discovery CenterUniversity of Miami Miller School of MedicineMiamiFlorida
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Abe M, Hamano T, Hoshino J, Wada A, Nakai S, Masakane I. Glycemic control and survival in peritoneal dialysis patients with diabetes: A 2-year nationwide cohort study. Sci Rep 2019; 9:3320. [PMID: 30824808 PMCID: PMC6397316 DOI: 10.1038/s41598-019-39933-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/04/2019] [Indexed: 12/21/2022] Open
Abstract
For glycemic control in patients with diabetes on peritoneal dialysis (PD), the level of glycated albumin (GA) associated with mortality is unclear. Accordingly, we examined the difference in the association of GA and glycated hemoglobin (HbA1c) with 2-year mortality in a Japanese Society for Dialysis Therapy cohort. We examined 1601 patients with prevalent diabetes who were on PD. Of these, 1282 had HbA1c (HbA1c cohort) and 725 had GA (GA cohort) measured. We followed them for 2 years from 2013 to 2015 and used Cox regression to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for 2-year mortality after adjusting for potential confounders in each cohort. No significant association was found between HbA1c levels and all-cause death HRs before and after adjustment for confounders in the HbA1c cohort. In contrast, the adjusted all-cause death HRs and 95% CIs for GAs < 12.0%, 12.0–13.9%, 16.0–17.9%, 18.0–19.9%, 20.0–21.9%, and ≥22.0%, compared with 14.0–15.9% (reference), were 1.56 (0.32–7.45), 1.24 (0.32–4.83), 1.32 (0.36–4.77), 2.02 (0.54–7.53), 4.36 (1.10–17.0), and 4.10 (1.20–14.0), respectively. In the GA cohort, GA ≥ 20.0% was significantly associated with a higher death HR compared with the reference GA. Thus, GA ≥ 20.0% appears to be associated with a decrease in survival in diabetic patients on PD. There were no associations between HbA1c levels and 2-year mortality in PD patients.
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Affiliation(s)
- Masanori Abe
- The Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan. .,Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.
| | - Takayuki Hamano
- The Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junichi Hoshino
- The Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.,Nephrology Center, Toranomon Hospital, Tokyo, Japan
| | - Atsushi Wada
- The Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Nephrology, Kitasaito Hospital, Asahikawa, Japan
| | - Shigeru Nakai
- The Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Clinical Engineering, Fujita Health University, Aichi, Japan
| | - Ikuto Masakane
- The Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.,Yabuki Hospital, Yamagata, Japan
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Abe M, Hamano T, Hoshino J, Wada A, Nakai S, Masakane I. Rate of the "burnt-out diabetes" phenomenon in patients on peritoneal dialysis. Diabetes Res Clin Pract 2018; 143:254-262. [PMID: 30056189 DOI: 10.1016/j.diabres.2018.07.026] [Citation(s) in RCA: 5] [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: 06/11/2018] [Revised: 07/14/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
AIMS In some diabetes patients on dialysis, glycemic control improves spontaneously, leading to normal HbA1c levels; this phenomenon is known as "burnt-out diabetes." Glycated albumin (GA) might be a better indicator of glycemic control than HbA1c in hemodialysis patients, but it has not been assessed in peritoneal dialysis (PD) patients. METHODS This study involved diabetes patients on PD, with HbA1c level and antidiabetes therapy records. First, the "burnt-out diabetes" phenomenon was investigated in patients with HbA1c measurements alone (HbA1c cohort). Then, it was investigated in patients with both HbA1c and GA measurements (GA cohort). RESULTS A total of 1296 patients were included in the HbA1c cohort. When "burnt-out diabetes" was defined as HbA1c < 6.0% without treatment, it was noted in 269 patients (20.8%). A total of 413 patients were subsequently included in the GA cohort. "Burnt-out diabetes," using the same definition, was found in 73 patients (17.7%). However, when defined as HbA1c < 6.0% and GA < 16.0% without treatment, "burnt-out diabetes" was found in 45 patients (10.9%). CONCLUSIONS Although the "burnt-out diabetes" phenomenon was present in 17.7% of patients with diabetes on PD based on HbA1c, the rate was significantly decreased to 10.9% when taking GA into account.
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Affiliation(s)
- Masanori Abe
- JSDT Renal Data Registry Committee (JRDR Committee), Japanese Society for Dialysis Therapy (JSDT), Tokyo, Japan; Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.
| | - Takayuki Hamano
- JSDT Renal Data Registry Committee (JRDR Committee), Japanese Society for Dialysis Therapy (JSDT), Tokyo, Japan; Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junichi Hoshino
- JSDT Renal Data Registry Committee (JRDR Committee), Japanese Society for Dialysis Therapy (JSDT), Tokyo, Japan; Nephrology Center, Toranomon Hospital, Tokyo, Japan
| | - Atsushi Wada
- JSDT Renal Data Registry Committee (JRDR Committee), Japanese Society for Dialysis Therapy (JSDT), Tokyo, Japan; Department of Nephrology, Kitasaito Hospital, Asahikawa, Japan
| | - Shigeru Nakai
- JSDT Renal Data Registry Committee (JRDR Committee), Japanese Society for Dialysis Therapy (JSDT), Tokyo, Japan; Department of Clinical Engineering, Fujita Health University, Aichi, Japan
| | - Ikuto Masakane
- JSDT Renal Data Registry Committee (JRDR Committee), Japanese Society for Dialysis Therapy (JSDT), Tokyo, Japan; Yabuki Hospital, Yamagata, Japan
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Dozio E, Corradi V, Proglio M, Vianello E, Menicanti L, Rigolini R, Caprara C, de Cal M, Corsi Romanelli MM, Ronco C. Usefulness of glycated albumin as a biomarker for glucose control and prognostic factor in chronic kidney disease patients on dialysis (CKD-G5D). Diabetes Res Clin Pract 2018; 140:9-17. [PMID: 29596954 DOI: 10.1016/j.diabres.2018.03.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/08/2018] [Indexed: 12/17/2022]
Abstract
In chronic kidney disease patients on dialysis (CKD-G5D) accurate assessment of glycemic control is vital to improve their outcome and survival. The best glycemic marker for glucose control in these patients is still debated because several clinical and pharmacological factors may affect the ability of the available biomarkers to reflect the patient's glycemic status properly. This review discusses the role of glycated albumin (GA) both as a biomarker for glucose control and as a prognostic factor in CKD-G5D; it also looks at the pros and cons of GA in comparison to the other markers and its usefulness in hemodialysis and peritoneal dialysis.
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Affiliation(s)
- Elena Dozio
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy.
| | - Valentina Corradi
- Department of Nephrology, Dialysis & Transplantation, San Bortolo Hospital, 36100 Vicenza, Italy; International Renal Research Institute Vicenza (IRRIV), San Bortolo Hospital, 36100 Vicenza, Italy
| | - Marta Proglio
- Department of Nephrology, Dialysis & Transplantation, San Bortolo Hospital, 36100 Vicenza, Italy
| | - Elena Vianello
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy
| | - Lorenzo Menicanti
- Department of Cardiac Surgery, I.R.C.C.S. Policlinico San Donato, 20097 San Donato Milanese, Milan, Italy
| | - Roberta Rigolini
- Service of Laboratory Medicine1-Clinical Pathology, I.R.C.C.S. Policlinico San Donato, 20097 San Donato Milanese, Milan, Italy
| | - Carlotta Caprara
- International Renal Research Institute Vicenza (IRRIV), San Bortolo Hospital, 36100 Vicenza, Italy
| | - Massimo de Cal
- Department of Nephrology, Dialysis & Transplantation, San Bortolo Hospital, 36100 Vicenza, Italy; International Renal Research Institute Vicenza (IRRIV), San Bortolo Hospital, 36100 Vicenza, Italy
| | - Massimiliano M Corsi Romanelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy; Service of Laboratory Medicine1-Clinical Pathology, I.R.C.C.S. Policlinico San Donato, 20097 San Donato Milanese, Milan, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis & Transplantation, San Bortolo Hospital, 36100 Vicenza, Italy; International Renal Research Institute Vicenza (IRRIV), San Bortolo Hospital, 36100 Vicenza, Italy
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Abstract
Diabetes is highly and increasingly prevalent in the dialysis population and negatively impacts both quality and quantity of life. Nevertheless, the best approach to these patients is still debatable. The question of whether the management of diabetes should be different in dialysis patients does not have a clear yes or no answer but is divided into too many sub-issues that should be carefully considered. In this review, lifestyle, cardiovascular risk, and hyperglycemia management are explored, emphasizing the possible pros and cons of a similar approach to diabetes in dialysis patients compared to the general population.
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Affiliation(s)
- Silvia Coelho
- Nephrology and Intensive Care Departments, Hospital Fernando Fonseca, Amadora, Portugal.,CEDOC - Chronic Diseases Research Center, NOVA Medical School, NOVA University of Lisbon, Lisbon, Portugal
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Jung M, Warren B, Grams M, Kwong YD, Shafi T, Coresh J, Rebholz CM, Selvin E. Performance of non-traditional hyperglycemia biomarkers by chronic kidney disease status in older adults with diabetes: Results from the Atherosclerosis Risk in Communities Study. J Diabetes 2018; 10:276-285. [PMID: 29055090 PMCID: PMC5867205 DOI: 10.1111/1753-0407.12618] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/08/2017] [Accepted: 09/23/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND In people with chronic kidney disease (CKD), HbA1c may be a problematic measure of glycemic control. Glycated albumin and fructosamine have been proposed as better markers of hyperglycemia in CKD. In the present study we investigated associations of HbA1c, glycated albumin, and fructosamine with fasting glucose by CKD categories. METHODS A cross-sectional analysis was performed of 1665 Atherosclerosis Risk in Communities Study participants with diagnosed diabetes aged ≥65 years. Spearman's rank correlations (r) were compared and Deming regression was used to obtain root mean square errors (RMSEs) for the associations across CKD categories defined using estimated glomerular filtration rate and urine albumin:creatinine ratio. RESULTS Correlations of HbA1c, glycated albumin, and fructosamine with fasting glucose were lowest in people with severe CKD (HbA1c r = 0.52, RMSE = 0.91; glycated albumin r = 0.39, RMSE = 1.89; fructosamine r = 0.41, RMSE = 1.87) and very severe CKD (r = 0.48 and RMSE = 1.01 for HbA1c; r = 0.36 and RMSE = 2.14 for glycated albumin; r = 0.36 and RMSE = 2.22 for fructosamine). Associations of glycated albumin and fructosamine with HbA1c were relatively similar across CKD categories. CONCLUSIONS In older adults with severe or very severe CKD, HbA1c, glycated albumin, and fructosamine were not highly correlated with fasting glucose. The results suggest there may be no particular advantage of glycated albumin or fructosamine over HbA1c for monitoring glycemic control in CKD.
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Affiliation(s)
- Molly Jung
- Johns Hopkins School of Public Health, Baltimore, MD
| | | | - Morgan Grams
- Johns Hopkins School of Public Health, Baltimore, MD
- Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Tariq Shafi
- Johns Hopkins School of Public Health, Baltimore, MD
- Johns Hopkins School of Medicine, Baltimore, MD
| | - Josef Coresh
- Johns Hopkins School of Public Health, Baltimore, MD
| | | | - Elizabeth Selvin
- Johns Hopkins School of Public Health, Baltimore, MD
- Johns Hopkins School of Medicine, Baltimore, MD
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Triebswetter S, Gutjahr-Lengsfeld LJ, Schmidt KR, Drechsler C, Wanner C, Krane V. Long-Term Survivor Characteristics in Hemodialysis Patients with Type 2 Diabetes. Am J Nephrol 2018; 47:30-39. [PMID: 29320770 DOI: 10.1159/000485842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/29/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Data concerning long-term mortality predictors among large, purely diabetic hemodialysis collectives are scarce. METHODS We used data from a multicenter, prospective, randomized trial among 1,255 hemodialysis patients with type 2 diabetes mellitus (T2DM) and its observational follow-up study. The association of 10 baseline candidate variables with mortality was assessed by Cox proportional hazards regression. RESULTS Overall, 103 participants survived the median follow-up of 11.5 years. Significant predictors of mortality were age (hazard ratio [HR] 1.03, 95% CI 1.02-1.04), cardiovascular (HR 1.42, 95% CI 1.25-1.62) and peripheral vascular disease (HR 1.55, 95% CI 1.36-1.76), higher hemoglobin A1c (HbA1c; HR 1.08, 95% CI 1.03-1.14), and loss of self-dependency (HR 1.20, 95% CI 1.03-1.39). Higher albumin (HR 0.72, 95% CI 0.59-0.89) and body mass index (BMI; HR 0.98, 95% CI 0.96-0.99) had protective associations. There was no significant association with sex, diabetes duration, and cerebrovascular diseases. Subgroup analyses by age and diabetes duration showed stronger associations of cardiovascular disease, HbA1c, albumin, BMI, and loss of self-dependency in younger patients and/or shorter diabetes duration. Loss of self-dependency and energy resources (albumin, BMI) increased mortality more severely in women, whilst the impact of cardiovascular and peripheral vascular diseases was more pronounced in men. CONCLUSION Long-term mortality risk in patients with T2DM on hemodialysis was associated with higher age, vascular diseases, HbA1c, loss of self-dependency, and low energy resources. Interestingly, it does not vary between sexes. Further individualized prognosis estimation and therapy should strongly depend on age, diabetes duration, and gender.
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Affiliation(s)
- Susanne Triebswetter
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
| | - Lena J Gutjahr-Lengsfeld
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| | - Kay-Renke Schmidt
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| | - Christiane Drechsler
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| | - Christoph Wanner
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| | - Vera Krane
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
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Abe M, Hamano T, Hoshino J, Wada A, Inaba M, Nakai S, Masakane I. Is there a "burnt-out diabetes" phenomenon in patients on hemodialysis? Diabetes Res Clin Pract 2017. [PMID: 28648854 DOI: 10.1016/j.diabres.2017.06.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIMS In patients with diabetes on hemodialysis (HD), glycemic control improves spontaneously, leading to normal glycated hemoglobin (HbA1c) levels; this phenomenon is known as "burnt-out diabetes." However, glycated albumin (GA) might be a better indicator of glycemic control than HbA1c in HD patients. Therefore, the aim of this study was to identify how many patients experience "burnt-out diabetes" using HbA1c and GA levels and to examine the association between cardiovascular comorbidity risk and GA levels. METHODS Patients with diabetes on HD whose HbA1c levels were measured and whose antidiabetic therapy was recorded were included. First, the "burnt-out diabetes" phenomenon was investigated in patients whose HbA1c levels were measured (HbA1c cohort). Then, it was investigated in patients who were assessed for both HbA1c and GA levels (GA cohort). Risk of cardiovascular comorbidity was assessed using multivariable logistic regression models. RESULTS In the HbA1c cohort, 60,019 patients were included. When "burnt-out diabetes" was defined as HbA1c<6.0% without treatment with antidiabetic medication, it was noted in 11,159 patients (18.6%). In the GA cohort, 23,668 patients were included, and it was found in 4899 patients (20.7%). However, when "burnt-out diabetes" was defined as HbA1c<6.0% and GA<16.0% without treatment with antidiabetic medication, it was found in 1286 patients (5.4%). Patients with GA>18% had a higher risk of cardiovascular comorbidity. CONCLUSIONS Although the "burnt-out diabetes" phenomenon might be present in 20.7% of patients with diabetes on HD in terms of HbA1c, the rate was significantly decreased to 5.4% in terms of GA. CLINICAL TRIAL REGISTRATION NUMBER UMIN000018641.
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Affiliation(s)
- Masanori Abe
- The Renal Data Registry Committee, The Japanese Society for Dialysis Therapy, Tokyo, Japan; Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo, Japan.
| | - Takayuki Hamano
- The Renal Data Registry Committee, The Japanese Society for Dialysis Therapy, Tokyo, Japan; Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Junichi Hoshino
- The Renal Data Registry Committee, The Japanese Society for Dialysis Therapy, Tokyo, Japan; Nephrology Center, Toranomon Hospital, Tokyo, Japan.
| | - Atsushi Wada
- The Renal Data Registry Committee, The Japanese Society for Dialysis Therapy, Tokyo, Japan; Department of Nephrology, Kitasaito Hospital, Asahikawa, Japan.
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka City University, Osaka, Japan.
| | - Shigeru Nakai
- The Renal Data Registry Committee, The Japanese Society for Dialysis Therapy, Tokyo, Japan; Department of Clinical Engineering, Fujita Health University, Aichi, Japan.
| | - Ikuto Masakane
- The Renal Data Registry Committee, The Japanese Society for Dialysis Therapy, Tokyo, Japan; Department of Nephrology, Yabuki Hospital, Yamagata, Japan.
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Rhee CM, Kovesdy CP, Ravel VA, Streja E, Brunelli SM, Soohoo M, Sumida K, Molnar MZ, Brent GA, Nguyen DV, Kalantar-Zadeh K. Association of Glycemic Status During Progression of Chronic Kidney Disease With Early Dialysis Mortality in Patients With Diabetes. Diabetes Care 2017; 40:1050-1057. [PMID: 28592525 PMCID: PMC5521972 DOI: 10.2337/dc17-0110] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 05/09/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Although early trials suggested that intensive glycemic targets reduce the number of complications with diabetes, contemporary trials indicate no cardiovascular benefit and potentially higher mortality risk. As patients with advanced chronic kidney disease (CKD) transitioning to treatment with dialysis were excluded from these studies, the optimal glycemic level in this population remains uncertain. We hypothesized that glycemic status, defined by hemoglobin A1c (HbA--1c) and random glucose levels, in the pre-end-stage renal disease (ESRD) period is associated with higher 1-year post-ESRD mortality among patients with incident diabetes who have ESRD. RESEARCH DESIGN AND METHODS Among 17,819 U.S. veterans with diabetic CKD transitioning to dialysis from October 2007 to September 2011, we examined the association of mean HbA--1c and random glucose levels averaged over the 1-year pre-ESRD transition period with mortality in the first year after dialysis initiation. All-cause mortality hazard ratios (HRs) were estimated using multivariable survival models. Secondary analyses examined cardiovascular mortality using competing risks methods. RESULTS HbA--1c levels ≥8% (≥64 mmol/mol) were associated with higher mortality in the first year after dialysis initiation (reference value 6% to <7% [42-53 mmol/mol]): adjusted HRs [aHRs] 1.19 [95% CI 1.07-1.32] and 1.48 (1.31-1.67) for HbA--1c 8% to <9% [64-75 mmol/mol] and ≥9% [≥75 mmol/mol], respectively). Random glucose levels ≥200 mg/dL were associated with higher mortality (reference value 100 to <125 mg/dL): aHR 1.34 [95% CI 1.20-1.49]). Cumulative incidence curves showed that incrementally higher mean HbA--1c and random glucose levels were associated with increasingly higher cardiovascular mortality. CONCLUSIONS In patients with diabetes and CKD transitioning to dialysis, higher mean HbA--1c and random glucose levels during the pre-ESRD prelude period were associated with higher 1-year post-ESRD mortality. Clinical trials are warranted to examine whether modulating glycemic status improves survival in this population.
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Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Vanessa A Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | | | - Melissa Soohoo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Gregory A Brent
- Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
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Hoshino J, Larkina M, Karaboyas A, Bieber BA, Ubara Y, Takaichi K, Akizawa T, Akiba T, Fukuhara S, Pisoni RL, Saito A, Robinson BM. Unique hemoglobin A1c level distribution and its relationship with mortality in diabetic hemodialysis patients. Kidney Int 2017; 92:497-503. [DOI: 10.1016/j.kint.2017.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 01/17/2017] [Accepted: 02/02/2017] [Indexed: 11/27/2022]
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Rajput R, Sinha B, Majumdar S, Shunmugavelu M, Bajaj S. Consensus statement on insulin therapy in chronic kidney disease. Diabetes Res Clin Pract 2017; 127:10-20. [PMID: 28315574 DOI: 10.1016/j.diabres.2017.02.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/16/2017] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Diabetes mellitus (DM) is one of the leading causes of chronic kidney disease (CKD) which eventually leads to insulin resistance and decreased insulin degradation. In patients with diabetic kidney disease (DKD), the overall insulin requirement declines which necessitates the reassessment for individualization, adjustment and titration of insulin doses depending on the severity of kidney disease. OBJECTIVE To provide simple and easily implementable guidelines to primary care physicians on appropriate insulin dosing and titration of various insulin regimens in patients with DKD. METHODS Each insulin regimen (basal, prandial, premix and basal-bolus) was presented and evaluated for dosing and titration based on data from approved medical literatures on chronic kidney disease. These evaluations were then factored into the national context based on the expert committee representatives' and key opinion leaders' clinical experience and common therapeutic practices followed in India. RESULTS Recommendations based on dosing and titration of insulins has been developed. Moreover, the consensus group also recommended the strategy for dose estimation of insulin, optimal glycaemic targets and self-monitoring in patients with DKD. CONCLUSION The consensus based recommendations will be a useful reference tool for health care practitioners to initiate, optimise and intensify insulin therapy in patients with DKD.
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Affiliation(s)
| | | | - Sujoy Majumdar
- G D Diabetes Institute & Peerless Hospital Kolkata, India
| | - M Shunmugavelu
- Trichy Diabetes Speciality Centre (P) Ltd, Trichy, Tamil Nadu, India
| | - Sarita Bajaj
- Dept of Medicine, MLN Medical College, Allahabad, India
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Nemes-Nagy E, Fazakas Z, Balogh-Sămărghițan V, Simon-Szabó Z, Dénes L, Uzun CC, Fodor MA, Tilinca MC, Reid D, Higgins T. Comparison of four chromatographic methods used for measurement of glycated hemoglobin. REV ROMANA MED LAB 2016. [DOI: 10.1515/rrlm-2016-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
This parameter’s results accuracy has a special importance in the management of diabetic patients since targets for optimal glycemic control are established using HbA1c values. Several error sources can influence the obtained value, some of them can be counteracted (ex. pipetting errors, storage), and others should be taken into consideration at the interpretation of the result (ex. presence of hemoglobin variants). The aim of this study was to compare four chromatographic methods regarding the costs and the influence of certain error sources on the accuracy of the result. Materials and methods: Samples and controls were analyzed using Variant I, Micromat II and In2it (Bio-Rad) systems, and the BIOMIDI reagent kit for HbA1c measurement. Results: Positive correlation could be observed comparing the results obtained using different methods, except the patients presenting elevated HbF. Pipetting errors modify the results up to 5% in case of Variant I, and up to 10% in case of Micromat II in the tested range. One day of improper storage at room temperature causes 3% deviation from the actual value using the Variant I analyzer and 5% in case of Micromat II and In2it equipment. As a conclusion, depending on the number of samples, automated chromatographic analyzers are the most appropriate equipments for the determination of HbA1c.
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Affiliation(s)
- Enikő Nemes-Nagy
- Department of Biochemistry and Chemistry of Environmental Factors, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
| | - Zita Fazakas
- Department of Biochemistry and Chemistry of Environmental Factors, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
| | - Victor Balogh-Sămărghițan
- Department of Biochemistry and Chemistry of Environmental Factors, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
| | | | - Lóránd Dénes
- Department of Anatomy and Embriology, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
| | - Cosmina Cristina Uzun
- Department of Biochemistry and Chemistry of Environmental Factors, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
| | - Márta Andrea Fodor
- Department of Clinical Laboratory, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
| | - Mariana Cornelia Tilinca
- Cellular and Molecular Biology Department, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
| | - Deborah Reid
- Clinical Chemistry Department, Dynalifedx Diagnostic Laboratory, Edmonton, Canada
| | - Trefor Higgins
- Clinical Chemistry Department, Dynalifedx Diagnostic Laboratory, Edmonton, Canada
- Clinical Professor of Laboratory Medicine, University of Alberta, Edmonton, Canada
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46
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Hayashi A, Takano K, Masaki T, Yoshino S, Ogawa A, Shichiri M. Distinct biomarker roles for HbA 1c and glycated albumin in patients with type 2 diabetes on hemodialysis. J Diabetes Complications 2016; 30:1494-1499. [PMID: 27614726 DOI: 10.1016/j.jdiacomp.2016.08.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/15/2016] [Accepted: 08/22/2016] [Indexed: 10/21/2022]
Abstract
AIMS HbA1c and glycated albumin (GA) are used to monitor glycemia, but their accuracy to represent glycemic profiles in hemodialysis remains controversial. METHODS Continuous glucose monitoring in 97 patients with type 2 diabetes (41 on hemodialysis [HD] and 56 without nephropathy) was analyzed to evaluate whether HbA1c and/or GA serve as appropriate glycemic profile markers. RESULTS The average glucose significantly correlated with HbA1c in both HD group and group without nephropathy (r=0.59, P<0.0001; r=0.40, P<0.005). The slopes of linear regression lines were statistically indistinguishable (F=0.30, P=0.744), while the y-intercepts were significantly different (F=57.86, P<0.0001). GA showed strong correlation with the glycemic standard deviation (r=0.68, P<0.0001), and with the average glucose (r=0.42, P<0.001). Least square analysis revealed that only HbA1c, but not GA, was significantly associated with the average glucose (F=10.20, P<0.0005; F=0.38, P=0.5427), while only GA was significantly associated with the glycemic variability in HD group. CONCLUSIONS In HD participants, HbA1c correlates with the average glucose more than GA, but underestimates it, and a correction formula of HbA1c can be developed as an appreciable marker. GA value itself reflects the average glucose, but less accurately than HbA1c, while it could serve as an indicator for hyperglycemia/hypoglycemia excursion.
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Affiliation(s)
- Akinori Hayashi
- 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
| | - Tsuguto Masaki
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
| | - Sonomi Yoshino
- 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
| | - Masayoshi Shichiri
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Kanagawa, Japan
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Toida T, Sato Y, Nakagawa H, Komatsu H, Kikuchi M, Uezono S, Yamada K, Ishihara T, Hisanaga S, Kitamura K, Fujimoto S. Glycaemic control is a predictor of infection-related hospitalization on haemodialysis patients: Miyazaki Dialysis Cohort study (MID study). Nephrology (Carlton) 2016; 21:236-40. [PMID: 26272229 DOI: 10.1111/nep.12587] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 12/11/2022]
Abstract
AIM Although infection is the second leading cause of death in maintenance haemodialysis patients, the effects of glycaemic control on infection in diabetic haemodialysis patients have not yet been examined in detail. We examined the relationship between diabetes or glycemic control and infection-related hospitalization (IRH) in haemodialysis patients. METHODS Patients receiving maintenance haemodialysis (n = 1551, 493 diabetic patients) were enrolled in this prospective cohort study in December 2009 and followed-up for 3 years. IRH during the follow-up period was abstracted from medical records. Kaplan-Meier and Cox regression analyses were used to investigate the relationship between diabetes or glycaemic control and IRH. RESULTS The Kaplan-Meier analysis revealed that the risk of IRH was significantly higher in haemodialysis patients with diabetes, particularly in those with poorly controlled HbA1c levels (HbA1c ≥ 7.0%), than in haemodialysis patients without diabetes. When patients with ≥HbA1c 7.0% were divided into two groups using a median value of HbA1c, the risk of IRH was significantly higher in those with the poorest glycaemic control (HbA1c ≥ 7.4%), an older age, or lower albumin levels. The multivariable-adjusted hazard ratio for the risk of IRH was not higher in the second criteria of HbA1c (HbA1c 7.0-7.3%), but was significantly higher in the group with the poorest glycaemic control (HbA1c ≥ 7.4%) than in those in the good control criterion (HbA1c < 7.0%). CONCLUSIONS Although diabetes is a risk factor for IRH among maintenance haemodialysis patients, the relationship between glycaemic control and the risk of infection is not linear. Therefore, the risk of infection may increase in a manner that is dependent on the glycaemic control threshold.
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Affiliation(s)
- Tatsunori Toida
- Division of Circulatory and Body Fluid Regulation, Department of Internal Medicine, University of Miyazaki, Miyazaki, Japan.,Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yuji Sato
- Dialysis Division, University of Miyazaki Hospital, Miyazaki, Japan
| | - Hideto Nakagawa
- Dialysis Division, University of Miyazaki Hospital, Miyazaki, Japan
| | - Hiroyuki Komatsu
- Fist Department of Internal Medicine, University of Miyazaki Hospital, Miyazaki, Japan
| | - Masao Kikuchi
- Division of Circulatory and Body Fluid Regulation, Department of Internal Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shigehiro Uezono
- Department of Internal Medicine, Miyazaki Prefectural Hospital, Miyazaki, Japan
| | - Kazuhiro Yamada
- Department of Internal Medicine, Miyazaki Social Insurance Hospital, Miyazaki, Japan
| | - Tabito Ishihara
- Department of Internal Medicine, Fujimoto Chuo Hospital, Miyazaki, Japan
| | - Shuichi Hisanaga
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan
| | - Kazuo Kitamura
- Division of Circulatory and Body Fluid Regulation, Department of Internal Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Chen CW, Drechsler C, Suntharalingam P, Karumanchi SA, Wanner C, Berg AH. High Glycated Albumin and Mortality in Persons with Diabetes Mellitus on Hemodialysis. Clin Chem 2016; 63:477-485. [PMID: 27737895 DOI: 10.1373/clinchem.2016.258319] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Monitoring of glycemic control with hemoglobin A1c (A1c) in hemodialysis patients may be compromised by anemia and erythropoietin therapy. Glycated albumin (GA) is an alternative measure of glycemic control but is not commonly used because of insufficient evidence of association to clinical outcomes. We tested whether GA measurements were associated with mortality in hemodialysis patients with diabetes mellitus. METHODS The German Diabetes and Dialysis Study (4D) investigated effects of atorvastatin on survival in 1255 patients with diabetes mellitus receiving hemodialysis. We measured GA during months 0, 6, and 12. Cox proportional hazards analysis was used to measure associations between GA and A1c and all-cause mortality. RESULTS Patients with high baseline GA (fourth quartile) had a 42% higher 4-year mortality compared to those in the first quartile (HR 1.42; 95% CI, 1.09-1.85, P = 0.009). Repeated measurements of GA during year one also demonstrated that individuals in the top quartile for GA (analyzed as a time-varying covariate) had a 39% higher 4-year mortality (HR 1.39; 95% CI, 1.05-1.85, P = 0.022). The associations between high A1c and mortality using similar analyses were less consistent; mortality in individuals with baseline A1c values in the 3rd quartile was increased compared to 1st quartile (HR 1.36; 95% CI, 1.04-1.77, P = 0.023), but risk was not significantly increased in the 2nd or 4th quartiles, and there was a less consistent association between time-varying A1c values and mortality. CONCLUSIONS High GA measurements are consistently associated with increased mortality in patients with diabetes mellitus on hemodialysis.
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Affiliation(s)
- Christina W Chen
- Division of Nephrology and Center for Vascular Biology Research, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Christiane Drechsler
- Division of Nephrology, Department of Internal Medicine 1, University Hospital Würzburg and Comprehensive Heart Failure Center, Würzburg, Germany
| | | | - S Ananth Karumanchi
- Division of Nephrology and Center for Vascular Biology Research, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Christoph Wanner
- Division of Nephrology, Department of Internal Medicine 1, University Hospital Würzburg and Comprehensive Heart Failure Center, Würzburg, Germany
| | - Anders H Berg
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
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Pecoits-Filho R, Abensur H, Betônico CCR, Machado AD, Parente EB, Queiroz M, Salles JEN, Titan S, Vencio S. Interactions between kidney disease and diabetes: dangerous liaisons. Diabetol Metab Syndr 2016; 8:50. [PMID: 27471550 PMCID: PMC4964290 DOI: 10.1186/s13098-016-0159-z] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/10/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (DM) globally affects 18-20 % of adults over the age of 65 years. Diabetic kidney disease (DKD) is one of the most frequent and dangerous complications of DM2, affecting about one-third of the patients with DM2. In addition to the pancreas, adipocytes, liver, and intestines, the kidneys also play an important role in glycemic control, particularly due to renal contribution to gluconeogenesis and tubular reabsorption of glucose. METHODS In this review article, based on a report of discussions from an interdisciplinary group of experts in the areas of endocrinology, diabetology and nephrology, we detail the relationship between diabetes and kidney disease, addressing the care in the diagnosis, the difficulties in achieving glycemic control and possible treatments that can be applied according to the different degrees of impairment. DISCUSSION Glucose homeostasis is extremely altered in patients with DKD, who are exposed to a high risk of both hyperglycemia and hypoglycemia. Both high and low glycemic levels are associated with increased morbidity and shortened survival in this group of patients. Factors that are associated with an increased risk of hypoglycemia in DKD patients include decreased renal gluconeogenesis, deranged metabolic pathways (including altered metabolism of medications) and decreased insulin clearance. On the other hand, decrease glucose filtration and excretion, and inflammation-induce insulin resistance are predisposing factors to hyperglycemic episodes. CONCLUSION Appropriate glycaemic monitoring and control tailored for diabetic patients is required to avoid hypoglycaemia and other glycaemic disarrays in patients with DM2 and kidney disease. Understanding the renal physiology and pathophysiology of DKD has become essential to all specialties treating diabetic patients. Disseminating this knowledge and detailing the evidence will be important to initiate breakthrough research and to encourage proper treatment of this group of patients.
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Affiliation(s)
- Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Católica do Paraná, Imaculada Conceição, 1155, Curitiba, PR 80215-901 Brazil
| | - Hugo Abensur
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Carolina C. R. Betônico
- Hospital Regional de Presidente Prudente, Universidade do Oeste Paulista, Presidente Prudente, São Paulo, Brazil
| | | | | | - Márcia Queiroz
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Silvia Titan
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Sergio Vencio
- Institute of Pharmaceutical Sciences, Goiania, Brazil
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50
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Singh-Franco D, Harrington C, Tellez-Corrales E. An updated systematic review and meta-analysis on the efficacy and tolerability of dipeptidyl peptidase-4 inhibitors in patients with type 2 diabetes with moderate to severe chronic kidney disease. SAGE Open Med 2016; 4:2050312116659090. [PMID: 27516879 PMCID: PMC4968114 DOI: 10.1177/2050312116659090] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/14/2016] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE This updated meta-analysis determines the effect of dipeptidyl peptidase-4 inhibitors on glycemic and tolerability outcomes in patients with type 2 diabetes mellitus and chronic kidney disease with glomerular filtration rate of ⩽60 mL/min or on dialysis. METHODS In all, 14 citations were identified from multiple databases. Qualitative assessments and quantitative analyses were performed. RESULTS There were 2261 participants, 49-79 years of age, 49% men and 44% Caucasians. In seven placebo-comparator studies, reduction in hemoglobin A1c at weeks 12-24 was 0.55% (95% confidence interval: -0.68 to -0.43), P < 0.00001). In three sulfonylurea-comparator studies, dipeptidyl peptidase-4 inhibitors did not significantly reduce hemoglobin A1c at weeks 52-54 (-0.15% (95% confidence interval: -0.32 to 0.02)). In one sitagliptin versus albiglutide study, albiglutide significantly reduced hemoglobin A1c in patients with moderate renal impairment (-0.51%). A similar reduction in hemoglobin A1c was seen with sitagliptin versus vildagliptin (-0.56% vs -0.54%). Compared with placebo or sulfonylurea, dipeptidyl peptidase-4 inhibitors did not significantly reduce hemoglobin A1c after 12 and 54 weeks in patients on dialysis. Hypoglycemia was reported by ~30% of patients in both dipeptidyl peptidase-4 inhibitors and placebo groups over 24-52 weeks. While hypoglycemia was more common with a sulfonylurea at 52-54 weeks (risk ratio: 0.46 (95% confidence interval: 0.18 to 1.18)), there was significant heterogeneity (I (2) = 87%). Limitations included high drop-out rate from most studies and small number of active-comparator studies. CONCLUSIONS Dipeptidyl peptidase-4 inhibitors in patients with chronic kidney disease caused a modest reduction in hemoglobin A1c versus placebo, but not when compared with sulfonylureas or albiglutide, or when used in patients on dialysis. Additional active-comparator studies are needed to further elucidate the role of dipeptidyl peptidase-4 inhibitors in patients with chronic kidney disease stages 3-5 or on dialysis.
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Affiliation(s)
- Devada Singh-Franco
- Department of Pharmacy Practice, College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Catherine Harrington
- Department of Sociobehavioral and Administrative Pharmacy, College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Eglis Tellez-Corrales
- Department of Pharmacy Practice, College of Pharmacy, Marshall B. Ketchum University, Fullerton, CA, USA
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