Quality of life among diabetic and non-diabetic patients on maintenance haemodialysis

AIMS

To compare the quality of life of end stage renal disease (ESRD) diabetic and non-diabetic patients undergoing chronic haemodialysis.

METHODS

A case-control study of 54 diabetic and 60 non-diabetic patients undergoing maintenance haemodialysis. All subjects completed the Kidney Disease Quality of Life Short Form (KDQOL-SF) version 1.3 questionnaire as well as the SF-36 Health Survey (SF-36).

RESULTS

When compared to the control non-diabetic group, physical health was significantly impaired in diabetic dialysis patients (P<0.005) and staff encouragement was significantly worse (P<0.05). In both groups, all other compounds of the SF-46 and variables related to kidney disease were similar.

CONCLUSIONS

To improve diabetic haemodialysis patients' quality of life, physical activity should be incorporated to the routine dialysis care and health care professionals should support them more intensively.

Inverse associations between androgens and renal function: the Young Men Cardiovascular Association (YMCA) study

BACKGROUND

Men exhibit higher risk of nondiabetic renal diseases than women. This male susceptibility to renal disease may be mediated by gender-specific factors such as sex hormones.

METHODS

We have undertaken a cross-sectional examination of associations between renal function (creatinine clearance estimated based on Cockcroft-Gault equation) and circulating levels of sex steroids (total testosterone, total estradiol, estrone, androstenedione, dehydroepiandrosterone sulfate (DHEA-S), and dihydrotestosterone) in 928 young (mean age: 18.5 +/- 1.2 years) men.

RESULTS

Both androstenedione and DHEA-S showed inverse linear associations with renal function in the crude analysis of lean men (those with body mass index (BMI) less than median). However, only DHEA-S retained its association with renal function in lean subjects after adjustment--assuming no changes in other independent variables 1 s.d. increase in DHEA-S was associated with 13%-s.d. decrease in creatinine clearance (P = 0.004). Testosterone decreased across tertiles of creatinine clearance only in the crude analysis of nonlean (BMI greater than median) subjects (P < 0.001). The adjusted regression analysis that assumed no changes in other independent variables showed that 1 s.d. increase in total testosterone was associated with 11%-s.d. decrease in creatinine clearance of nonlean men (P = 0.006). Factor analysis confirmed an inverse association of renal function with both sex steroids and a different pattern of their loadings on glomerular filtration-related factors in lean (DHEA-S) and nonlean (testosterone) subjects.

CONCLUSIONS

Our data may suggest that androgens are inversely associated with estimated renal function in apparently healthy men without history of cardiovascular disease.

A multinational, multi-centre, observational, cross-sectional survey assessing diabetes secondary care in Central and Eastern Europe (DEPAC Survey)

AIMS

The objective of this study was to assess diabetes care in outpatient diabetes clinics in the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia.

METHODS

Questionnaires for each randomly enrolled patient were completed by an endocrinologist or diabetologist. Data concerning age, sex, diabetes duration, diabetes type, treatment type, glycated haemoglobin (HbA(1c)), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C), blood pressure (BP) and short- and long-term diabetes complications were recorded. Questionnaires were analysed centrally for each country and stratified for Type 1 diabetes (T1D), Type 2 diabetes (T2D) and other types of diabetes.

RESULTS

Data on 10 950 individuals were analysed (mean population age 56.2 years; females 52%; T1D 22.9%; T2D 75.3%; mean time from diagnosis 11 years). Patients with HbA(1c) within target (< 6.5%): T1D 13.1%, T2D 21.4%; for TC levels (< 4.5 mmol/l): T1D 37%, T2D 20%; for TG levels (< 1.7 mmol/l): T1D 78%, T2D 44%; for HDL-C (> 1.1 mmol/l): T1D 81%, T2D 60%; for LDL-C (< 2.5 mmol/l): T1D 36%, T2D 23%; for BP (< 130/80 mm Hg): T1D 42%, T2D 9%. The prevalence of severe hypoglycaemia (within the last 6 months) was 12% in T1D and 2% in T2D. Prevalence of diabetic ketoacidosis was 0.3-6.6%, blindness 0.15-1.3% and diabetic nephropathy 19-42%.

CONCLUSIONS

The data show the current quality of care and potential areas for improvement. The quality of care is generally comparable with that in Western Europe.

Quantitative ultrasound of phalanges of adults with end-stage renal disease or who have undergone renal transplantation

In patients with end-stage renal disease (ESRD), bone disturbances are common. The aim of this study was to compare the bone mineral status in patients with ESRD, in patients post renal transplantation and in healthy controls. The groups were composed of 218 males and 126 females (ESRD), 43 males and 23 females (renal transplantation) and 614 males and 927 females (healthy controls). Skeletal status was evaluated by quantitative ultrasound measurements of the phalanges using a DBM 1200 (IGEA, Carpi, Italy), which measures the amplitude-dependent speed of sound (Ad-SoS) in m/s. Data analyses were performed with Statistica 6 for Windows (StatSoft, Inc., Tulsa, OK, USA). The Z-scores in gender subgroups were significantly lower in patients undergoing dialysis and after transplantation than in controls (p<0.00001). The Z-scores did not differ between gender subgroups after transplantation and the Z-scores of dialyzed males were significantly better than in females (p<0.00001). The mean value of Z-scores in patients after transplantation was significantly lower than in all patients with ESRD (p<0.05) and in males (p<0.01). The duration of dialysis negatively influenced the Ad-SoS; however, the time elapsed since transplantation did not. The cumulative corticosteroid dose did not correlate with skeletal variables. In conclusion, patients with ESRD treated with hemodialysis and postrenal transplantation patients, across both genders, were observed to have skeletal disturbances.

Expression pattern of genes in peripheral blood mononuclear cells in diabetic nephropathy

AIMS

Only one-third of Type 1 diabetes patients develop diabetic nephropathy, and a genetic predisposition is postulated. To obtain more insight into processes that lead to diabetic nephropathy, messenger RNA expression profiles of peripheral blood mononuclear cells from patients with and without diabetic nephropathy were compared.

METHODS

We studied seven male patients with Type 1 diabetes and proteinuria and 12 male patients with Type 1 diabetes and normoalbuminuria after at least 20 years of diabetes duration. The expression of genes was examined using the microarray method with Human Genome U133A Arrays (Affymetrix, Santa Clara, CA, USA). We analysed the expression of all candidate genes suggested to be involved in the pathogenesis of diabetic nephropathy in previously published articles. Altogether, expression of 198 genes was analysed.

RESULTS

We found that thrombospondin 1 (THBS1) and cyclooxygenase 1(COX1) genes were over-expressed in patients with diabetic nephropathy, and matrix metalloproteinase 9 (MMP9) and cyclooxygenase 2 (COX2) genes had lower expression in diabetic nephropathy. For other genes, we did not observe different expression between patients with and without diabetic nephropathy,or the expression was too low for analysis.

CONCLUSIONS

The different gene expression pattern in peripheral blood mononuclear cells in patients with diabetic nephropathy might indicate an important pathway in the pathogenesis of this complication.

Glomerular hyperfiltration: a new marker of metabolic risk

Chronic kidney disease coexists with metabolic syndrome and this relationship may be apparent before overt manifestations of cardiovascular disease. To investigate early stages of the natural history of associations between renal function and metabolic syndrome, we phenotyped 1572 young (mean age=18.4 years), apparently healthy men for metabolic risk factors and estimated their creatinine clearance based on the Cockcroft-Gault equation. High metabolic risk (clustering of at least three metabolic risk factors) was revealed in 8.7% (137) of the subjects and was associated with a 6.9-fold increase in the odds of glomerular hyperfiltration (95% confidence interval (CI): 3.9-11.5) when compared to reference (from none to two metabolic risk factors). Overweight, elevated blood pressure, and low high-density lipoprotein (HDL) cholesterol increased the multivariate-adjusted odds ratio of glomerular hyperfiltration to 6.6 (95% CI: 3.8-11.6), 1.8 (95% CI: 1.0-3.0), and 2.5 (95% CI: 1.5-4.3), respectively. Systolic and diastolic blood pressures clustered together with leptin in the factor analysis and this blood pressure-adiposity component correlated with estimated creatinine clearance (r=0.329, P<0.0001) and explained on its own 10.2% of the variance in the estimated renal function. Our data reveal the silent epidemics of metabolic risk among young, apparently healthy men. Furthermore, the results indicate that high metabolic risk is associated with glomerular hyperfiltration before overt manifestations of cardiovascular disease.

Charcot's Joint of the Wrist in Type 2 Diabetes Mellitus

In patients with diabetes mellitus, Charcot's neuroarthropathy mainly affects major weight-bearing joints, especially the foot and ankle. Remarkably, we report a case of Charcot's joint of the wrist - an unusually rare localization in type 2 diabetic patient. A review of medical literature identified only three such cases so far.

The role of R576Q polymorphism of interleukin-4 receptor alpha gene in atopy: results of a family-based study design

INTRODUCTION

There is strong evidence that the R576 allele of interleukin-4 receptor alpha gene (IL-4R) might predispose to atopy. To test this hypothesis, we examined the association between the R576Q polymorphism and atopy in a Polish population using the family-based study design.

MATERIALS AND METHODS

44 atopic patients (age range from 11 to 34 years) with pollen and house dust mite allergy or/and mild asthma together with both parents were studied. The R576Q polymorphism of the IL-4R gene was genotyped in each patient and both parents, respectively, using the PCR-based protocol. The results were analyzed by the transmission disequilibrium test (TDT). The total IgE serum level, allergen-specific IgE to the common aeroallergens, IL-4, and sIL-4Ralpha were assessed in each patient and both parents.

RESULTS

In the TDT test the R576 and Q576 alleles were transmitted from the heterozygous parents to the affected offspring 20 and 15 times, respectively (McNemar test: p = 0.19). The results of the transmission disequilibrium test did not reach statistical significance. Thus, the R576 allele might contribute to the pathogenesis of allergic diseases in patients with high total IgE serum level (p < 0.05). A larger study group has to be studied to prove the observed linkage and association.

[The effect of improved glycemic control on quality of life in patients with type I and type II diabetes]

Patients with diabetes (type 1 or type 2) live shorter because of the long-term complications of hyperglycemia. One of the most important aims of therapy in diabetic subjects is delay in the development of long-term diabetes complications. However, another important aim of therapy in diabetic patients is the use of drugs, which not only delay the time of long-term complications development but also improve the quality of life. The paper presents the results of studies on quality of life in diabetic subjects basing on contemporary literature. In patients with type 1 diabetes mellitus a quality of life decreases gradually with the duration of diabetes. The influence of intensive insulin therapy on quality of life is minimal or absent. In UKPDS study no differences in quality of live between conventionally or intensively treated patients were observed. In subjects with macrovascular complications the quality of life is significantly worse. Generally, the authors of UKPDS suggested that better glycemic control is not associated with better quality of life. Only Testa and Simonsen demonstrated that type 2 diabetic subjects treated by new "intelligent" drug--glipizide GITS (Glibenese GITS) is associated not only with better metabolic control but also with better quality of life.

[Bone complications in diabetic subjects with good metabolic control and without any long-term complications--certain problems. Part III: The influence of hypertension and type 2 diabetes mellitus co-incidence of calcium, phosphorus and magnesium metabolism]

Both high morbidity and potentiation of systemic complications emphasise significance of diabetes mellitus and hypertension co-incidence. The aim of the study was to analyse the influence of hypertension accompanied with type 2 diabetes mellitus on calcium phosphorus and magnesium metabolism. The study was performed in standard low-calcium diet conditions on the group of 49 patients with type 2 diabetes mellitus (among them 27 had hypertension), 14 patients with essential hypertension and 20 healthy persons. Both serum and urine concentration of creatinine, calcium, phosphorus, hydroxyproline, hydroxylysine and uric acid were analysed. Oral calcium load test was done. Serum alkaline phosphatase activity and oxalic acid urine excretion were also estimated. There were no significant differences between diabetic patients with and without hypertension as far as calcium, phosphorus or magnesium metabolism were concerned.

[Bone complication in diabetes subjects with good metabolic control and without longterm complications: certain problems. Part II. Basal parameters of bone turnover]

The resorption and osteogenesis equilibrium is commonly known basal condition of bone tissue homeostasis. For the purpose of bone turnover analysis in the group of good controlled diabetic patients without any diabetic complications basal biochemical parameters of osteogenesis and resorption were estimated. During low-calcium diet conditions both serum concentration and urine excretion of creatinine, hydroxyproline, hydroxylysine and uric acid were investigated. Serum alkaline phosphatase activity and oxalic acid urine excretion were also measured. As the result of the study the higher serum alkaline phosphatase activity and hydroksyproline urine excretion in type 1 diabetic patients as well as higher hydroxyproline and hydroxylysine urine excretion in type 2 diabetic patients were found.

[Bone complication in diabetic subjects with good metabolic control and without any late complications: selected problems. Part I: calcium, phosphorus and magnesium metabolism]

The aim of the study was to evaluate whether in diabetics with good metabolic control and without any diabetic complications, disturbances of calcium, phosphorus and magnesium metabolism or hormonal regulation (parathormone/calcitonin) were present, and if they depended on type of diabetes, duration time of diabetes, kind of hypoglycaemic treatment, sex or age of patients. 83 subjects were examined, including: 14 with type 1 diabetes mellitus, 49 with type 2 diabetes mellitus and 20 healthy persons. All tests were performed in standarized low-calcium diet conditions. In basal conditions both serum concentrations and daily urine excretion of calcium, phosphorus, magnesium were estimated. Oral and intravenous calcium load tests with simultaneous parathormone, calcitonin, calcium, magnesium and phosphorus concentrations estimation were done. The final conclusions were as follow: Both in type 1 diabetes mellitus and type 2 diabetes mellitus subjects with good metabolic compensation and without advanced diabetic complications a tendency to early disturbances of calcium-phosphorus metabolism is observed. Physiological hormonal control (parathormone/calcitonin) is preserved. Correlations between mineral metabolism and type of diabetes, duration time of diabetes, daily insulin dose, body mass index and sex are observed. Kind of hypoglycaemic treatment has only slight influence on the mineral metabolism.

[Hypertension in patients with diabetes mellitus--selected pathogenetic and therapeutic aspects]

The pathogenesis of hypertension in diabetes type 1 and type 2 is different. Diabetic nephropathy is regarded as the most essential factor contributing to the development of hypertension in patients with diabetes mellitus type 1. Obesity, insulin resistance and hyperinsulinaemia are responsible for hypertension in diabetes mellitus type 2. In both types of diabetes, hypertension is involved in fast progress of diabetic renal disease. Antihypertensive treatment in diabetic patients should include: non-pharmacological interventions, drug-therapy, regular blood pressure monitoring, educational efforts. ACE-inhibitors, calcium antagonists, diuretics, beta-blockers, angiotensin II receptor antagonists and alpha 1-blockers are used as antihypertensive agents in diabetic patients. Neutral endopeptidase inhibitors are the new, promising therapeutic option.

Transmission of G-protein beta3 subunit C825T alleles to offspring affected with end-stage renal disease

BACKGROUND

Results of epidemiological studies have suggested that a hereditary predisposition to the development of chronic renal failure exists, and that such predisposition might be independent from underlying etiology of kidney disease. On the other hand, high blood pressure contributes substantially to a faster rate of progression of renal damage, regardless of underlying etiology of kidney disease. In this study we tested whether GNB3 C825T polymorphism, previously reported to be associated with hypertension, contributes to predisposition to end-stage renal disease (ESRD).

METHODS

GNB3 polymorphism was genotyped in 247 family trios: offspring affected with ESRD and both parents, and transmission/disequilibrium test was used to establish the allele-phenotype association. Among the examined offspring, 47 patients had ESRD in the course of type 1 diabetes and diabetic nephropathy, 120 had primary glomerulonephritis and 80 had interstitial nephritis. We observed no significant differences between the GNB3 C and T allele transmission from heterozygous parents to affected offspring.

RESULTS

In the overall group of examined patients, the C:T allele transmission (%) was 48:52, while in patients with diabetic nephropathy, chronic glomerulonephritis and chronic interstitial nephritis the transmission was (%) 50:50, 48:52 and 48:52, respectively.

CONCLUSION

The results of our study suggest that GNB3 C825T polymorphism does not contribute substantially to the increased risk of the development of ESRD.

Role of hemochromatosis C282Y and H63D mutations in HFE gene in development of type 2 diabetes and diabetic nephropathy

OBJECTIVE

In patients with clinical hemochromatosis, the frequency of diabetes ranges from 20 to 50%, and the heterozygosity for the C282Y mutation in the HFE gene might be associated with an increased risk for diabetes. There are also some reports that suggest that iron overload might cause diabetic nephropathy.

RESEARCH DESIGN AND METHODS

We performed an association study to assess the role of the C282Y and H63D mutations in the HFE gene as a risk factor for type 2 diabetes and diabetic nephropathy. Altogether, 563 patients with type 2 diabetes were included in the study. In the analyzed group, 108 patients had overt proteinuria, 154 had microalbuminuria, and 301 had normoalbuminuria. Among the patients with normoalbuminuria, only those with known diabetes duration > or = 10 years were considered normoalbuminuric (n = 162). A total of 196 unrelated healthy subjects were used as a control group. All subjects were genotyped for C282Y and H63D using the polymerase chain reaction-based protocol.

RESULTS

There was an increased frequency of 282Y allele carriers among patients with type 2 diabetes versus healthy control subjects (OR 5.3, 95% CI 1.6-17.3). We observed an increased frequency of the 63D allele carriers among patients with diabetic nephropathy (1.8, 1.2-2.8).

CONCLUSIONS

In conclusion, our study is the first to indicate that being a carrier of the H63D hemochromatosis mutation is a risk factor for nephropathy in type 2 diabetic patients. We also confirmed previous observations that the frequency of the 282Y mutation was higher in patients with type 2 diabetes than it was in the general population of healthy subjects.

[Cardura XL--a unique drug formulation--doxazosine administered in a slow-release form (doxazosine GITS)]

An active component in the tablet Cardura XL is doxazosine. Doxazosine belongs to the third generation of alpha 1-adrenolytics. It is a blocker of post-synaptic alpha 1-receptors both in humans and in animals. It is a long acting preparation. A tablet cover of Cardura XL is built of two layers (GITS system). It has enabled administration of doxazosine once a day. A great advance of the GITS system is a verly slow and systematic release of the drug from the tablet. This release is independent of pH of gastro-intestinal content or peristalsis. After administration of the tablet of Cardura XL, over 85% of the drug is released after 12 hours and the release ends after 12-16 hours. Maximal serum drug level after administration of doxazosine GITS is observed after 14-16 hours. Higher maximal serum drug level is achieved when the drug is administered together with a meal. Using doxazosine in the GITS form, minimal and maximal serum drug levels during the whole 24 hours differ non significantly. GITS technology enabled achieving stable daily serum drug concentration. Introducing doxazosine GITS caused: 1. decrease of Cmax; 2. elongation of Tmax; and 3. decrease of Cmin compared to doxazosine. It became possible due to gradual absorption of the preparation from gastrointestinal tract and improved coefficient of the drug fluctuation. It should be stated that the described pharmacological differences of doxazosine GITS in younger and elderly, in female and male patients do not influence significantly initial dosing of the drug. Stenosis of the gastrointestinal tract or chronic diarrhea affecting bowel passage of the drug, change its therapeutic effect. An effect of doxazosine GITS, doxazosine and placebo on blood pressure was studied in 392 patients with mild and moderate hypertension (< or = 220/95-115 mm Hg). Doxazosine GITS similarly to doxazosine effectively decreases blood pressure. The value of diastolic blood pressure decrease increases together with the therapy duration. Use of the unique GITS technology assures stable daily serum drug concentration. It results in: mild but permanent decrease of the blood pressure, decreased risk of side-effects, including orthostatic hypotony. Based on the performed post-registration studies it should be stated that doxazosine GITS is not only a very effective but also a safe preparation, which may be administered once daily. The treatment should be initialized with a dose of 4 mg daily. In as much as 60% of the patients with mild or moderate arterial hypertension, an initial dose (4 mg of Cardura XL) effectively lowers blood pressure. Taking into consideration unique features of the described preparation, it is worth thinking of Cardura XL while initializing or switching therapy in hypertensive patients. Cardura XL, due to favourable metabolic effects as well as the unique GITS technology seems to be the drug particularly suitable in hypertensive patients with accompanying dyslipidaemia, diabetes mellitus type 2 and/or benign prostata hypertrophy.

[Evaluation of the relationship between the occurrence of headache, use of analgesics and realizing a therapeutic effect among patients with hypertension]

The aim of the study was to assess the prevalence of headaches and analgesic use in hypertensive patients and to evaluate the relationship between taking analgesic drugs and adherence to antihypertensive therapy. 754 consecutive hypertensive patients (446 women and 308 men, aged 18-89 years, median age--58 years) from 7 out-patient centres participated in the study. Anonymous questionnaires consisted of 13 simple questions concerning demographic parameters (age, gender), clinical data (the duration of hypertension and antihypertensive therapy), the history of headache and use of analgesics were distributed among the participants. Among the hypertensives participating in the study, 82.9% (625) reported headaches. Analgesics were used by 65.3% (408) of hypertensive patients with headaches. There was significant, positive linear correlation between the history of headaches and the duration of analgesic use in hypertensive patients. The rate of non-compliance was significantly higher among patients with headaches who reported regular use of analgesics when compared to non-users of analgesics. There were statistically more non-compliants among patients taking more than 1 type of analgesics than in hypertensives reporting use of only 1 analgesic drug. The prevalence of headaches and the rate of analgesic use is considerably significant among hypertensive patients. Analgesic consumption seems to be a risk factor for non-adherence to antihypertensive medication.

[Genetic factors with significance in pathogenesis of diabetic nephropathy--the role of polymorphism of renin-angiotensin system genes]

The article presents the contemporary view about the role of polymorphisms of renin-angiotensin system genes in the pathogenesis of diabetic nephropathy in subjects with type 1 and type 2 diabetes.