Glycemic control in diabetic dialysis patients and the burnt-out diabetes phenomenon

Assessment of Glycemic Control by Continuous Glucose Monitoring, Hemoglobin A1c, Fructosamine, and Glycated Albumin in Patients With End-Stage Kidney Disease and Burnt-Out Diabetes

OBJECTIVE

Patients with diabetes and end-stage kidney disease (ESKD) may experience "burnt-out diabetes," defined as having an HbA1c value <6.5% without antidiabetic therapy for >6 months. We aim to assess glycemic control by continuous glucose monitoring (Dexcom G6 CGM) metrics and glycemic markers in ESKD patients on hemodialysis with burnt-out diabetes.

RESEARCH DESIGN AND METHODS

In this pilot prospective study, glycemic control was assessed by continuous glucose monitoring (CGM), HbA1c measures, and glycated albumin and fructosamine measurements in patients with burnt-out diabetes (n = 20) and without a history of diabetes (n = 20).

RESULTS

Patients with burnt-out diabetes had higher CGM-measured daily glucose levels, lower percent time in the range 70-180 mg/dL, higher percent time above range (>250 mg/dL), and longer duration of hyperglycemia >180 mg/dL (hours/day) compared with patients without diabetes (all P < 0.01). HbA1c and fructosamine levels were similar; however, patients with burnt-out diabetes had higher levels of glycated albumin than did patients without diabetes.

CONCLUSIONS

The use of CGM demonstrated that patients with burnt-out diabetes have significant undiagnosed hyperglycemia. CGM and glycated albumin provide better assessment of glycemic control than do values of HbA1c and fructosamine in patients with ESKD.

Untargeted Metabolomic Plasma Profiling of Emirati Dialysis Patients with Diabetes versus Non-Diabetic: A Pilot Study

Diabetic kidney disease (DKD) is a severe irreversible complication of diabetes mellitus that further disturbs glucose metabolism. Identifying metabolic changes in the blood may provide early insight into DKD pathogenesis. This study aims to determine blood biomarkers differentiating DKD from non-diabetic kidney disease in the Emirati population utilizing the LC-MS/MS platform. Blood samples were collected from hemodialysis subjects with and without diabetes to detect indicators of pathological changes using an untargeted metabolomics approach. Metabolic profiles were analyzed based on clinically confirmed diabetic status and current HbA1c values. Five differentially significant metabolites were identified based on the clinically confirmed diabetic status, including hydroxyprogesterone and 3,4-Dihydroxymandelic acid. Similarly, we identified seven metabolites with apparent differences between Dialysis Diabetic (DD) and Dialysis non-Diabetic (DND) groups, including isovalerylglycine based on HbA1c values. Likewise, the top three metabolic pathways, including Tyrosine metabolism, were identified following the clinically confirmed diabetic status. As a result, nine different metabolites were enriched in the identified metabolic pathways, such as 3,4-Dihydroxymandelic acid. As a result, eleven different metabolites were enriched, including Glycerol. This study provides an insight into blood metabolic changes related to DKD that may lead to more effective management strategies.

Diabetes Prevalence, Treatment, Control, and Outcomes Among Hemodialysis Patients in the Gulf Cooperation Council Countries

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.

Blood Pressure and Glycemic Control Among Ambulatory US Adults With Heart Failure: National Health and Nutrition Examination Survey 2001 to 2018

BACKGROUND

Multisociety guidelines recommend a goal systolic blood pressure (BP) <130 mm Hg and a hemoglobin A1c (HbA1c) <8% in patients with heart failure (HF), regardless of ejection fraction. Few studies have described BP and glycemic control in ambulatory patients with HF and racial and ethnic disparities in this subset of the population.

METHODS

We evaluated prevalence of uncontrolled BP and HbA1c in non-Hispanic Black, non-Hispanic White, and Mexican American adults aged ≥20 years with self-reported HF (National Health and Nutrition Examination Surveys: 2001-2018). Prevalence ratios (95% CI) for uncontrolled BP and HbA1c were calculated by race and ethnicity and adjusted for sex, age, treatment, and socioeconomic status. In secondary analyses, we examined trends in the prevalence of uncontrolled BP and HbA1c.

RESULTS

Uncontrolled BP was present in 48% (95% CI, 49%-56%) of adults with HF (representing 2.3 million people). Non-Hispanic Black participants had a higher prevalence of uncontrolled BP compared with non-Hispanic White participants (53% [48%-58%] compared with 47% [43%-51%], P<0.05). In adjusted models, non-Hispanic Black participants were 1.19 (1.02-1.39) times more likely to have uncontrolled BP than non-Hispanic White participants. Overall, uncontrolled HbA1c was found in 8% (6%, 10%) with no differences by race and ethnicity. Prevalence of uncontrolled BP improved over time but uncontrolled risk factors remained high-2017 to 2018: 41% (36%, 47%) and 7% (5%, 12%) had uncontrolled BP and HbA1c, respectively.

CONCLUSIONS

We document an unacceptably high prevalence of uncontrolled BP and HbA1c in a nationally representative, ambulatory HF sample with significant differences in BP control by race and ethnicity.

Chronic Renal Failure and Cardiovascular Disease: A Comprehensive Appraisal

Coronary artery disease is highly prevalent in patients with chronic kidney disease. The concomitant renal disease often poses a major challenge in decision making as symptoms, cardiac biomarkers and noninvasive studies for evaluation of myocardial ischemia have different sensitivity and specificity thresholds in this specific population. Moreover, the effectiveness and safety of intervention and medical treatment in those patients is of great doubt as most clinical studies exclude patients with advance CKD. In the present paper, we discuss and review the literature in the diagnosis, treatment and prevention of CAD in the acute and chronic setting, in patients with CKD.

Effect of anti-diabetic drugs in dialysis patients with diabetes: a nationwide retrospective cohort study

BACKGROUND

Type 2 diabetes mellitus is common in patients undergoing dialysis. However, the association between anti-diabetic drug use and survival outcomes is rarely discussed. We aimed to investigate whether continued anti-diabetic medication use affects the survival of diabetic dialysis patients and whether different hypoglycemic drug use influences prognosis.

METHODS

Using a nationwide database, we enrolled patients with incident end-stage renal disease under maintenance dialysis during 2011-2015 into the pre-existing diabetes dialysis (PDD), incident diabetes after dialysis (IDD), and non-diabetic dialysis (NDD) groups. The PDD group was further subclassified into patients who continued (PDD-M) and discontinued (PDD-NM) anti-diabetic drug use after dialysis.

RESULTS

A total of 5249 dialysis patients were examined. The PDD-NM group displayed a significantly higher mortality rate than the IDD, PDD-M, and NDD groups (log-rank test P < 0.001). The PDD-M group had a significantly lower risk of death, regardless of insulin (P < 0.001) or oral hypoglycemic agent (OHA) (P < 0.001) use. Initial insulin administration or OHA had no statistically significant effect on overall mortality in the IDD group. But OHA use had better survival trends than insulin administration for the older (P = 0.02) and male subgroups (P = 0.05).

CONCLUSIONS

For dialysis patients with diabetes, continuous administration of anti-diabetic drugs after dialysis and choice of medication may affect outcomes.

Biomarkers of Glyco-Metabolic Control in Hemodialysis Patients: Glycated Hemoglobin vs. Glycated Albumin

Background and Objectives: Glycated hemoglobin (HbA1c) dosage is considered the gold standard in glycol-metabolic monitoring, but it presents limits, which can underestimate the glycemia trend. In this regard, it was introduced the glycated albumin (GA). The aim of the study is to verify the predictivity of the GA compared to HbA1c in identifying glyco-metabolic alterations in non-diabetic and diabetic hemodialysis (HD) patients. Materials and Methods: For this purpose, we conducted a multicenter study involving one analysis laboratory and six dialysis centers in the Lazio region (Rome, Italy). Both diabetic and non-diabetic HD patients represent the study population, and the protocol included five time points. Results: The analyzed data highlighted the ability of GA to predict changes in glycemic metabolism in HD patients, and GA values are not significantly influenced, like HbA1c, by dialysis therapy itself and by comorbidities of the uremic state, such as normochromic and normocytic anemia. Thus, GA seems to reflect early glyco-metabolic alterations, both in patients with a previous diagnosis of diabetes and in subjects without diabetes mellitus. As part of this study, we analyzed two HD patients (one diabetic and one non-diabetic) in which GA was more predictive of glycol-metabolic alterations compared to HbA1c. Our study confirms the need to compare classical biomarkers used for the monitoring of glyco-metabolic alterations with new ones, likely more reliable and effective in specific subgroups of patients in which the classic biomarkers can be influenced by the preexisting pathological conditions. Conclusions: In conclusion, our evidence highlights that in uremic patients, GA shows a better ability to predict glyco-metabolic alterations allowing both an earlier diagnosis of DM and a prompt modulation of the hypoglycemic therapy, thus improving the clinical management of these patients.

[Preparation of the dialysis patient with type 1 diabetes mellitus for kidney transplantation]

Kidney transplantation is unique method of renal replacement therapy, allowing to improve quality and duration of life for patients with diabetes mellitus type 1 (DM1) and end-stage renal disease (ESRD) on dialysis therapy. Recently using of innovation technologies for diabetes management and modern immunosuppression enable achieving better results of posttransplant rehabilitation for patients with DM1, especially if kidney transplantation is performed early after initiation of dialysis. Detailed examination of patient with DM1 before potential kidney transplantation is very important to reduce of early and late postoperative complications. Kidney transplantation preparation includes effective glycemic control, adequate dialysis therapy, treatment of diabetes and ESRD complications and concomitant conditions, especially cardiovascular diseases, accounting for kidney transplantation perspective. Furthermore, diagnostics and treatment of any infectious process, timely vaccination, cancer screening are basic approaches of kidney transplantation preparation program, providing the best survival rate of kidney graft and patient.

Assessment of renal impairment using estimated glomerular filtration rate among type 2 diabetes mellitus patients in North-East Ethiopia: a cross-sectional study

BACKGROUND

Chronic kidney disease (CKD) is the known cause of morbidity and mortality among diabetes mellitus (DM) patients. Targeted screening of renal impairment based on estimated glomerular filtration rate (eGFR) among DM patients has potential benefits in early identification and treatment of CKD. Hence, this study was aimed to estimate the magnitude of renal impairment using eGFR among type 2 DM patients.

METHODS

An institution-based cross-sectional study was conducted from February-1 to April 30/2020 among 422 type 2 DM patients in Northeast Ethiopia. Data were collected by the semi-structured questioner and serum creatinine measurement. The collected data were edited into Epi-data manager version 4.4.1.0, and the analysis was performed by SPSS-25. The Simplified Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology (CKD-EPI), and Cockcroft-Gault (C-G) equations were used to calculate eGFR.

RESULTS

Of all study participants, 82(19.4%), 92(21.8%), and 103(24.4%) had eGFR < 60 ml/min/1.73 m², according to the MDRD, CKD-EPI, and C-G equations, respectively. Female sex, (MDRD:AOR = 4.44, 95%CI:1.97-9.97, CKD-EPI:AOR = 3.17, 95%CI:1.27-6.17, and C-G:AOR = 2.65, 95%CI:1.35-5.21), duration ≥ 10 years (MDRD:AOR = 3.38, 95%CI:1.45-7.92, CKD-EPI:AOR = 3.09, 95%CI:1.07-7.77, and C-G:AOR = 2.92, 95%CI:1.29-6.61), age ˃60 years (MDRD:AOR = 2.29, 95%CI:1.09-4.77, CKD-EPI:AOR = 4.12, 95%CI:1.68-6.78, and C-G: AOR = 3.42, 95%CI:1.77-6.60), hypertension (MDRD:AOR = 3.12, 95%CI:1.51-6.45, CKD-EPI: AOR = 4.21,95%CI:2.07-7.98, and C-G:AOR = 3.99, 95%CI:2.08-7.65), poor glycemic control (MDRD:AOR = 2.82, 95%CI:1.13-7.05, and C-G:AOR = 2.34, 95%CI:1.09-5.04), and body mass index (MDRD:AOR = 1.11, 95%CI:1.01-1.22, and CKD-EPI:AOR = 2.43, 95%CI:1.27-5.76) were significantly associated with renal impairment.

CONCLUSION

Renal impairment was prevalent among type 2 DM patients. Older age, female sex, duration, hypertension, poor glycemic control, and BMI were significantly associated with renal impairment.

Burnt Out? The Phenomenon of Type 2 Diabetes Mellitus in End-Stage Renal Disease

In patients with T2DM and ESRD, insulin is the antidiabetic medication of choice with a hemoglobin A_1c target of 6 to 8%, using fructosamine levels or other measures for better assessment of glycemic control.

Evaluation of Efficacy of Mirtazapine on Pruritus and Serum Histamine and Serotonin Levels in Patients Undergoing Hemodialysis: A Before-After Pilot Clinical Trial

Background

Although chronic kidney disease-associated pruritus (CKD-aP) remains a frequent and frustrating symptom in patients with advanced kidney diseases, its optimal treatments are not well defined. Based on its mechanism of action, as a histamine-1 (H1), 5-(hydroxytryptamine) HT2, and 5HT3-receptor blocker, mirtazapine may be effective in the treatment of CKD-aP. Hence, this study aimed to investigate the efficacy of mirtazapine for the treatment of pruritus in patients undergoing hemodialysis (HD).

Methods

A before-after clinical trial was conducted from September 2018 until March 2019, on 30 HD-patients that had been referred to the HD ward of a tertiary hospital, in Hamadan, Iran. After the 2-week washout period, mirtazapine was administered with a dosage of 15 mg/day for an additional 2 weeks. At baseline and at each dialysis session, the effects of the mirtazapine on the pruritus severity based on the visual analogue scale (VAS) and degree of sleep interference resulting from the pruritus were asked and recorded. Additionally, at the baseline and the end of 2 weeks of treatment, the serum histamine and serotonin levels, as the main chemical pruritogens evoking pruritus symptoms, were also determined.

Results

Twenty-seven patients completed the entire course of the study. Based on the general linear model analysis, a progressive decline in the mean VAS score was observed over time during the study. The mean VAS score decreased from 8.48 ± 1.01 at baseline to 1.04 ±0.79 at the end of treatment (P-value<0.001). Similarly, the mean sleep interference scores were also significantly improved throughout treatment (decreased from 8.07±1.43 to 2.81± 0.74; P-value<0.001). Further, at the end of the treatment, a noticeable decrement in the serum histamine level was also seen (P-value = 0.006). The drug was acceptably well-tolerated and a majority of the patients were satisfied with this treatment.

Conclusion

This pilot study suggests that mirtazapine may be an effective treatment option for the management of CKD-aP. However, further studies would be needed to confirm these results.

[Glycemic control in patients with diabetes mellitus on hemodialysis]

Achievement of stabilization of carbohydrate metabolism in patients with diabetes mellitus, receiving renal replacement therapy with hemodialysis, is a significant problem in endocrinology. It has to do with multiple factors of this cohort of patients, which affect the level of glycemia, pharmacokinetic of drugs, the efficiency of glycemic control. At the moment, the most efficiency method of glycemic control in patients with type 2 diabetes mellitus on hemodialysis is insulin therapy in the basis - bolus regime by analogues of human insulin. The use of oral hypoglycemic agents is significantly limited. The hemoglobin A1c (HbA1c) remains the main parameter of glycemic control. The simultaneous use of continuous glucose monitoring allows to reveal the true level of glucose of the blood and to carry out the timely correction of therapy in order to achieve targets for glycemic control and to decrease the risk of hypoglycemic episodes. At the moment other glycemic control markers such as glycated albumin and fructosamine are described. However, in routine practice at the moment these indicators are not used due to the lack of sufficient evidentiary base of their use in this cohort of patients.

Association between End-Stage Renal Disease and Incident Diabetes Mellitus-A Nationwide Population-Based Cohort Study

Background: Glucose is one of the constituents in hemodialysates and peritoneal dialysates. How the dialysis associates with the incident diabetes mellitus (DM) remains to be assessed. Methods: The claim data of end-stage renal disease (ESRD) patients who initiated dialysis from and a cohort of matched non-dialysis individuals from 2000 to 2013 were retrieved from the Taiwan National Health Insurance Research Database to examine the risk of incident DM among patients on hemodialysis (HD) and peritoneal dialysis (PD). Predictors of incident DM were determined for HD and PD patients using Fine and Gray models to treat death as a competing event, respectively. Results: A total of 2228 patients on dialysis (2092 HD and 136 PD) and 8912 non-dialysis individuals were the study population. The PD and HD patients had 12 and 97 new-onset of DM (incidence rates of 15.98 and 8.69 per 1000 patient-years, respectively), while the comparison cohort had 869 DM events with the incidence rate of 15.88 per 1000 patient-years. The multivariable-adjusted Cox models of Fine and Gray method showed that the dialysis cohort was associated with an adjusted hazard ratio (HR) of 0.49 (95% CI 0.39–0.61, p value < 0.0001) for incident DM compared with the comparison cohort. The adjusted HR of incident DM was 0.46 (95% CI 0.37–0.58, p value < 0.0001) for HD and 0.84 (95% CI 0.47–1.51, p value = 0.56) for PD. Conclusions: ESRD patients were associated with a lower risk of incident DM. HD was associated with a lower risk of incident DM, whereas PD was not.

Rate of the "burnt-out diabetes" phenomenon in patients on peritoneal dialysis

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.

Management of adults with diabetes on the haemodialysis unit: summary of guidance from the Joint British Diabetes Societies and the Renal Association

Diabetic nephropathy remains the principal cause of end-stage renal failure in the UK and its prevalence is set to increase. People with diabetes and end-stage renal failure on maintenance haemodialysis are highly vulnerable, with complex comorbidities, and are at high risk of adverse cardiovascular outcomes, the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionals providing foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and end-stage renal failure require improved delivery of care to overcome organizational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of people with diabetes on maintenance haemodialysis. The guidelines are based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and people with diabetes to promote empowerment and self-management.

Clinical assessment and treatment of diabetes in patients with chronic kidney disease

Diabetes mellitus type 2 is the main cause of chronic kidney disease. Patients with this disease have higher morbidity and mortality and risk of hypoglycaemia than those without this disease. In 2010, type 2 diabetes was the reason for starting renal replacement therapy in 24.7% of patients. The prevalence of microalbuminuria, proteinuria and a reduced glomerular filtration rate is 36%, 8% and 22%, respectively. The presence of albuminuria is a predictor of chronic kidney disease. Diabetic kidney disease, previously known as diabetic nephropathy, refers to kidney disease caused by diabetes. Renal hyperfiltration is a marker of intraglomerular hypertension and a risk factor for onset and progression. The new antidiabetic drugs, mainly dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter inhibitors and glucagon-like peptide-1 agonists, have been shown to prevent or slow the progression of kidney disease.

Effects of Intensive Control of Glycemia on Clinical Kidney Outcomes in Type 2 Diabetes Patients Compared with Standard Control: A Meta-Analysis

Background: Association between poor control of glycemia and the onset of microvascular complications in type 2 diabetes mellitus (T2DM) patients is a hard issue. However, it seems that the impact of pharmacological treatment is important only in early stages of diabetic nephropathy. We sought to examine whether intensive glycemic control is associated with improvement of clinical Chronic Kidney Disease (CKD) outcomes compared to standard glycemic control. Methods: Meta-analysis of published and unpublished randomized controlled trials (RCT) and post-hoc analysis of RCTs comparing anti-diabetic drugs and/or insulin (intensive control) vs. dietary measures (standard control) for relevant outcomes related to progression of CKD clinically manifest was undertaken. Summary estimates obtained by random effects model and funnel plots for assessing reporting bias are presented. Results: Our analysis was based on four RCTs representing 27,391 adult T2DM patients with CKD from around the world. The pooled OR for the outcomes of doubling of serum creatinine and need of dialysis were, respectively, of 0.98 with 95% confidence interval (95% CI) 0.81-1.19, and 0.84 with 95% CI 0.69-1.02. The pooled OR for the outcome of death from kidney failure was 0.62 with 95% CI 0.39-0.98. Clinical differences between studies were not translated in statistical heterogeneity. Reporting bias may be present. Conclusions: Intensive glycemic control has an effect on death from kidney failure compared to standard glycemic control. Better comprehension of glycemic control effects on both T2DM patients with and without CKD is important for individualization of these two treatment modalities.

Is there a "burnt-out diabetes" phenomenon in patients on hemodialysis?

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.

Current therapeutic approaches in the management of hyperglycemia in chronic renal disease

Diabetes mellitus (DM) and chronic kidney disease (CKD) are intricately intertwined. DM is the most common cause of CKD. Adequate control of DM is necessary for prevention of progression of CKD, while careful management of the metabolic abnormalities in CKD will assist in achieving better control of DM. Two of the key organs involved in glucose production are the kidney and the liver. Furthermore, the kidney also plays a role in glucose filtration and reabsorption. In CKD, monitoring of glycemic control using traditional methods such as Hemoglobin A1c (Hba1c) must be done with caution secondary to associated hematological abnormalities in CKD. With regard to medication management in the care of patients with DM, CKD has significant effects. For example, the dosages of oral and non-insulin anti-hyperglycemic agents often need to be modified according to renal function. Insulin metabolism is altered in CKD, and a reduction in insulin dose is almost always needed. Dialysis also affects various aspects of glucose homeostasis, necessitating appropriate changes in therapy. Due to the aforementioned factors glycemic management in patients with DM and CKD can be quiet challenging.

Distinct biomarker roles for HbA1c and glycated albumin in patients with type 2 diabetes on hemodialysis

AIMS

HbA_1c 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 HbA_1c and/or GA serve as appropriate glycemic profile markers.

RESULTS

The average glucose significantly correlated with HbA_1c 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 HbA_1c, 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, HbA_1c 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 HbA_1c, while it could serve as an indicator for hyperglycemia/hypoglycemia excursion.

A practical and evidence-based approach to management of inpatient diabetes in non-critically ill patients and special clinical populations

Inpatient diabetes is a common medical problem encountered in up to 25-30% of hospitalized patients. Several prospective trials showed benefits of structured insulin therapy in managing inpatient hyperglycemia albeit in the expense of high hypoglycemia risk. These approaches, however, remain underutilized in hospital practice. In this review, we discuss clinical applications and limitations of current therapeutic strategies. Considerations for glycemic strategies in special clinical populations are also discussed. We suggest that given the complexity of inpatient glycemic control factors, the "one size fits all" approach should be modified to safe and less complex patient-centered evidence-based treatment strategies without compromising the treatment efficacy.

North American experience with Low protein diet for Non-dialysis-dependent chronic kidney disease

Whereas in many parts of the world a low protein diet (LPD, 0.6-0.8 g/kg/day) is routinely prescribed for the management of patients with non-dialysis-dependent chronic kidney disease (CKD), this practice is infrequent in North America. The historical underpinnings related to LPD in the USA including the non-conclusive results of the Modification of Diet in Renal Disease Study may have played a role. Overall trends to initiate dialysis earlier in the course of CKD in the US allowed less time for LPD prescription. The usual dietary intake in the US includes high dietary protein content, which is in sharp contradistinction to that of a LPD. The fear of engendering or worsening protein-energy wasting may be an important handicap as suggested by a pilot survey of US nephrologists; nevertheless, there is also potential interest and enthusiasm in gaining further insight regarding LPD’s utility in both research and in practice. Racial/ethnic disparities in the US and patients’ adherence are additional challenges. Adherence should be monitored by well-trained dietitians by means of both dietary assessment techniques and 24-h urine collections to estimate dietary protein intake using urinary urea nitrogen (UUN). While keto-analogues are not currently available in the USA, there are other oral nutritional supplements for the provision of high-biologic-value proteins along with dietary energy intake of 30–35 Cal/kg/day available. Different treatment strategies related to dietary intake may help circumvent the protein- energy wasting apprehension and offer novel conservative approaches for CKD management in North America.

Should Restrictions Be Relaxed for Metformin Use in Chronic Kidney Disease? No, We Should Never Again Compromise Safety!

Metformin is and has been considered as first-line therapy for type 2 diabetes for over a quarter of a century. Like other biguanides, metformin can cause a lactic acidosis that is exceptionally rare but fatal. The likelihood of metformin-associated lactic acidosis is substantially higher in patients with kidney impairment and also among those with seemingly normal kidney function who are at risk of acute kidney injury (AKI). Hence, regulatory agencies in many industrialized nations have maintained strict renal restrictions surrounding metformin. However, there have been millions of people exposed to metformin for many years, many of them with serum creatinine values at or close to 1.5 mg/dL with estimated glomerular filtration rates (eGFRs) much below 60 mL/min/1.73 m(2) who have not developed lactic acidosis. Thus, there clearly remains controversy in this area, and there has been heightened pressure to remove the renal restrictions of metformin. To provide a discussion on the pros and cons of relaxing the renal restrictions for metformin use, we provide a Point-Counterpoint. In the point narrative below, Drs. Kalantar-Zadeh and Kovesdy provide their argument that although there is little evidence of the potential benefits of metformin in kidney disease, just considering the sheer numbers of metformin users and the high fatality rate of its associated lactic acidosis, the most appropriate practice is to avoid metformin use in people with eGFR <45 mL/min/1.73 m(2) or in those who are at high risk of AKI irrespective of underlying eGFR. In the following counterpoint narrative, Drs. Bakris and Molitch argue that the data from a very large analysis demonstrate clearly that serum creatinine should be supplanted with eGFR as the criteria for metformin use and that the incidence of lactic acidosis is only elevated in those with a reduced eGFR who become dehydrated for various reasons or in those exposed to some toxin resulting in AKI. Otherwise the data clearly support the use of metformin under normal circumstances down to eGFR >30 mL/min/1.73 m(2)-William T. CefaluEditor in Chief, Diabetes Care.

Nutrition Intervention for Advanced Stages of Diabetic Kidney Disease

IN BRIEF For the goals of reducing diabetic kidney disease (DKD) onset and progression, approaches to nutritional therapy are a subject of much debate. This article discusses selected nutrients that have a role in affecting DKD outcomes and introduces application of newer, individualized concepts for healthful eating, as supported by clinical evidence relevant to patients with DKD. Selected aspects of management of advanced DKD are also reviewed.

Evaluation and management of diabetic and non-diabetic hypoglycemia in end-stage renal disease

Patients with end-stage renal disease (ESRD) regardless of diabetes status are at increased risk of hypoglycemia with a resultant array of adverse clinical outcomes. Therefore, hypoglycemia should be thoroughly evaluated in ESRD patients. In diabetic dialysis patients, hypoglycemic agents and nutritional alterations can trigger hypoglycemia in the background of diminished gluconeogenesis, reduced insulin clearance by the kidney and improved insulin sensitivity following initiation of renal replacement therapy. Detailed evaluation of antidiabetic regimen and nutritional patterns, patient education on self-monitoring of blood glucose and/or referral to a diabetes specialist may reduce risk of subsequent hypoglycemia. In certain situations, it is important to recognize the possibility of non-diabetic causes of hypoglycemia in patients with diabetes and to avoid treating pseudo-hyperglycemia caused by glucose- non-specific glucometers in patients utilizing icodextrin-based solutions for peritoneal dialysis. Adrenal insufficiency, certain medications, malnutrition and/or infection are among the most common causes of hypoglycemia in non-diabetic ESRD patients, and they should be suspected after exclusion of inadvertent use of hypoglycemic agents. The goal of this review article is to summarize approaches and recommendations for the work up and treatment of hypoglycemia in ESRD.

Common polymorphisms in antioxidant genes are associated with diabetic nephropathy in Type 2 diabetes patients

AIM

To investigate if antioxidative genes' polymorphisms influence the risk for Type 2 diabetes (T2D) complications.

MATERIALS & METHODS

In total, 181 T2D patients were genotyped for SOD2, CAT, GPX1, GSTP1, GSTM1*0, GSTT1*0, GCLC and GCLM.

RESULTS

After adjustment for duration of T2D, CAT rs1001179 and GSTP1 rs1138272 showed strongest association with risk for end-stage kidney failure (p = 0.005 and p = 0.049, respectively). In patients without end-stage kidney failure CAT rs1001179 influenced urea levels (p = 0.003), while GSTP1 rs1695 and GSTP1 haplotypes influenced the risk of moderately increased albuminuria (p = 0.024 and p = 0.014, respectively).

CONCLUSION

Common CAT and GSTP1 polymorphisms could be used to identify T2D patients at an increased risk for developing end-stage kidney failure.

Haemodialysis-induced hypoglycaemia and glycaemic disarrays

In patients with diabetes receiving chronic haemodialysis, both very high and low glucose levels are associated with poor outcomes, including mortality. Conditions that are associated with an increased risk of hypoglycaemia in these patients include decreased gluconeogenesis in the remnant kidneys, deranged metabolic pathways, inadequate nutrition, decreased insulin clearance, glucose loss to the dialysate and diffusion of glucose into erythrocytes during haemodialysis. Haemodialysis-induced hypoglycaemia is common during treatments with glucose-free dialysate, which engenders a catabolic status similar to fasting; this state can also occur with 5.55 mmol/l glucose-containing dialysate. Haemodialysis-induced hypoglycaemia occurs more frequently in patients with diabetes than in those without. Insulin therapy and oral hypoglycaemic agents should, therefore, be used with caution in patients on dialysis. Several hours after completion of haemodialysis treatment a paradoxical rebound hyperglycaemia may occur via a similar mechanism as the Somogyi effect, together with insulin resistance. Appropriate glycaemic control tailored for patients on haemodialysis is needed to avoid haemodialysis-induced hypoglycaemia and other glycaemic disarrays. In this Review we summarize the pathophysiology and current management of glycaemic disarrays in patients on haemodialysis.

Dietary restrictions in dialysis patients: is there anything left to eat?

A significant number of dietary restrictions are imposed traditionally and uniformly on maintenance dialysis patients, whereas there is very little data to support their benefits. Recent studies indicate that dietary restrictions of phosphorus may lead to worse survival and poorer nutritional status. Restricting dietary potassium may deprive dialysis patients of heart-healthy diets and lead to intake of more atherogenic diets. There is little data about the survival benefits of dietary sodium restriction, and limiting fluid intake may inherently lead to lower protein and calorie consumption, when in fact dialysis patients often need higher protein intake to prevent and correct protein-energy wasting. Restricting dietary carbohydrates in diabetic dialysis patients may not be beneficial in those with burnt-out diabetes. Dietary fat including omega-3 fatty acids may be important caloric sources and should not be restricted. Data to justify other dietary restrictions related to calcium, vitamins, and trace elements are scarce and often contradictory. The restriction of eating during hemodialysis treatment is likely another incorrect practice that may worsen hemodialysis induced hypoglycemia and nutritional derangements. We suggest careful relaxation of most dietary restrictions and adoption of a more balanced and individualized approach, thereby easing some of these overzealous restrictions that have not been proven to offer major advantages to patients and their outcomes and which may in fact worsen patients' quality of life and satisfaction. This manuscript critically reviews the current paradigms and practices of recommended dietary regimens in dialysis patients including those related to dietary protein, carbohydrate, fat, phosphorus, potassium, sodium, and calcium, and discusses the feasibility and implications of adherence to ardent dietary restrictions and future research.

Diabetic kidney disease: a report from an ADA Consensus Conference

The incidence and prevalence of diabetes mellitus have grown significantly throughout the world, due primarily to the increase in type 2 diabetes. This overall increase in the number of people with diabetes has had a major impact on development of diabetic kidney disease (DKD), one of the most frequent complications of both types of diabetes. DKD is the leading cause of end-stage renal disease (ESRD), accounting for approximately 50% of cases in the developed world. Although incidence rates for ESRD attributable to DKD have recently stabilized, these rates continue to rise in high-risk groups such as middle-aged African Americans, Native Americans, and Hispanics. The costs of care for people with DKD are extraordinarily high. In the Medicare population alone, DKD-related expenditures among this mostly older group were nearly $25 billion in 2011. Due to the high human and societal costs, the Consensus Conference on Chronic Kidney Disease and Diabetes was convened by the American Diabetes Association in collaboration with the American Society of Nephrology and the National Kidney Foundation to appraise issues regarding patient management, highlighting current practices and new directions. Major topic areas in DKD included 1) identification and monitoring, 2) cardiovascular disease and management of dyslipidemia, 3) hypertension and use of renin-angiotensin-aldosterone system blockade and mineralocorticoid receptor blockade, 4) glycemia measurement, hypoglycemia, and drug therapies, 5) nutrition and general care in advanced-stage chronic kidney disease, 6) children and adolescents, and 7) multidisciplinary approaches and medical home models for health care delivery. This current state summary and research recommendations are designed to guide advances in care and the generation of new knowledge that will meaningfully improve life for people with DKD.

Anti-diabetes therapy: safety considerations for patients with impaired kidney function

The presence of type 2 diabetes mellitus (T2DM) is a common risk factor for the development of chronic kidney disease, but appropriate glycemic control can slow the progression of kidney dysfunction in patients with T2DM. The kidney plays a role in insulin resistance and gluconeogenesis, therefore, impaired kidney function alters glucose dynamics compared with normal kidney function, thus affecting antihyperglycemic treatment strategies. Glycemic management is further complicated by reduced drug clearance and a greater risk of hypoglycemia with use of certain medications, notably the sulfonylureas. Of the classes of antihyperglycemic drugs discussed in this review, caution is advised when using some classes in patients with T2DM and kidney disease.

Reducing the risk of hypoglycemia associated with intravenous insulin: experience with a computerized insulin infusion program in 4 adult intensive care units

Computerized insulin infusion protocols have facilitated more effective blood glucose (BG) control in intensive care units (ICUs). This is particularly important in light of the risks associated with hypoglycemia. End stage renal disease (ESRD) increases the risk of insulin-induced hypoglycemia. We evaluated BG control in 210 patients in 2 medical ICUs and in 2 surgical ICUs who were treated with a computerized insulin infusion program (CIIP). Our CIIP was programmed for a BG target of 140-180 mg/dL for medical ICU patients or 120-160 mg/dL for surgical ICU patients. In addition, we focused on BG control in the 11% of our patients with ESRD. Mean BG was 147 ± 20 mg/dL for surgical ICU patients and 171 ± 26 mg/dL for medical ICU patients. Of both surgical and medical ICU patients, 17% had 1 or more BG 60-79 mg/dL, while 3% of surgical ICU and 8% of medical ICU patients had 1 or more BG < 60 mg/dL. Mean BG in ESRD patients was 147 ± 16 mg/dL similar to 152 ± 23 mg/dL in patients without ESRD. Of ESRD patients, 41% had 1 or more BG < 79 mg/dL as compared with 17.8% of non-ESRD patients (P < .01). A higher BG target for medical ICU patients as compared with surgical ICU patients yielded comparably low rates of moderate or severe hypoglycemia. However, hypoglycemia among ESRD patients was more common compared to non-ESRD patients, suggesting a need for a higher BG target specific to ESRD patients.

Updates on the management of diabetes in dialysis patients

Diabetes mellitus is the leading cause of end-stage renal disease (ESRD) in the U.S. and many countries globally. The role of improved glycemic control in ameliorating the exceedingly high mortality risk of diabetic dialysis patients is unclear. The treatment of diabetes in ESRD patients is challenging, given changes in glucose homeostasis, the unclear accuracy of glycemic control metrics, and the altered pharmacokinetics of glucose-lowering drugs by kidney dysfunction, the uremic milieu, and dialysis therapy. Up to one-third of diabetic dialysis patients may experience spontaneous resolution of hyperglycemia with hemoglobin A1c (HbA1c) levels <6%, a phenomenon known as "Burnt-Out Diabetes," which remains with unclear biologic plausibility and undetermined clinical implications. Conventional methods of glycemic control assessment are confounded by the laboratory abnormalities and comorbidities associated with ESRD. Similar to more recent approaches in the general population, there is concern that glucose normalization may be harmful in ESRD patients. There is uncertainty surrounding the optimal glycemic target in this population, although recent epidemiologic data suggest that HbA1c ranges of 6% to 8%, as well as 7% to 9%, are associated with increased survival rates among diabetic dialysis patients. Lastly, many glucose-lowering drugs and their active metabolites are renally metabolized and excreted, and hence, require dose adjustment or avoidance in dialysis patients.

[Treatment of type 2 diabetes mellitus in patients with chronic kidney disease. Grupo de Trabajo para el Documento de Consenso sobre el tratamiento de la diabetes tipo 2 en el paciente con enfermedad renal crónica]

Chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM) are highly prevalent chronic diseases, which represent an important public health problem and require a multidisciplinary management. T2DM is the main cause of CKD and it also causes a significant comorbidity with regard to non-diabetic nephropathy. Patients with diabetes and kidney disease represent a special risk group as they have higher morbi-mortality as well as higher risk of hypoglycemia than diabetic individuals with a normal kidney function. Treatment of T2DM in patients with CKD is controversial because of the scarcity of available evidence. The current consensus report aims to ease the appropriate selection and dosage of antidiabetic treatments as well as the establishment of safety objectives of glycemic control in patients with CKD.

Using hemoglobin A1c to derive mean blood glucose in peritoneal dialysis patients

BACKGROUND

Although hemoglobin A1c (HbA1c) has been widely used as a clinical assessment tool for outcome analyses related to glycemic control, the relationship between HbA1c and average blood glucose (BG) specific to peritoneal dialysis (PD) patients with diabetes has not been characterized. We sought to develop HbA1c-BG equation models for PD patients.

METHODS

We examined associations between HbA1c and random serum BG values over time in a contemporary 5-year (2001-2006) cohort of DaVita PD patients with diabetes. We identified 850 patients (mean age: 58 ± 13 years, 56% male) with 4,566 paired measurements of HbA1c and BG. The bootstrapping method was used to estimate average BG and corresponding HbA1c.

RESULTS

Linear regression analyses yielded the following HbA1c-BG equations: (1) BG (mg/dl) = 24.1 + 28.6 × HbA1c - 12.2 × albumin [adjusted R(2) (R(2)adj = 0.454)], (2) BG = 55.3 + 28.8 × HbA1c - 10.2 × albumin - 3.3 × Hb (R(2)adj = 0.457), and (3) BG = 69.5 + 28.7 × HbA1c - 10.1 × albumin - 3.7 × Hb - 0.1 × age + race/ethnicity (-10.1 African Americans, -5.4 other race/ethnicities; R(2)adj = 0.457). All models showed greater explanatory power of BG variation than previously established HbA1c-BG equation models defined within non-PD cohorts [R(2)adj = 0.446 for both the Diabetes Control and Complications Trial (DCCT) and the A1c-Derived Average Glucose (ADAG) equations].

CONCLUSIONS

The association between HbA1c and BG in PD patients is different than that of patients with normal kidney function. Our analysis suggests that equations incorporating serum albumin and/or Hb values better estimate the HbA1c-BG relationship in PD patients compared to equations using HbA1c alone.

Management of hyperglycemia in hospitalized patients with renal insufficiency or steroid-induced diabetes

Pharmacologic doses of glucocorticoids and chronic renal failure are challenging comorbidities and complications for safe and effective dosing of insulin for the management of hospitalized patients with diabetes. Glucocorticoids are used widely in hospitalized patients and will commonly provoke new-onset hyperglycemia in patients without a prior history of diabetes or will provoke severely uncontrolled hyperglycemia in patients with known diabetes. Insulin therapy is invariably necessary for the treatment of glucocorticoid-induced hyperglycemia and must be tailored to the pharmacodynamics of the glucocorticoid being given. Renal failure causes a decrease in the clearance of insulin, especially exogenous injected insulin. Dosing algorithms for hospitalized patients should be adjusted for patients with renal failure in order to minimize hypoglycemia. Many patients with type 2 diabetes will need little or no therapy after the development of end-stage renal failure. Care must be taken to avoid the overtreatment of hyperglycemia.