Management of diabetes mellitus in dialysis patients: Obstacles and challenges

Selection of dialysis methods for end-stage kidney disease patients with diabetes

The increasing prevalence of diabetes has led to a growing population of end-stage kidney disease (ESKD) patients with diabetes. Currently, kidney transplantation is the best treatment option for ESKD patients; however, it is limited by the lack of donors. Therefore, dialysis has become the standard treatment for ESKD patients. However, the optimal dialysis method for diabetic ESKD patients remains controversial. ESKD patients with diabetes often present with complex conditions and numerous complications. Furthermore, these patients face a high risk of infection and technical failure, are more susceptible to malnutrition, have difficulty establishing vascular access, and experience more frequent blood sugar fluctuations than the general population. Therefore, this article reviews nine critical aspects: Survival rate, glucose metabolism disorder, infectious complications, cardiovascular events, residual renal function, quality of life, economic benefits, malnutrition, and volume load. This study aims to assist clinicians in selecting individualized treatment methods by comparing the advantages and disadvantages of hemodialysis and peritoneal dialysis, thereby improving patients’ quality of life and survival rates.

Incorporation of Chest Computed Tomography Quantification to Predict Outcomes for Patients on Hemodialysis with COVID-19

Introduction

Patients undergoing maintenance hemodialysis are vulnerable to coronavirus disease 2019 (COVID-19), exhibiting a high risk of hospitalization and mortality. Thus, early identification and intervention are important to prevent disease progression in these patients.

Methods

This was a two-center retrospective observational study of patients on hemodialysis diagnosed with COVID-19 at the Lingang and Xuhui campuses of Shanghai Sixth People's Hospital. Patients were randomized into the training (130) and validation cohorts (54), while 59 additional patients served as an independent external validation cohort. Artificial intelligence-based parameters of chest computed tomography (CT) were quantified, and a nomogram for patient outcomes at 14 and 28 days was created by screening quantitative CT measures, clinical data, and laboratory examination items, using univariate and multivariate Cox regression models.

Results

The median dialysis duration was 48 (interquartile range, 24-96) months. Age, diabetes mellitus, serum phosphorus level, lymphocyte count, and chest CT score were identified as independent prognostic indicators and included in the nomogram. The concordance index values were 0.865, 0.914, and 0.885 in the training, internal validation, and external validation cohorts, respectively. Calibration plots showed good agreement between the expected and actual outcomes.

Conclusion

This is the first study in which a reliable nomogram was developed to predict short-term outcomes and survival probabilities in patients with COVID-19 on hemodialysis. This model may be helpful to clinicians in treating COVID-19, managing serum phosphorus, and adjusting the dialysis strategies for these vulnerable patients to prevent disease progression in the context of COVID-19 and continuous emergence of novel viruses.

Chinese Healthcare Workers' Knowledge, Attitudes, and Practices in Diabetic Kidney Management: A Multi-Centered Cross-Sectional Study

Background

Given the importance of diabetic kidney disease (DKD) management, this study aims to explore the knowledge, attitudes, and practices in disease management demonstrated by healthcare workers from the nephrology department.

Materials and Methods

This study is a multi-centered cross-sectional study, and adopts snowball sampling, with 530 healthcare workers being recruited to complete a questionnaire covering areas such as demographic characteristics, knowledge, attitude, and practices (KAP) of DKD management. This data was analyzed using descriptive statistics and binary logistics analysis.

Results

In this study, 530 healthcare workers were studied, including 94 doctors and 436 nurses. The participants were mainly from general tertiary hospitals in 14 provinces. For Chinese nurse, the results indicate that both poor knowledge level (Odds Ratio (OR) =0.63, 95% Confidence Interval (CI): 0.42-0.94) and having experience in further medical training in nephrology (OR=1.92, 95% CI: 1.20-3.08) are associated with the practice levels. For Chinese doctors, having not experience in further medical training in nephrology (OR=0.36, 95% CI: 0.15-0.83) are associated with their practice levels.

Conclusion

In summary, Chinese doctors and nurses in this study showed positive attitudes towards DKD management, but their knowledge and practical skills were lacking. This underscores a notable gap in achieving optimal DKD care. Notably, nurses' knowledge influenced their management practices, and additional nephrology training correlated with better engagement. To improve patient care, enhancing nephrology healthcare professional training and addressing knowledge-practice disparities are recommended.

Supporting Type 1 and Type 2 Diabetes Care in the Hemodialysis Unit: A Quality-improvement Initiative Throughout the COVID-19 Pandemic

OBJECTIVE

People living with diabetes mellitus (DM) and chronic kidney disease can have difficulty attending multiple appointments to receive DM care. We developed and studied the utility of a DM outreach program to offer in the hemodialysis (HD) unit.

METHODS

We conducted a quality improvement project in a satellite HD unit in London, Ontario, Canada, between August 1, 2019, and July 31, 2022. We assessed for baseline gaps in DM care among those with DM, performed root-cause analysis with key stakeholders to identify critical drivers of gaps, and conceptualized a certified diabetes educator-led outreach program to offer in the HD unit. We aimed to improve DM self-monitoring, hypo- and hyperglycemia, and DM-related screening. We used run and control charts to track outcome measures over time and modified our outreach program iteratively.

RESULTS

Fifty-eight persons with DM receiving HD participated in our program. Support spanned multiple waves of the COVID-19 pandemic. With 4 tests of change, we observed improvement in DM self-monitoring with a modest decline in self-reported hyperglycemia. There were no adverse consequences, and satisfaction with our program was high.

CONCLUSIONS

Although we did not meet all measures of success during the pandemic, outreach DM support in the HD unit appeared to improve self-monitoring and self-reported hyperglycemia. Similar programs could be modified and implemented in other centres.

Peritoneal Dialysis Care for People with Diabetes, Polycystic Kidney Disease, or Advanced Liver Disease

People treated with peritoneal dialysis (PD) often have complicating conditions that require careful management. Three such conditions are reviewed in this article-diabetes mellitus, polycystic kidney disease, and chronic liver disease. Each of these conditions requires an understanding of both its effect on the delivery of the PD and the effect of the PD on the condition itself. In diabetes, glucose absorption from the dialysate complicates metabolic control and affects salt and water management and patient outcome. There is particular benefit in clinical care being delivered through a multidisciplinary team that involves both kidney and diabetes experts. In relation to polycystic kidney disease, a key issue is the potential for increased intraperitoneal pressure due to the combined effect of the enlarged polycystic organs and the presence of the dialysis solution, and therefore, the PD prescription requires to be managed with a particular focus on limiting that pressure. For patients with liver disease, key issues include nutritional support because PD can add to protein losses already consequent on the liver disease itself. Considered approaches are required to manage ascites and reduce infection risk and the potential for hernias and leaks to develop. Mortality in this group is unfortunately high-however, PD may present a better management option than hemodialysis in many patients-particularly in those where the liver disease is complicated by low BP, clotting abnormalities, or troublesome ascites. Overall, the choice to use PD in patients with these complicating conditions should be based on shared decision making with the patient and their family members informed by high-quality information in which risks, benefits, and management strategies are clearly presented.

Comorbidity Patterns and Management in Inpatients with Endocrine Diseases by Age Groups in South Korea: Nationwide Data

This study aimed to examine comorbidity associations across age groups of inpatients with endocrine diseases as the primary diagnosis throughout the life cycle to develop an effective management strategy. Data were obtained from the Korean National Hospital Discharge In-depth Injury Survey (KNHDS) from 2006 to 2021, involving 68,515 discharged patients aged ≥ 19 years with a principal diagnosis of endocrine disease. A database was constructed for analysis, extracting general characteristics and comorbidities. Employing R version 4.2.3, the Chi-squared test and the Apriori algorithm of ARM (association rule mining) were used for analyzing general characteristics and comorbidity associations. There were more women (53.1%) than men (46.9%) (p < 0.001, with women (61.2 ± 17.2) having a higher average age than men (58.6 ± 58.6) (p < 0.001). Common comorbidities include unspecified diabetes mellitus; essential (primary) hypertension; unspecified diabetes mellitus; and other disorders of fluid, electrolyte, and acid-base balance. Notably, type 2 diabetes mellitus, disorders of lipoprotein metabolism and other lipidemia, polyneuropathy in diseases classified elsewhere, retinal disorders in diseases classified elsewhere, and essential (primary) hypertension prevail across all age groups. Association rules further highlight specific comorbidities appearing selectively in certain age groups. In conclusion, establishing a management strategy for comorbidities in patients with a primary diagnosis of an endocrine disorder is necessary.

Low Blood Glucose Index Associated with Cardiovascular Events in Diabetic Hemodialysis Patients

INTRODUCTION

Blood glucose monitoring was vitally important in diabetic kidney disease (DKD) patients for preventing complications and improving survival rates. The associations between glycemic variability and blood biochemical indicators were underestimated in patients with DKD undergoing hemodialysis. Therefore, we primarily aimed to investigate the glycemic variability and 1-year risk of cardiovascular disease events in diabetic hemodialysis patients. And we secondarily aimed to explore the association between glycemic variability and blood biochemical indicators.

METHODS

In total, 27 patients were included in the final analysis. Continuous glucose monitoring (CGM) was used to evaluate glucose variability for 14 days. Patients were divided into two groups by the cutoff level of time in range (TIR; >70% or ≤70%). The three-point major adverse cardiovascular event (3P MACE) was recorded within 1 year.

RESULTS

After 1 year of follow-up, 4 patients in the high-TIR group and 3 patients in the low-TIR group had 3p MACE. Higher low blood glucose index (LBGI) level in diabetic hemodialysis patients increased the risk of 3p MACE outcomes (HR = 2.37, p = 0.018). And the level of albumin was positively associated with LBGI (β = 0.51, p = 0.036). The plasma levels of albumin, glycosylated hemoglobin, and hemoglobin were positively associated with other CGM parameters.

CONCLUSION

LBGI during 14 days was positively associated with the risk of cardiovascular events in diabetic hemodialysis patients.