Diabetic kidney disease in elderly individuals

Temporal and regional trends in adults with diabetics kidney disease in the US from 1999 to 2020

AIMS

We aim to analyze trends in mortality rates among adults with diabetic kidney disease (DKD) in the US from 1999 to 2020.

METHODS

We queried the Centers for Disease Control Wide-Ranging Online Data for Epidemiologic Research database for mortality statistics from 1999 to 2020 associated with DKD in adults aged ≥25 years. Age-adjusted mortality rates (AAMRs) were calculated and trends were analyzed using the Joinpoint Regression Program.

RESULTS

From 1999 to 2020, a total of 528,430 deaths were reported among adults with DKD. The mortality rates increased over time with males consistently exhibiting higher AAMR than females. NH American Indian or Alaska Native individuals had the highest AAMR, followed by NH Blacks, Hispanics, NH Whites, and NH Asians. The West region had the highest AAMR, followed by the Midwest, South, and Northeast. Rural regions had higher AAMR than urban areas, and mortality rates increased with age.

CONCLUSIONS

This study reveals notable disparities in DKD mortality rates across demographic groups and geographic regions. NH American Indians or Alaska Natives, males, elderly individuals, rural residents, and those in the West region were disproportionately affected. Understanding these trends is crucial for developing targeted interventions to reduce DKD-related mortality and address healthcare disparities.

Age-related markers and predictors of diabetic kidney disease progression in type 2 diabetes patients: a retrospective cohort study

Background

Diabetic kidney disease (DKD) is characterized by reduced estimated glomerular filtration rate (eGFR) and albuminuria, which play a pivotal role in both diagnosing and determining the disease's progression. This study aimed to assess the trajectory of these markers concerning age in individuals with DKD and identify predictive factors for the decline in eGFR decline, variation in albuminuria, mortality, and progression to renal replacement therapy (RRT).

Design

This retrospective cohort encompassed patients with type 2 diabetes (T2D), divided into two age categories: <75 and ⩾75 years old.

Methods

Over a 3-year span, the study evaluated eGFR (CKD-EPI) and 24-h albuminuria. Univariate and multivariate analyses were employed to pinpoint factors associated with deteriorating renal function and mortality. Significance was set at p < 0.05, and Kaplan-Meier survival curves were constructed to illustrate renal and overall survival.

Results

The analysis comprised 304 patients. Comparable eGFR declines were evident in both age groups during the transition from the first to the second year and from the second to the third year. Nonetheless, a more pronounced rise in albuminuria was evident in the ⩾75 years group during the first to the second year. Multivariate analysis unveiled that systolic blood pressure (SBP) measurements in the first year positively forecasted eGFR decline. Age was associated with heightened albuminuria and mortality, while hospitalizations linked to cardiovascular causes robustly predicted mortality. Hospitalizations due to sepsis and cardiovascular reasons, coupled with first-year SBP measurements, served as predictive indicators for progression to RRT.

Conclusion

Both age groups experienced similar declines in eGFR, though the ⩾75 years group displayed a more significant increase in albuminuria during the first to the second year. Age, hospitalizations, and higher blood pressure levels were correlated with exacerbated renal function deterioration and/or elevated mortality in DKD. Timely intervention and tailored management strategies stand as critical components for enhancing outcomes among DKD patients.

Characteristics of elderly diabetes patients: focus on clinical manifestation, pathogenic mechanism, and the role of traditional Chinese medicine

Diabetes mellitus has become a major public health issue globally, putting an enormous burden on global health systems and people. Among all diseased groups, a considerable part of patients are elderly, while their clinical features, pathogenic processes, and medication regimens are different from patients of other ages. Despite the availability of multiple therapies and techniques, there are still numerous elderly diabetes patients suffering from poor blood glucose control, severe complications, and drug adverse effects, which negatively affect the quality of life in their golden years. Traditional Chinese Medicine (TCM) has been widely used in the treatment of diabetes for several decades, and its relevant clinical practice has confirmed that it has a satisfactory effect on alleviating clinical symptoms and mitigating the progression of complications. Chinese herbal medicine and its active components were used widely with obvious clinical advantages by multiple targets and signaling pathways. However, due to the particular features of elderly diabetes, few studies were conducted to explore Traditional Chinese Medicine intervention on elderly diabetic patients. This study reviews the research on clinical features, pathogenic processes, treatment principles, and TCM treatments, hoping to provide fresh perspectives on the prevention and management strategies for elderly diabetes.

Chronic Kidney Disease in the Older Adult Patient with Diabetes

Diabetes mellitus (DM) and chronic kidney disease (CKD) are common in middle aged and older adult individuals. DM may accelerate the aging process, and the age-related declines in the estimated glomerular filtration rate (eGFR) can pose a challenge to diagnosing diabetic kidney disease (DKD) using standard diagnostic criteria especially with the absence of severe albuminuria among older adults. In the presence of CKD and DM, older adult patients may need multidisciplinary care due to susceptibility to various health issues, e.g., cognitive decline, auditory or visual impairment, various comorbidities, complex medical regimens, and increased sensitivity to medication adverse effects. As a result, it can be challenging to apply recent therapeutic advancements for the general population to older adults. We review the evidence that the benefits from these newer therapies apply equally to older and younger patients with CKD and diabetes type 2 and propose a comprehensive management. This framework will address nonpharmacological measures and pharmacological management with renin angiotensin system inhibitors (RASi), sodium glucose co-transporter 2 inhibitors (SGLT2i), non-steroidal mineralocorticoids receptor antagonists (MRAs), and glucagon like peptide 1 receptor agonists (GLP1-RAs).

Multifactorial Diseases of the Heart, Kidneys, Lungs, and Liver and Incident Cancer: Epidemiology and Shared Mechanisms

Within the aging population, the frequency of cancer is increasing dramatically. In addition, multiple genetic and environmental factors lead to common multifactorial diseases, including cardiovascular disease, chronic kidney disease, chronic obstructive pulmonary disease, and metabolic-associated fatty liver disease. In recent years, there has been a growing awareness of the connection between cancer and multifactorial diseases, as well as how one can affect the other, resulting in a vicious cycle. Although the exact mechanistic explanations behind this remain to be fully explored, some progress has been made in uncovering the common pathologic mechanisms. In this review, we focus on the nature of the link between cancer and common multifactorial conditions, as well as specific shared mechanisms, some of which may represent either preventive or therapeutic targets. Rather than organ-specific interactions, we herein focus on the shared mechanisms among the multifactorial diseases, which may explain the increased cancer risk. More research on this subject will highlight the significance of developing new drugs that target multiple systems rather than just one disease.

The Biological Roles of Urea: A Review of Preclinical Studies

Urea is an organic compound that has been reported to be effective against many pathological conditions. However, many other studies have reported the toxic effects of urea. These controversies on the biological roles of urea remain unresolved. This review aims to evaluate the biological roles of urea in experimental animals from data published in peer-reviewed journals. A PubMed search was conducted using the phrase, "urea application in experimental animals." A total of 13 publications that met the inclusion criteria were evaluated. The test substance, animal model, number of animals, doses, duration of treatment, and effects were recorded. Regarding the toxic effect, urea caused decreased excretion of other nitrogenous compounds, increased oxidative stress, decreased insulin, and impairment of beta-cell glycolysis. Furthermore, it caused endothelial dysfunction, loss of synapsis, and decreased olfaction. Regarding the therapeutic effects, urea caused increased growth, increased digestion, and decreased hepatic dysfunction. It also induced apoptosis of tumor cells and exerted neuroprotective properties. Products containing urea should be used with caution, especially in individuals with symptoms of chronic kidney disease. However, more studies are needed to elucidate the mechanisms of its therapeutic effects.

Circ_0068087 Promotes High Glucose-Induced Human Renal Tubular Cell Injury through Regulating miR-106a-5p/ROCK2 Pathway

<b><i>Background:</i></b> Many studies have confirmed that circular RNA (circRNA) is an important target for regulating human disease progression. This study aimed to explore the role of circ_0068087 in diabetic nephropathy (DN) progression. <b><i>Methods:</i></b> High glucose (HG)-induced renal tubular cells (HK2) were used to mimic DN cell models in vitro. The expression levels of circ_0068087, microRNA (miR)-106a-5p, and Rho-associated coiled-coil-containing kinase 2 (ROCK2) were detected by quantitative real-time PCR. Cell proliferation and apoptosis were examined by cell counting kit-8 assay, 5-ethynyl-2′-deoxyuridine assay, colony formation assay, and flow cytometry. The protein levels were examined by Western blot analysis. Cell oxidative stress was assessed by measuring MDA level and SOD activity, and cell inflammation was evaluated by detecting the concentrations of inflammatory factors. RNA interaction was verified by dual-luciferase reporter assay and RNA pull-down assay. <b><i>Results:</i></b> The present study showed that circ_0068087 was highly expressed in the serum of DN patients and HG-induced HK2 cells. Interference of circ_0068087 alleviated HG-induced apoptosis, oxidative stress, inflammation, and fibrosis in HK2 cells, while accelerated cell proliferation. miR-106a-5p could be sponged by circ_0068087, and its inhibitor eliminated the regulation of circ_0068087 knockdown on HG-induced HK2 cell injury. ROCK2 was a target of miR-106a-5p, and its expression was suppressed by circ_0068087 knockdown. miR-106a-5p overexpression suppressed HG-induced HK2 cell injury, and this effect was reversed by ROCK2 upregulation. <b><i>Conclusion:</i></b> Our data indicated that circ_0068087 downregulation mitigated HG-induced HK2 cell injury through the miR-106a-5p/ROCK2 axis, providing a potential circRNA-targeted therapy for DN.

Chronic kidney disease (CKD) -a brand ambassador/alarming bell for potentially inappropriate medication in elderly inpatients

BACKGROUND

In the past decade, the prevalence of Potentially Inappropriate Medication (PIM) among elderly inpatients has increased drastically. However, limited data is available on PIM indicators, and PIMs use among the elderly in patients with Chronic Kidney Disease (CKD).

OBJECTIVE

To determine the prevalence of PIMs in elderly hospitalized patients with CKD.

METHODS

A cross-sectional study was carried out on 102 patients in a tertiary care hospital. PIMs were identified using Beers criteria 2019. A Chi-square test was used to determine the association between variables and PIMs use.

RESULTS

PIMs, as assessed according to AGS updated Beers criteria 2019 was found to be in more than 68.6% of patients of median age 65years and 3 number of diagnoses and seven days median length of stay. Most of the patients (47.1%) had ≥four diagnoses. The most common comorbidities in the patient were diabetes mellitus (n=54) and hypertension (n=55). Most of the subjects (66.7%) were on polypharmacy (5-9 medications/day), and 25.5% were on a higher level of polypharmacy (>10 medicines/day). Approximately 90% of the patients had very low CrCl < 21ml/min (calculated with the help of Cockcroft- Gault formula). A significant association between PIM use and an increased number of diagnoses, polypharmacy or high-level polypharmacy, was observed.

CONCLUSION

The prevalence of PIMs in elderly inpatients suffering from CKD is relatively high. The study indicates negligence/ lack of awareness amongst physicians leading to increase PIM use. The authors propose that the CKD patients should attract the special attention of the physician and should be treated as brand ambassadors or alarming bells for PIM use.

Chronic Kidney Disease After Partial Nephrectomy in Patients With Preoperative Inconspicuous Renal Function - Curiosity or Relevant Issue?

BACKGROUND

Chronic kidney disease (CKD) is a severe long-term complication after partial nephrectomy (PN). Clinical and scientific focus lies on patients with impaired renal function at the time of surgery. Little data is available on patients with normal preoperative renal function (NPRF).

PATIENTS AND METHODS

Patients who underwent PN with a preoperative estimated glomular filtration rate > 60 mL/min/1.73m² were retrospectively examined at 8 European urologic centers. The occurrence of new onset CKD ≥ stage III after surgery (sCKD) was defined as the primary endpoint. Group comparisons and risk correlations were determined. Based on this data, a risk stratification model for sCKD was developed.

RESULTS

Of the 1315 patients with NPRF included, 249 (18.9%) developed sCKD after a median follow-up of 44 months (range, 6-255 months). Pair analysis and univariable regression revealed age, arterial hypertension, American Society of Anesthesiologists score, tumor stage, surgical approach, intraoperative blood loss, perioperative blood transfusions and preoperative CKD stage as predictors for sCKD development. Multivariate analysis confirmed perioperative blood transfusion (hazard ratio [HR], 2.96; P ≤ .0001), age (≥ 55 years; HR, 2.60; P = .0002), tumor stage (> pT1; HR, 2.15; P = .025), and preoperative CKD stage (stage II vs. I; HR, 3.85; P ≤ .0001) as independent risk factors. A model that stratified patient risk for new onset CKD was highly significant (P < .0001).

CONCLUSION

Every fifth patient with NPRF developed sCKD following PN. Elderly patients with higher tumor stage and who require blood transfusion appear to be at increased risk. Based on our risk stratification, patients with ≥ 2 risk factors are candidates for an early, nephrologic follow-up.

[Kidney disease care for the elderly]

In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care.

Diabetes Management in Older Adults With Chronic Kidney Disease

PURPOSE OF REVIEW

Older adults often live with chronic disease including diabetes and its complications. In this review, we examine the complexity and heterogeneity of older adults with diabetes and chronic kidney disease, explore the nuances in their diabetes-related monitoring, and discuss their best diabetes management.

RECENT FINDINGS

Although there remains an overall lack of studies in older adults with diabetes and chronic kidney disease, recent reports have highlighted their vulnerabilities. These individuals face an increased risk of cognitive impairment and dementia, frailty, dysglycemia, polypharmacy, declining kidney function, and acute kidney injury. Their diabetes management should focus upon safer antihyperglycemic medications, close monitoring, and care individualization. Older adults with diabetes and chronic kidney disease are a complex population who requires careful diabetes management and monitoring. Research efforts might focus on improving the care and outcomes of these patients.

Prevalence of chronic kidney disease using estimated glomerular filtration rate among diabetes patients attending a tertiary clinic in Botswana

OBJECTIVES

Diabetes mellitus (DM) is one of the most common contributors of chronic kidney disease (CKD). The epidemiology of CKD, a concern among patients with DM, has not been studied in Botswana. Consequently, the objective of this study was to estimate its prevalence among these patients in Botswana to provide future guidance to both government personnel and physicians.

METHODS

Observational cross-sectional study in a leading clinic in Botswana. Demographic and clinical data were obtained from patients through interviews and from their notes using a standard questionnaire. The study was conducted from July to October 2015. The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet for Renal Disease equation. CKD was defined as an eGFR < 60 ml/min/1.73 m². Multivariable logistic regression analyses were performed to assess the associations between CKD and potential factors.

RESULTS

The mean age and duration of DM among study participants were 54.67 years (range 21-92 years) and 5.0 years, respectively. Over half, i.e. 213/370 (57.6%) and 232/370 (62.7%), had an average blood pressure greater than 140/90 mmHg and poor glycemic control (HbA1c > 7%), respectively. 31/370 patients (8.4%) had CKD. However, only 18/370 (4.9%) had a diagnosis of CKD documented in their charts. Age, level of education, and duration of diabetes were independently associated with CKD.

CONCLUSION

The prevalence of CKD by estimated eGFR was low compared to most previous studies. However, half of patients with CKD are not documented resulting in the potential for prescription errors and drug toxicity. A substantial number of our patients had uncontrolled hypertension and poor glycemic control. Older age, low level of education and longer duration of DM were associated with CKD. There is a need to carry out prospective studies to determine the association and role of glycemic and blood pressure control in CKD causation among patients with DM in Botswana.

Dialysis in the Elderly and Impact of Institutionalization in the United States Renal Data System

BACKGROUND

We hypothesized that in the very elderly dialysis patients in the United States, institutionalization in nursing homes would increase mortality in addition to age alone.

METHODS

Incident dialysis patients from 2001 to 2008 above the age of 70 were included. Patients above 70 were categorized into 4 groups according to age as 70-75, 76-80, 81-85, and >85 years and further divided into institutionalized and noninstitutionalized. Kaplan-Meier survival curves were plotted to assess patient survival.

RESULTS

A total of 349,440 patients were identified above the age of 70 at the time of initiation of dialysis. For institutionalized patients, the mean survival was significantly lower, 1.71 ± 0.03 years for those in the age range 70-75, 1.44 ± 0.02 years for those in the age range 76-80, 1.25 ± 0.02 years for those in the age range 81-85, and 1.04 ± 0.02 for those in the >85 years age group (p = 0.0001). The hazard ratio for mortality in institutionalized elderly patients on dialysis was 1.80 ([95% CI 1.77-1.83]; p = 0.0001). After adjustment for other variables (multivariate Cox regression), to be institutionalized was still an independent risk factor for mortality (adjusted hazard ratio = 1.57 [95% CI 1.54-1.60]; p = 0.0001).

CONCLUSION

There was increased mortality in institutionalized elderly patients as compared to noninstutionalized elderly patients in the same age group. In accordance with the increased frailty and decreased benefits of therapies in the very elderly, especially in those with additional co-morbidities besides age, palliative and end-of-life care should be considered.

Considerations on glycaemic control in older and/or frail individuals with diabetes and advanced kidney disease

The increasing prevalence of chronic kidney disease (CKD) and diabetes over the last decade has resulted in increasing numbers of frail older patients with a combination of these conditions. Current treatment guidelines may not necessarily be relevant for such patients, who are mostly excluded from the trials upon which these recommendations are based. There is a paucity of data upon which to base the management of older patients with CKD. Nearly all current guidelines recommend less-tight glycaemic control for the older population, citing the lack of proven medium-term benefits and concerns about the high short-term risk of hypoglycaemia. However, reports from large landmark trials have shown potential benefits for both microvascular and macrovascular complications, though the relevance of these findings to this specific population is uncertain. The trials have also highlighted potential alternative explanations for the hazards of intensive glycaemic control. These include depression, low endogenous insulin reserve, low body mass index and side effects of the medication. Over the last few years, newer classes of hypoglycaemic drugs with a lower risk of hypoglycaemia have emerged. This article aims to present a balanced view of advantages and disadvantages of intense glycaemic control in this group of patients, which we hope will help the clinician and patient to come to an individualized management approach.

Understanding CKD among patients with T2DM: prevalence, temporal trends, and treatment patterns-NHANES 2007-2012

OBJECTIVE

To describe the estimated prevalence and temporal trends of chronic kidney disease (CKD) treatment patterns, and the association between CKD and potential factors for type 2 diabetes mellitus (T2DM) in different demographic subgroups.

RESEARCH DESIGN AND METHODS

This was a cross-sectional analysis of adults with T2DM based on multiple US National Health and Nutrition Examination Survey (NHANES) datasets developed during 2007-2012. CKD severity was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 guidelines using the CKD Epidemiology Collaboration (CKD-EPI) equation: mild to moderate=stages 1-3a; moderate to kidney failure=stages 3b-5. Multivariable logistic regression analyses were performed to assess the associations between CKD and potential factors.

RESULTS

Of the adult individuals with T2DM (n=2006), age-adjusted CKD prevalence was 38.3% during 2007-2012; 77.5% were mild-to-moderate CKD. The overall age-adjusted prevalence of CKD was 40.2% in 2007-2008, 36.9% in 2009-2010, and 37.6% in 2011-2012. The prevalence of CKD in T2DM was 58.7% in patients aged ≥65 years, 25.7% in patients aged <65 years, 43.5% in African-Americans and Mexican-Americans, and 38.7% in non-Hispanic whites. The use of antidiabetes and antihypertensive medications generally followed treatment guideline recommendations. Older age, higher hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and having hypertension were significantly associated with CKD presence but not increasing severity of CKD.

CONCLUSIONS

CKD continued to be prevalent in the T2DM population; prevalence remained fairly consistent over time, suggesting that current efforts to prevent CKD could be improved overall, especially by monitoring certain populations more closely.

Differences in clinical and biological characteristics and prevalence of chronic complications related to aging in patients with type 2 diabetes

Type 2 diabetes mellitus (T2DM) is a chronic, highly prevalent disease that increases with age. Because of this, and due to its chronic complications, T2DM causes high human, social, and financial costs. In addition, the elderly population with T2DM has a marked clinical heterogeneity. Therefore, our main objective was to analyze the relationship of age with the clinical and biological manifestations of the disease and the prevalence of chronic complications in patients with T2DM.

MATERIAL AND METHODS

A cross-sectional study of a large population with T2DM (n=405) randomly selected from a Diabetes Unit and 2 health care centers (60%). The clinical, anthropometric, and biochemical variables of the subjects were collected using standard methods to assess the effect of age on the clinical and biochemical phenotype of patients with T2DM.

RESULTS

We have noted that patients with T2DM > 70 years old have a clinical and biochemical phenotype different from younger subjects (<60 years) including longer times since diabetes onset, higher diastolic blood pressure levels, and lower body mass index (BMI) values. As regards to biological variables, these patients have lower triglyceride levels, impaired kidney function, and lower HbA1c values. Prevalence of metabolic syndrome is lower in patients with T2DM > 70 years of age. Age was inversely related to parameters associated to metabolic syndrome (BMI, waist circumference, blood pressure, and triglyceride levels).

CONCLUSIONS

We have defined the clinical and biochemical profile of patients with T2DM > 70 years attending health care centers. In addition, the prevalence of stroke, kidney disease, and distal symmetrical polyneuropathy is higher in patients with T2DM >70 years as compared to younger patients (<60 years).

Serum phosphate as an additional marker for initiating hemodialysis in patients with advanced chronic kidney disease

BACKGROUND

Reconsidering when to initiate renal replacement therapy (RRT) in patients with chronic kidney disease (CKD) has been emphasized recently. With evolving modern aged and diabetes-prone populations, conventional markers of uremia are not sufficient for determining the optimal timing for dialysis initiation. This retrospective cohort study examined the association between hyperphosphatemia and uremic patients who need RRT registration.

METHODS

All patients from the department of nephrology in one tertiary medical center in northern Taiwan who had advanced CKD and estimated glomerular filtration rates <8 mL/min/1.73 m(2) from July 2009 to May 2013 were enrolled. We reviewed the medical records and collected data on demographics, comorbidities, underlying diseases, duration of nephrology care, use of phosphate binders, and laboratory results. Univariable and multivariable logistic regression models were used to identify factors associated with hemodialysis initiation decision making.

RESULTS

During the study period, 209 of 292 patients with advanced CKD were enrolled in hemodialysis program and 83 patients (controls) were not. Univariable analysis indicated that male sex, current smoking, diabetes mellitus, hypertension, coronary artery disease, high serum creatinine level, and high serum phosphate level were associated with initiation of hemodialysis. Multivariable analysis indicated that those with higher serum phosphate level (odds ratio [OR] = 2.4, 95% confidence interval [CI] = 1.6-3.5, p = 1.4 × 10(-5)) and being in nephrology care for <12 months (OR = 0.4, 95% CI = 0.2-0.8, p = 0.016) tended to be significant markers for hemodialysis initiation.

CONCLUSION

Hyperphosphatemia, in addition to conventional laboratory markers and uremic symptoms, may be a useful marker to determine timing of hemodialysis initiation in patients with advanced CKD.

Update on blood pressure control and renal outcomes in diabetes mellitus

Diabetic nephropathy (DN) is associated with a high incidence of cardiovascular (CV) morbidity and mortality. Although relationships between hypertension and diabetic nephropathy are complex, blood pressure (BP) control is an important management strategy in the prevention of onset and progression of DN in patients with diabetes mellitus (DM). Recent guidelines recommend less stringent BP targets among patients with type 2 DM and chronic kidney disease. These recommendations are based mostly on lack of benefit in CV outcomes with a low BP target. We review the current information on efficacy of BP control in improving renal outcomes in patients with type 2 DM. Presently, although intensive BP control has been was beneficial in decreasing albuminuria, it has not translated into reductions in risks of hard renal endpoints, such as progression to end-stage renal disease, the need for renal replacement therapy, and mortality from renal causes.

[Significance of hemoglobin A1C in the management of diabetes in dialysis patients]

According to latest guidelines hemoglobin A1C plays a central role in the diagnosis of diabetes mellitus. It is well-known from epidemiologic studies that a high rate of diabetic patients enters into dialysis programs and these patients have an unfavourable mortality outcome. Based on surveys conducted in recent years in this patient group, hemoglobin A1C has an important role in assessing carbohydrate metabolism. However, there are several factors independent of blood glucose may affect hemoglobin A1C values both in hemodialysis and peritoneal dialysis patients. Hemodialysis disturbs hemoglobin A1c assessment because of an accelerated turnover of lost red blood cells. During peritoneal dialysis a considerable amount of glucose may be absorbed from the peritoneal solutions that may influence hemoglobin A1C level. Several alternative markers such as glycated albumin and fructosamine have been evaluated but they failed to have prognostic advantage. It has been concluded that among dialysis patients the hemoglobin A1C range between 6.5 and 8% is associated with the lowest mortality risk.

Chronic kidney disease in the elderly: evaluation and management

Chronic kidney disease (CKD) is a very common clinical problem in elderly patients and is associated with increased morbidity and mortality. As life expectancy continues to improve worldwide, there is a rising prevalence of comorbidities and risk factors such as hypertension and diabetes predisposing to a high burden of CKD in this population. The body of knowledge on the approach to elderly patient with CKD is still evolving. Thus, this review seeks to explore the epidemiology and to discuss current understanding of challenges in the diagnosis and management of elderly patients CKD.

The impact of blood pressure on kidney function in the elderly: a cross-sectional study

BACKGROUND/AIMS

Intensive blood pressure (BP) target decreases blood perfusion of kidneys that attenuates the benefits of BP treatment in elderly hypertensive individuals. The optimal BP goal for renal function in the hypertensive elderly has been unclear. We investigated the impact of BP on renal function to define the appropriate BP target in the elderly.

METHODS

A total of 28,258 elderly subjects were categorized into normotensive (Norm), hypotensive (Hypo) and hypertensive (Hyper) groups according to BP levels. Systolic, diastolic and pulse BP (SBP, DBP and PBP) were further stratified by 10 mmHg. Blood urea nitrogen, serum creatinine, uric acid, glomerular filtration rate (GFR), renal insufficiency prevalence (RIP) and proteinuria prevalence (PP) were compared among different groups and BP strata. The RIP and PP in the elderly with obesity, hyperlipidemia or diabetes in Norm, Hypo and Hyper groups were evaluated.

RESULTS

GFR in Hypo and Hyper groups was significantly lower than that in Norm group. The RIP and PP was higher in Hypo and Hyper groups than that in the Norm group. Proteinuria became more prevalent when SBP was >140 mmHg or <90 mmHg. DBP>80 mmHg increased PP while DBP<70 mmHg increased RIP. PBP>60 mmHg led to an increased RIP and PP. Obesity or hyperlipidemia only combined with hypertension caused a significantly increased RIP and PP. Diabetes independent of hypertension contributed to higher RIP and PP.

CONCLUSIONS

The most beneficial BP target for kidney function in the elderly may be SBP of 90-140 mmHg and DBP of 70-80 mmHg. PBP <60 mmHg may be appropriate.

Current and emerging treatment options for the elderly patient with chronic kidney disease

The objective of this article is to review the current and emerging treatments of CKD prior to dialysis in the elderly. Worldwide, there are increasing numbers of people who are aged over 65 years. In parallel, there are increasing numbers of elderly patients presenting with chronic kidney disease (CKD), particularly in the more advanced stages. The elderly have quite different health care needs related to their associated comorbidity, frailty, social isolation, poor functional status, and cognitive decline. Clinical trials assessing treatments for CKD have usually excluded patients older than 70–75 years; therefore, it is difficult to translate current therapies recommended for younger patients with CKD across to the elderly. Many elderly people with CKD progress to end-stage kidney disease and face the dilemma of whether to undertake dialysis or accept a conservative approach supported by palliative care. This places pressure on the patient, their family, and on health care resources. The clinical trajectory of elderly CKD patients has in the past been unclear, but recent evidence suggests that many patients over 75 years of age with multiple comorbidities have greatly reduced life expectancies and quality of life, even if they choose dialysis treatment. Offering a conservative pathway supported by palliative care is a reasonable option for some patients under these circumstances. The elderly person who chooses to have dialysis will frequently have different requirements than younger patients. Kidney transplantation can still result in improved life expectancy and quality of life in the elderly, in carefully selected people. There is a genuine need for the inclusion of the elderly in CKD clinical trials in the future so we can produce evidence-based therapies for this group. In addition, new therapies to treat and slow CKD progression are needed for all age groups.

Type 1 diabetes, diabetic nephropathy, and pregnancy: a systematic review and meta-study

BACKGROUND

In the last decade, significant improvements have been achieved in maternal-fetal and diabetic care which make pregnancy possible in an increasing number of type 1 diabetic women with end-organ damage. Optimal counseling is important to make the advancements available to the relevant patients and to ensure the safety of mother and child. A systematic review will help to provide a survey of the available methods and to promote optimal counseling.

OBJECTIVES

To review the literature on diabetic nephropathy and pregnancy in type 1 diabetes.

METHODS

Medline, Embase, and the Cochrane Library were scanned in November 2012 (MESH, Emtree, and free terms on pregnancy and diabetic nephropathy). Studies were selected that report on pregnancy outcomes in type 1 diabetic patients with diabetic nephropathy in 1980-2012 (i.e. since the detection of microalbuminuria). Case reports with less than 5 cases and reports on kidney grafts were excluded. Paper selection and data extraction were performed in duplicate and matched for consistency. As the relevant reports were highly heterogeneous, we decided to perform a narrative review, with discussions oriented towards the period of publication.

RESULTS

Of the 1058 references considered, 34 fulfilled the selection criteria, and one was added from reference lists. The number of cases considered in the reports, which generally involved single-center studies, ranged from 5 to 311. The following issues were significant: (i) the evidence is scattered over many reports of differing format and involving small series (only 2 included over 100 patients), (ii) definitions are non-homogeneous, (iii) risks for pregnancy-related adverse events are increased (preterm delivery, caesarean section, perinatal death, and stillbirth) and do not substantially change over time, except for stillbirth (from over 10% to about 5%), (iv) the increase in risks with nephropathy progression needs confirmation in large homogeneous series, (v) the newly reported increase in malformations in diabetic nephropathy underlines the need for further studies.

CONCLUSIONS

The heterogeneous evidence from studies on diabetic nephropathy in pregnancy emphasizes the need for further perspective studies on this issue.