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Zhang J, Le Leu RK, Xu Q, Bennett P. The futility of post-haemodialysis blood glucose levels: A retrospective cohort study. J Ren Care 2024. [PMID: 38477224 DOI: 10.1111/jorc.12492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Frequent blood glucose tests are performed for people with diabetes receiving haemodialysis. OBJECTIVES To determine the rate of out-of-range post-haemodialysis blood glucose levels that are clinically acted upon, the intervention and outcome of each intervention, and the associations between post-haemodialysis blood glucose levels and relevant clinical predictors. DESIGN 12-month retrospective cohort medical record review in one Australian haemodialysis centre. Post-haemodialysis blood glucose levels, prehaemodialysis blood glucose levels, time of treatment, diabetes medications, intradialytic fluid removal, dialysate dextrose concentration, clinical actions, interventions, and outcomes on out-of-range blood glucose levels were retrieved. PARTICIPANTS 22 participants with a median time receiving dialysis 3.1 years (interquartile range 2.3-4.7). MEASUREMENTS AND RESULTS The proportion of out-of-range post-haemodialysis blood glucose levels was 87.3% (95% confidence interval, 86.1%-88.5%). No out-of-range post-haemodialysis blood glucose levels were clinically acted upon. Out-of-range post-haemodialysis blood glucose levels were 4.6 times more likely if a higher dextrose bath was used (95% confidence interval: 3.3; 6.3. p < 0.001). The odds of the post-haemodialysis blood glucose levels increased by each 1 mmol/L. Intradialytic fluid removal, dialysate dextrose concentration, sex, dialysis time, anti-hyperglycaemic agents were also associated with out-of-range post-haemodialysis blood glucose levels. CONCLUSION Routine post-haemodialysis blood glucose levels testing has limited clinical utility in care for people with diabetes receiving maintenance haemodialysis. Higher dextrose dialysate may require individual titration depending on prehaemodialysis blood glucose levels.
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Affiliation(s)
- Jing Zhang
- Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Richard K Le Leu
- Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Qunyan Xu
- Clinical & Health Sciences, University of South Australia, Adelaide, Australia
| | - Paul Bennett
- School of Nursing and Midwifery, Griffith Health, Griffith University, Brisbane, Queensland, Australia
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Saleh MA, Shaaban AA, Talaat IM, Elmougy A, Adra SF, Ahmad F, Qaisar R, Elmoselhi AB, Abu-Gharbieh E, El-Huneidi W, Eladl MA, Shehatou G, Kafl HE. RhoA/ROCK inhibition attenuates endothelin-1-induced elevated glomerular permeability to albumin, inflammation, and fibrosis. Life Sci 2023; 323:121687. [PMID: 37030613 DOI: 10.1016/j.lfs.2023.121687] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/25/2023] [Accepted: 04/05/2023] [Indexed: 04/10/2023]
Abstract
Endothelin-1 (ET-1) contributes to the development of kidney diseases. However, the underlying molecular mechanism is largely undefined. Here we sought to investigate the potential role of ET-1 receptors, ETA and ETB in the regulation of increased glomerular permeability and underlying signaling pathways post-ET-1 infusion. Male Sprague-Dawley rats were infused with ET-1 (2 pmol/kg per minute, i.v.) for four weeks, and the effect on glomerular permeability to albumin (Palb) and albuminuria was measured. The selective ROCK-1/2 inhibitor, Y-27632, was administered to a separate group of rats to determine its effect on ET-1-induced Palb and albuminuria. The role of ETA and ETB receptors in regulating RhoA/ROCK activity was determined by incubating isolated glomeruli from normal rats with ET-1 and with selective ETA and ETB receptor antagonists. ET-1 infusion for four weeks significantly elevated Palb and albuminuria. Y-27632 significantly reduced the elevation of Palb and albuminuria. The activities of both RhoA and ROCK-1/2 were increased by ET-1 infusion. Selective ETB receptor antagonism had no effect on the elevated activity of both RhoA and ROCK-1/2 enzymes. Selective ETA receptor and combined ETA/ETB receptors blockade restored the activity of RhoA and ROCK-1/2 to normal levels. In addition, chronic ET-1 infusion increased the levels of glomerular inflammatory and fibrotic markers. These effects were all attenuated in rats following ROCK-1/2 inhibition. These observations suggest that ET-1 contributes to increased albuminuria, inflammation, and fibrosis by modulating the activity of the ETA-RhoA/ROCK-1/2 pathway. Selective ETA receptor blockade may represent a potential therapeutic strategy to limit glomerular injury and albuminuria in kidney disease.
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Affiliation(s)
- Mohamed A Saleh
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates; Sharjah Institute for Medical Research, University of Sharjah, Sharjah 27272, United Arab Emirates; Department of Pharmacology and Toxicology, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt.
| | - Ahmed A Shaaban
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt; Department of Pharmacology and Biochemistry, Faculty of Pharmacy, Delta University for Science and Technology, Gamasa City 35712, Egypt
| | - Iman M Talaat
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates; Sharjah Institute for Medical Research, University of Sharjah, Sharjah 27272, United Arab Emirates; Pathology Department, Faculty of Medicine, Alexandria University, Alexandria 21526, Egypt
| | - Atef Elmougy
- Pediatric Nephrology Unit, Mansoura University Children's Hospital, Mansoura University, Mansoura 35516, Egypt
| | - Saryia F Adra
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Firdos Ahmad
- Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates; Department of Biomedical Sciences, College of Health Sciences, Abu Dhabi University, Abu Dhabi 59911, United Arab Emirates
| | - Rizwan Qaisar
- Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Adel B Elmoselhi
- Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Eman Abu-Gharbieh
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates; Sharjah Institute for Medical Research, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Waseem El-Huneidi
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah 27272, United Arab Emirates; Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Mohamed A Eladl
- Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - George Shehatou
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt; Department of Pharmacology and Biochemistry, Faculty of Pharmacy, Delta University for Science and Technology, Gamasa City 35712, Egypt
| | - Hoda E Kafl
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt
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Li J, Zhang R, Wu Z, Guo J, Wang Z, Li S, Li C, Yang G, Cheng X. Blood Glucose Fluctuation in Older Adults with Diabetes Mellitus and End-Stage Renal Disease on Maintenance Hemodialysis: An Observational Study. Diabetes Ther 2022; 13:1353-1365. [PMID: 35689733 PMCID: PMC9240155 DOI: 10.1007/s13300-022-01274-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/12/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Patients with diabetes mellitus and end-stage renal disease are at a high risk of developing coronary, cerebrovascular, and peripheral vascular diseases. This study aimed to characterize hypoglycemia and blood glucose fluctuations associated with maintenance hemodialysis in older adult patients with diabetes mellitus and end-stage renal disease using a continuous glucose monitoring system. METHODS Seven patients were enrolled in this study, and 13 pairs of continuous glucose monitoring system data were collected. Each pair included data of 1 dialysis-on day and 1 dialysis-off day. Information on basic patient characteristics, including age, diabetes mellitus duration, hemodialysis duration, and proportions of hemoglobin A1c and glycated albumin, were collected. Differences in blood glucose fluctuation were compared between dialysis-on days and dialysis-off days. RESULTS The mean blood glucose on dialysis-on days (6.96 ± 2.57 mmol/L) was significantly lower than that on dialysis-off days (7.68 ± 2.31 mmol/L; P < 0.05). In contrast, the following parameters had significantly higher values (all P < 0.05) on dialysis-on days compared to dialysis-off days: large amplitude of glycemic excursion level (5.82 ± 2.86 mmol/L versus 4.21 ± 1.71 mmol/L), large amplitude of glycemic excursion level from 8 a.m. to 2 p.m. (3.6 ± 1.74 mmol/L versus 2.8 ± 1.33 mmol/L), mean amplitude of glycemic excursion level (4.78 ± 1.68 mmol/L versus 3.89 ± 1.67 mmol/L), mean amplitude of glycemic excursion level from 8 a.m. to 2 p.m. (4.01 ± 1.03 mmol/L versus 3.12. ± 0.97 mmol/L), standard deviation of blood glucose (1.55 ± 0.89 mmol/L versus 1.03 ± 0.4 mmol/L), and time below a target glucose range of less than 3.9 mmol/L (8.27% versus 4.25%). CONCLUSION Fluctuations in blood glucose levels were larger on dialysis-on days, particularly from the start of hemodialysis to 2 h post-hemodialysis, than on dialysis-off days. Hypoglycemia, as indicated by the time below a target glucose range of less than 3.9 mmol/L, occurred more frequently on dialysis-on days than on dialysis-off days.
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Affiliation(s)
- Jinzhu Li
- Department of Geriatric Nephrology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Ruiqin Zhang
- Department of Geriatric Nephrology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Zhen Wu
- Department of Geriatric Nephrology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Jiayu Guo
- Department of Geriatric Nephrology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Zhiying Wang
- Department of Geriatric Nephrology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Shuhui Li
- Department of Geriatric Nephrology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Chunlin Li
- Department of Geriatric Endocrinology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Guang Yang
- Department of Geriatric Nephrology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China.
| | - Xiaoling Cheng
- Department of Geriatric Endocrinology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China.
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Gallieni M, De Salvo C, Lunati ME, Rossi A, D'Addio F, Pastore I, Sabiu G, Miglio R, Zuccotti GV, Fiorina P. Continuous glucose monitoring in patients with type 2 diabetes on hemodialysis. Acta Diabetol 2021; 58:975-981. [PMID: 33743082 PMCID: PMC8272699 DOI: 10.1007/s00592-021-01699-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/27/2021] [Indexed: 12/14/2022]
Abstract
Diabetic kidney disease is the leading cause of end-stage kidney disease in high-income countries. The strict control of glycemic oscillations is the principal therapeutic target, but this could be hard to achieve in uremic patients due to their unpredictable insulin sensitivity. Currently, the evaluation of the glycemic profile relies on serum markers (glycated hemoglobin HbA1c, glycated albumin, and fructosamine), capillary glucose blood control (self-monitoring of blood glucose), and interstitial glucose control (continue glucose monitoring). We conducted a systematic review of published articles on continue glucose monitoring in hemodialysis patients with type 2 diabetes, which included 12 major articles. Four studies found significant fluctuations in glucose levels during hemodialysis sessions. All studies reported a higher mean amplitude of glucose variations on the hemodialysis day. Three studies agreed that continue glucose monitoring is better than glycated hemoglobin in detecting these abnormalities. Moreover, continue glucose monitoring was more accurate and perceived as easier to use by patients and their caregivers. In patients with type 2 diabetes on hemodialysis, glucose levels show different variation patterns than the patients on hemodialysis without diabetes. Considering manageability, accuracy, and cost-effectiveness, continue glucose monitoring could be the ideal diagnostic tool for the patient with diabetes on hemodialysis.
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Affiliation(s)
- Maurizio Gallieni
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Di Milano, Milano, Italy.
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milano, Italy.
| | - Cristina De Salvo
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milano, Italy
| | | | - Antonio Rossi
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Francesca D'Addio
- International Center for T1D, Pediatric Clinical Research Center Romeo Ed Enrica Invernizzi, Department of Biomedical and Clinical Sciences "L. Sacco", Università Di Milano, Milan, Italy
| | - Ida Pastore
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Gianmarco Sabiu
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milano, Italy
| | - Roberta Miglio
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milano, Italy
| | - Gian Vincenzo Zuccotti
- Pediatric Clinical Research Center Romeo Ed Enrica Invernizzi, Department of Biomedical and Clinical Sciences "L. Sacco", Università Di Milano and Pediatric Department, Buzzi Children's Hospital, Milan, Italy
| | - Paolo Fiorina
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, Milan, Italy
- International Center for T1D, Pediatric Clinical Research Center Romeo Ed Enrica Invernizzi, Department of Biomedical and Clinical Sciences "L. Sacco", Università Di Milano, Milan, Italy
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Sahai V, Kumar V. Anti-diabetic, hepatoprotective and antioxidant potential of Brassica oleracea sprouts. BIOCATALYSIS AND AGRICULTURAL BIOTECHNOLOGY 2020. [DOI: 10.1016/j.bcab.2020.101623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Pazarín-Villaseñor L, Alejandro Gutiérrez-Prieto J, Soto-Vargas J, Parra-Michel R, García-Sanchez A, Guillermina Miranda-Diaz A. Increase of Oxidants and Antioxidant Consumption in Patients with Type 2 Diabetes Mellitus in Peritoneal Dialysis. Antioxidants (Basel) 2019. [DOI: 10.5772/intechopen.82880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Rhee JJ, Zheng Y, Montez-Rath ME, Chang TI, Winkelmayer WC. Associations of Glycemic Control With Cardiovascular Outcomes Among US Hemodialysis Patients With Diabetes Mellitus. J Am Heart Assoc 2017; 6:JAHA.117.005581. [PMID: 28592463 PMCID: PMC5669174 DOI: 10.1161/jaha.117.005581] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background There is a lack of data on the relationship between glycemic control and cardiovascular end points in hemodialysis patients with diabetes mellitus. Methods and Results We included adult Medicare‐insured patients with diabetes mellitus who initiated in‐center hemodialysis treatment from 2006 to 2008 and survived for >90 days. Quarterly mean time‐averaged glycated hemoglobin (HbA1c) values were categorized into <48 mmol/mol (<6.5%) (reference), 48 to <58 mmol/mol (6.5% to <7.5%), 58 to <69 mmol/mol (7.5% to <8.5%), and ≥69 mmol/mol (≥8.5%). Medicare claims were used to identify outcomes of cardiovascular mortality, nonfatal myocardial infarction (MI), fatal or nonfatal MI, stroke, and peripheral arterial disease. We used Cox models as a function of time‐varying exposure to estimate multivariable adjusted hazard ratios and 95%CI for the associations between HbA1c and time to study outcomes in a cohort of 16 387 eligible patients. Patients with HbA1c 58 to <69 mmol/mol (7.5% to <8.5%) and ≥69 mmol/mol (≥8.5%) had 16% (CI, 2%, 32%) and 18% (CI, 1%, 37%) higher rates of cardiovascular mortality (P‐trend=0.01) and 16% (CI, 1%, 33%) and 15% (CI, 1%, 32%) higher rates of nonfatal MI (P‐trend=0.05), respectively, compared with those in the reference group. Patients with HbA1c ≥69 mmol/mol (≥8.5%) had a 20% (CI, 2%, 41%) higher rate of fatal or nonfatal MI (P‐trend=0.02), compared with those in the reference group. HbA1c was not associated with stroke, peripheral arterial disease, or all‐cause mortality. Conclusions Higher HbA1c levels were significantly associated with higher rates of cardiovascular mortality and MI but not with stroke, peripheral arterial disease, or all‐cause mortality in this large cohort of hemodialysis patients with diabetes mellitus.
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Affiliation(s)
- Jinnie J Rhee
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Yuanchao Zheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Heath, Baylor College of Medicine, Houston, TX
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Rhee JJ, Ding VY, Rehkopf DH, Arce CM, Winkelmayer WC. Correlates of poor glycemic control among patients with diabetes initiating hemodialysis for end-stage renal disease. BMC Nephrol 2015; 16:204. [PMID: 26645204 PMCID: PMC4673753 DOI: 10.1186/s12882-015-0204-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/30/2015] [Indexed: 12/21/2022] Open
Abstract
Background Maintaining tight glycemic control is important for prevention of diabetes-related outcomes in end-stage renal disease patients with diabetes, especially in light of their poor prognosis. This study aimed to determine factors associated with poor glycemic control among U.S. patients with diabetes mellitus initiating hemodialysis for end-stage renal disease. Methods Using data from the U.S. Renal Data System, electronic health records of a large national dialysis provider, and U.S. Census data, we performed a cross-sectional multivariable Poisson regression analysis to characterize risk factors associated with poor glycemic control, defined as glycated hemoglobin (HbA1c) >7 vs. ≤7 %, in adult patients with diabetes who initiated hemodialysis at an outpatient facility between 2006 and 2011. Results Of 16,297 patients with diabetes, 21.2 % had HbA1c >7 %. In multivariable analysis, younger patients, patients of Native American race, and those of Hispanic ethnicity had higher prevalence of poor glycemic control. Independent correlates of poor glycemic control further included higher platelet count, white blood cell count, and ferritin; higher body mass index, systolic blood pressure, total cholesterol and triglyceride concentrations; lower HDL and albumin concentrations; lower normalized protein catabolic rate; and higher estimated glomerular filtration rate at initiation of dialysis (all P < 0.05). No independent associations were found with area-level socioeconomic indicators. Occurrence of diabetes in patients <40 years of age, a proxy for type 1 diabetes, was associated with poor HbA1c control compared with that in patients ≥40 years of age, which was classified as type 2 diabetes. These findings were robust to the different outcome definitions of HbA1c >7.5 % and >8 %. Conclusion In this cohort of incident end-stage renal disease patients with diabetes, poor glycemic control was independently associated with younger age, Native American race, Hispanic ethnicity, higher body mass index, and clinical risk factors including atherogenic lipoprotein profile, hypertension, inflammation, and markers indicative of malnutrition and a more serious systemic disease.
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Affiliation(s)
- Jinnie J Rhee
- Division of Nephrology, Stanford University School of Medicine, 1070 Arastradero Road #3C3109, Palo Alto, CA, 94304, USA.
| | - Victoria Y Ding
- Division of Bioinformatics Research, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - David H Rehkopf
- Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Cristina M Arce
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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Hassan K, Hassan F, Edgem R, Moshe S, Hassan S. The impact of the peritoneal glucose load index on hydration status and inflammation in peritoneal dialysis patients. J Int Med Res 2014; 43:42-53. [DOI: 10.1177/0300060514550013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate the impact of the peritoneal glucose load (PGL) on hydration status and inflammation in peritoneal dialysis (PD) patients. Methods This cross-sectional study evaluated stable PD patients using a novel PGL index (PGLI), which was calculated as the net glucose content (g) in the PD solutions administered in the daily PD prescription divided by the dry body weight (kg) assessed by whole-body bioimpedance spectroscopy. The relationship between PGLI and glycosylated haemoglobin (HbA1c), fluid overload (FO), and inflammatory markers was investigated. Results A total of 43 stable PD patients participated in the study. Significant positive correlations were found between PGLI and HbA1c, FO, plasma high sensitivity C-reactive protein (hsCRP), and plasma interleukin-6 (IL-6) levels. HbA1c, FO, plasma hsCRP and plasma IL-6 levels were significantly higher in patients with PGLI >3 g/kg/day compared with those with PGLI ≤3 g/kg/day. Conclusions PGLI values >3 g/kg/day may be associated with poor glycaemic control, over hydration and augmented inflammation. PGLI might be a useful tool for the quantitative assessment of the PGL and could be applied when managing PD patients.
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Affiliation(s)
- Kamal Hassan
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
- Department of Nephrology and Hypertension, Peritoneal Dialysis Unit, Western Galilee Hospital, Nahariya, Israel
| | - Fadi Hassan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rabia Edgem
- Department of Nephrology and Hypertension, Peritoneal Dialysis Unit, Western Galilee Hospital, Nahariya, Israel
| | - Smadar Moshe
- Department of Nephrology and Hypertension, Peritoneal Dialysis Unit, Western Galilee Hospital, Nahariya, Israel
| | - Shadi Hassan
- Department of Internal Medicine, Carmel Medical Centre, Haifa, Israel
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Ricks J, Molnar MZ, Kovesdy CP, Shah A, Nissenson AR, Williams M, Kalantar-Zadeh K. Glycemic control and cardiovascular mortality in hemodialysis patients with diabetes: a 6-year cohort study. Diabetes 2012; 61:708-15. [PMID: 22315308 PMCID: PMC3282812 DOI: 10.2337/db11-1015] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 12/01/2011] [Indexed: 11/23/2022]
Abstract
Previous observational studies using differing methodologies have yielded inconsistent results regarding the association between glycemic control and outcomes in diabetic patients receiving maintenance hemodialysis (MHD). We examined mortality predictability of A1C and random serum glucose over time in a contemporary cohort of 54,757 diabetic MHD patients (age 63 ± 13 years, 51% men, 30% African Americans, 19% Hispanics). Adjusted all-cause death hazard ratio (HR) for baseline A1C increments of 8.0-8.9, 9.0-9.9, and ≥10%, compared with 7.0-7.9% (reference), was 1.06 (95% CI 1.01-1.12), 1.05 (0.99-1.12), and 1.19 (1.12-1.28), respectively, and for time-averaged A1C was 1.11 (1.05-1.16), 1.36 (1.27-1.45), and 1.59 (1.46-1.72). A symmetric increase in mortality also occurred with time-averaged A1C levels in the low range (6.0-6.9%, HR 1.05 [95% CI 1.01-1.08]; 5.0-5.9%, 1.08 [1.04-1.11], and ≤5%, 1.35 [1.29-1.42]) compared with 7.0-7.9% in fully adjusted models. Adjusted all-cause death HR for time-averaged blood glucose 175-199, 200-249, 250-299, and ≥300 mg/dL, compared with 150-175 mg/dL (reference), was 1.03 (95% CI 0.99-1.07), 1.14 (1.10-1.19), 1.30 (1.23-1.37), and 1.66 (1.56-1.76), respectively. Hence, poor glycemic control (A1C ≥8% or serum glucose ≥200 mg/dL) appears to be associated with high all-cause and cardiovascular death in MHD patients. Very low glycemic levels are also associated with high mortality risk.
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Affiliation(s)
- Joni Ricks
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor–University of California, Los Angeles, Medical Center, Torrance, California
| | - Miklos Z. Molnar
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor–University of California, Los Angeles, Medical Center, Torrance, California
- Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Csaba P. Kovesdy
- Division of Nephrology, Salem VA Medical Center, Salem, Virginia
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Anuja Shah
- Division of Nephrology and Hypertension, Harbor–University of California, Los Angeles, Medical Center, Torrance, California
| | - Allen R. Nissenson
- DaVita Inc., Denver, Colorado
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Mark Williams
- Renal Unit, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor–University of California, Los Angeles, Medical Center, Torrance, California
- Division of Nephrology and Hypertension, Harbor–University of California, Los Angeles, Medical Center, Torrance, California
- Renal Unit, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, University of California, Los Angeles, School of Public Health, Los Angeles, California
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Duong U, Mehrotra R, Molnar MZ, Noori N, Kovesdy CP, Nissenson AR, Kalantar-Zadeh K. Glycemic control and survival in peritoneal dialysis patients with diabetes mellitus. Clin J Am Soc Nephrol 2011; 6:1041-8. [PMID: 21511838 PMCID: PMC3087769 DOI: 10.2215/cjn.08921010] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 12/20/2010] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES The optimal target for glycemic control has not been established for diabetic peritoneal dialysis (PD) patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined mortality-predictability of hemoglobin A1c random serum glucose in a contemporary cohort of diabetic PD patients treated in DaVita dialysis clinics July 2001 through June 2006 with follow-up through June 2007. RESULTS We identified 2798 diabetic PD patients with A1c data. Serum glucose correlated with A1C (r=0.51). Adjusted all-cause death hazard ratio and 95% confidence interval for baseline A1c increments of 7.0 to 7.9%, 8.0 to 8.9%, 9.0 to 9.9%, and ≥10%, compared with 6.0 to 6.9% (reference), were 1.13 (0.97 to 1.32), 1.05 (0.88 to 1.27), 1.06 (0.84 to 1.34), and 1.48 (1.18 to 1.86); and for time-averaged A1c values were 1.10 (0.96 to 1.27), 1.28 (1.07 to 1.53), 1.34 (1.05 to 1.70), and 1.81 (1.33 to 2.46), respectively. The A1c-mortality association was modified by hemoglobin level such that higher all-cause mortality was evident only in nonanemic patients. Similar but non-significant trends in cardiovascular death risk was found across A1c increments. Adjusted all-cause death HR for time-averaged blood glucose 150 to 199, 200 to 249, 250 to 299, and ≥300 mg/dl, compared with 60 to 99 mg/dl (reference), were 1.02 (0.70 to 1.47), 1.12 (0.77 to 1.63), 1.45 (0.97 to 2.18), and 2.10 (1.37 to 3.20), respectively. CONCLUSIONS Poor glycemic control appears associated incrementally with higher mortality in PD patients. Moderate to severe hyperglycemia is associated with higher death risk especially in certain subgroups.
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Affiliation(s)
- Uyen Duong
- Harold Simmons Center for Chronic Disease Research & Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Rajnish Mehrotra
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Miklos Z. Molnar
- Harold Simmons Center for Chronic Disease Research & Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
- Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Nazanin Noori
- Harold Simmons Center for Chronic Disease Research & Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Salem VA Medical Center, Salem, Virginia
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Allen R. Nissenson
- David Geffen School of Medicine at UCLA, Los Angeles, California
- DaVita, Inc., El Segundo, California; and
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research & Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Epidemiology, UCLA School of Public Health, Los Angeles, California
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Shima K, Komatsu M, Kawahara K, Minaguchi J, Kawashima S. Stringent glycaemic control prolongs survival in diabetic patients with end-stage renal disease on haemodialysis. Nephrology (Carlton) 2011; 15:632-8. [PMID: 20883284 DOI: 10.1111/j.1440-1797.2010.01273.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM No suitable index or optimal target for diabetic control has been established for diabetic patients with end-stage renal disease (ESRD) undergoing haemodialysis. To address these issues, the single-centre observational study was conducted. METHODS Two hundred and forty-five diabetic ESRD patients (23.3% female; age at initiation of haemodialysis 61.7 ± 10.7 years) at start of haemodialysis between 1 January 1995 and 31 December 2004 were enrolled. Subjects were grouped according to glycaemic control level throughout the observational period as follows: mean postprandial plasma glucose (PPG) <8.9 mmol/L, 8.9 mmol/L ≤ PPG < 10.0 mmol/L, 10.0 mmol/L ≤ PPG < 11.1 mmol/L, 11.1 mmol/L ≤ PPG < 12.2 mmol/L and PPG ≥ 12.2 mmol/L; and HbA1c < 6.0%, 6.0-6.4%, 6.5-6.9% and ≥ 7.0%. Survival was then followed until 31 December 2005. RESULTS Cumulative survival of groups of 10.0 mmol/L ≤ PPG < 11.1 mmol/L, 11.1 ≤ PPG < 12.2 and PPG ≥ 12.2 mmol/L was significantly lower than that for PPG < 8.9 mmol/L as determined by Kaplan-Meier estimation (P = 0.016, 0.009 and 0.031, respectively; log-rank test). In both uni- and multivariate Cox proportional hazard models, mortality hazard ratios were significantly higher for PPG ≥ 10.0 mmol/L than for PPG < 8.9 mmol/L (P = 0.002-0.021). Kaplan-Meier survival curves grouped by HbA1c levels showed no correlation between HbA1c and survival during the observational period. No significant difference in mortality hazard ratios was seen for any HbA1c groups evaluated by Cox proportional hazard model. CONCLUSION Intensive management of diabetic control at a stringent mean on-study PPG < 10.0 mmol/L will improve the life expectancy in diabetic dialysis patients. However, no range of HbA1c values obtained in this study showed any clear difference in clinical outcomes.
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Affiliation(s)
- Kenji Shima
- Department of Medicine, Kawashima Hospital, Tokushima, Japan.
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13
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Kovesdy CP, Park JC, Kalantar-Zadeh K. Glycemic control and burnt-out diabetes in ESRD. Semin Dial 2010; 23:148-56. [PMID: 20374552 DOI: 10.1111/j.1525-139x.2010.00701.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Treatment of early diabetes mellitus, the most common cause of chronic kidney disease (CKD), may prevent or slow the progression of diabetic nephropathy and lower mortality and the incidence of cardiovascular disease in the general diabetic population and in patients with early stages of CKD. It is unclear whether glycemic control in patients with advanced CKD, including those with end-stage renal disease (ESRD) who undergo maintenance dialysis treatment is beneficial. Aside from the uncertain benefits of treatment in ESRD, hypoglycemic interventions in this population are also complicated by the complex changes in glucose homeostasis related to decreased kidney function and to dialytic therapies, occasionally leading to spontaneous resolution of hyperglycemia and normalization of hemoglobin A1c levels, a condition which might be termed "burnt-out diabetes." Further difficulties in ESRD are posed by the complicated pharmacokinetics of antidiabetic medications and the serious flaws in our available diagnostic tools used for monitoring long-term glycemic control. We review the physiology and pathophysiology of glucose homeostasis in advanced CKD and ESRD, the available antidiabetic medications and their specifics related to kidney function, and the diagnostic tools used to monitor the severity of hyperglycemia and the therapeutic effects of available treatments, along with their deficiencies in ESRD. We also review the concept of burnt-out diabetes and summarize the findings of studies that examined outcomes related to glycemic control in diabetic ESRD patients, and emphasize areas in need of further research.
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Affiliation(s)
- Csaba P Kovesdy
- Division of Nephrology, Salem Veterans Affairs Medical Center, Salem, VA 24153, USA.
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14
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Kovesdy CP, Sharma K, Kalantar-Zadeh K. Glycemic Control in Diabetic CKD Patients: Where Do We Stand? Am J Kidney Dis 2008; 52:766-77. [DOI: 10.1053/j.ajkd.2008.04.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 04/01/2008] [Indexed: 11/11/2022]
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15
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Yu T, Khraibi AA. Enalapril treatment restores the decreased proximal tubule reabsorption in response to acute volume expansion in diabetic rats. Life Sci 2008; 83:364-8. [DOI: 10.1016/j.lfs.2008.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Revised: 05/22/2008] [Accepted: 06/30/2008] [Indexed: 11/30/2022]
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Kalantar-Zadeh K, Kopple JD, Regidor DL, Jing J, Shinaberger CS, Aronovitz J, McAllister CJ, Whellan D, Sharma K. A1C and survival in maintenance hemodialysis patients. Diabetes Care 2007; 30:1049-55. [PMID: 17337501 DOI: 10.2337/dc06-2127] [Citation(s) in RCA: 192] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The optimal target for glycemic control has not been established in diabetic dialysis patients. RESEARCH DESIGN AND METHODS To address this question, the national database of a large dialysis organization (DaVita) was analyzed via time-dependent survival models with repeated measures. RESULTS Of 82,933 patients undergoing maintenance hemodialysis (MHD) in DaVita outpatient clinics over 3 years (July 2001 through June 2004), 23,618 diabetic MHD patients had A1C measurements at least once. Unadjusted survival analyses indicated paradoxically lower death hazard ratios (HRs) with higher A1C values. However, after adjusting for potential confounders (demographics, dialysis vintage, dose, comorbidity, anemia, and surrogates of malnutrition and inflammation), higher A1C values were incrementally associated with higher death risks. Compared with A1C in the 5-6% range, the adjusted all-cause and cardiovascular death HRs for A1C > or = 10% were 1.41 (95% CI 1.25-1.60) and 1.73 (1.44-2.08), respectively (P < 0.001). The incremental increase in death risk for rising A1C values was monotonic and robust in nonanemic patients (hemoglobin > 11.0 g/dl). In subgroup analyses, the association between A1C > 6% and increased death risk was more prominent among younger patients, those who had undergone dialysis for > 2 years, and those with higher protein intake (> 1 g x kg(-1) x day(-1)), blood hemoglobin (> 11 g/dl), or serum ferritin values (> 500 ng/ml). CONCLUSIONS In diabetic MHD patients, the apparently counterintuitive association between poor glycemic control and greater survival is explained by such confounders as malnutrition and anemia. All things equal, higher A1C is associated with increased death risk. Lower A1C levels not related to malnutrition or anemia appear to be associated with improved survival in MHD patients.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California 90509-2910, USA.
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Inclusion Complexes of Manidipine with γ-Cyclodextrin and Identification of Photodegradation Products. J INCL PHENOM MACRO 2005. [DOI: 10.1007/s10847-004-6975-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Jamerson KA. The first hypertension trial comparing the effects of two fixed-dose combination therapy regimens on cardiovascular events: Avoiding Cardiovascular events through Combination therapy in Patients Living with Systolic Hypertension (ACCOMPLISH). J Clin Hypertens (Greenwich) 2003; 5:29-35. [PMID: 12941995 PMCID: PMC8099324 DOI: 10.1111/j.1524-6175.2003.02676.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Current recommendations for the treatment of hypertension clarify the need to achieve lower blood pressure levels in the general population (<140/90 mm Hg) and in specific high-risk patient groups such as patients with diabetes or chronic renal disease (<130/80 mm Hg). Further, it is evident that to reach appropriate blood pressure control, most patients with high blood pressure will require two or more antihypertensive agents. There is scarce clinical trial outcome evidence to guide clinicians in the selection of optimal combinations of antihypertensive classes for high-risk hypertensive patients. A new clinical trial, Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH), is the first large clinical trial to directly compare cardiovascular mortality and morbidity rates for two fixed-dose combination therapies. Results from ACCOMPLISH should provide much-needed guidance for selecting optimal combination therapy for high-risk hypertensive patients.
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Affiliation(s)
- Kenneth A Jamerson
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
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