Diabetic kidney disease patients on hemodialysis: a retrospective survival analysis across different socioeconomic groups

A Comparative Study on Graft and Overall Survival Rates Between Diabetic and Nondiabetic Kidney Transplant Patients Through Survival Analysis

Background

Patients with diabetes mellitus (DM) have worse graft and overall survival, but recent evidence suggests that the difference is no longer significant.

Objective

To compare the outcomes between patients with end-stage kidney disease due to DM (ESKD-DM) and ESKD due to nondiabetic etiology (ESKD-non-DM) who underwent kidney transplantation (KT) up to 10 years of follow-up.

Design

Survival analysis of a retrospective cohort.

Setting and Patients

All patients who underwent KT at the Hospital Universitario San Ignacio, Colombia, between 2004 and 2022.

Measurements

Overall and graft survival in ESKD-DM and ESKD-non-DM who received KT. Patients who died with functional graft were censored for the calculation of kidney graft survival.

Methods

Log-rank test, Cox proportional hazards model, and competing risk analysis were used to compare overall and graft survival in patients with ESKD-DM and ESKD-non-DM who underwent KT.

Results

A total of 375 patients were included: 60 (16%) with ESKD-DM and 315 (84%) with ESKD-non-DM. Median follow-up was 83.3 months. Overall survival was lower in patients with ESKD-DM at 5 (75.0% vs 90.8%, P < .001) and 10 years (55.0% vs 86.7%, P < .001). Cardiovascular death was higher in patients with diabetes (27.3% vs 8.2%, P = .021). Death-censored graft survival was similar in both groups (96.7% vs 93.3% at 5 years, P = .324). On multivariate analysis, the factors associated with global survival were DM (hazard ratio [HR] = 2.11, 95% confidence interval [CI] = 1.23-3.60, P = .006), recipient age (HR = 1.05, 95% CI = 1.02-1.08, P < .001), delayed graft function (HR = 2.07, 95% CI = 1.24-3.46, P = .005), and donor age (HR = 1.03, 95% CI = 1.01-1.05, P = .002). In the competing risk analysis, DM was associated with mortality only in the cardiovascular death group (sub-hazard ratio [SHR] = 6.06, 95% CI = 1.01-36.4, P = .049).

Limitations

Change in diabetes treatment received over time and adherence to glycemic targets were not considered. The sample size is relatively small, which limits the precision of our estimates. The Kidney Donor Profile Index and the occurrence of treated acute rejection were not included in the regression models.

Conclusion

Overall survival is lower in patients with diabetes, possibly due to older age and cardiovascular comorbidities. Therefore, patients with diabetes should be followed more closely to control cardiovascular risk factors. However, there is no difference in graft survival.

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

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

The association of socioeconomic deprivation with access and survival after hematopoietic stem cell transplantation in New Zealand

BACKGROUND

Socioeconomic deprivation (SED) is a risk factor for reduced survival of hematopoietic stem cell transplant (HSCT) recipients. This study aimed to evaluate access and long-term survival of HSCT recipients.

METHODS

This was a hospital HSCT Registry-based retrospective cohort study. Patients who underwent HSCT from January 2010 to June 2020 were identified. HSCT recipients younger than 16 years of age, patients who reported their residential address as a post office box or the Department of Corrections, and those who left the country after HSCT were excluded from the study. HSCT recipients with the 2018 New Zealand deprivation index (NZDep2018) deciles 8, 9, and 10 were assigned to the higher SED group and those with NZDep2018 deciles from 1 to 7 were allocated to the lower SED group. The total number of New Zealanders in the higher and lower SED strata was obtained from the 2018 Census.

RESULTS

Eight hundred fifty-one HSCT recipients met the eligibility criteria. HSCT recipients from the higher and lower SED strata of the New Zealand population had similar access to HSCT (odds ratio = .9; 95% confidence interval (CI): .77-1.04; p = .155). Mortality in the higher and lower SED groups of HSCT recipients was 9.6/100 person-years (95% CI: 7.7-12/100 person-years) and 8.1/100 person-years (95% CI: 6.9-9.4/100 person-years), respectively. The mortality ratio was 1.2 (95% CI: .9-1.6), p = .098. Both groups had similar survival.

CONCLUSION

New Zealand residents from the higher and lower SED strata have similar access to HSCT. SED is not associated with reduced survival in adult HSCT recipients.

Socioeconomic inequality: Accessibility and outcomes after renal transplantation in New Zealand

BACKGROUND

Socioeconomic deprivation (SED) is a risk factor for worse outcomes after renal transplantation (RTx). This study aimed to evaluate access to RTx in different SED strata of the New Zealand population. We also assessed patient survival, acute cellular allograft rejection (AR) and allograft loss.

METHODS

This was an Australian and New Zealand Dialysis and Transplantation and Organ Donation Registries-based retrospective cohort study. Patients who underwent RTx in New Zealand from 2008 to 2018 were identified. Patients younger than 16 years of age and those who left the country after RTx were excluded.

RESULTS

In the higher SED stratum of New Zealanders, the rate of RTx was 53% greater than in the lower SED stratum (odds ratio = 1.53; 95% confidence interval: 1.33-1.76; p < 0.00005).

RESULTS

One hundred and thirteen (23%) patients from the lower SED group and 51 (14.8%) patients from the higher SED group underwent living unrelated RTx, p = 0.0033. In 233 (67.5%) patients from the higher SED group and 265 (53.9%) patients from the lower SED group, transplanted kidneys were from deceased donors RTx, p = 0.0001. The incidence of allograft loss and patient survival were similar in these groups.

CONCLUSION

Our data demonstrated a lower overall survival in the more socioeconomically deprived patients than in the lower SED group however this was not statistically significant after adjustment for covariates. A larger study is required to determine whether SED is associated with reduced survival.

Additional cost of end-stage kidney disease in diabetic patients according to renal replacement therapy modality: a systematic review

The prevalence of end-stage kidney disease (ESKD) is growing worldwide; the survival of these patients requires renal replacement therapy (RRT, a complex and costly treatment). Over 20% of the patients that start RTT had diabetes. Limited evidence on the effect of comorbidities on the cost of RRT exists. This review summarizes the available evidence on the effect of diabetes mellitus (DM) on the cost of RRT. Electronic databases were searched using key words that combined RRT with DM and cost. References were identified with title, abstract, and full-text screening. The studies included were published in English and presented data on the cost of RRT in ESKD patients with comparison between DM status. Seventeen studies were included in this review. The crude and adjusted cost of care estimates for patients on dialysis was generally higher for DM patients. The cost of care of ESKD patients differed according to various treatment modalities and these differences, mainly driven by inpatient costs. Overall, we found an increased cost of RRT care in patients with DM regardless of the type of treatment. Future analysis of the effects of multiple comorbidities should be considered to better understand the effect of DM on the cost of RRT.

Regional evidence and international recommendations to guide lipid management in Asian patients with type 2 diabetes with special reference to renal dysfunction

The anticipated increase in the prevalence and incidence of type 2 diabetes in Asia, and its associated cardiovascular-renal complications, will place a significant burden on patients, caregivers, and society. Despite the proven effectiveness of lipid management in reducing these complications, there are major treatment gaps, especially in Asian patients with young-onset diabetes and chronic kidney disease (CKD). Recent international guidelines recommended the adoption of absolute risk estimation of atherosclerosis and cardiovascular disease to guide treatment intensity. These recommendations replaced the previous strategy of using low-density lipoprotein cholesterol targets to guide initiation and intensification of lipid lowering, albeit still widely practiced in Asia. The latest guidelines also highlight the high risk of atherosclerosis and cardiovascular disease (ASCVD) for people with diabetes, who should be protected with statins, except for young patients without other risk factors, who will need yearly monitoring of blood lipid levels. Given the propensity of Asian patients with diabetes to develop CKD and the amplifying effect of CKD on ASCVD, the use of statins in Asian patients is particularly important. Due to interethnic differences in drug metabolism, rosuvastatin, which is largely cleared by the kidney, should be prescribed in low dosages (5-10 mg daily) in Asian populations. Conversely, epidemiological and experimental data confirm pleotropic and organ-protective effects of atorvastatin, with proven safety in Asian populations within a daily dose range of 10-40 mg. Thus, there is a need for Asian countries to review and align their lipid-lowering treatment guidelines to reduce the substantial burden of diabetes in the Asian region.

Recommendations for perioperative management of lung cancer patients with comorbidities

Objectives

To improve surgical outcomes, clinicians must provide optimal perioperative care for comorbidities identified as significant factors in risk models for patients undergoing lung cancer surgery.

Methods

We reviewed trends in perioperative care for idiopathic pulmonary fibrosis, cardiovascular diseases, and end-stage renal diseases in patients undergoing lung cancer surgery, as large clinical databases indicate that these comorbidities are significant risk factors for lung cancer surgery. Articles identified by keyword searches were included in the analysis.

Results

Significant predictive factors for acute exacerbation of idiopathic pulmonary fibrosis were identified. However, no effective perioperative care was identified for prevention of acute exacerbation of interstitial pneumonia. The timing of coronary revascularization and antithrombotic management for cardiovascular diseases are subjects of ongoing research, and acid–base balance is essential in the management of hemodialysis patients with end-stage renal diseases.

Conclusions

To improve surgical outcomes for lung cancer patients, future studies should continue to study optimal perioperative management of comorbidities.

Clinical and pathological characteristics of non-diabetic renal disease in type 2 diabetes patients

Background

Renal involvement in type 2 diabetes is mainly due to diabetic nephropathy (DN). Nevertheless, a sizable proportion of diabetic patients could actually have nondiabetic renal diseases (NDRDs) or DN plus NDRDs. This study aimed to explore the pathological features of NDRD in diabetic patients and to assess the predictability of diagnosing NDRD (±DN) versus isolated DN on the basis of clinical parameters.

Methods

Medical records of type 2 diabetes patients who underwent renal biopsy under suspicion of NDRD from January 2011 through November 2015 were analyzed retrospectively.

Results

A total of 101 patients were enrolled in this study. The most frequent indication for renal biopsy was recent onset of nephrotic syndrome (41%), followed by rapidly progressive renal failure (29%) and active urinary sediment (21%). On renal biopsy, 51% of patients had isolated DN, 20% had isolated NDRD and 29% had DN plus NDRD. IgA nephropathy was the most common cause of isolated NDRD, whereas acute tubular necrosis (39%) and acute interstitial nephritis (33%) were the main causes of NDRD superimposed on DN. Male gender, short-duration diabetes (<8 years), lower glycated hemoglobin and active urinary sediment (≥10 red and white blood cells per high-power field) were independent predictors of NDRD according to multiple logistic regression analysis.

Conclusions

Judicious use of renal biopsy revealed NDRD (±DN) in nearly half of type 2 diabetes patients with atypical renal presentation, especially in male patients with well-controlled diabetes, those who have had diabetes for a short duration and those with active urinary sediment.

Impact of single centre kidney paired donation transplantation to increase donor pool in India: a cohort study

In a living donor kidney transplantation (LDKT) dominated transplant programme, kidney paired donation (KPD) may be a cost-effective and valid alternative strategy to increase LDKT in countries with limited resources where deceased donation kidney transplantation (DDKT) is in the initial stages. Here, we report our experience of 300 single-centre KPD transplantations to increase LDKT in India. Between January 2000 and July 2016, 3616 LDKT and 561 DDKT were performed at our transplantation centre, 300 (8.3%) using KPD. The reasons for joining KPD among transplanted patients were ABO incompatibility (n = 222), positive cross-match (n = 59) and better matching (n = 19). A total of 124 two-way (n = 248), 14 three-way (n = 42), one four-way (n = 4) and one six-way exchange (n = 6) yielded 300 KPD transplants. Death-censored graft and patient survival were 96% (n = 288) and 83.3% (n = 250), respectively. The mean serum creatinine was 1.3 mg/dl at a follow-up of 3 ± 3 years. We credit the success of our KPD programme to maintaining a registry of incompatible pairs, counselling on KPD, a high-volume LDKT programme and teamwork. KPD is legal, cost effective and rapidly growing for facilitating LDKT with incompatible donors. This study provides large-scale evidence for the expansion of single-centre LDKT via KPD when national programmes do not exist.