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

INTRODUCTION

Diabetes mellitus (DM) is a leading cause of end-stage kidney disease (ESKD). We provide the first description of DM prevalence, related outcomes, and the hemoglobin A1c (HbA1c)/mortality relationship in national hemodialysis (HD) patient samples across the Gulf Cooperation Council (GCC) countries.

METHODS

We analyzed data from the prospective Dialysis Outcomes and Practice Patterns Study (DOPPS) in the GCC (2012-2018, N = 2274 HD patients ≥18 years old). Descriptive statistics were calculated, and all-cause mortality was analyzed for patients with DM versus without DM and by HbA1c levels in patients with DM by Cox regression with progressive confounder adjustments.

RESULTS

DM in the GCC ranged from 45% to 74% in patients with HD by country. Patients with DM were 13 years older (59.9 vs. 46.7 years) and had greater body mass index (BMI), shorter median years on dialysis (1.5 vs. 3.0 years), and higher comorbidity burden. In patients with DM, insulin use was 26% to 50% across countries, with variable oral antidiabetic drug use (2%-32%); median HbA1c levels were 6.1% to 7.5% across countries. Patients with DM (vs. without DM) had higher crude death rates (15.6 vs. 6.2 deaths per 100 patient-years, mean follow-up 1.3 years) and adjusted mortality (hazard ratio [HR] = 1.72 [95% CI 1.23-2.39]). In patients with DM, mortality was lowest at HbA1c 6.5% to 7.5%, with mortality particularly elevated at high HbA1c >9% (HR = 2.13 [95% CI 1.10-4.10]).

CONCLUSION

Patients with DM in the GCC have high comorbidity burden and mortality rates despite a relatively young mean age. In GCC countries, a holistic strategy for improving diabetes care and outcomes for HD patients is needed at the primary, secondary, and tertiary levels.

Shenqi Jiangtang Granule Ameliorates Kidney Function by Inhibiting Apoptosis in a Diabetic Rat Model

Diabetic nephropathy (DN) is a major microvascular complication of diabetes. In addition to moderating hyperglycemia, Shenqi Jiangtang Granule (SJG) had a beneficial effect on kidney function in a clinical trial. However, the mechanism involved remains unclear. This study was conducted to identify the underlying molecular mechanisms. A diabetic rat model was generated by using a high-fat diet and streptozotocin (STZ) injection. Then, rats were given SJG at dosages of 400 mg/kg/d or 800 mg/kg/d by gavage for 8 weeks. After 8 weeks of treatment, blood glucose, serum creatinine, blood urea nitrogen (BUN), and 24-h urinary albumin were measured. Histochemical staining and TdT-mediated dUTP nick-end labeling (TUNEL) assays were performed in kidney. Kidney genomic expression in the SJG-treated group and diabetic group was detected by using a genome expression microarray. We found that SJG treatment reduced blood glucose, serum creatinine, BUN, and 24-h urinary albumin and affected kidney histology. The gene array revealed that the expression of 99 genes increased and the expression of 91 genes decreased in the HSJG group, compared with those of in the diabetic group. Pathway and gene ontology analysis of the differentially expressed genes showed an enrichment of the apoptosis pathway. SJG treatment reduced TUNEL- and caspase-3-positive cells in diabetic kidneys. SJG upregulated Bcl-2 and regucalcin expressions and reduced casp3 and Apaf1 expressions in diabetic rats. Our results suggest that SJG exerts a renal protective effect through the inhibition of cell apoptosis in a diabetic rodent model.

Cost of diabetic eye, renal and foot complications: a methodological review

INTRODUCTION

Diabetic retinopathy (DR), diabetic kidney disease (DKD) and diabetic foot ulcer (DFU) represent a public health and economic concern that may be assessed with cost-of-illness (COI) studies.

OBJECTIVES

(1) To review COI studies published between 2000 and 2015, about DR, DKD and DFU; (2) to analyse methods used.

METHODS

Disease definition, epidemiological approach, perspective, type of costs, activity data sources, cost valuation, sensitivity analysis, cost discounting and presentation of costs may be described in COI studies. Each reviewed study was assessed with a methodological grid including these nine items.

RESULTS

The five following items have been detailed in the reviewed studies: epidemiological approach (59 % of studies described it), perspective (75 %), type of costs (98 %), activity data sources (91 %) and cost valuation (59 %). The disease definition and the presentation of results were detailed in fewer studies (respectively 50 and 46 %). In contrast, sensitivity analysis was only performed in 14 % of studies and cost discounting in 7 %. Considering the studies showing an average cost per patient and per year with a societal perspective, DR cost estimates were US $2297 (range 5-67,486), DKD cost ranged from US $1095 to US $16,384, and DFU cost was US $10,604 (range 1444-85,718).

DISCUSSION

This review reinforces the need to adequately describe the method to facilitate literature comparisons and projections. It also recalls that COI studies represent complementary tools to cost-effectiveness studies to help decision makers in the allocation of economic resources for the management of DR, DKD and DFU.

Economic evaluations of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in type 2 diabetic nephropathy: a systematic review

Background

Structured comparison of pharmacoeconomic analyses for ACEIs and ARBs in patients with type 2 diabetic nephropathy is still lacking. This review aims to systematically review the cost-effectiveness of both ACEIs and ARBs in type 2 diabetic patients with nephropathy.

Methods

A systematic literature search was performed in MEDLINE and EMBASE for the period from November 1, 1999 to Oct 31, 2011. Two reviewers independently assessed the quality of the articles included and extracted data. All cost-effectiveness results were converted to 2011 Euros.

Results

Up to October 2011, 434 articles were identified. After full-text checking and quality assessment, 30 articles were finally included in this review involving 39 study settings. All 6 ACEIs studies were literature-based evaluations which synthesized data from different sources. Other 33 studies were directed at ARBs and were designed based on specific trials. The Markov model was the most common decision analytic method used in the evaluations. From the cost-effectiveness results, 37 out of 39 studies indicated either ACEIs or ARBs were cost-saving comparing with placebo/conventional treatment, such as amlodipine. A lack of evidence was assessed for valid direct comparison of cost-effectiveness between ACEIs and ARBs.

Conclusion

There is a lack of direct comparisons of ACEIs and ARBs in existing economic evaluations. Considering the current evidence, both ACEIs and ARBs are likely cost-saving comparing with conventional therapy, excluding such RAAS inhibitors.

Effects of bariatric surgery on diabetic nephropathy after 5 years of follow-up

BACKGROUND

Studies have reported that the benefits of bariatric surgery extend beyond durable weight loss and include significant improvement in glycemic control. We hypothesized that improving diabetes control may have positive effects on end-organ complications of this disease, such as diabetic nephropathy (DN).

METHODS

We identified all patients with type 2 diabetes mellitus (T2DM) who underwent bariatric surgery at our institution and had completed a 5-year follow-up. Patients' current diabetes status (remission, improvement, or no change) was determined by biochemical analyses and medication review. The presence of DN, preoperatively and postoperatively, was determined by urinary albumin/creatinine ratio (uACR).

RESULTS

Fifty-two T2DM patients underwent bariatric surgery and had completed 5-year follow-up, including serial uACR measurements (25% male; age 51.2 ± 10.1 years). Preoperative body mass index (BMI) was 49 ± 8.7 kg/m(2), mean duration of T2DM was 8.6 years (range .3-39), and baseline HbA(1c) was 7.7% ± 1.4%. DN, as indicated by microalbuminuria (30-300 mg/g) or macroalbuminuria (>300 mg/g), was present in 37.6% preoperatively. Of these, DN resolved in 58.3% at a mean follow-up of 66 months (range 60-92 ). Among those with no evidence of DN preoperatively, albuminuria proceeded to develop 5 years later in only 25%. The 5-year remission and improvement rates for T2DM were 44% and 33%, respectively. Mean reductions in fasting glucose and glycosylated hemoglobin (HbA(1c)) were 36.6 mg/dL and 1.2%, respectively.

CONCLUSION

Bariatric surgery can induce a significant and sustainable improvement in T2DM and improve or halt the development of microvascular complications such as nephropathy. Considering that diabetes is often a progressive disease, these results are clinically important and warrant further investigation.

Proteinuria versus albuminuria in chronic kidney disease

Chronic kidney disease (CKD) is defined according to a decrease in the glomerular filtration rate and kidney damage such as proteinuria or albuminuria. Dip-stick proteinuria is only sensitive to albumin and correlates poorly with quantitative 24 h proteinuria, the most commonly used measure in renoprotective randomized controlled clinical trials (RCT). The amount of proteinuria correlates with the efficacy of angiotensin-converting enzyme inhibitors in non-diabetics in RCT. Random urine protein to creatinine ratio (PCR) or albumin to creatinine ratio (ACR) correlates with 24 h urinary excretion. Dip-stick proteinuria correlates poorly with ACR, while PCR correlates reasonably well with ACR. Because of a high analytical variability, efforts are in progress to standardize ACR (but not PCR) measurement. There have been no studies on the direct comparison between proteinuria and albuminuria in terms of utilities (biomarker, surrogate end-point and cost-effectiveness). In this regard, both proteinuria and albuminuria are good biomarkers for cardiovascular events, renal events or mortality. However, there are limitations in RCT regarding the validity of proteinuria or albuminuria as a surrogate end-point. In contrast, measuring proteinuria or albuminuria followed by treatment with angiotensin inhibitors is cost-effective for diabetics, hypertension and aging. CKD guidelines differ in their opinions regarding the choice between ACR and PCR. Based on the current evidence, ACR might be recommended for the diabetics and PCR for the non-diabetics.

Uremia (end-stage renal disease): how cost-effective are preventive strategies?

Many strategies have been shown to be cost-effective for prevention of end-stage renal disease (ESRD), most often by Markov modeling using assumptions based on randomized clinical trails and observational studies. Targeted screening for proteinuria in diabetics and in hypertensive patients is cost-effective for prevention of ESRD, but such screening is not cost-effective when applied to the general population. Screening for chronic kidney disease based on estimated glomerular filtration rate alone is not recommended. Perhaps, treatment of all newly diagnosed type 2 diabetics with an inhibitor of angiotensin-II without screening for proteinuria will also prevent or delay ESRD in a cost-effective manner. Intensive interventions and the use of angiotensin-II inhibition in incipient and overt nephropathy in type 1 and type 2 diabetes is also cost-effective in preventing ESRD. Rigorous control of blood pressure to desired targets also lowers the risks of ESRD in both diabetic and nondiabetic nephropathies, most likely in a cost-effective manner. Newer strategies involving statins and new combinations of agents are emerging but have not yet been tested for their cost-effectiveness in preventing ESRD cost-effectiveness.