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Huret P, Lopes P, Dardari R, Penfornis A, Thomas C, Dardari D. Rapid correction of hyperglycemia: A necessity but at what price? A brief report of a patient living with type 1 diabetes. World J Diabetes 2023; 14:1710-1716. [DOI: 10.4239/wjd.v14.i11.1710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/31/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND The correction and control of chronic hyperglycemia are the management goals of patients living with diabetes. Chronic hyperglycemia is the main factor inducing diabetes-related complications. However, in certain situations, the rapid and intense correction of chronic hyperglycemia can paradoxically favor the onset of microvascular complications.
CASE SUMMARY In this case report, we describe the case of a 25-year-old woman living with type 1 diabetes since the age of 9 years. Her diabetes was chronic and unstable but without complications. During an unplanned pregnancy, her diabetes was intensely managed with the rapid correction of her hyperglycemia. However, over the following 2 years, she developed numerous degenerative microvascular complications: Charcot neuroarthropathy with multiple joint involvement, severe proliferative diabetic retinopathy, gastroparesis, bladder voiding disorders, and end-stage renal failure requiring hemodialysis.
CONCLUSION In the literature to date, the occurrence of multiple microvascular complications following the rapid correction of chronic hyperglycemia has been rarely described in the same individual.
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Affiliation(s)
- Priscille Huret
- LBEPS, University Evry, IRBA, Université Paris Saclay, Evry 91000, France
| | - Philippe Lopes
- LBEPS, University Evry, IRBA, Université Paris Saclay, Evry 91000, France
| | | | - Alfred Penfornis
- Diabetology, Centre Hospitalier Sud Francilien, Corbeil Essonne 91100, France
| | - Claire Thomas
- LBEPS, University Evry, IRBA, Université Paris Saclay, Evry 91000, France
| | - Dured Dardari
- LBEPS, University Evry, IRBA, Université Paris Saclay, Evry 91000, France
- Diabetology, Centre Hospitalier Sud Francilien, Corbeil Essonne 91100, France
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2
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Fu EL, Evans M, Carrero JJ, Putter H, Clase CM, Caskey FJ, Szymczak M, Torino C, Chesnaye NC, Jager KJ, Wanner C, Dekker FW, van Diepen M. Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study. BMJ 2021; 375:e066306. [PMID: 34844936 PMCID: PMC8628190 DOI: 10.1136/bmj-2021-066306] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To identify the optimal estimated glomerular filtration rate (eGFR) at which to initiate dialysis in people with advanced chronic kidney disease. DESIGN Nationwide observational cohort study. SETTING National Swedish Renal Registry of patients referred to nephrologists. PARTICIPANTS Patients had a baseline eGFR between 10 and 20 mL/min/1.73 m2 and were included between 1 January 2007 and 31 December 2016, with follow-up until 1 June 2017. MAIN OUTCOME MEASURES The strict design criteria of a clinical trial were mimicked by using the cloning, censoring, and weighting method to eliminate immortal time bias, lead time bias, and survivor bias. A dynamic marginal structural model was used to estimate adjusted hazard ratios and absolute risks for five year all cause mortality and major adverse cardiovascular events (composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) for 15 dialysis initiation strategies with eGFR values between 4 and 19 mL/min/1.73 m2 in increments of 1 mL/min/1.73 m2. An eGFR between 6 and 7 mL/min/1.73 m2 (eGFR6-7) was taken as the reference. RESULTS Among 10 290 incident patients with advanced chronic kidney disease (median age 73 years; 3739 (36%) women; median eGFR 16.8 mL/min/1.73 m2), 3822 started dialysis, 4160 died, and 2446 had a major adverse cardiovascular event. A parabolic relation was observed for mortality, with the lowest risk for eGFR15-16. Compared with dialysis initiation at eGFR6-7, initiation at eGFR15-16 was associated with a 5.1% (95% confidence interval 2.5% to 6.9%) lower absolute five year mortality risk and 2.9% (0.2% to 5.5%) lower risk of a major adverse cardiovascular event, corresponding to hazard ratios of 0.89 (95% confidence interval 0.87 to 0.92) and 0.94 (0.91 to 0.98), respectively. This 5.1% absolute risk difference corresponded to a mean postponement of death of 1.6 months over five years of follow-up. However, dialysis would need to be started four years earlier. When emulating the intended strategies of the Initiating Dialysis Early and Late (IDEAL) trial (eGFR10-14 v eGFR5-7) and the achieved eGFRs in IDEAL (eGFR7-10 v eGFR5-7), hazard ratios for all cause mortality were 0.96 (0.94 to 0.99) and 0.97 (0.94 to 1.00), respectively, which are congruent with the findings of the randomised IDEAL trial. CONCLUSIONS Very early initiation of dialysis was associated with a modest reduction in mortality and cardiovascular events. For most patients, such a reduction may not outweigh the burden of a substantially longer period spent on dialysis.
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Affiliation(s)
- Edouard L Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Marie Evans
- Department of Clinical Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Fergus J Caskey
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Claudia Torino
- IFC-CNR, Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Nicholas C Chesnaye
- ERA-EDTA Registry, Department of Medical Informatics, Academic University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
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Durkin M, Blais J. Linear Projection of Estimated Glomerular Filtration Rate Decline with Canagliflozin and Implications for Dialysis Utilization and Cost in Diabetic Nephropathy. Diabetes Ther 2021; 12:499-508. [PMID: 33340064 PMCID: PMC7846621 DOI: 10.1007/s13300-020-00953-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Diabetes is a common cause of end-stage kidney disease leading to dialysis or kidney transplantation. Estimated glomerular filtration rate (eGFR) measures kidney function, and differences in the rate (slope) of eGFR decline can be used to assess treatment effects on kidney function over time. In the CREDENCE trial, the sodium glucose co-transporter 2 inhibitor canagliflozin slowed the rate of eGFR decline by 60% compared to placebo in patients with diabetes and chronic kidney disease. This analysis utilized eGFR slopes from CREDENCE to estimate the difference in time to dialysis by treatment arm and estimated the economic value of that delay. METHODS A linear decline in eGFR and maintenance of stable therapy were assumed for the canagliflozin and placebo arms in CREDENCE. Mean eGFR over time was calculated using acute (baseline to week 3) and chronic (week 3 onward) slopes. Reaching eGFR of 10 ml/min/1.73 m2 was assumed to represent the need for chronic dialysis. The difference in time to dialysis between treatments was calculated. Based on the average duration of dialysis, annual dialysis costs were determined, discounting 2020 US dollars at an inflation rate of 4%. RESULTS Following the acute and chronic eGFR slopes, the projected time to dialysis was 22.85 years for canagliflozin and 9.90 years for placebo. Based on 95% confidence intervals from CREDENCE, the model-estimated difference in time to dialysis was 9.27-17.48 years. With a mean baseline participant age of 63 years, the delay in dialysis with canagliflozin would be associated with a reduction in dialysis costs of approximately $170,000 per patient in 2020 dollars. CONCLUSION Using clinical trial data, canagliflozin treatment was projected to delay dialysis by approximately 13 years, which could translate to a substantial cost savings. More precise estimates should be investigated with considerations for nonlinear eGFR slope trajectory, competing risks, and patient characteristics. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02065791.
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Affiliation(s)
- Michael Durkin
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA.
| | - Jaime Blais
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
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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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Peng Y, Yang X, Chen W, Yu XQ. Association between timing of peritoneal dialysis initiation and mortality in end-stage renal disease. Chronic Dis Transl Med 2018; 5:37-43. [PMID: 30993262 PMCID: PMC6449773 DOI: 10.1016/j.cdtm.2018.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Indexed: 12/23/2022] Open
Abstract
Despite the widespread use of chronic dialysis for end-stage renal disease (ESRD), there is no consensus on the optimal timing of initiating renal replacement therapy. Over the past decade, a worldwide trend toward increasing glomerular filtration rate at the initiation of dialysis has been noted. However, available data indicate that early dialysis has no survival benefit or is harmful. Peritoneal dialysis (PD) is one alternative for ESRD and has potential survival factors different from those of hemodialysis. The association between the timing of PD initiation and survival is unclear. This review examines the effect of the timing of dialysis on clinical outcomes in PD patients.
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Affiliation(s)
- Yuan Peng
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510080, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong 510080, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510080, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong 510080, China
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510080, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong 510080, China
| | - Xue-Qing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510080, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong 510080, China
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Piccoli GB, Nielsen L, Gendrot L, Fois A, Cataldo E, Cabiddu G. Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status. J Clin Med 2018; 7:E331. [PMID: 30297628 PMCID: PMC6210736 DOI: 10.3390/jcm7100331] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022] Open
Abstract
There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a "one size fits all" rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: "good dialysis" should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis "menu".
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Affiliation(s)
- Giorgina Barbara Piccoli
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Ospedale san Luigi, Regione Gonzole, 10100 Torino, Italy.
| | - Louise Nielsen
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Lurilyn Gendrot
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Antioco Fois
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Emanuela Cataldo
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Nefrologia, Università Aldo Moro, Piazza Umberto I, 70121 Bari, Italy.
| | - Gianfranca Cabiddu
- Nefrologia Ospedale Brotzu, Piazzale Alessandro Ricchi, 1, 09134 Cagliari, Italy.
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7
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Yang X, Liu S, Zhang R, Sun B, Zhou S, Chen R, Yu P. Microribonucleic acid-192 as a specific biomarker for the early diagnosis of diabetic kidney disease. J Diabetes Investig 2017; 9:602-609. [PMID: 28940849 PMCID: PMC5934266 DOI: 10.1111/jdi.12753] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/18/2017] [Accepted: 09/13/2017] [Indexed: 01/08/2023] Open
Abstract
AIMS/INTRODUCTION To evaluate the diagnostic value of microribonucleic acid (miR) as biomarkers in patients with diabetic kidney disease (DKD). MATERIALS AND METHODS A total of 230 diabetes mellitus patients and 53 healthy participants were enrolled, and the diabetes mellitus group was further divided into normoalbuminuria, microalbuminuria and large amount of albuminuria group. MiRs of serum and urine were quantificated using real-time polymerase chain reaction. General clinical information was collected and analyzed for the risk factors. Cut-off values of diagnosis sensitivity were determined by receiver operating characteristic curves and the Youden Index. RESULTS Compared with the healthy participants, the expression of miR-192 in serum decreased, whereas in urine it increased with the progression of DKD. The expression of both serum and urine miR-126 increased in the diabetes mellitus group, but no significant change was obtained among the DKD groups. The area under the curve receiver operating characteristic of both serum and urine miR-192 was higher than that of the albumin-to-creatinine ratio. Combined detection of urine and serum miR-192 has a higher specificity and lower misdiagnosis rate. CONCLUSIONS Both serum and urinary miR-192 could be a potential biomarker of DKD, playing a crucial role in the prevention and treatment of DKD.
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Affiliation(s)
- Xinyi Yang
- Key Laboratory of Hormones and Development (Ministry of Health)Metabolic Diseases Hospital & Tianjin Institute of EndocrinologyTianjin Medical UniversityTianjinChina
| | - Shuaihui Liu
- Key Laboratory of Hormones and Development (Ministry of Health)Metabolic Diseases Hospital & Tianjin Institute of EndocrinologyTianjin Medical UniversityTianjinChina
| | - Rui Zhang
- Key Laboratory of Hormones and Development (Ministry of Health)Metabolic Diseases Hospital & Tianjin Institute of EndocrinologyTianjin Medical UniversityTianjinChina
| | - Bei Sun
- Key Laboratory of Hormones and Development (Ministry of Health)Metabolic Diseases Hospital & Tianjin Institute of EndocrinologyTianjin Medical UniversityTianjinChina
| | - Saijun Zhou
- Key Laboratory of Hormones and Development (Ministry of Health)Metabolic Diseases Hospital & Tianjin Institute of EndocrinologyTianjin Medical UniversityTianjinChina
| | - Rui Chen
- Key Laboratory of Hormones and Development (Ministry of Health)Metabolic Diseases Hospital & Tianjin Institute of EndocrinologyTianjin Medical UniversityTianjinChina
| | - Pei Yu
- Key Laboratory of Hormones and Development (Ministry of Health)Metabolic Diseases Hospital & Tianjin Institute of EndocrinologyTianjin Medical UniversityTianjinChina
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Abstract
The optimal timing of initiation of maintenance dialysis in patients with end-stage renal disease currently is unknown. This transition period is one of exceptionally high vulnerability for patients; annual mortality rates in stage 5 chronic kidney disease through the first year of maintenance dialysis exceed 20%. The results of the Initiating Dialysis Early and Late (IDEAL) study, a randomized trial that tested the impact of dialysis initiation at two different levels of kidney function on outcomes, showed no significant difference in survival or other patient-centered outcomes between treatment groups. These data have challenged the established paradigm of using estimates of glomerular filtration as the primary guide for initiation of maintenance dialysis and illustrate the compelling need for research to optimize the high-risk transition period from chronic kidney disease to end-stage renal disease. This article reviews the findings of the IDEAL study and summarizes the evolution of research findings, updated clinical practice guidelines, and trends in dialysis initiation practices in the United States in the 6 years since the publication of the results from IDEAL. Complementary strategies to the use of estimated glomerular filtration rate to optimally time the initiation of maintenance dialysis and potentially improve patient-centered outcomes also are considered.
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Affiliation(s)
- Matthew B Rivara
- Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, WA.
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, WA
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