Avoidable Iatrogenic Hypoglycemia in Patients on Peritoneal Dialysis: The Risks of Nonspecific Glucose Monitoring Devices and Drug-Device Interaction

Does Acinetobacter calcoaceticus glucose dehydrogenase produce self-damaging H2O2?

The soluble glucose dehydrogenase (sGDH) from Acinetobacter calcoaceticus has been widely studied and is used, in biosensors, to detect the presence of glucose, taking advantage of its high turnover and insensitivity to molecular oxygen. This approach, however, presents two drawbacks: the enzyme has broad substrate specificity (leading to imprecise blood glucose measurements) and shows instability over time (inferior to other oxidizing glucose enzymes). We report the characterization of two sGDH mutants: the single mutant Y343F and the double mutant D143E/Y343F. The mutants present enzyme selectivity and specificity of 1.2 (Y343F) and 5.7 (D143E/Y343F) times higher for glucose compared with that of the wild-type. Crystallographic experiments, designed to characterize these mutants, surprisingly revealed that the prosthetic group PQQ (pyrroloquinoline quinone), essential for the enzymatic activity, is in a cleaved form for both wild-type and mutant structures. We provide evidence suggesting that the sGDH produces H2O2, the level of production depending on the mutation. In addition, spectroscopic experiments allowed us to follow the self-degradation of the prosthetic group and the disappearance of sGDH's glucose oxidation activity. These studies suggest that the enzyme is sensitive to its self-production of H2O2. We show that the premature aging of sGDH can be slowed down by adding catalase to consume the H2O2 produced, allowing the design of a more stable biosensor over time. Our research opens questions about the mechanism of H2O2 production and the physiological role of this activity by sGDH.

Managing Hospitalized Peritoneal Dialysis Patients: Ten Practical Points for Non-Nephrologists

Although nephrologists are responsible for the long-term care of dialysis patients, physicians from all disciplines will potentially be involved in the management of patients with kidney failure, including patients on peritoneal dialysis, the major home-based form of kidney-replacement therapy. This review aims to fill knowledge gaps of non-experts in peritoneal dialysis and to highlight key management aspects of in-hospital care of patients on peritoneal dialysis, with a focus on acute scenarios to facilitate prompt decision-making. The clinical pearls provided should enable non-nephrologists to avoid common pitfalls in the initial assessment of peritoneal dialysis-related complications and guide their decision regarding when to refer their patients to a specialist, resulting in improved multidisciplinary patient care.

When ESKD complicates the management of diabetes mellitus

Given the increased incidence and prevalence of ESKD (end-stage kidney disease) attributed to diabetes mellitus, it is important to consider the physiological and global sociodemographic factors that give rise to unique challenges in providing excellent care to this population. The individual with diabetes and ESKD faces alterations of glucose homeostasis that require close therapeutic attention, as well as the consideration of safe and effective means of maintaining glycemic control. Implementation of routine monitoring of blood glucose and thoughtful alteration of the individual's hypoglycemic drug regimen must be employed to reduce the risk of neurological, cardiovascular, and diabetes-specific complications that may arise as a result of ESKD. Titration of insulin therapy may become quite challenging, as kidney replacement therapy often significantly impacts insulin requirements. New medications have significantly improved the ability of the clinician to provide effective therapies for the management of diabetes, but have also raised an equal amount of uncertainty with respect to their safety and efficacy in the ESKD population. Additionally, the clinician must consider the challenges related to the delivery of kidney replacement therapy, and how inter-modality differences may impact glycemic control, diabetes, and ESKD-related complications, and issues surrounding dialysis vascular access creation.

Critical Care Glucose Point-of-Care Testing

Maintaining blood glucose concentration within an acceptable range is a goal for patients with diabetes mellitus. Point-of-care glucose meters initially designed for home self-monitoring in patients with diabetes have been widely used in the hospital settings because of ease of use and quick reporting of blood glucose information. They are not only utilized for the general inpatient population but also for critically ill patients. Many factors affect the accuracy of point-of-care glucose testing, particularly in critical care settings. Inaccurate blood glucose information can result in unsafe insulin delivery which causes poor glucose control and can be fatal. Healthcare professionals should be aware of the limitations of point-of-care glucose testing. This chapter will first introduce glucose regulation in diabetes mellitus, hyperglycemia/hypoglycemia in the intensive care unit, importance of glucose control in critical care patients, and pathophysiological variables of critically ill patients that affect the accuracy of point-of-care glucose testing. Then, we will discuss currently available point-of-care glucose meters and preanalytical, analytical, and postanalytical sources of variation and error in point-of-care glucose testing.

Practical considerations when prescribing icodextrin: a narrative review

BACKGROUND

Icodextrin is a peritoneal dialysis solution that is commonly used to increase ultrafiltration during the long dwell. The other major clinical benefit of icodextrin is that it is glucose-sparing, which may help preserve peritoneal membrane function. Since it has a different chemical composition than dextrose, and with its increasing use, there are several clinical considerations healthcare providers must familiarize themselves with prior to prescribing icodextrin.

SUMMARY

Failure to recognize these special properties of icodextrin can lead to adverse events reaching patients. This narrative review explores the hemodynamic, metabolic, and idiopathic effects of icodextrin to facilitate the safe use of icodextrin in peritoneal dialysis.

KEY MESSAGES

Hemodynamic effects include hypotension from enhanced ultrafiltration contributing to loss of residual kidney function. Metabolic effects include the chemical structure of icodextrin interfering with biochemical assays, resulting in misleading glucose readings on non-specific glucometers. Idiopathic adverse effects include a diffuse rash and sterile peritonitis. It is also important to remember that not all antibiotic combinations have undergone stability testing in icodextrin. This narrative review will help healthcare providers to confidently prescribe icodextrin to maximize its benefit in peritoneal dialysis patients.