Clinical outcomes and quality of life in hemodialysis diabetic patients versus non-diabetics

Five-year survival analysis and predictors of mortality of adult hemodialysis patients in Indonesia: a nationwide database analysis

BACKGROUND

Hemodialysis (HD) is the modality of renal replacement therapy (RRT) with the highest mortality rate. The identification of prognostic factors will help achieve better outcomes among HD patients. In this study, we sought to conduct a survival analysis and determine the predictors of mortality among adult Indonesian HD patients using data obtained from Indonesian Renal Registry (IRR).

METHODS

This is a retrospective cohort study which reviewed all adult hemodialysis patients in Indonesia based on the records of IRR during 2007-2022. Variables analyzed in this study include age, sex, etiology of CKD, cause of death, HD frequency, and initial vascular access. A 5-year follow-up was performed until the outcome of death or drop out was found.

RESULTS

Among 99,552 eligible patients, the mean survival length was 1536.21 ± 2.50 days. The 5-year survival rate was 77%. Cox proportional hazard regression model revealed demographic and clinical characteristics that are significantly associated with mortality: male sex (HR: 1.038, 95% CI 1.002-1.075), age of 60 years or older (HR: 1.329, 95% CI 1.281-1.379), diabetic nephropathy (HR: 1.347, 95% CI 1.249-1.452), twice-weekly hemodialysis frequency (HR: 1.080, 95% CI 1.011-1.155), initial vascular accesses with femoral vein puncture (HR: 2.710, 95% CI 2.568-2.860), and CVC (HR: 2.992, 95% CI 2.848-3.144).

CONCLUSIONS

The 5-year survival rate of Indonesian HD patients is 77. Male sex, age of HD onset at 60 years or older, diabetic nephropathy, twice-weekly HD frequency, and the initial vascular accesses with femoral vein puncture and CVC are associated with increased risk of mortality.

The Prognostic Role of Serum β-Trace Protein Levels among Patients on Maintenance Hemodialysis

Cardiovascular (CV) diseases are the most commonly encountered etiology of mortality in patients having kidney failure. β-Trace protein (BTP) is a biomarker of glomerular filtration function as well as a potential predictor of adverse CV outcomes. This study aimed to determine the prognostic value of BTP in patients on chronic hemodialysis (HD). A total of 96 patients undergoing HD were enrolled. Baseline variables were collected, and the patients were tracked for 3 years. Twenty-five patients died at 3 years. Those who experienced mortality were noted to have higher serum concentrations of BTP and a higher incidence of diabetes mellitus (DM). The area under the receiver operating characteristic curve for serum BTP distinguishing mortality from survival was 0.659 (95% confidence interval [CI], 0.555-0.752; p = 0.027). After the adjustment of variables potentially affecting survival rates, BTP levels above the median (adjusted hazard ratio [aHR]: 2.913, 95% CI, 1.256-6.754; p = 0.013), the presence of DM (aHR: 2.474, 95% CI, 1.041-5.875; p = 0.040), and low serum albumin (aHR: 0.298, 95% CI, 0.110-0.806; p = 0.017) independently correlated with survival in HD patients. Serum BTP is a novel biomarker for predicting overall outcomes in HD patients.

Associations of Estradiol With Mortality and Health Outcomes in Patients Undergoing Hemodialysis: A Prospective Cohort Study

Background

Both lower and higher estradiol (E2) levels have been associated with increased mortality among women with kidney failure. However, robust data are still lacking.

Objective

We investigated the interaction of diabetes and age on linear and nonlinear associations between E2 levels, adverse outcomes, and health-related quality of life (HRQOL) in Canadian women undergoing hemodialysis (HD).

Design

Population-based cohort study; data from Canadian Kidney Disease Cohort Study (CKDCS).

Setting & patients

A total of 427 women undergoing HD enrolled in the CKDCS.

Measurements

Baseline E2 (in pmol/L) and E2 tertiles (<38 pmol/L, 38-95 pmol/L, >95 pmol/L).

Methods

Cox-proportional hazards used for all-cause and cardiovascular disease (CVD) mortality. Fine-Gray models used for incident CVD. Mixed models used for Health Utilities Index Mark 3 (HUI3), Kidney Disease Quality of Life Physical Component Scores (KDQOL12-PCS), and Mental Component Scores (KDQOL12-MCS).

Results

Over a median follow-up of 3.6 (interquartile range [IQR]: 1.6-7.5) years, 250 (58.6%) participants died; 74 deaths (29.6%) were CV-related. Among 234 participants without prior CV events, 80 (34.2%) had an incident CVD event. There were no significant linear associations between E2 and all-cause mortality, CVD mortality, and incident CVD. However, E2 showed a significant concave association with all-cause mortality, but not with CVD mortality and incident CVD. Among patients aged ≥63 years, higher E2 levels were associated with lower HUI3 scores, mean difference (MD) = -0.062 per 1 - SD pmol/L, 95% confidence interval (CI) = -0.112 to -0.012, but the opposite was observed in younger patients (<63 years) in whom higher E2 levels were associated with higher HUI3 scores (MD = 0.032 per 1 - SD pmol/L, 95% CI = 0.008-0.055), Pinteraction = .045. No associations were observed among E2, KDQOL12-PCS (MD = -0.15 per 1 - SD pmol/L, 95% CI = -1.15 to 0.86), and KDQOL12-MCS (MD = -0.63 per 1 - SD pmol/L, 95% CI = -1.82 to 0.57).

Limitations

Unmeasured confounding and small sample size.

Conclusions

The association between E2 and all-cause mortality may be nonlinear, while no association was observed for CVD mortality, incident CVD, KDQOL12-PCS, and KDQOL12-MCS. Furthermore, the association between serum E2 and HUI3 was modified by age: Higher levels were associated with higher utility among women aged <63 years and the converse observed among older women.

Characteristics and 1-year survival of incident patients on chronic peritoneal dialysis compared with hemodialysis:a large 11-year cohort study

PURPOSE

Few studies have evaluated patients' characteristics and survival by dialysis modality in Brazil. We evaluated changes in dialysis modality and its survival in the country.

METHODS

This is a retrospective database of a cohort with incident chronic dialysis patients from Brazil. Patients' characteristics and one-year multivariate survival risk were assessed considering dialysis modality from 2011 to 2016 and 2017 to 2021. Survival analysis was also performed on a reduced sample after adjustment using propensity score matching.

RESULTS

Of the 8295 dialysis patients, 5.3% were on peritoneal dialysis (PD) and 94.7% on hemodialysis (HD). PD patients had higher BMI, schooling and the prevalence of elective dialysis starting in the first period than those on HD. In the second period, PD patients were predominantly women, non-white, from the Southeast region, and funded by the public health system, having more frequent elective dialysis starting and predialysis nephrologist follow-ups than those on HD. There was no difference in mortality comparing PD and HD (HR 0.67, 95% CI 0.39-2.42; and HR 1.17, 95% CI 0.63-2.16; first and second period, respectively). This non-significantly different survival between both dialysis methods was also found in the reduced matched sample. Higher age and non-elective dialysis initiation were associated with higher mortality. In the second period, the lack of predialysis nephrologist follow-up and living in the Southeast region increased the mortality risk.

CONCLUSION

Some sociodemographic factors have changed according to dialysis modality over the last decade in Brazil. The one-year survival of the two dialysis methods was comparable.

The structure of mineral and bone disorders in patients with сhronic kidney disease of the 5th dialysis stage, taking into account the presence or absence of a diagnosis of type 1 diabetes mellitus

BACKGROUND: In patients with end-stage CKD, receiving renal replacement therapy (RRT) with programmed hemodialysis (HD), the severity of complications is associated with metabolic disturbances: accumulation of uremic toxins, nephrogenic anemia, secondary hyperparathyroidism (SHPT), extraskeletal calcification, impaired clearance and rhythm of hormone secretion.

AIM: To evaluate the main biochemical and hormonal parameters, and manifestations of mineral bone disease (MBD) in patients receiving RRT with HD, before and after hemodialysis, taking into account the presence or absence of diabetes mellitus.

MATERIALS AND METHODS: We divided all patients receiving RRT with HD in two groups: #1 (n=24) — patients with DM, #2 (n=16) — patients without DM. All of them had their blood analyzed before and immediately after the HD. Data analysis was performed with the Statistica 13 (StatSoft, USA). A prognostically significant model was considered at p<0.05.

RESULTS: The level of iPTH, both at baseline and after HD, was lower in group #1 (p<0.001). The level of alkaline phosphatase (AP) was significantly higher in group #2 (p=0.012). In both groups before HD, a high incidence of hypocalcemia was detected (according to albumin-corrected calcium in group #1 in 58.3%, in group #2 in 43.7% of cases, p = 0.366) and hyperphosphatemia (in 66.7% and in 43 .7% of cases, respectively, p=0.151). Hypocalcemia after HD in group #1 persisted in 14%, in group #2 — in 20% of cases (p>0.05); hyperphosphatemia in group #1 was completely leveled, in group #2 it persisted in 7% of cases (p=0.417). Prior to the HD session, group #1 had significantly higher levels of RAGE, glucagon, immunoreactive insulin (IRI), cortisol, and glucose than after the HD session (p<0.05). In group #2, after HD, the levels of glucagon, IRI and cortisol significantly decreased (p<0.05), and the level of 3-nitrotyrosine (3-HT) increased significantly (p=0.026). In group #1, fibrocalcinosis of the heart valves according to ECHO and calcification of the arteries of the lower extremities according to ultrasonic doplerography were more common than in group #2 (42% vs 25%, p<0.001 and 75% vs 37.5%, p=0.018, respectively). (χ2)). Compression fractures occurred with the same frequency in both groups (60%). A decrease in bone mineral density (BMD) to the level of osteopenia was noted more often in group #1 (50% vs 18.8%), and osteoporosis was more common in group #2 (68.8% vs 33.3%) (p<0.001, χ2).

CONCLUSION: The low level of PTH in group #1 may reflect the effect of diabetes on calcium-phosphorus metabolism. Patients with DM have an increased risk of renal osteodystrophy with a low bone turnover because of a number of metabolic factors inherent in diabetes. At the same time, the dynamics of phosphorus and calcium indicators during the HD procedure were similar.

The value of administering intravenous antibiotics during haemodialysis in the treatment of diabetic foot infections

OBJECTIVE

People with diabetes who are on haemodialysis (HD) are at a high risk of diabetic foot infections (DFI) and related complications. We explored the value of treating DFI with intravenous (IV) antibiotics during HD.

METHOD

This was an observational study of consecutively treated patients with DFIs with IV antibiotics during HD. Data collected included baseline characteristics, IV antibiotics used, details of multidisciplinary interventions and DFI treatment outcome.

RESULTS

A cohort of 11 patients, mean (±standard deviation) age 62.4±12.7 years, had 15 episodes of treatment with IV antibiotics during HD. Of the patients, six (54.5%) were male and nine (81.8%) had type 2 diabetes. The estimated mean glomerular filtration rate (eGFR) was 11.4±3.9ml/minute. All patients had infected foot ulceration, soft tissue infection, six (54.5%) patients had osteomyelitis, and two (18.2%) had wet gangrene. The commonest IV antibiotic used was vancomycin (10/15 episodes, 66.7%). Other IV antibiotics used were daptomycin and meropenem. In three episodes, oral ciprofloxacin was used with IV antibiotics. The mean duration of antibiotic treatment was 9.2±4.9 weeks. Of the episodes, 11 (73.3%) were treated successfully with IV antibiotics alone and two (13.3%) episodes required minor surgical debridement/amputation. Some 10 (90.9%) members of the cohort had peripheral arterial disease and of those, five (50%) underwent angioplasty during IV antibiotic treatment.

CONCLUSION

HD provides a good opportunity for treatment with IV antibiotics in DFI. This mode of administration of IV antibiotics, along with multidisciplinary intervention, is associated with ulcer healing and resolution of infection in over three-quarters of patients with DFI.

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Diabetes and Mortality among Patients with Chronic Kidney Disease and COVID-19: A Systematic Review, Meta-analysis, and Meta-regression

Introduction

Patients with kidney disease and COVID-19, whether on hemodialysis (HD) or not, have a higher risk of contracting COVID-19 accompanied by a higher mortality rate due to suppressed immune functions. Diabetes, one of the ubiquitous etiology of kidney disease, is also associated with a composite of poor outcomes.

Methods

Meta-analysis and meta-regression of 13 articles on COVID-19 patients with chronic kidney disease, with information on diabetes and mortality were performed using Review Manager 5.4 and OpenMetaAnalyst.

Results

The meta-analysis of a pooled subject of 18,822 patients showed that the presence of diabetes in CKD patients with COVID-19 was associated with an increased risk of mortality (RR 1.41 (1.15, 1.72); P < 0.001; I2 70%, P < 0.001). Subgroup analysis showed that diabetes was not associated with mortality in the HD group (RR 1.27 (1.06, 1.54); P = 0.01; I2 0%, P = 0.70) but showed a significant association in the non-HD group (RR 1.66 (1.59, 1.73); P < 0.001; I2 85%, P < 0.001). Male gender (P = 0.070) contributed to the effect size differences (age: P < 0.001; hypertension: P = 0.007; CVD: P < 0.001; lung disease: P < 0.001).

Conclusions

Diabetes was associated with higher mortality risk among CKD patients, primarily those who did not need RRT.

Effect of anti-diabetic drugs in dialysis patients with diabetes: a nationwide retrospective cohort study

BACKGROUND

Type 2 diabetes mellitus is common in patients undergoing dialysis. However, the association between anti-diabetic drug use and survival outcomes is rarely discussed. We aimed to investigate whether continued anti-diabetic medication use affects the survival of diabetic dialysis patients and whether different hypoglycemic drug use influences prognosis.

METHODS

Using a nationwide database, we enrolled patients with incident end-stage renal disease under maintenance dialysis during 2011-2015 into the pre-existing diabetes dialysis (PDD), incident diabetes after dialysis (IDD), and non-diabetic dialysis (NDD) groups. The PDD group was further subclassified into patients who continued (PDD-M) and discontinued (PDD-NM) anti-diabetic drug use after dialysis.

RESULTS

A total of 5249 dialysis patients were examined. The PDD-NM group displayed a significantly higher mortality rate than the IDD, PDD-M, and NDD groups (log-rank test P < 0.001). The PDD-M group had a significantly lower risk of death, regardless of insulin (P < 0.001) or oral hypoglycemic agent (OHA) (P < 0.001) use. Initial insulin administration or OHA had no statistically significant effect on overall mortality in the IDD group. But OHA use had better survival trends than insulin administration for the older (P = 0.02) and male subgroups (P = 0.05).

CONCLUSIONS

For dialysis patients with diabetes, continuous administration of anti-diabetic drugs after dialysis and choice of medication may affect outcomes.

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.

Systematic Review and Meta-Analysis on Quality of Life in Diabetic Patients in Iran

Background:

Diabetes is the fifth leading cause of death in the world, which reduces the patients' quality of life (QOL) and is considered as an important subject especially in medicine and medical community. The present study aimed at investigating the QOL of diabetic patients in Iran through meta-analysis.

Methods:

The search was conducted using relevant keywords in national and international databases including Iranmedex, SID, Magiran, IranDoc, Medlib, Science Direct, PubMed, Scopus, Cochrane, Embase, Web of Science. Questionnaires WHOQOL, SF-36, SF-20, DQOL, QOL, PedsQL, ADDQOL, D-39, DQOL-BCI, SWED-QUAL, IRDQOL, PHG-2, EQ-5D, and IDQOL-BCI were used to assess the QOL. Heterogeneity of studies was assessed using I² index. Data were analyzed using STATA version 11.

Results:

In 96 studies of 17,994 people, the mean score of QOL in diabetic patients was based on the questionnaires WHOQOL [66.55 (95% CI: 45.83, 87.26)], D-39 [129.43 (95%CI: 88.77, 170.10)], SF-36 [65.64 (95% CI: 59.82, 71.46)], SF-20 [46.50 (95% CI: 37.19, 55.81], DQOL [61.19 (95% CI: 35.73, 86.66)], QOL [117.91 (95% CI: -62.97, 298.79)], PedsQL [34.36 (95% CI: -31.49, 100.22)], ADDQOL [41.76 (95% CI: 12.01-71.50)], SWED-QUAL [59.19 (95% CI: 21.15, 97.23)], IRDQOL [105.92 (95% CI: 102.73, 109.10)], PHG-2 [61.00 (95%CI: 59.63, 62.37)], EQ-5D [0.62 (95% CI: 0.61, 0.64)], DQOL-BCI [3.40 (95% CI: 3.31, 3.49)], and IDQOL-BCI [22.63 (95% CI: -2.38, 47.64)].

Conclusions:

The QOL of diabetic patients was evaluated according to different types of questionnaires and the QOL of diabetic patients was found to be lower than normal population.

Diabetic nephropathy in pregnancy: Report of two cases progressing to end-stage renal disease within one year postpartum

Background

Diabetes mellitus is a leading cause of nephropathy and end-stage renal disease. However, diabetic nephropathy during pregnancy in patients with normal glomerular filtration rate and subsequent progression to end-stage renal disease has not been well studied.

Cases

This report presents two patients with poorly controlled type 1 diabetes mellitus who had diabetic nephropathy with preserved estimated glomerular filtration rate (Case 1: 117 mL/min/1.73m²; Case 2: 79 mL/min/1.73m²) and shared a similar clinical course, with glomerular filtration rates decreasing by approximately one-half during pregnancy and progression to end-stage renal disease within the first year postpartum. Both women had a long history of type 1 diabetes: 18 years and 24 years for case 1 and case 2 respectively. The first patient's course of pregnancy was complicated by difficult-to-control blood glucose and hypertension with subsequent preeclampsia. The second patient's course of pregnancy was complicated by difficult-to-control blood sugars and preterm labor resulting in classical cesarean delivery at 24 weeks. Both patients had renal biopsies shortly after delivery as their renal function continued to worsen postpartum. Both kidney biopsies demonstrated advanced diabetic nephropathy changes and ultimately required chronic renal replacement therapy within 7–9 months postpartum.

Conclusion

Comprehensive family planning discussions with women who have diabetic nephropathy should include the risks of renal disease progression, even in those patients with preserved renal function at the time of conception.

•

Diabetic nephropathy carries a high risk for renal disease progression.

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Diabetics with nephropathy need counseling on risk of kidney disease progression.

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Diabetic women should be started on kidney-protective medications postpartum.

Management of diabetes mellitus in dialysis patients: Obstacles and challenges

BACKGROUND AND AIMS

Diabetic kidney disease (DKD) is a major health issue that is associated with an increased risk of morbidity and mortality. The treatment of DKD is challenging given changes in blood glucose homeostasis, unclear accuracy of glucose metrics, and altered kinetics of the blood glucose-lowering medications. There is uncertainty surrounding the optimal glycemic target in this population although recent epidemiologic data suggest that HbA1c ranges of 6-8%, as well as 7-9%, are associated with increased survival rates among diabetic dialysis patients. Furthermore, the treatment of diabetes in patients maintained on dialysis is challenging, and many blood glucose-lowering medications are renally metabolized and excreted hence requiring dose adjustment or avoidance in dialysis patients.

METHOD

ology: PubMed, Google Scholar, and Medline were searched for all literature discussing the management of diabetes in dialysis patients.

RESULTS

The literature was discussed under many subheadings providing the latest evidence in the treatment of diabetes in dialysis patients.

CONCLUSION

The management of diabetes in dialysis is very complex requiring a multi-disciplinary team involving endocrinologists and nephrologists to achieve targets and reduce morbidity and mortality.

Chronic Kidney Disease Is Associated with High Mortality Risk in Patients with Diabetes after Primary Shoulder Arthroplasty: A Nationwide Population-Based Cohort Study

The number of diabetic patients with chronic kidney disease (CKD) undergoing shoulder arthroplasty is growing. This study aims to compare perioperative outcomes of shoulder arthroplasty in diabetic patients at different renal function stages. Between 1998 and 2013, a total of 4443 diabetic patients with shoulder arthroplasty were enrolled: 1174 (26%) had CKD without dialysis (CKD group), 427 (9%) underwent dialysis (dialysis group), and 3042 (68%) had no CKD (non-CKD group). Compared with the non-CKD group, the CKD (odds ratio [OR], 4.69; 95% confidence interval [CI], 2.02–10.89) and dialysis (OR, 6.71; 95% CI, 1.63–27.73) groups had a high risk of in-hospital death. The dialysis group had a high risk of infection after shoulder arthroplasty compared with the CKD (subdistribution hazard ratio [SHR], 1.69; 95% CI, 1.07–2.69) and non-CKD (SHR, 1.76; 95% CI, 1.14–2.73) groups. The dialysis group showed higher risks of all-cause readmission and mortality than the CKD and non-CKD groups after a 3-month follow-up. In conclusion, CKD was associated with worse outcomes after shoulder arthroplasty. Compared with those without CKD, CKD patients had significantly increased readmission and mortality risks but did not have an increased risk of surgical complications, including superficial infection or implant removal.

Tetrandrine mediates renal function and redox homeostasis in a streptozotocin-induced diabetic nephropathy rat model through Nrf2/HO-1 reactivation

Background

Diabetic nephropathy (DN) is the leading cause of morbidity and mortality in diabetic patients. Tetrandrine (Tet), a bisbenzylisoquinoline alkaloid isolated from the roots of Stephania tetrandra, possesses anti-oxidative, anti-hypertensive, anti-inflammatory capacities. In this study, the maintenance role of Tet in DN was evaluated in streptozotocin (STZ)-induced diabetic rats.

Methods

In vitro study, rats were divided into five groups (n=10): the control group, the DN model group, the Tet-treatment group (5, 15, 30 mg/kg). DN damage was assessed by levels of blood glucose, serum creatinine (CRE), proteinuria, and urea nitrogen. ELISA assay was used to detecte tumor necrosis factor-α (TNF-α), inducible nitric oxide synthase (iNOS), interleukin-6 (IL-6) and IL-10 levels. Kits were used to detecte contents of malondialdehyde (MDA), lactate dehydrogenase (LDH) and superoxide dismutase (SOD). Dichlorofluorescein (DCF) staining was used to detecte reactive oxygen species (ROS). HE staining assessed pathological damage. TUNEL staining assessed tissue apoptosis. Western Blot (WB) was used to detecte levels of Ki67, Survivin, Bax, Bcl-2, caspase-3, -9, c-Myc, nuclear factor erythroid-derived 2-related factor 2 (Nrf2), p-Nrf2, and heme oxygenase-1 (HO-1).

Results

Compared with the control group, STZ-induced significantly inhibited proliferation proteins’ level, activated oxidative stress, aggravated tissue inflammation and promoted tissue apoptosis. STZ-induced further aggravated DN damage. Of note, these anomalies were restored by Tet pretreatment. Additionally, Tet upgraded the expression of p-Nrf2 and HO-1.

Conclusions

These results indicated that Tet could significantly restrain diabetic process and renal damage. Tet is a potential therapeutic agent in DN treatment via the reactivation of the Nrf2/HO-1.

lncRNA MIRF Promotes Cardiac Apoptosis through the miR-26a-Bak1 Axis

Acute myocardial infarction (AMI) is the leading cause of death worldwide. Identifying the pathways that block cardiac cell death is a therapeutic strategy for ischemic heart disease. We found that long noncoding RNA (lncRNA) myocardial infarction-regulatory factor (MIRF) promoted ischemic myocardial injury by regulating autophagy through targeting miR-26a. However, the role of MIRF-miR-26a in apoptosis during AMI has not been delineated. In this study, we found the downregulation of miR-26a both in the heart of myocardial infarction (MI) mice and in H₂O₂-treated cardiomyocytes. miR-26a silencing resulted in apoptosis, whereas overexpression of miR-26a attenuated H₂O₂-induced apoptosis through promoting mitochondrial ATP content and increasing mitochondrial membrane potential (MMP). Moreover, forced expression of miR-26a protected against MI-induced cardiac injury and attenuated cardiac apoptosis. Further studies showed that miR-26a inhibited apoptosis through regulation of Bak1. Furthermore, MIRF decreased ATP content and MMP through regulating miR-26a, which then promoted the cardiomyocyte apoptosis. In contrast, deficiency of MIRF promoted mitochondrial ATP content and increased MMP, and then inhibited MI or H₂O₂-induced cardiac apoptosis, which was abolished by miR-26a inhibitor. Taken together, these results suggested that MIRF contributed to cardiomyocyte apoptosis through modulating Bak1 by regulation of miR-26a, which can be a potential therapeutic target for the treatment of ischemic heart disease.

Metabolic Surgery to Treat Obesity in Diabetic Kidney Disease, Chronic Kidney Disease, and End-Stage Kidney Disease; What Are the Unanswered Questions?

Obesity is a major factor in contemporary clinical practice in nephrology. Obesity accelerates the progression of both diabetic and non-diabetic chronic kidney disease and, in renal transplantation, both recipient and donor obesity increase the risk of allograft complications. Obesity is thus a major driver of renal disease progression and a barrier to deceased and living donor kidney transplantation. Large observational studies have highlighted that metabolic surgery reduces the incidence of albuminuria, slows chronic kidney disease progression, and reduces the incidence of end-stage kidney disease over extended follow-up in people with and without type 2 diabetes. The surgical treatment of obesity and its metabolic sequelae has therefore the potential to improve management of diabetic and non-diabetic chronic kidney disease and aid in the slowing of renal decline toward end-stage kidney disease. In the context of patients with end-stage kidney disease, although complications of metabolic surgery are higher, absolute event rates are low and it remains a safe intervention in this population. Pre-transplant metabolic surgery increases access to kidney transplantation in people with obesity and end-stage kidney disease. Metabolic surgery also improves management of metabolic complications post-kidney transplantation, including new-onset diabetes. Procedure selection may be critical to mitigate the risks of oxalate nephropathy and disruption to immunosuppressant pharmacokinetics. Metabolic surgery may also have a role in the treatment of donor obesity, which could increase the living kidney donor pool with potential downstream impact on kidney paired exchange programmes. The present paper provides a comprehensive coverage of the literature concerning renal outcomes in clinical studies of metabolic surgery and integrates findings from relevant mechanistic pre-clinical studies. In so doing the key unanswered questions for the field are brought to the fore for discussion.

Assess the Illness Perception and Treatment Adherence among Patients with End-Stage Renal Disease

Background:

Chronic Renal Disease (CRD) complications had a sizeable effect on the patients. This study evaluates illness perception, treatment adherence and clinical outcomes of patients with End-Stage Renal Disease (ESRD) and finds an association with variables.

Materials and Methods:

A descriptive cross-sectional study was conducted among patients at Sri Ramachandra Institute of Higher Education and Research, Chennai, India during October and November 2017. Data were collected through interviews of each patient separately before hemodialysis. Demographic, clinical variables, identity dimension and control dimension of patients were assessed. Adherence behaviours were measured using ESRD-AQ in four dimensions. Clinical outcome was evaluated based on biochemical parameters. The collected data were analysed by percentage distribution and regression analysis.

Results:

The study had 120 patients with ESRD with male to female ratio of 2:1 where the majority (35.80%) were in the age group of 51–60. The identity dimension mean (SD) score was 10.80 (1.51). Under the control dimension mean scores were higher in the sub-dimension of emotional representations, consequences and personal control. Among 120 patients, 63 (52.50%) had adherence to dietary restriction. A statistically significant association was observed between timeline with Body Mass Index (BMI) (F₃ = 4.81, p = 0.003) and comorbidity (F₂ = 2.99, p = 0.022).

Conclusions:

The higher mean score in the sub-dimensions of emotional representations indicates a higher degree of emotional distress due to low adherence to prescribed medications.

National Analyses on Survival in Maltese Adult Patients on Renal Replacement Therapy Started During 2009–2012

Chronic kidney disease patients on maintenance dialysis (CKD 5D) experience major morbidity and mortality. No data on survival in Maltese dialysis patients exist; therefore, the aim of this study was to rigorously examine survival statistics in a complete cohort of Maltese CKD 5D patients. The study population was comprised of all incident chronic patients (N=328) starting dialysis at the renal unit, Mater Dei hospital, Msida, Malta, for 4 consecutive years (2009–2012). Each yearly cohort was analysed in detail up to 31st December 2017, providing up to 8 years follow-up. Demographics (male 65%; female 35%), aetiology of renal failure (diabetic kidney disease: n=191; 58.2%), comorbidities, transplant status, and death were documented. Data collection and follow up were completed and statistical analysis was performed on the aggregated cohorts with SPSS version 23 with censoring up to 31st December 2017. The cumulative adjusted 5-year overall survival in Maltese CKD 5D patients was 0.36 and 0.25 at 8 years. No statistical difference was observed according to the year of starting dialysis. Cox regression analysis showed that age and transplant status influenced survival. The unadjusted hazard of death increased by 3% for every 1-year increase in age and was increased by 7% if the patient did not receive a transplant, and overall 22% (n=72) of the entire cohort eventually received transplants. This study reports an approximate 65% mortality at 5 years in Maltese haemodialysis patients, a poor prognosis that, despite optimal medical management, is consistent with worldwide reports.

Chronic Kidney Disease Worsens Health Outcomes in Diabetic Patients After Hip Fracture Surgery: An Asian Nationwide Population-Based Cohort Study

There is an increased tendency for hip fractures in patients with chronic kidney disease (CKD). Although surgery is the mainstay of treatment for hip fractures, there is scant information on outcomes after hip fracture surgery in diabetic patients at different stages of CKD. In this population-based cohort study, we compared the surgical outcome, readmission, and mortality rates after osteosynthesis of hip fractures in diabetic patients with different stages of renal function. Diabetic patients who received primary osteosynthesis for hip fracture between January 1997 and December 2013 were enrolled. The primary outcomes were surgical outcomes, including infection and revision surgery. The secondary outcomes were all-cause readmission and mortality. This study included 44,065 patients; 11,954 had CKD (diabetic CKD group), 1662 patients were receiving dialysis (diabetic dialysis group), and 30,449 patients had no CKD (diabetic non-CKD group). We found that the diabetic dialysis group had a significantly higher risk of infection and revision surgery compared with diabetic non-CKD patients (HR = 1.52, 95% CI, 1.24 to 1.87; HR = 1.62, 95% CI, 1.33 to 1.97, respectively, both P < 0.001) and diabetic CKD patients (HR = 1.62, 95% CI, 1.32 to 1.99; HR = 1.48, 95% CI, 1.22 to 1.80, respectively, both P < 0.001). Diabetic CKD patients had a comparable risk of surgical complications including infection and revision as diabetic non-CKD patients. For readmission and mortality, the diabetic dialysis group had the highest risk among the three groups at all time-points (3 months after surgery, 1 year, and the last follow-up, all P < 0.001). Compared with the diabetic non-CKD group, the diabetic CKD group had an elevated risk of readmission and mortality at all time-points (all P < 0.001). In conclusion, CKD was associated with worse outcomes after hip fracture fixation surgery. Although at significantly higher risk of readmission and mortality, CKD patients still had a comparable risk of infection and revision to non-CKD patients. © 2019 American Society for Bone and Mineral Research.

Patients' perceptions of their experience, control and knowledge of fluid management when receiving haemodialysis

BACKGROUND

Person-centred care is increasingly promoted, empowering patients to become more involved in their treatment rather than being passive recipients of care (Barnes et al. 2013). Haemodialysis is typically required three times a week, with fluid management decision-making occurring at each treatment session (Ahmed et al. 2017). However, no research has yet explored how haemodialysis patients' perceptions of their fluid management may impact upon this decision-making.

OBJECTIVES

This study sought to explore patients' perceptions of their fluid management.

METHOD

DESIGN, PARTICIPANTS & APPROACH: Semi-structured interviews were conducted with 12 patients undergoing in-hospital haemodialysis treatment. These were digitally recorded one-to-one interviews to allow for verbatim transcription. The data was analysed by thematic analysis, generating thematic patterns across patients' experiences, control and knowledge of their fluid management.

RESULTS

Five themes were produced: determining who has the expertise, impediments affecting patients' lifestyle, additional difficulty of experiencing comorbidities, perceived quality of care, and establishing consistency.

CONCLUSIONS

Despite varied levels of patient participation in their treatment, overall there appears to be a limited understanding of specific areas of fluid management. The implications for further research and the development of shared-care are discussed.

The Protective Role of Adiponectin for Lipoproteins in End-Stage Renal Disease Patients: Relationship with Diabetes and Body Mass Index

Cardiovascular disease (CVD) events are the main causes of death in end-stage renal disease (ESRD) patients on dialysis. The number and severity of CVD events remain inappropriate and difficult to explain by considering only the classic CVD risk factors. Our aim was to clarify the changes and the relationship of lipoprotein subfractions with other CVD risk factors, namely, body mass index (BMI) and adipokines, inflammation and low-density lipoprotein (LDL) oxidation, and the burden of the most prevalent comorbidities, diabetes mellitus (DM) and hypertension (HT). We studied 194 ESRD patients on dialysis and 22 controls; lipid profile, including lipoprotein subpopulations and oxidized LDL (oxLDL), C-reactive protein (CRP), adiponectin, leptin, and paraoxonase 1 activity were evaluated. Compared to controls, patients presented significantly lower levels of cholesterol, high-density lipoprotein cholesterol (HDLc), LDLc, oxLDL, and intermediate and small HDL and higher triglycerides, CRP, adiponectin, large HDL, very-low-density lipoprotein (VLDL), and intermediate-density lipoprotein- (IDL) B. Adiponectin levels correlated positively with large HDL and negatively with intermediate and small HDL, oxLDL/LDLc, and BMI; patients with DM (n = 17) and with DM+HT (n = 70), as compared to patients without DM or HT (n = 69) or only with HT (n = 38), presented significantly higher oxLDL, oxLDL/LDLc, and leptin and lower adiponectin. Obese patients (n = 45), as compared to normoponderal patients (n = 81), showed lower HDLc, adiponectin, and large HDL and significantly higher leptin, VLDL, and intermediate and small HDL. In ESRD, the higher adiponectin seems to favor atheroprotective HDL modifications and protect LDL particles from oxidative atherogenic changes. However, in diabetic and obese patients, adiponectin presents the lowest values, oxLDL/LDLc present the highest ones, and the HDL profile is the more atherogenic. Our data suggest that the coexistence of DM and adiposity in ESRD patients on dialysis contributes to a higher CVD risk, as showed by their lipid and adipokine profiles.

Quality of life and depression in haemodialysis patients

Chronic kidney disease is associated with a high prevalence of depression, which increases inversely with the glomerular filtration rate. This paper aims to evaluate the factors associated with a low quality of life and depression in patients on haemodialysis. Two hundred patients undergoing haemodialysis answered the Medical Outcomes Study 36 - Item Short - Form Health Survey (SF-36) and Beck Depression Inventory (BDI). Clinical and laboratory variables were analysed and correlated with these two tools. The prevalence of depression was 29%. Anaemia and hypoalbuminemia were independent risk factors for depression. All SF-36 domains showed worse results in patients with depression, and the pain domain presented the highest correlation. Our findings provide evidence that patients on haemodialysis have a low quality of life and a high prevalence of depression. A greater number of comorbidities, an excessive number of medications, diabetes mellitus, anaemia and hypoalbuminemia were associated with a reduced quality of life.