1
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Evaluation of the relationship between hemodialysis-related glycemic variability and hormonal profiles in patients with type 2 diabetes on hemodialysis: a pilot study. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00429-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The number of dialysis patients with diabetes is currently increasing in Japan and a similar proportion worldwide. It was suggested that approximately 20% of these patients had hypoglycemia after dialysis session and most of these hypoglycemia were unconscious. Furthermore, it was suggested that glucose variabilities induced by hemodialysis may be related to insulin and insulin-counter hormones, such as glucagon, adrenocorticotropic hormone (ACTH), and cortisol and growth hormone, but conclusive evidence has not still been obtained.
Methods
We investigated in detail the glucose and hormonal profiles in 7 patients with type 2 diabetes on hemodialysis (all male, HbA1c 6.8 ± 2.1%, glycated albumin 24.7 ± 10.2%). All participants were attached continuous glucose monitoring (iPro2®). Blood glucose level, C-peptide immunoreactivity, plasma glucagon, ACTH, cortisol and growth hormone were measured by 7 points blood tests at before breakfast, after breakfast (predialysis), 2 h and 4 h after starting dialysis, after lunch and before/after dinner on the dialysis day and 6 points at before/after each meal on the non-dialysis day, and these relationship with blood glucose dynamics were examined. The meal contents were set to the indicated energy amount, and the same menu was served daily for breakfast, lunch, and dinner on dialysis and non-dialysis days of this study period. In addition, the start time of lunch on non-dialysis day was the same as the start time of lunch on the dialysis day.
Results
Serum C-peptide level was significantly increased by taking breakfast and lunch on the hemodialysis day, significantly decreased during hemodialysis, and was significantly lower before and after lunch on the hemodialysis day than on the non-hemodialysis day. Plasma glucagon level significantly decreased during hemodialysis and that before lunch on hemodialysis day was significantly lower than on non-hemodialysis day. ACTH, cortisol, and growth hormone did not show any changes related to hemodialysis.
Conclusions
It was suggested that C-peptide and glucagon play an important role in hemodialysis-related glycemic variabilities in patients with type 2 diabetic hemodialysis.
Trial registration UMIN Clinical Trial Registry (Registration Number UMIN000018707). Registered 18 August 2015, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&language=J&recptno=R000021647.
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2
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Kleinaki Z, Kapnisi S, Theodorelou-Charitou SA, Nikas IP, Paschou SA. Type 2 diabetes mellitus management in patients with chronic kidney disease: an update. Hormones (Athens) 2020; 19:467-476. [PMID: 32500461 DOI: 10.1007/s42000-020-00212-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023]
Abstract
Diabetes mellitus (DM) is a chronic multisystem disease. Diabetic nephropathy (DN) is one of its significant microvascular complications, associated with increased morbidity and mortality. The aim of this article is to review the literature regarding the latest advances in the management of type 2 DM (T2DM) in patients with chronic kidney disease (CKD). We initially refer to the screening guidelines, the diagnostic tests used, the need for novel biomarkers in DN, the recent advances in high-risk patient identification, the recommended glycemic targets, and concerns regarding the accuracy of HbA1c in these patients. Then, a detailed explanation of the appropriate medical management based on evidence from recent trials is presented, analyzed, and discussed. All patients with T2DM should be screened for albuminuria at initial diagnosis and annually thereafter. Proteomics and metabolomics today represent promising diagnostic tools. Optimal glycemic control, with individualized HbA1c targets, is fundamental for reduced onset or delayed progression of DN and microvascular complications, in general. This can be enhanced by lifestyle modifications and pharmacological interventions when needed. Metformin represents the first pharmacological step, with, recently, a broadened indication for patients with impaired renal function. If HbA1c remains above the target in patients with established CKD, SGLT2i or GLP-1 RA are the preferred second-line agents, as introduced in all new guidelines. This change was the result of recent landmark trials that highlighted the superiority of the two aforementioned medication categories in terms of both renal and cardiovascular outcomes.
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Affiliation(s)
- Zoi Kleinaki
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Stella Kapnisi
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | | | - Ilias P Nikas
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Stavroula A Paschou
- School of Medicine, European University Cyprus, Nicosia, Cyprus.
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
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3
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Tsabang N, Djeufack LWT, Yedjou CG, Tchounwou PB. Importance of food plants in the prevention and treatment of diabetes in Cameroon. BIOACTIVE COMPOUNDS IN HEALTH AND DISEASE 2019; 2:11-26. [PMID: 32864583 PMCID: PMC7451804 DOI: 10.31989/bchd.v2i2.554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Diabetes is a metabolic pathology that affects the human body's capacity to adequately produce and use insulin. Type 1 (insulin-dependent) diabetes accounts for 5-10 % of diabetic patients. In Type 2 diabetes the insulin produced by the pancreatic islets is not properly used by cells due to insulin resistance. Gestational diabetes sometimes occurs in pregnant women and affects about 18 % of all pregnancies.Diabetes is one of the most important multifactorial metabolic chronic diseases with fatal complications. According to the International Diabetes Federation's estimations in 2015, 415 million people had diabetes and there will be an increase to 642 million people by 2040. Although many ethnopharmacological surveys have been carried out in several parts of the world, no ethnomedical and ethnopharmacological surveys have been done to identify plants used for the prevention and treatment of diabetes. OBJECTIVE This study aimed to collect and document information on food plants' remedies consumed for the prevention and treatment of diabetes in Cameroon. METHODS Ethnomedical and ethnopharmacological thorough preparations were conducted with 1131 interviewees from 58 tribes, following a random distribution. Diabetic patients recorded among this sample signed the informed consent and allowed us to evaluate the effectiveness of 10 identified food plants usually used for self-medication. They were divided into two groups: Group 1 comprised of 42 diabetic patients who regularly consume certain of these food plants, and Group 2 included 58 patients who were town-dwellers and did not regularly eat these identified food plants. RESULTS It was recorded that the onset of diabetes in patients were at about 70 years and 45 years for Group 1 and Group 2 respectively. Hence, a relationship was demonstrated between the onset of diabetes and the consumption of food plants. They contributed to the prevention and/or the delay in clinical manifestations. CONCLUSION Further investigations and/or clinical trials involving a large number of both type 1 and type 2 diabetics are needed to describe the therapeutic action of many food plants against diabetes. However, this study provides scientific support for the use of herbal medicines in the management of diabetes.
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Affiliation(s)
- Nole Tsabang
- Independent Consultant (Ex researcher of the Institute of Medical Researches and Medicinal Plants Studies (IMPM), Visiting lecturer at the University of Yaoundé I, Faculty of Medicine of Biomedical Science, at the University of Dschang, Faculty of Animal Biology and at the High Institute of Environmental Science, Yaounde-Cameroon
| | | | - Clément G Yedjou
- Cellomics and Toxicogenomics Research Laboratory, NIH-RCMI Center for Environmental Health, Jackson State University, Jackson, USA
| | - Paul B Tchounwou
- Molecular Toxicology Research Laboratory, NIH-Center for Environmental Health, College of Science, Engineering and Technology, Jackson State University, 1400 Lynch Street, P.O. Box 18540, Jackson, Mississippi, USA
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4
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Nakamura A, Kodera R, Sakamoto N, Ujike H, Wada J, Shikata K, Makino H. Development of a novel estimation method for hemoglobin A1c using glycated albumin in type 2 diabetes mellitus patients with end-stage renal disease. Diabetol Int 2018; 9:179-188. [PMID: 30603365 DOI: 10.1007/s13340-018-0342-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/26/2017] [Indexed: 01/08/2023]
Abstract
Aim We developed a novel estimation method for hemoglobin A1c (HbA1c) in type 2 diabetes (T2D) patients with end-stage renal disease (ESRD). This method is based on the glycated albumin (GA) level. Methods Of the 788 Japanese patients with T2D included in this study, 545 had normal renal function (NRF group) and 243 had ESRD. Oral glucose tolerance tests (OGTTs) were performed in 80 subjects. The variables GA, body mass index (BMI), hemoglobin (Hb), and estimated glomerular filtration rate (eGFR) were significantly associated with the GA-to-HbA1c ratio and were used to determine the estimated HbA1c (eHbA1c). One method of estimating HbA1c involved dividing GA by the GA-to-HbA1c ratio predicted from the estimated regression equation; the estimated HbA1c obtained in this manner was denoted eHbA1c-1. Results eHbA1c-1 (%) = GA × [4.688 - 18.833 × GA-1 - 0.015 × BMI - 0.037 × Hb (- 0.002 × eGFR for patients without ESRD)]-1; adjusted R 2 = 0.676 for actual HbA1c. The sensitivity of eHbA1c-1 was better than that of GA for diabetes diagnosis using the 75-g OGTT. There were no differences in the slope of eHbA1c-1 versus GA and the variance of eHbA1c-1 between the ESRD and NRF groups. eHbA1c-1 was not associated with Hb, erythropoiesis-stimulating agent use, or ESRD concomitance. Conclusions eHbA1c-1 may be a useful parameter for estimating HbA1c in T2D patients with ESRD.
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Affiliation(s)
- Akihiko Nakamura
- Osafune Clinic, 332-1 Haji, Osafune, Setouchi, Okayama 701-4264 Japan
| | - Ryo Kodera
- Osafune Clinic, 332-1 Haji, Osafune, Setouchi, Okayama 701-4264 Japan.,2Center for Innovative Clinical Medicine, Okayama University Hospital, 2-5-1 Shikata, Kita-ku, Okayama, Japan
| | - Noriko Sakamoto
- Diabetes, Metabolism, and Endocrinology, Shin Kashiwa Clinic, 1-7, Shinkashiwa, Kashiwa, Chiba Japan
| | - Haruyo Ujike
- 4Departments of Nephrology, Kagawa Prefectural Central Hospital, 1-2-1, Asahi, Takamatsu, Kagawa Japan.,5Dentistry and Pharmaceutical Sciences, Medicine and Clinical Science, Okayama University Graduate School of Medicine, 2-5-1 Shikata, Kita-ku, Okayama, Japan
| | - Jun Wada
- 5Dentistry and Pharmaceutical Sciences, Medicine and Clinical Science, Okayama University Graduate School of Medicine, 2-5-1 Shikata, Kita-ku, Okayama, Japan
| | - Kenichi Shikata
- 2Center for Innovative Clinical Medicine, Okayama University Hospital, 2-5-1 Shikata, Kita-ku, Okayama, Japan
| | - Hirofumi Makino
- 6Okayama University Hospital, 2-5-1 Shikata, Kita-ku, Okayama, Japan
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5
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Molitch ME. Glycemic Control Assessment in the Dialysis Patient: Is Glycated Albumin the Answer? Am J Nephrol 2017; 47:18-20. [PMID: 29275401 DOI: 10.1159/000485844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/28/2017] [Indexed: 12/24/2022]
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6
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Barrett EJ, Liu Z, Khamaisi M, King GL, Klein R, Klein BEK, Hughes TM, Craft S, Freedman BI, Bowden DW, Vinik AI, Casellini CM. Diabetic Microvascular Disease: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab 2017; 102:4343-4410. [PMID: 29126250 PMCID: PMC5718697 DOI: 10.1210/jc.2017-01922] [Citation(s) in RCA: 296] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 08/29/2017] [Indexed: 01/18/2023]
Abstract
Both type 1 and type 2 diabetes adversely affect the microvasculature in multiple organs. Our understanding of the genesis of this injury and of potential interventions to prevent, limit, or reverse injury/dysfunction is continuously evolving. This statement reviews biochemical/cellular pathways involved in facilitating and abrogating microvascular injury. The statement summarizes the types of injury/dysfunction that occur in the three classical diabetes microvascular target tissues, the eye, the kidney, and the peripheral nervous system; the statement also reviews information on the effects of diabetes and insulin resistance on the microvasculature of skin, brain, adipose tissue, and cardiac and skeletal muscle. Despite extensive and intensive research, it is disappointing that microvascular complications of diabetes continue to compromise the quantity and quality of life for patients with diabetes. Hopefully, by understanding and building on current research findings, we will discover new approaches for prevention and treatment that will be effective for future generations.
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Affiliation(s)
- Eugene J. Barrett
- Division of Endocrinology, Department of Medicine, University of Virginia, Charlottesville, Virginia 22908
| | - Zhenqi Liu
- Division of Endocrinology, Department of Medicine, University of Virginia, Charlottesville, Virginia 22908
| | - Mogher Khamaisi
- Section of Vascular Cell Biology, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts 02215
| | - George L. King
- Section of Vascular Cell Biology, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts 02215
| | - Ronald Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53705
| | - Barbara E. K. Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53705
| | - Timothy M. Hughes
- Sticht Center for Healthy Aging and Alzheimer’s Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina 27157
| | - Suzanne Craft
- Sticht Center for Healthy Aging and Alzheimer’s Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina 27157
| | - Barry I. Freedman
- Divisions of Nephrology and Endocrinology, Department of Internal Medicine, Centers for Diabetes Research, and Center for Human Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, North Carolina 27157
| | - Donald W. Bowden
- Divisions of Nephrology and Endocrinology, Department of Internal Medicine, Centers for Diabetes Research, and Center for Human Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, North Carolina 27157
| | - Aaron I. Vinik
- EVMS Strelitz Diabetes Center, Eastern Virginia Medical Center, Norfolk, Virginia 23510
| | - Carolina M. Casellini
- EVMS Strelitz Diabetes Center, Eastern Virginia Medical Center, Norfolk, Virginia 23510
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7
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Rhee CM, Kovesdy CP, Ravel VA, Streja E, Brunelli SM, Soohoo M, Sumida K, Molnar MZ, Brent GA, Nguyen DV, Kalantar-Zadeh K. Association of Glycemic Status During Progression of Chronic Kidney Disease With Early Dialysis Mortality in Patients With Diabetes. Diabetes Care 2017; 40:1050-1057. [PMID: 28592525 PMCID: PMC5521972 DOI: 10.2337/dc17-0110] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 05/09/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Although early trials suggested that intensive glycemic targets reduce the number of complications with diabetes, contemporary trials indicate no cardiovascular benefit and potentially higher mortality risk. As patients with advanced chronic kidney disease (CKD) transitioning to treatment with dialysis were excluded from these studies, the optimal glycemic level in this population remains uncertain. We hypothesized that glycemic status, defined by hemoglobin A1c (HbA--1c) and random glucose levels, in the pre-end-stage renal disease (ESRD) period is associated with higher 1-year post-ESRD mortality among patients with incident diabetes who have ESRD. RESEARCH DESIGN AND METHODS Among 17,819 U.S. veterans with diabetic CKD transitioning to dialysis from October 2007 to September 2011, we examined the association of mean HbA--1c and random glucose levels averaged over the 1-year pre-ESRD transition period with mortality in the first year after dialysis initiation. All-cause mortality hazard ratios (HRs) were estimated using multivariable survival models. Secondary analyses examined cardiovascular mortality using competing risks methods. RESULTS HbA--1c levels ≥8% (≥64 mmol/mol) were associated with higher mortality in the first year after dialysis initiation (reference value 6% to <7% [42-53 mmol/mol]): adjusted HRs [aHRs] 1.19 [95% CI 1.07-1.32] and 1.48 (1.31-1.67) for HbA--1c 8% to <9% [64-75 mmol/mol] and ≥9% [≥75 mmol/mol], respectively). Random glucose levels ≥200 mg/dL were associated with higher mortality (reference value 100 to <125 mg/dL): aHR 1.34 [95% CI 1.20-1.49]). Cumulative incidence curves showed that incrementally higher mean HbA--1c and random glucose levels were associated with increasingly higher cardiovascular mortality. CONCLUSIONS In patients with diabetes and CKD transitioning to dialysis, higher mean HbA--1c and random glucose levels during the pre-ESRD prelude period were associated with higher 1-year post-ESRD mortality. Clinical trials are warranted to examine whether modulating glycemic status improves survival in this population.
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Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Vanessa A Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | | | - Melissa Soohoo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Gregory A Brent
- Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
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8
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Neumiller JJ, Alicic RZ, Tuttle KR. Therapeutic Considerations for Antihyperglycemic Agents in Diabetic Kidney Disease. J Am Soc Nephrol 2017; 28:2263-2274. [PMID: 28465376 PMCID: PMC5533243 DOI: 10.1681/asn.2016121372] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Diabetic kidney disease is among the most frequent complications of diabetes, with approximately 50% of patients with ESRD attributed to diabetes in developed countries. Although intensive glycemic management has been shown to delay the onset and progression of increased urinary albumin excretion and reduced GFR in patients with diabetes, conservative dose selection and adjustment of antihyperglycemic medications are necessary to balance glycemic control with safety. A growing body of literature is providing valuable insight into the cardiovascular and renal safety and efficacy of newer antihyperglycemic medications in the dipeptidyl peptidase-4 inhibitor, glucagon-like peptide-1 receptor agonist, and sodium-glucose cotransporter 2 inhibitor classes of medications. Ongoing studies will continue to inform future use of these agents in patients with diabetic kidney disease.
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Affiliation(s)
- Joshua J Neumiller
- Department of Pharmacotherapy, Washington State University College of Pharmacy, Spokane, Washington;
| | - Radica Z Alicic
- Providence Medical Research Center, Providence Health Care, Spokane, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington; and
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington; and
- Nephrology Division, Kidney Research Institute and
- Institute of Translational Health Sciences, University of Washington, Seattle, Washington
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9
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Panduru NM, Nistor I, Groop PH, Van Biesen W, Farrington K, Covic A. Considerations on glycaemic control in older and/or frail individuals with diabetes and advanced kidney disease. Nephrol Dial Transplant 2017; 32:591-597. [PMID: 28340246 DOI: 10.1093/ndt/gfx021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/24/2017] [Indexed: 12/15/2022] Open
Abstract
The increasing prevalence of chronic kidney disease (CKD) and diabetes over the last decade has resulted in increasing numbers of frail older patients with a combination of these conditions. Current treatment guidelines may not necessarily be relevant for such patients, who are mostly excluded from the trials upon which these recommendations are based. There is a paucity of data upon which to base the management of older patients with CKD. Nearly all current guidelines recommend less-tight glycaemic control for the older population, citing the lack of proven medium-term benefits and concerns about the high short-term risk of hypoglycaemia. However, reports from large landmark trials have shown potential benefits for both microvascular and macrovascular complications, though the relevance of these findings to this specific population is uncertain. The trials have also highlighted potential alternative explanations for the hazards of intensive glycaemic control. These include depression, low endogenous insulin reserve, low body mass index and side effects of the medication. Over the last few years, newer classes of hypoglycaemic drugs with a lower risk of hypoglycaemia have emerged. This article aims to present a balanced view of advantages and disadvantages of intense glycaemic control in this group of patients, which we hope will help the clinician and patient to come to an individualized management approach.
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Affiliation(s)
- Nicolae Mircea Panduru
- 2nd Clinical Department, Diabetes, Nutrition and Metabolic Diseases Chair, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland.,Research Program Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Ionut Nistor
- ERBP, Ghent University Hospital, Ghent, Belgium.,Nephrology Department, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland.,Research Program Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Ken Farrington
- Renal Unit, Lister Hospital, Stevenage, UK.,Centre for Clinical and Health Services Research, University of Herts, Hatfield, UK
| | - Adrian Covic
- Nephrology Department, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania
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10
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Yoon SA, Han BG, Kim SG, Han SY, Jo YI, Jeong KH, Oh KH, Park HC, Park SH, Kang SW, Na KR, Kang SW, Kim NH, Jang YH, Shin SH, Cha DR. Efficacy, safety and albuminuria-reducing effect of gemigliptin in Korean type 2 diabetes patients with moderate to severe renal impairment: A 12-week, double-blind randomized study (the GUARD Study). Diabetes Obes Metab 2017; 19:590-598. [PMID: 28019072 DOI: 10.1111/dom.12863] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 01/12/2023]
Abstract
AIMS This multicentre, randomized, double-blind study investigated the efficacy and safety of gemigliptin in Korean type 2 diabetes mellitus (T2DM) patients with moderate to severe renal impairment (RI). METHODS The study comprised a 12-week main part and a 40-week extension. We report here the results from the main part. In total, 132 patients were randomized to receive gemigliptin (n = 66) or placebo (n = 66). Changes in glycated haemoglobin (HbA1c; primary endpoint), other glycaemic control parameters (fasting plasma glucose, glycated albumin and fructosamine), lipid profiles, renal function parameters and safety profiles were evaluated. RESULTS Baseline characteristics were comparable between the groups (mean HbA1c, 8.4% [68 mmol/mol]; age, 62.0 years; duration of type 2 diabetes, 16.3 years; estimated glomerular filtration rate, 33.3 mL/min/1.73 m2 ). At Week 12, the adjusted mean change ± standard error in HbA1c with gemigliptin was -0.82% ± 0.14% (-8.9 ± 1.5 mmol/mol), whereas it was 0.38% ± 0.14% (4.2 ± 1.5 mmol/mol) with placebo (significant between-group difference, P < .001). Other glycaemic control parameters showed beneficial changes as well. Body weight change (gemigliptin, -0.3 kg; placebo, -0.2 kg) was not significant. In the gemigliptin group, the mean decrease in urinary albumin creatinine ratio (UACR) was significant, both in patients with microalbuminuria (-41.9 mg/g creatinine, P = .03) and macroalbuminuria (-528.9 mg/g creatinine, P < .001). Drug-related adverse events were similar with gemigliptin and placebo (15% and 12%, respectively). CONCLUSIONS A 12-week treatment with gemigliptin improved glycaemic control and provided UACR reduction in T2DM patients with moderate to severe RI. Gemigliptin was well tolerated, with no additional risk of hypoglycaemia and change in body weight.
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Affiliation(s)
- Sun A Yoon
- Department of Internal Medicine, Catholic University Uijeongbu St. Mary's Hospital, Uijeongbu, Republic of Korea
| | - Byoung G Han
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Sung G Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Sang Y Han
- Department of Internal Medicine, Inje University, Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Young I Jo
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Kyung H Jeong
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Kook H Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyeong C Park
- Department of Internal Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Sun H Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | | | - Ki R Na
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Sun W Kang
- Department of Internal Medicine, Busan Paik Hospital, Busan, Republic of Korea
| | - Nam H Kim
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Republic of Korea
| | | | | | - Dae R Cha
- Korea University Ansan-Hospital, Ansan, Republic of Korea
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11
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Kalantar-Zadeh K, Kovesdy CP. Should Restrictions Be Relaxed for Metformin Use in Chronic Kidney Disease? No, We Should Never Again Compromise Safety! Diabetes Care 2016; 39:1281-6. [PMID: 27330129 PMCID: PMC4915554 DOI: 10.2337/dc15-2327] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Metformin is and has been considered as first-line therapy for type 2 diabetes for over a quarter of a century. Like other biguanides, metformin can cause a lactic acidosis that is exceptionally rare but fatal. The likelihood of metformin-associated lactic acidosis is substantially higher in patients with kidney impairment and also among those with seemingly normal kidney function who are at risk of acute kidney injury (AKI). Hence, regulatory agencies in many industrialized nations have maintained strict renal restrictions surrounding metformin. However, there have been millions of people exposed to metformin for many years, many of them with serum creatinine values at or close to 1.5 mg/dL with estimated glomerular filtration rates (eGFRs) much below 60 mL/min/1.73 m(2) who have not developed lactic acidosis. Thus, there clearly remains controversy in this area, and there has been heightened pressure to remove the renal restrictions of metformin. To provide a discussion on the pros and cons of relaxing the renal restrictions for metformin use, we provide a Point-Counterpoint. In the point narrative below, Drs. Kalantar-Zadeh and Kovesdy provide their argument that although there is little evidence of the potential benefits of metformin in kidney disease, just considering the sheer numbers of metformin users and the high fatality rate of its associated lactic acidosis, the most appropriate practice is to avoid metformin use in people with eGFR <45 mL/min/1.73 m(2) or in those who are at high risk of AKI irrespective of underlying eGFR. In the following counterpoint narrative, Drs. Bakris and Molitch argue that the data from a very large analysis demonstrate clearly that serum creatinine should be supplanted with eGFR as the criteria for metformin use and that the incidence of lactic acidosis is only elevated in those with a reduced eGFR who become dehydrated for various reasons or in those exposed to some toxin resulting in AKI. Otherwise the data clearly support the use of metformin under normal circumstances down to eGFR >30 mL/min/1.73 m(2)-William T. CefaluEditor in Chief, Diabetes Care.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, School of Medicine, University of California, Irvine, Irvine, CA Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA VA Long Beach Healthcare System, Long Beach, CA
| | - Csaba P Kovesdy
- The University of Tennessee Health Science Center, Memphis, TN Memphis VA Medical Center, Memphis, TN
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Low S, Chi LS, Yeoh LY, Liu JJ, Fun S, Su C, Zhang X, Subramaniam T, Sum CF. Long-term diabetes outcomes in multi-ethnic Asians living in Singapore. Diabetes Res Clin Pract 2016; 111:83-92. [PMID: 26597212 DOI: 10.1016/j.diabres.2015.09.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/28/2015] [Accepted: 09/30/2015] [Indexed: 11/21/2022]
Abstract
AIMS This study aims to assess ethnic and gender disparities on long-term complications among multi-ethnic Asians with Diabetes Mellitus (DM) living in Singapore. METHODS We conducted a retrospective cohort study involving 3006 patients who attended a diabetes centre in a hospital from 2003 to 2011. Demographics and clinical data were obtained from standardised questionnaire and patient's case records. Age at onset of diabetes was calculated as current age minus duration of DM in years. Outcomes on Acute Myocardial Infarction (AMI), End-Stage Renal Failure (ESRF) and all-cause death were ascertained by data linkage with national registries. RESULTS The mean duration of diabetes exposure was 15.6 ± 9.1 years for AMI, 15.4 ± 9.0 years for ESRF and 17.0 ± 9.0 years for death. After adjusting for traditional cardiovascular risk factors, Malay and Indian with diabetes remained significantly associated with AMI with HRs 2.81(95%CI, 1.81-4.37) and 2.03 (95%CI, 1.15-3.59), respectively. The effect of Malays on ESRF and death became attenuated post-adjustment. Besides mortality, there was preponderance for other adverse outcomes associated with male. CONCLUSIONS Ethnic (Malay worse) and gender (male worse) disparities were observed in DM-related outcomes. The results may inform allocation of finite resources and to organize care targeted at high-risk groups.
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Affiliation(s)
- Serena Low
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore.
| | - Lim Su Chi
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore; Diabetes Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Lee Ying Yeoh
- Department of Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Jian Jun Liu
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Sharon Fun
- Diabetes Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chang Su
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Xiao Zhang
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Tavintharan Subramaniam
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore; Diabetes Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chee Fang Sum
- Diabetes Centre, Khoo Teck Puat Hospital, Singapore, Singapore
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13
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Nasri H, Rafieian-Kopaei M. Diabetes mellitus and renal failure: Prevention and management. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2015; 20:1112-20. [PMID: 26941817 PMCID: PMC4755100 DOI: 10.4103/1735-1995.172845] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 09/14/2015] [Accepted: 11/20/2015] [Indexed: 01/10/2023]
Abstract
Nowadays, diabetes mellitus (DM) and hypertension are considered as the most common causes of end-stage renal disease (ESRD). In this paper, other than presenting the role of DM in ESRD, glucose metabolism and the management of hyperglycemia in these patients are reviewed. Although in several large studies there was no significant relationship found between tight glycemic control and the survival of ESRD patients, it is recommended that glycemic control be considered as the main therapeutic goal in the treatment of these patients to prevent damage to other organs. Glycemic control is perfect when fasting blood sugar is less than 140 mg/dL, 1-h postprandial blood glucose is less than 200 mg/dL, and glycosylated hemoglobin (HbA1c) is 6-7 in patients with type 1 diabetes and 7-8 in patients with type 2 diabetes. Administration of metformin should be avoided in chronic renal failure (CRF) because of lactic acidosis, the potentially fatal complication of metformin, but glipizide and repaglinide seem to be good choices.
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Affiliation(s)
- Hamid Nasri
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Affiliation(s)
| | - Irl B. Hirsch
- University of Washington, Division of Metabolism, Endocrinology, and Nutrition, Seattle, WA
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15
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Boyle SM, Simon B, Kobrin SM. Antidiabetic Therapy in End-Stage Renal Disease. Semin Dial 2015; 28:337-44. [DOI: 10.1111/sdi.12368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Suzanne M. Boyle
- Division of Nephrology and Hypertension; Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Barbara Simon
- Division of Endocrinology; Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Sidney M. Kobrin
- Renal, Electrolyte, and Hypertension Division; Hospital of the University of Pennsylvania; Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
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16
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Hahr AJ, Molitch ME. Management of diabetes mellitus in patients with chronic kidney disease. Clin Diabetes Endocrinol 2015; 1:2. [PMID: 28702221 PMCID: PMC5469199 DOI: 10.1186/s40842-015-0001-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/03/2015] [Indexed: 12/11/2022] Open
Abstract
Glycemic control is essential to delay or prevent the onset of diabetic kidney disease. There are a number of glucose-lowering medications available but only a fraction of them can be used safely in chronic kidney disease and many of them need an adjustment in dosing. The ideal target hemoglobin A1c is approximately 7 % but this target is adjusted based on the needs of the patient. Diabetes control should be optimized for each individual patient, with measures to reduce diabetes-related complications and minimize adverse events. Overall care of diabetes necessitates attention to multiple aspects, including reducing the risk of cardiovascular disease, and often, multidisciplinary care is needed.
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Affiliation(s)
- Allison J. Hahr
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, 60611 Chicago, Illinois USA
| | - Mark E. Molitch
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, 60611 Chicago, Illinois USA
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17
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Williams ME, Mittman N, Ma L, Brennan JI, Mooney A, Johnson CD, Jani CM, Maddux FW, Lacson E. The Glycemic Indices in Dialysis Evaluation (GIDE) study: Comparative measures of glycemic control in diabetic dialysis patients. Hemodial Int 2015; 19:562-71. [DOI: 10.1111/hdi.12312] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - Neal Mittman
- Department of Dialysis; Kidney Care of Brooklyn and Queens; Brooklyn New York USA
| | - Lin Ma
- Department of Clinical Research; Fresenius Medical Care North America; Waltham Massachusetts USA
| | - Julia I. Brennan
- Department of Research; Spectra Laboratories; Rockleigh New Jersey USA
- Spectra Laboratories; Milpitas California USA
| | - Ann Mooney
- Department of Clinical Research; Fresenius Medical Care North America; Waltham Massachusetts USA
| | - Curtis D. Johnson
- Department of Research; Spectra Laboratories; Rockleigh New Jersey USA
- Spectra Laboratories; Milpitas California USA
| | - Chinu M. Jani
- Department of Research; Spectra Laboratories; Rockleigh New Jersey USA
- Spectra Laboratories; Milpitas California USA
| | - Franklin W. Maddux
- Department of Clinical Research; Fresenius Medical Care North America; Waltham Massachusetts USA
| | - Eduardo Lacson
- Department of Clinical Research; Fresenius Medical Care North America; Waltham Massachusetts USA
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18
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Jin YP, Su XF, Yin GP, Xu XH, Lou JZ, Chen JJ, Zhou Y, Lan J, Jiang B, Li Z, Lee KO, Ye L, Ma JH. Blood glucose fluctuations in hemodialysis patients with end stage diabetic nephropathy. J Diabetes Complications 2015; 29:395-9. [PMID: 25681043 DOI: 10.1016/j.jdiacomp.2014.12.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/24/2014] [Accepted: 12/24/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To characterize blood glucose fluctuation during hemodialysis in patients with end stage diabetic nephropathy (ESDN) by a continuous glucose monitoring system (CGMS), and aim to improve blood glucose control in this patient population. METHODS Forty-six patients with or without type 2 diabetes mellitus (T2DM), receiving hemodialysis, were recruited in this study. Thirty-six patients had end stage diabetic nephropathy (ESDN group), the other ten patients had end stage renal disease without diabetes (ESRD group). A continuous glucose monitoring system (CGMS) was employed to monitor glycemic fluctuation for 72 hours. Blood samples were collected and analyzed. RESULTS Mean, standard deviation (SD), maximum, and mean amplitude glycemic excursion (MAGE) of blood glucose and the ratio of blood glucose readings that was greater than 13.9 mmol/L of ESDN group, were significantly greater than those of ESRD group (p<0.01 for all) during 72 hours of observation. The mean blood glucose was significantly lower, while SD and MAGE were significantly higher in ESDN group on hemodialysis day than on days off hemodialysis (p<0.05), while these were not been observed in ESRD group. Though mean, SD, and MAGE of blood glucose during hemodialysis were significantly lower than those of peri-hemodialysis in both groups (p<0.01 or p<0.05, respectively), they were significantly higher in ESDN group than that in ESRD group (p<0.05). The mean blood glucose value calculated from HbA1c did not reflect the actual mean blood glucose measured by CGM in both groups, and gave an inaccurate impression of a significantly lower mean glucose. CONCLUSIONS ESDN patients had larger glycemic fluctuations as compared with ESRD patients. Hemodialysis caused reduction in mean, SD, and MAGE, which in turn caused bigger glycemic fluctuations on hemodialysis day. The HbA1c in ESDN patients gave an inaccurate value, which did not truly reflect blood glucose status for a prolonged period.
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Affiliation(s)
- Yue-ping Jin
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China
| | - Xiao-fei Su
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China
| | - Guo-ping Yin
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China
| | - Xiao-hua Xu
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China
| | - Ji-zhuang Lou
- Hemodialysis Center, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China
| | - Jian-jun Chen
- Hemodialysis Center, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China
| | - Yue Zhou
- Hemodialysis Center, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China
| | - Jie Lan
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China
| | - Bing Jiang
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China
| | - Zheng Li
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China
| | - Kok-Onn Lee
- Department of Medicine, National University of Singapore, Singapore
| | - Lei Ye
- National Heart Research Institute Singapore, National Heart Centre, Singapore
| | - Jian-hua Ma
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing Hospital, Nanjing, China.
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19
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Kalantar-Zadeh K, Brown A, Chen JLT, Kamgar M, Lau WL, Moradi H, Rhee CM, Streja E, Kovesdy CP. Dietary restrictions in dialysis patients: is there anything left to eat? Semin Dial 2015; 28:159-68. [PMID: 25649719 PMCID: PMC4385746 DOI: 10.1111/sdi.12348] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A significant number of dietary restrictions are imposed traditionally and uniformly on maintenance dialysis patients, whereas there is very little data to support their benefits. Recent studies indicate that dietary restrictions of phosphorus may lead to worse survival and poorer nutritional status. Restricting dietary potassium may deprive dialysis patients of heart-healthy diets and lead to intake of more atherogenic diets. There is little data about the survival benefits of dietary sodium restriction, and limiting fluid intake may inherently lead to lower protein and calorie consumption, when in fact dialysis patients often need higher protein intake to prevent and correct protein-energy wasting. Restricting dietary carbohydrates in diabetic dialysis patients may not be beneficial in those with burnt-out diabetes. Dietary fat including omega-3 fatty acids may be important caloric sources and should not be restricted. Data to justify other dietary restrictions related to calcium, vitamins, and trace elements are scarce and often contradictory. The restriction of eating during hemodialysis treatment is likely another incorrect practice that may worsen hemodialysis induced hypoglycemia and nutritional derangements. We suggest careful relaxation of most dietary restrictions and adoption of a more balanced and individualized approach, thereby easing some of these overzealous restrictions that have not been proven to offer major advantages to patients and their outcomes and which may in fact worsen patients' quality of life and satisfaction. This manuscript critically reviews the current paradigms and practices of recommended dietary regimens in dialysis patients including those related to dietary protein, carbohydrate, fat, phosphorus, potassium, sodium, and calcium, and discusses the feasibility and implications of adherence to ardent dietary restrictions and future research.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
- Dept. Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Amanda Brown
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | - Joline L. T. Chen
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | | | - Wei-Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | - Csaba P. Kovesdy
- Univ. of Tennessee Health Science Center, Memphis, Tennessee
- Memphis Veterans Affairs Healthcare System, Memphis, Tennessee
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20
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Tuttle KR, Bakris GL, Bilous RW, Chiang JL, de Boer IH, Goldstein-Fuchs J, Hirsch IB, Kalantar-Zadeh K, Narva AS, Navaneethan SD, Neumiller JJ, Patel UD, Ratner RE, Whaley-Connell AT, Molitch ME. Diabetic Kidney Disease: A Report From an ADA Consensus Conference. Am J Kidney Dis 2014; 64:510-33. [DOI: 10.1053/j.ajkd.2014.08.001] [Citation(s) in RCA: 365] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/24/2014] [Indexed: 12/19/2022]
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21
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Tuttle KR, Bakris GL, Bilous RW, Chiang JL, de Boer IH, Goldstein-Fuchs J, Hirsch IB, Kalantar-Zadeh K, Narva AS, Navaneethan SD, Neumiller JJ, Patel UD, Ratner RE, Whaley-Connell AT, Molitch ME. Diabetic kidney disease: a report from an ADA Consensus Conference. Diabetes Care 2014; 37:2864-83. [PMID: 25249672 PMCID: PMC4170131 DOI: 10.2337/dc14-1296] [Citation(s) in RCA: 705] [Impact Index Per Article: 70.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The incidence and prevalence of diabetes mellitus have grown significantly throughout the world, due primarily to the increase in type 2 diabetes. This overall increase in the number of people with diabetes has had a major impact on development of diabetic kidney disease (DKD), one of the most frequent complications of both types of diabetes. DKD is the leading cause of end-stage renal disease (ESRD), accounting for approximately 50% of cases in the developed world. Although incidence rates for ESRD attributable to DKD have recently stabilized, these rates continue to rise in high-risk groups such as middle-aged African Americans, Native Americans, and Hispanics. The costs of care for people with DKD are extraordinarily high. In the Medicare population alone, DKD-related expenditures among this mostly older group were nearly $25 billion in 2011. Due to the high human and societal costs, the Consensus Conference on Chronic Kidney Disease and Diabetes was convened by the American Diabetes Association in collaboration with the American Society of Nephrology and the National Kidney Foundation to appraise issues regarding patient management, highlighting current practices and new directions. Major topic areas in DKD included 1) identification and monitoring, 2) cardiovascular disease and management of dyslipidemia, 3) hypertension and use of renin-angiotensin-aldosterone system blockade and mineralocorticoid receptor blockade, 4) glycemia measurement, hypoglycemia, and drug therapies, 5) nutrition and general care in advanced-stage chronic kidney disease, 6) children and adolescents, and 7) multidisciplinary approaches and medical home models for health care delivery. This current state summary and research recommendations are designed to guide advances in care and the generation of new knowledge that will meaningfully improve life for people with DKD.
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Affiliation(s)
- Katherine R Tuttle
- University of Washington School of Medicine, Seattle, WA, and Providence Health Care, Spokane, WA
| | - George L Bakris
- Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL (National Kidney Foundation liaison)
| | | | | | - Ian H de Boer
- Division of Nephrology, University of Washington, Seattle, WA
| | | | - Irl B Hirsch
- Division of Metabolism, Endocrinology and Nutrition, University of Washington School of Medicine, Seattle, WA
| | | | - Andrew S Narva
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Sankar D Navaneethan
- Department of Nephrology and Hypertension, Novick Center for Clinical and Translational Research, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Joshua J Neumiller
- Department of Pharmacotherapy, College of Pharmacy, Washington State University, Spokane, WA
| | - Uptal D Patel
- Divisions of Nephrology and Pediatric Nephrology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (American Society of Nephrology liaison)
| | | | - Adam T Whaley-Connell
- Harry S. Truman Memorial Veterans Hospital, Columbia, MO, and Department of Internal Medicine, Division of Nephrology and Hypertension, University of Missouri School of Medicine, Columbia, MO
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Mácsai E, Rakk E, Miléder M, Fulcz A. [Significance of hemoglobin A1C in the management of diabetes in dialysis patients]. Orv Hetil 2014; 155:1421-5. [PMID: 25176516 DOI: 10.1556/oh.2014.29986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
According to latest guidelines hemoglobin A1C plays a central role in the diagnosis of diabetes mellitus. It is well-known from epidemiologic studies that a high rate of diabetic patients enters into dialysis programs and these patients have an unfavourable mortality outcome. Based on surveys conducted in recent years in this patient group, hemoglobin A1C has an important role in assessing carbohydrate metabolism. However, there are several factors independent of blood glucose may affect hemoglobin A1C values both in hemodialysis and peritoneal dialysis patients. Hemodialysis disturbs hemoglobin A1c assessment because of an accelerated turnover of lost red blood cells. During peritoneal dialysis a considerable amount of glucose may be absorbed from the peritoneal solutions that may influence hemoglobin A1C level. Several alternative markers such as glycated albumin and fructosamine have been evaluated but they failed to have prognostic advantage. It has been concluded that among dialysis patients the hemoglobin A1C range between 6.5 and 8% is associated with the lowest mortality risk.
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Affiliation(s)
- Emília Mácsai
- Csolnoky Ferenc Oktatókórház Diabetológiai Szakambulancia Veszprém Kórház u. 1. 8200 BBRAUN 3 Dialíziscentrum Veszprém
| | - Erika Rakk
- Csolnoky Ferenc Oktatókórház Diabetológiai Szakambulancia Veszprém Kórház u. 1. 8200
| | - Margit Miléder
- Csolnoky Ferenc Oktatókórház Diabetológiai Szakambulancia Veszprém Kórház u. 1. 8200
| | - Agnes Fulcz
- Csolnoky Ferenc Oktatókórház Diabetológiai Szakambulancia Veszprém Kórház u. 1. 8200
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Affiliation(s)
- Mark E. Williams
- Joslin Diabetes Center; Harvard Medical School; Boston Massachusetts
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Rhee CM, Leung AM, Kovesdy CP, Lynch KE, Brent GA, Kalantar-Zadeh K. Updates on the management of diabetes in dialysis patients. Semin Dial 2014; 27:135-45. [PMID: 24588802 PMCID: PMC3960718 DOI: 10.1111/sdi.12198] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Diabetes mellitus is the leading cause of end-stage renal disease (ESRD) in the U.S. and many countries globally. The role of improved glycemic control in ameliorating the exceedingly high mortality risk of diabetic dialysis patients is unclear. The treatment of diabetes in ESRD patients is challenging, given changes in glucose homeostasis, the unclear accuracy of glycemic control metrics, and the altered pharmacokinetics of glucose-lowering drugs by kidney dysfunction, the uremic milieu, and dialysis therapy. Up to one-third of diabetic dialysis patients may experience spontaneous resolution of hyperglycemia with hemoglobin A1c (HbA1c) levels <6%, a phenomenon known as "Burnt-Out Diabetes," which remains with unclear biologic plausibility and undetermined clinical implications. Conventional methods of glycemic control assessment are confounded by the laboratory abnormalities and comorbidities associated with ESRD. Similar to more recent approaches in the general population, there is concern that glucose normalization may be harmful in ESRD patients. There is uncertainty surrounding the optimal glycemic target in this population, although recent epidemiologic data suggest that HbA1c ranges of 6% to 8%, as well as 7% to 9%, are associated with increased survival rates among diabetic dialysis patients. Lastly, many glucose-lowering drugs and their active metabolites are renally metabolized and excreted, and hence, require dose adjustment or avoidance in dialysis patients.
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Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
| | - Angela M. Leung
- Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis Tennessee
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Katherine E. Lynch
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Gregory A. Brent
- Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
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Speeckaert M, Van Biesen W, Delanghe J, Slingerland R, Wiecek A, Heaf J, Drechsler C, Lacatus R, Vanholder R, Nistor I, Bilo H, Bolignano D, Couchoud C, Covic A, Coentrao L, Sutter JD, Drechsler C, Gnudi L, Goldsmith D, Heaf J, Heimburger O, Jager K, Nacak H, Nistor I, Soler M, Tomson C, Vanhuffel L, Biesen WV, Laecke SV, Weekers L, Wiecek A. Are there better alternatives than haemoglobin A1c to estimate glycaemic control in the chronic kidney disease population? Nephrol Dial Transplant 2014; 29:2167-77. [DOI: 10.1093/ndt/gfu006] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Meyer L, Chantrel F, Imhoff O, Sissoko A, Serb L, Dorey F, Fleury D, Smagala A, Kepenekian L, Krummel T, Le Floch JP, Kessler L. Glycated albumin and continuous glucose monitoring to replace glycated haemoglobin in patients with diabetes treated with haemodialysis. Diabet Med 2013; 30:1388-9. [PMID: 23909880 DOI: 10.1111/dme.12294] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2013] [Indexed: 12/24/2022]
Affiliation(s)
- L Meyer
- Department of Endocrinology, Diabetes and Metabolic Diseases, Civil Hospital, Strasbourg, France.
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Kalantar-Zadeh K, Uppot RN, Lewandrowski KB. Case records of the Massachusetts General Hospital. Case 23-2013. A 54-year-old woman with abdominal pain, vomiting, and confusion. N Engl J Med 2013; 369:374-82. [PMID: 23841704 DOI: 10.1056/nejmcpc1208154] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Shafi T, Sozio SM, Plantinga LC, Jaar BG, Kim ET, Parekh RS, Steffes MW, Powe NR, Coresh J, Selvin E. Serum fructosamine and glycated albumin and risk of mortality and clinical outcomes in hemodialysis patients. Diabetes Care 2013; 36:1522-33. [PMID: 23250799 PMCID: PMC3661814 DOI: 10.2337/dc12-1896] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Assays for serum total glycated proteins (fructosamine) and the more specific glycated albumin may be useful indicators of hyperglycemia in dialysis patients, either as substitutes or adjuncts to standard markers such as hemoglobin A1c, as they are not affected by erythrocyte turnover. However, their relationship with long-term outcomes in dialysis patients is not well described. RESEARCH DESIGN AND METHODS We measured fructosamine and glycated albumin in baseline samples from 503 incident hemodialysis participants of a national prospective cohort study, with enrollment from 1995-1998 and median follow-up of 3.5 years. Outcomes were all-cause and cardiovascular disease (CVD) mortality and morbidity (first CVD event and first sepsis hospitalization) analyzed using Cox regression adjusted for demographic and clinical characteristics, and comorbidities. RESULTS Mean age was 58 years, 64% were white, 54% were male, and 57% had diabetes. There were 354 deaths (159 from CVD), 302 CVD events, and 118 sepsis hospitalizations over follow-up. Both fructosamine and glycated albumin were associated with all-cause mortality; adjusted HR per doubling of the biomarker was 1.96 (95% CI 1.38-2.79) for fructosamine and 1.40 (1.09-1.80) for glycated albumin. Both markers were also associated with CVD mortality [fructosamine 2.13 (1.28-3.54); glycated albumin 1.55 (1.09-2.21)]. Higher values of both markers were associated with trends toward a higher risk of hospitalization with sepsis [fructosamine 1.75 (1.01-3.02); glycated albumin 1.39 (0.94-2.06)]. CONCLUSIONS Serum fructosamine and glycated albumin are risk factors for mortality and morbidity in hemodialysis patients.
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Affiliation(s)
- Tariq Shafi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Robinson TW, Freedman BI. Assessing glycemic control in diabetic patients with severe nephropathy. J Ren Nutr 2013; 23:199-202. [PMID: 23510670 DOI: 10.1053/j.jrn.2013.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/17/2013] [Indexed: 01/08/2023] Open
Abstract
Diabetes mellitus is the leading cause of chronic kidney disease and end-stage renal failure in westernized societies, including the United States. In addition to renal manifestations, complications of poorly controlled diabetes include accelerated atherosclerosis, congestive heart failure, neuropathy, and retinopathy. The estimated total cost of diabetes care in the United States was $174 billion in 2007-a number expected to increase markedly in the coming decades. Clinicians must be able to accurately recognize patients with poor glycemic control to have opportunities to intensify treatment and potentially reduce hyperglycemia-related complications. Detecting hyperglycemia is uniquely difficult in patients with severe kidney disease. This paper reviews the literature on the accuracy of glucose monitoring assays in diabetic patients with advanced nephropathy. Interpretation of commonly used tests is affected to a great extent by the uremic milieu and frequently complicates disease management.
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Affiliation(s)
- Todd W Robinson
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina 27157-1053, USA
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Baldwin D, Apel J. Management of hyperglycemia in hospitalized patients with renal insufficiency or steroid-induced diabetes. Curr Diab Rep 2013; 13:114-20. [PMID: 23090580 DOI: 10.1007/s11892-012-0339-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Pharmacologic doses of glucocorticoids and chronic renal failure are challenging comorbidities and complications for safe and effective dosing of insulin for the management of hospitalized patients with diabetes. Glucocorticoids are used widely in hospitalized patients and will commonly provoke new-onset hyperglycemia in patients without a prior history of diabetes or will provoke severely uncontrolled hyperglycemia in patients with known diabetes. Insulin therapy is invariably necessary for the treatment of glucocorticoid-induced hyperglycemia and must be tailored to the pharmacodynamics of the glucocorticoid being given. Renal failure causes a decrease in the clearance of insulin, especially exogenous injected insulin. Dosing algorithms for hospitalized patients should be adjusted for patients with renal failure in order to minimize hypoglycemia. Many patients with type 2 diabetes will need little or no therapy after the development of end-stage renal failure. Care must be taken to avoid the overtreatment of hyperglycemia.
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Affiliation(s)
- David Baldwin
- Section of Endocrinology, Rush University Medical Center, 1725 W. Harrison St. suite 250, Chicago, IL 60612, USA.
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Little RR, Rohlfing CL, Tennill AL, Hanson SE, Connolly S, Higgins T, Wiedmeyer CE, Weykamp CW, Krause R, Roberts W. Measurement of Hba(1C) in patients with chronic renal failure. Clin Chim Acta 2013; 418:73-6. [PMID: 23318566 DOI: 10.1016/j.cca.2012.12.022] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 11/14/2012] [Accepted: 12/17/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Carbamylated hemoglobin (carbHb) is reported to interfere with measurement and interpretation of HbA(1c) in diabetic patients with chronic renal failure (CRF). There is also concern that HbA1c may give low results in these patients due to shortened erythrocyte survival. METHODS We evaluated the effect of carbHb on HbA(1c) measurements and compared HbA(1c) with glycated albumin (GA) in patients with and without renal disease to test if CRF causes clinically significant bias in HbA(1c) results by using 11 assay methods. Subjects included those with and without renal failure and diabetes. Each subject's estimated glomerular filtration rate (eGFR) was used to determine the presence and degree of the renal disease. A multiple regression model was used to determine if the relationship between HbA(1c) results obtained from each test method and the comparative method was significantly (p<0.05) affected by eGFR. These methods were further evaluated for clinical significance by using the difference between the eGRF quartiles of >7% at 6 or 9% HbA(1c). The relationship between HbA(1c) and glycated albumin (GA) in patients with and without renal failure was also compared. RESULTS Some methods showed small but statistically significant effects of eGFR; none of these differences were clinically significant. If GA is assumed to better reflect glycemic control, then HbA(1c) was approximately 1.5% HbA(1c) lower in patients with renal failure. CONCLUSIONS Although most methods can measure HbA(1c) accurately in patients with renal failure, healthcare providers must interpret these test results cautiously in these patients due to the propensity for shortened erythrocyte survival in renal failure.
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Affiliation(s)
- Randie R Little
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, One Hospital Dr., Columbia, MO 65212, USA.
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Murea M, Moran T, Russell GB, Shihabi ZK, Byers JR, Andries L, Bleyer AJ, Freedman BI. Glycated albumin, not hemoglobin A1c, predicts cardiovascular hospitalization and length of stay in diabetic patients on dialysis. Am J Nephrol 2012; 36:488-96. [PMID: 23147746 DOI: 10.1159/000343920] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 10/02/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND The utility of glycated hemoglobin (HbA1c) and glycated albumin (GA) in diabetic dialysis patients remains unknown. GA was previously associated with all-cause hospitalization and patient survival. Relationships between GA, HbA1c, and casual plasma glucose (PG) with cause-specific cardiovascular (CV) disease, infectious disease (ID), and vascular access- (VA) related hospitalization rates and length of stay (LOS) were assessed. METHODS 444 prevalent diabetic dialysis patients had monthly PG, quarterly GA, and all HbA1c values recorded for 2.33 years; hospitalizations within 17 and 30 days of testing were evaluated. Best-fit, time-dependent Cox models were constructed in unadjusted, case-mix-adjusted (age, sex, race, BMI, diabetes duration, dialysis vintage), and case-mix- plus lab-adjusted (hemoglobin, albumin, phosphorus) models. RESULTS Mean ± SD diabetes duration was 18.5 ± 10.8 years and dialysis vintage 2.9 ± 2.6 years. In fully adjusted models, CV hospitalization rates were associated with increasing GA (HR 1.32; 95% CI 1.11-1.57; p = 0.002 at 17 days; HR 1.21; p = 0.02 at 30 days) and PG (HR 1.10; 95% CI 1.02-1.17; p = 0.01 at 17 days; HR 1.07; p = 0.03 at 30 days), not HbA1c (HR 1.24; 95% CI 0.89-1.73; p = 0.21 at 17 days; HR 1.26; p = 0.10 at 30 days). LOS for CV admissions was positively associated with GA (HR 1.18; 95% CI 1.01-1.39; p = 0.03), not PG (HR 1.04; 95% CI 0.99-1.10; p = 0.15) or HbA1c (HR 1.03; 95% CI 0.92-1.15; p = 0.21). Admissions due to ID and VA complications (and LOS) did not correlate with these assays. CONCLUSIONS Improved glycemic control based on GA and PG predicted CV-related hospitalizations; GA also predicted CV hospitalization LOS. HbA1c did not predict cause-specific hospitalizations in dialysis populations.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine-Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Park J, Lertdumrongluk P, Molnar MZ, Kovesdy CP, Kalantar-Zadeh K. Glycemic control in diabetic dialysis patients and the burnt-out diabetes phenomenon. Curr Diab Rep 2012; 12:432-9. [PMID: 22638938 PMCID: PMC5796524 DOI: 10.1007/s11892-012-0286-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Diabetes mellitus (DM) is the most common cause of end-stage kidney disease and a major risk of morbidity and mortality. It is not clear whether medical management of DM has any significant beneficial effect on clinical outcomes at the end-stage of diabetic nephropathy with full-blown micro- and macro-angiopathic complications. Both loss of kidney function and dialysis treatment interfere with glucose homeostasis and confound glycemic control. Given the unique nature of uremic milieu and dialysis therapy related alterations, there have been some debates about reliance on the conventional measures of glycemic control, in particular the clinical relevance of hemoglobin A1c and its recommended target range of <7 % in diabetic dialysis patients. Moreover, a so-called burnt-out diabetes phenomenon has been described, in that many diabetic dialysis patients experience frequent hypoglycemic episodes prompting cessation of their anti-diabetic therapies transiently or even permanently. By reviewing the recent literature we argue that the use of A1c for management of diabetic dialysis patients should be encouraged if appropriate target ranges specific for these patients (e.g. 6 to 8 %) are used. We also argue that "burnt-out diabetes" is a true biologic phenomenon and highly prevalent in dialysis patients with established history and end-stage diabetic nephropathy and explore the role of protein-energy wasting to this end. Similarly, the J- or U-shaped associations between A1c or blood glucose concentrations and mortality are likely biologically plausible phenomena that should be taken into consideration in the management of diabetic dialysis patients to avoid hypoglycemia and its fatal consequences in diabetic dialysis patients.
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Affiliation(s)
- Jongha Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Paungpaga Lertdumrongluk
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Miklos Z Molnar
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Csaba P Kovesdy
- Division of Nephrology, University of Virginia, Charlottesville, VA, USA
- Division of Nephrology, Salem VA Medical Center, Salem, VA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- David Geffen School of Medicine at UCLA, and Fielding School of Public Health at UCLA, Los Angeles, CA, USA
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