Association between glycemia and mortality in diabetic individuals on renal replacement therapy in the U.K

Novel clinical relationships between time in range and microangiopathies in people with type 2 diabetes mellitus on hemodialysis

AIMS/HYPOTHESIS

We investigated associations among glucose time in range (TIR, 70-180 mg/dL), glycemic markers and prevalence of diabetic microangiopathy in people with diabetes undergoing hemodialysis (HD).

METHODS

A total of 107 people with type 2 diabetes undergoing HD (HbA_1c 6.4 %; glycated albumin [GA] 20.6 %) using continuous glucose monitoring were analyzed in this observational and cross-sectional study.

RESULTS

HbA_1c and GA levels significantly negatively correlated with TIR, and positively correlated with time rate of hyperglycemia, but not with time rate of hypoglycemia. TIR of 70 % corresponded to HbA_1c of 6.5 % and GA of 21.2 %. The estimated HbA_1c level corresponding to TIR of 70 % in this study was lower than that previously reported in people with diabetes without HD. The prevalence of diabetic neuropathy was not significantly different between people with TIR ≥ 70 % and those with TIR < 70 % (P = 0.1925), but the prevalence of diabetic retinopathy in people with TIR ≥ 70 % was significantly lower than in those with TIR < 70 % (P = 0.0071).

CONCLUSION/INTERPRETATION

TIR correlated with HbA_1c and GA levels in people with type 2 diabetes on HD. Additionally, a higher TIR resulted in a lower rate of diabetic retinopathy.

RESEARCH IN CONTEXT

What is already known about this subject? What is the key question? What are the new findings? How might this impact on clinical practice in the foreseeable future?

The association between long-term glycemic control and all-cause mortality is different among older versus younger patients with diabetes mellitus and maintenance hemodialysis treatment

AIMS

Knowledge about association between glycated hemoglobin (HbA1c) and risk of all-cause mortality in patients with diabetes mellitus on maintenance hemodialysis (HD)-treatment is sparse. The study aims to investigate association between HbA1c and all-cause mortality in patients with diabetes and maintenance HD-treatment, separately for two age groups- above and below 75 years.

METHODS

2487 patients (mean age 66 years, 66 % men) were separated in two age groups: ≤75 years (n = 1810) and > 75 years (n = 677) and followed up between 2008 and 2018. Hazard ratios (HR) and 95 % confidence intervals (CI) for associations between HbA1c and all-cause mortality were calculated using Cox-regression-models.

RESULTS

1295 (52 %) patients died and 473 (70 %) among the patients above 75 years old. In the multivariate analysis, HbA1c5-6 % was used as reference. In patients ≤ 75 years old, only increased HbA1c > 9.7 %, HR2.03(CI1.43-2.89) was associated with increased risk of all-cause mortality. In patients > 75 years, HbA1c ≤ 5 %, HR1.67(CI1.16-2.40); HbA1c6.9-7.8 %, HR1.41(CI1.03-1.93) and HbA1c8.7-9.7 %, HR1.79 (CI1.08-2.96) were associated with increased risk of all-cause mortality.

CONCLUSIONS

We found a J-shaped association between HbA1c and mortality only in diabetic HD-patients > 75 years. This probably indicates that in an old population of diabetic HD-patients, both intensive glucose control and hyperglycemia could be harmful and associated with higher risk of death.

Glycated hemoglobin levels and risk of all-cause and cause-specific mortality in hemodialysis patients with diabetes

AIM

Adequate glycemic control is fundamental for improving clinical outcomes in hemodialysis patients with diabetes. However, the target for glycated hemoglobin (HbA1c) level and whether cause-specific mortality differs based on HbA1c levels remain unclear.

METHODS

A total of 24,243 HD patients with diabetes were enrolled from a multicenter, nationwide registry. We examined the association between HbA1c levels and the risk of all-cause and cause-specific mortality.

RESULTS

Compared to patients with HbA1c 6.5%-7.5%, patients with HbA_1c 8.5-9.5% and ≥9.5% were associated with a 1.26-fold (95% CI, 1.12-1.42) and 1.56-fold (95% CI, 1.37-1.77) risk for all-cause mortality. The risk of all-cause mortality did not increase in patients with HbA1c < 5.5%. In cause-specific mortality, the risk of cardiovascular deaths significantly increased from small increase of HbA1c levels. However, the risk of other causes of death increased only in patients with HbA1c > 9.5%. The slope of HR increase with increasing HbA1c levels was significantly faster for cardiovascular causes than for other causes.

CONCLUSIONS

There was a linear relationship between HbA1c levels and risk of all-cause mortality in hemodialysis patients, and the risk of cardiovascular death increased earlier and more rapidly, with increasing HbA1c levels, compared with other causes of death.

The association between diabetes coexisting with low levels of high-density lipoprotein cholesterol and peritoneal dialysis-related peritonitis

BACKGROUND

Low levels of high-density lipoprotein cholesterol (HDL-C) and diabetes are common in patients undergoing peritoneal dialysis (PD). The aim of this study was to investigate the association between the coexistence of diabetes with a low level of HDL-C and the first episode of peritoneal dialysis-related peritonitis (PDRP) in patients with PD.

METHODS

We retrospectively investigated patients with PD from January 1, 2003, to May 31, 2020, in four PD centers. Patients with PD were divided into four groups: no comorbidities, low HDL-C only, diabetes only, and diabetes plus low HDL-C. The clinical and laboratory baseline data of the four groups were collected and compared. The association between diabetes coexisting with low HDL-C levels and the first episode of PDRP was analyzed by multivariate Cox regression analysis.

RESULTS

A total of 1013 patients with PD were included in our study. The mean age was 49.94 ± 14.32 years, and 597 (58.99%) patients were males. A total of 301 (29.7%) patients had their first episodes of PDRP, and low HDL-C levels coexisted with diabetes in 72 patients with PD. After adjusting for confounding factors, a low level of HDL-C coexisting with diabetes was significantly associated with the first episode of PDRP in our study (hazard ratio: 2.81, 95% CI 1.32 ~ 4.73, p = 0.005). The associations among HDL-C, diabetes and PDRP were consistent in the following subgroups: sex, age, and pre-existing CVD (all P interaction > 0.05).

CONCLUSIONS

Patients with both diabetes and low HDL-C levels were at higher risk for PDRP in patients with PD.

Hemodialysis-Related Glycemic Disarray Proven by Continuous Glucose Monitoring; Glycemic Markers and Hypoglycemia

OBJECTIVE

There is a high risk of asymptomatic hypoglycemia associated with hemodialysis (HD) using glucose-free dialysate; therefore, the inclusion of glucose in the dialysate is believed to prevent intradialytic hypoglycemia. However, the exact glycemic fluctuation profiles and frequency of asymptomatic hypoglycemia using dialysates containing >100 mg/dL glucose have not been determined.

RESEARCH DESIGN AND METHODS

We evaluated the glycemic profiles of 98 patients, 68 of whom were men, with type 2 diabetes undergoing HD (HbA_1c 6.4 ± 1.2%; glycated albumin 20.8 ± 6.8%) with a dialysate containing 100, 125, or 150 mg/dL glucose using continuous glucose monitoring.

RESULTS

Sensor glucose level (SGL) showed a sustained decrease during HD, irrespective of the dialysate glucose concentration, and reached a nadir that was lower than the dialysate glucose concentration in 49 participants (50%). Twenty-one participants (21%) presented with HD-related hypoglycemia, defined by an SGL <70 mg/dL during HD and/or between the end of HD and their next meal. All these hypoglycemic episodes were asymptomatic. Measures of glycemic variability calculated using the SGL data (SD, coefficient of variation, and range of SGL) were higher and time below range (<70 mg/dL) was lower in participants who experienced HD-related hypoglycemia than in those who did not, whereas time in range between 70 and 180 mg/dL, time above range (>180 mg/dL), HbA_1c, and glycated albumin of the two groups were similar.

CONCLUSIONS

Despite the use of dialysate containing 100-150 mg/dL glucose, patients with diabetes undergoing HD experienced HD-related hypoglycemia unawareness frequently. SGL may fall well below the dialysate glucose concentration toward the end of HD.

Association of Nuclear Factor Erythroid-2-Related Actor 2 Gene Polymorphisms with Diabetic Nephropathy in Chinese Patients

Aim

Nuclear factor erythroid-2-related factor 2 (NRF2) has emerged as a therapeutic target in many diseases. To explore this further, we evaluated the relationships between the -617C/A (rs6721961) polymorphisms within the NRF2 promoter and diabetic nephropathy (DN) in Chinese Han patients with type 2 diabetes mellitus (T2DM).

Methods

A total of 883 subjects with T2DM (500 without and 383 with DN) were enrolled in this study. Multivariable linear regression models were carried out to assess the association of DN with the -617C/A (rs6721961) polymorphisms.

Results

The AA genotype frequencies in patients with DN were significantly lower than those in patients without DN (χ² = 8.04, p = 0.018). Multivariate logistic regression analyses showed that individuals with the AA genotype had a significantly lower risk for DN (OR 0.52; 95% CI 0.28, 0.94; p = 0.029) than those with the CC genotype. Moreover, AA carriers had a significantly lower risk of DN (OR 0.46; 95% CI 0.26, 0.82; p = 0.009) relative to those with the CC + CA genotype, even after adjusting for known DN risk factors.

Conclusion

Our study indicated that the -617C/A polymorphism within the NRF2 promoter was significantly associated with DN in Chinese Han patients with T2DM.

The Challenges of Using UK Renal Registry Data to Audit the Care of Patients with Diabetes on Renal Replacement Therapy

INTRODUCTION

Diabetes is a major cause of CKD and of mortality in patients on renal replacement therapy (RRT). Auditing the care of patients with diabetes on RRT against published guidelines relies on robust data collection.

OBJECTIVE

This article assesses the completeness of data items collected by the UK Renal Registry (UKRR) that are required to audit the care of patients with diabetes on RRT.

METHODS

The UKRR receives data on all patients receiving RRT in the UK. Patients with diabetes, diabetes type, and method of renal diagnosis were identified from primary renal disease (PRD) codes and comorbidity data for patients commencing RRT at one of the 57 renal centres in England and Wales between 2010 and 2016. The completeness of demographic and clinical data (blood pressure, cholesterol, glycated haemoglobin [HbA1c], and smoking status) was assessed for the first year of RRT.

RESULTS

Ninety-three per cent of all patients on RRT irrespective of diagnosis had a PRD code, but only 28/57 renal centres had comorbidity data completeness ≥70%; 34.9% of patients with diabetic nephropathy (DN) had type 1 diabetes, but this varied between centres (9.2-100%). Overall, 4.2% of DN diagnoses were by biopsy. Data completeness in the first year of RRT for cardiovascular risk factors ranged between 50.0 and 80.0%, with HbA1c data completeness being 63.0%. Of 57 centres, 20 had HbA1c data for ≥70% of patients in the first year of RRT.

CONCLUSIONS

There is persistent variation between renal centres in the completeness of data collected on patients with diabetes on RRT, impacting on the ability to undertake robust audit. Data linkages and expanded data permissions could see registry data play a key role in ongoing audit and research into patients with diabetes and CKD, provided adequate data can be collected.

Fully closed-loop insulin delivery improves glucose control of inpatients with type 2 diabetes receiving hemodialysis

Inpatient diabetes management of those on hemodialysis poses a major challenge. In a post hoc analysis of a randomized controlled clinical trial, we compared the efficacy of fully automated closed-loop insulin delivery vs. usual care in patients undergoing hemodialysis while in hospital. Compared to control patients receiving conventional subcutaneous insulin therapy, those patients receiving closed-loop insulin delivery significantly increased the proportion of time when a continuous glucose monitor was in the target range of 5.6-10.0 mmol/l by 37.6 percent without increasing the risk of hypoglycemia. Thus, closed-loop insulin delivery offers a novel way to achieve effective and safe glucose control in this vulnerable patient population.

Glycemic control and survival in peritoneal dialysis patients with diabetes: A 2-year nationwide cohort study

For glycemic control in patients with diabetes on peritoneal dialysis (PD), the level of glycated albumin (GA) associated with mortality is unclear. Accordingly, we examined the difference in the association of GA and glycated hemoglobin (HbA1c) with 2-year mortality in a Japanese Society for Dialysis Therapy cohort. We examined 1601 patients with prevalent diabetes who were on PD. Of these, 1282 had HbA1c (HbA1c cohort) and 725 had GA (GA cohort) measured. We followed them for 2 years from 2013 to 2015 and used Cox regression to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for 2-year mortality after adjusting for potential confounders in each cohort. No significant association was found between HbA1c levels and all-cause death HRs before and after adjustment for confounders in the HbA1c cohort. In contrast, the adjusted all-cause death HRs and 95% CIs for GAs < 12.0%, 12.0–13.9%, 16.0–17.9%, 18.0–19.9%, 20.0–21.9%, and ≥22.0%, compared with 14.0–15.9% (reference), were 1.56 (0.32–7.45), 1.24 (0.32–4.83), 1.32 (0.36–4.77), 2.02 (0.54–7.53), 4.36 (1.10–17.0), and 4.10 (1.20–14.0), respectively. In the GA cohort, GA ≥ 20.0% was significantly associated with a higher death HR compared with the reference GA. Thus, GA ≥ 20.0% appears to be associated with a decrease in survival in diabetic patients on PD. There were no associations between HbA1c levels and 2-year mortality in PD patients.

Rate of the "burnt-out diabetes" phenomenon in patients on peritoneal dialysis

AIMS

In some diabetes patients on dialysis, glycemic control improves spontaneously, leading to normal HbA1c levels; this phenomenon is known as "burnt-out diabetes." Glycated albumin (GA) might be a better indicator of glycemic control than HbA1c in hemodialysis patients, but it has not been assessed in peritoneal dialysis (PD) patients.

METHODS

This study involved diabetes patients on PD, with HbA1c level and antidiabetes therapy records. First, the "burnt-out diabetes" phenomenon was investigated in patients with HbA1c measurements alone (HbA1c cohort). Then, it was investigated in patients with both HbA1c and GA measurements (GA cohort).

RESULTS

A total of 1296 patients were included in the HbA1c cohort. When "burnt-out diabetes" was defined as HbA1c < 6.0% without treatment, it was noted in 269 patients (20.8%). A total of 413 patients were subsequently included in the GA cohort. "Burnt-out diabetes," using the same definition, was found in 73 patients (17.7%). However, when defined as HbA1c < 6.0% and GA < 16.0% without treatment, "burnt-out diabetes" was found in 45 patients (10.9%).

CONCLUSIONS

Although the "burnt-out diabetes" phenomenon was present in 17.7% of patients with diabetes on PD based on HbA1c, the rate was significantly decreased to 10.9% when taking GA into account.

The Health and Health Care of Adults With Type 1 And 2 Diabetes Across the Spectrum of Estimated Glomerular Filtration Rates

OBJECTIVES

Little is known about the health and health-care patterns of patients with diabetes according to their estimated glomerular filtration rates, especially within a publicly funded health-care system.

METHODS

Using linked health-care databases in Ontario, Canada, we performed a population-based study of adults 50 years of age and older (mean age, 68 years) with prevalent diabetes on January 1, 2014. We categorized patients according to their levels of kidney function (estimated glomerular filtration rate ≥90, 60 to 89, 30 to 59, 15 to 29 or <15 mL/min/1.73 m², or the receipt of ongoing maintenance dialysis). We then followed patients for 2 years to determine: 1) their level of contact with health-care providers (i.e. visits to family doctors, specialists); 2) their use and repeated use of acute medical services (i.e. hospitalizations and emergency department encounters; 3) diabetes-related monitoring and screening (i.e. glycated hemoglobin and cholesterol tests, vision screening); 4) glycemic and lipid control; and 5) diabetes-related outcomes.

RESULTS

There were 569,384 patients in our study. Most had estimated glomerular filtration rates between 60 and 89 mL/min/1.73 m². At baseline, patients with lower kidney function had longer durations of diabetes and more comorbidities. Over 2 years of follow up, they had higher burdens of medical care, excessive diabetes monitoring and were underscreened for diabetes-related complications. Although metabolic control was reasonable across groups, patients with low kidney function had more hospital encounters and more diabetes-related complications.

CONCLUSIONS

Patients with diabetes and low kidney function are a vulnerable population that faces health system challenges and care gaps. Suggestions for policy and practice are discussed.

Association of hyperglycemic crisis with an increased risk of end-stage renal disease: A nationwide population-based cohort study

BACKGROUND

A hyperglycemic crisis episode (HCE) is associated with poor management of diabetes, which is a risk factor for end-stage renal disease (ESRD); however, the association between an HCE and ESRD has not been clarified. We conducted a nationwide population-based cohort study with the purpose of delineating this issue.

METHODS

We identified 9208 diabetic patients with an HCE and an identical number of diabetic patients with matched age, sex, and index date without an HCE between 2000 and 2002. A comparison of the risk of ESRD between the diabetic patients with and without an HCE was achieved by a follow-up until 2014.

RESULTS

A Cox proportional hazard regression analysis showed that the diabetic patients with an HCE were at a higher risk of ESRD than those without an HCE (the adjusted hazard ratio [AHR]: 1.47; 95% confidence interval [CI]: 1.34-1.62) by adjusting for renal disease, hypertension, hyperlipidemia, coronary artery disease, hyperuricemia, anemia, chronic obstructive pulmonary disease, liver disease, malignancy, connective tissue disease, non-steroid anti-inflammatory drug use, and monthly income. The increased risk of ESRD was more prominent in the age subgroup of 15-25 years (AHR: 4.91; 95% CI: 1.92-12.56); 25-35 years (AHR: 2.42; 95% CI: 1.51-3.86); 35-45 years (AHR: 3.01; 95% CI: 2.21-4.09); and 45-55 years (AHR: 1.75; 95% CI: 1.41-2.19).

CONCLUSIONS

An HCE was associated with an increased risk of ESRD, especially in the younger diabetic patients (15-55 years). A close follow-up for the control of diabetes and for monitoring renal function is proposed.

Long-Term Survivor Characteristics in Hemodialysis Patients with Type 2 Diabetes

BACKGROUND

Data concerning long-term mortality predictors among large, purely diabetic hemodialysis collectives are scarce.

METHODS

We used data from a multicenter, prospective, randomized trial among 1,255 hemodialysis patients with type 2 diabetes mellitus (T2DM) and its observational follow-up study. The association of 10 baseline candidate variables with mortality was assessed by Cox proportional hazards regression.

RESULTS

Overall, 103 participants survived the median follow-up of 11.5 years. Significant predictors of mortality were age (hazard ratio [HR] 1.03, 95% CI 1.02-1.04), cardiovascular (HR 1.42, 95% CI 1.25-1.62) and peripheral vascular disease (HR 1.55, 95% CI 1.36-1.76), higher hemoglobin A1c (HbA1c; HR 1.08, 95% CI 1.03-1.14), and loss of self-dependency (HR 1.20, 95% CI 1.03-1.39). Higher albumin (HR 0.72, 95% CI 0.59-0.89) and body mass index (BMI; HR 0.98, 95% CI 0.96-0.99) had protective associations. There was no significant association with sex, diabetes duration, and cerebrovascular diseases. Subgroup analyses by age and diabetes duration showed stronger associations of cardiovascular disease, HbA1c, albumin, BMI, and loss of self-dependency in younger patients and/or shorter diabetes duration. Loss of self-dependency and energy resources (albumin, BMI) increased mortality more severely in women, whilst the impact of cardiovascular and peripheral vascular diseases was more pronounced in men.

CONCLUSION

Long-term mortality risk in patients with T2DM on hemodialysis was associated with higher age, vascular diseases, HbA1c, loss of self-dependency, and low energy resources. Interestingly, it does not vary between sexes. Further individualized prognosis estimation and therapy should strongly depend on age, diabetes duration, and gender.

Association of Glycemic Status During Progression of Chronic Kidney Disease With Early Dialysis Mortality in Patients With Diabetes

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 A_1c (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.

Impact of Diabetes on Extracellular Volume Status in Patients Initiating Peritoneal Dialysis

BACKGROUND

Recent reports have highlighted that diabetic patients with kidney failure are at increased risk of technique failure and transfer to haemodialysis within 90 days of initiating peritoneal dialysis (PD). We wished to determine whether there were differences between diabetic and non-diabetic patients within the first 3 months of starting PD.

METHODS

We reviewed results of corresponding bioimpedance and the 1st test of peritoneal membrane function (PET) in consecutive patients, 6-10 weeks after initiating PD electively.

RESULTS

Adult patients numbering 386 - 230 males (59.6%), 152 (39.4%) diabetic, 188 (48.7%) white, mean age 57.3 ±16.9 years - were studied. Although weight, residual renal function and peritoneal clearances were not different, diabetic patients had greater extracellular water to total body water (ECW/TBW; 40.4 ± 1.1 vs. 39.2 ± 1.4) and % ECW excess (9.6 [6.3-12.3] vs. 4.9 [0.7-8.9]), lower serum albumin (35.2 ± 4.7 vs. 37.8 ± 4.9 g/L), greater fat mass index (9.5 ± 4.2 vs. 7.7 ± 4.2), and although mean arterial blood pressure was similar, arterial pulse pressure was greater (66.9 ± 10.8 vs. 54.3 ± 17.3 mm Hg, all p < 0.001). On multivariate analysis, glycated haemoglobin was associated with pulse pressure (standardised β 0.24, p < 0.001), N terminal brain natriuretic peptide (β 0.24, p < 0.001), ECW/TBW (β 0.19, p = 0.012) and negatively with serum albumin (β -0.14, p = 0.033) and creatinine (β -0.18, p = 0.02).

CONCLUSION

Diabetic patients electively starting PD were found to have greater ECW/TBW ratios and ECW excess 6-10 weeks after starting PD compared to non-diabetics, despite similar PET. Increased ECW could predispose diabetic patients to be at greater risk of volume overload.

Consensus statement on insulin therapy in chronic kidney disease

INTRODUCTION

Diabetes mellitus (DM) is one of the leading causes of chronic kidney disease (CKD) which eventually leads to insulin resistance and decreased insulin degradation. In patients with diabetic kidney disease (DKD), the overall insulin requirement declines which necessitates the reassessment for individualization, adjustment and titration of insulin doses depending on the severity of kidney disease.

OBJECTIVE

To provide simple and easily implementable guidelines to primary care physicians on appropriate insulin dosing and titration of various insulin regimens in patients with DKD.

METHODS

Each insulin regimen (basal, prandial, premix and basal-bolus) was presented and evaluated for dosing and titration based on data from approved medical literatures on chronic kidney disease. These evaluations were then factored into the national context based on the expert committee representatives' and key opinion leaders' clinical experience and common therapeutic practices followed in India.

RESULTS

Recommendations based on dosing and titration of insulins has been developed. Moreover, the consensus group also recommended the strategy for dose estimation of insulin, optimal glycaemic targets and self-monitoring in patients with DKD.

CONCLUSION

The consensus based recommendations will be a useful reference tool for health care practitioners to initiate, optimise and intensify insulin therapy in patients with DKD.

PATHOPHYSIOLOGY AND MANAGEMENT OF HYPOGLYCEMIAIN END-STAGE RENAL DISEASE PATIENTS: A REVIEW

OBJECTIVE

This review focuses on hypoglycemia in patients with end-stage renal disease (ESRD). It discusses the pathophysiology of glucose metabolism in the kidney, the impact of dialysis on glucose and insulin metabolism, and the challenges of glucose monitoring in ESRD. The clinical relevance of these changes is reviewed in relation to altered blood glucose targets and modification of antidiabetes therapy to prevent hypoglycemia. Based on current data and guidelines, recommendations for the outpatient and inpatient setting are provided for diabetes management in ESRD.

METHODS

PubMed, OVID, and Google Scholar were searched to identify related articles through May 2016 using the following keywords: "glucose metabolism," "kidney," "diabetes," "hypoglycemia," "ESRD," and "insulin" in various combinations for this review.

RESULTS

In ESRD, a combination of impaired insulin clearance, changes in glucose metabolism, and the dialysis process make patients vulnerable to low blood glucose levels. Hypoglycemia accounts for up to 3.6% of all ESRD-related admissions. At admission or during hospitalization, hypoglycemia in ESRD has a poor prognosis, with mortality rates reported at 30%. Several guidelines suggest a modified hemoglobin A1c (A1c) goal of 7 to 8.5% (53 to 69 mmol/mol) and an average blood glucose goal of 150 to 200 mg/dL. Noninsulin antidiabetes agents like dipeptidyl peptidase 4 inhibitors, repaglinide, and glipizide in appropriate doses and reduction of insulin doses up to 50% may help decrease hypoglycemia.

CONCLUSION

Patients with ESRD are at high risk for hypoglycemia. Increased awareness by providers regarding these risks and appropriate diabetes regimen adjustments can help minimize hypoglycemic events.

ABBREVIATIONS

ADA = antidiabetes agent BG = blood glucose CKD = chronic kidney disease DPP-4 = dipeptidyl peptidase 4 eGFR = estimated glomerular filtration rate ESRD = end-stage renal disease GFR = glomerular filtration rate HD = hemodialysis NPH = neutral protamine Hagedorn PD = peritoneal dialysis SA = short acting SU = sulfonylurea.

Determinant Effects of Average Fasting Plasma Glucose on Mortality in Diabetic End-Stage Renal Disease Patients on Maintenance Hemodialysis

Introduction

Diabetic kidney disease is an increasingly frequent cause of end-stage renal disease. However, mixed results were shown between glycated hemoglobin and mortality.

Methods

We used the average fasting plasma glucose (FPG) levels to predict mortality rates in long-term hemodialysis patients. We enrolled 46,332 hemodialysis patients with diabetes mellitus, who were registered in the Taiwan Renal Registry Data System between January 2005 and December 2012. The patients were stratified based on the quartiles of average FPG levels measured for the first (1-year FPG) and third years (3-year FPG) of hemodialysis. Survival analysis was conducted via multivariable Cox regression.

Results

After the first year of hemodialysis, the mean FPG levels were 103.5 ± 14.5, 144.7 ± 11.5, 189.6 ± 15.2, and 280.8 ± 1.2 mg/dl for the first, second, third, and fourth quartile, respectively. The Kaplan-Meier curve showed an incremental reduction in the survival as FPG levels increased (P < 0.0001). In the Cox regression model, the adjusted hazard ratios were 1.15 (95% CI: 1.10–1.20), 1.30 (95% CI: 1.25–1.36), and 1.45 (95% CI: 1.39–1.51) for the pairwise comparisons between the first quartile and the second, third, and fourth quartile, respectively. Similar trends were observed by 3-year FPG. Patients whose FPG levels increased had a 22% increased risk (95% CI: 1.16–1.29) for all-cause mortality compared with patients whose FPG levels decreased.

Discussion

Our results suggest that the average FPG levels are useful predictors of all-cause mortality in dialysis patients. In addition, an increasing trend in average FPG levels indicates poor survival.

Cadmium Level, Glycemic Control, and Indices of Renal Function in Treated Type II Diabetics: Implications for Polluted Environments

Cadmium (Cd) has recently emerged as a major concern not only in environmental toxicology but also in metabolic diseases such as diabetes mellitus and its complications. Conflicting data aside, these studies have not been examined in a clinical population undergoing management as well as possible modulation by the prominent metabolic antagonist of Cd such as zinc (Zn). This study examined the relationship between cadmium levels, glycemic control, and renal pathology in established type II diabetic patients with focus on populations exposed to modern environmental health hazards (MEHHs). Sixty-five participants, consisting of 45 type-2 diabetics and 20 non-diabetics were enrolled for the study, mean age 61.51 ± 5.27 years. Glycated hemoglobin (HbA_1c) was used to classify them into three sub-groups: (A) good glycemic control (44.4%), (B) fair glycemic control (24.4%), and (C) poor glycemic control (31.1%). Plasma levels of glucose, Cd, Zn, HbA_1c, creatinine, urinary creatinine, microalbuminuria, and estimated glomerular filtration rate (eGFR) were determined in all participants using standard methods. Fasting plasma glucose was higher in diabetics than in non-diabetics (p = 0.000) as well as Zn level, though not significantly. Interestingly, Cd level, Cd/Zn ratio, and urinary creatinine were significantly lower in diabetics than in non-diabetics. The group with poor glycemic control (C) had significantly higher Cd level compared to the one with good glycemic control (group A). The renal function revealed that microalbuminuria and urinary albumin/creatinine ratio (UACR) was significantly higher in diabetics than in non-diabetics, while eGFR was found to be similar in both diabetics and non-diabetics. UACR inversely correlated with Cd level, while plasma creatinine level positively correlated with Cd but not significantly. Correlation between Cd and HbA_1c revealed non-significant inverse correlation (r = −0.007; p > 0.05), while Zn showed a significant inverse correlation with Cd (r = −0.317; p < 0.014). The lower Cd level in diabetics compared to non-diabetics probably reflects the modulating effect of Zn in treated diabetics given nutritional education in addition to their regular regime, including good sources of Zn. The renal insufficiency with increasing Cd level may suggest that the progression of renal impairment may not be responsive to the putative modulating effect of Zn.

Glycemic Control and Mortality in Diabetic Patients Undergoing Dialysis Focusing on the Effects of Age and Dialysis Type: A Prospective Cohort Study in Korea

Background

Active glycemic control has been proven to delay the onset and slow the progression of diabetic retinopathy, nephropathy, and neuropathy in diabetic patients, but the optimal level is obscure in end-stage renal disease. In this study, we evaluated the effect of hemoglobin A1c (HbA1c) on mortality of diabetic patients on dialysis, focusing on age and dialysis type.

Methods

Of 3,302 patients enrolled in the prospective cohort for end-stage renal disease in Korea between August 2008 and October 2013, 1,239 diabetic patients who had been diagnosed with diabetes or having HbA1c≥6.5% at the time of enrollment were analyzed. Age was categorized as <55, 55–64 and ≥65 years old. Age, sex, modified Charlson comorbidity index, hemoglobin, primary renal disease, body mass index, and dialysis duration were adjusted.

Results

A total of 873 patients received hemodialysis (HD) and 366 underwent peritoneal dialysis (PD). During the mean follow-up of 19.1 months, 141 patients died. Patients with poor glucose control (HbA1c≥8%) showed worse survival than patients with HbA1c<8% (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.48–3.29; P<0.001). Subgroup analysis divided by age revealed that HbA1c≥8% was a predictor of mortality in age <55 (HR, 4.3; 95% CI, 1.78–10.41; P = 0.001) and age 55–64 groups (HR, 3.3; 95% CI, 1.56–7.05; P = 0.002), but not in age ≥65 group. Combining dialysis type and age, poor glucose control negatively affected survival only in age < 55 group among HD patients, but it was significant in age < 55 and age 55–64 groups in PD patients. Deaths from infection were more prevalent in the PD group, and poor glucose control tended to correlate with more deaths from infection in PD patients (P = 0.050).

Conclusions

In this study, the effect of glycemic control differed according to age and dialysis type in diabetic patients. Thus, the target of glycemic control should be customized; further observational studies may strengthen the clinical relevance.

Management of diabetes mellitus in patients with chronic kidney disease

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.

Risk of hypoglycemia during hemodialysis in diabetic patients is related to lower pre-dialysis glycemia

OBJECTIVE

To compare the occurrence of hypoglycemia during hemodialysis in chronic kidney disease diabetic patients who present different levels of pre-dialysis glycemia both when using dialysis solutions with and without glucose.

SUBJECTS AND METHODS

Twenty type 2 diabetic patients in maintenance hemodialysis were submitted to three dialysis sessions (at a 7-day interval each) with dialysis solutions without glucose, with glucose at 55 mg/dL, and at 90 mg/dL subsequently. Blood glucose levels were measured immediately pre-dialysis and at 4 moments during the session, and values under 70 mg/dL were considered as hypoglycemia.

RESULTS

Average pre-dialysis glycemia was lower in those who presented intra-dialytic hypoglycemia than in those who did not, both in glucose-free (140.4 ± 50.7 vs. 277.7 ± 91.0 mg/dL; p = 0.005; 95%CI: 46.4 to 228.1) and in glucose 55 mg/dL (89.5 ± 10.6 vs. 229.7 ± 105.0 mg/dL; p < 0.05; 95%CI: 9.8 to 270.5). In patients with pre-dialysis glycemia under 140 mg/dL, average intradialytic glycemia was significantly lower than pre-dialysis glycemia only when using glucose-free dialysate (p < 0.0001; 95%CI: 29.9 to 56.0 - t-test). Hypoglycemia during dialysis was observed only when using glucose-free or glucose-poor dialysis solutions.

CONCLUSIONS

The use of glucose-free or glucose-poor dialysis solution presents a high risk of intradialytic hypoglycemia in diabetic renal patients, especially in those with presumed better glycemic control.

[Significance of hemoglobin A1C in the management of diabetes in dialysis patients]

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.