Importance of Early Screening and Diagnosis of Chronic Kidney Disease in Patients with Type 2 Diabetes

It is estimated that one in ten people in the USA have diabetes. Approximately 40% of those with diabetes also develop chronic kidney disease (CKD), which in turn increases their risk of developing cardiovascular disease. Evidence-based recommendations for the treatment of patients with type 2 diabetes (T2D) and concomitant CKD are provided by several medical societies, including the American Diabetes Association (ADA), but in real life are only carried out in fewer than 50% of individuals for whom they are recommended. Screening for CKD is recommended using the spot urine albumin-to-creatinine ratio and estimated glomerular filtration rate in all patients with T2D at the time of diagnosis, and at least annually thereafter. Screening enables early CKD diagnosis, counseling, pharmacologic intervention and, when appropriate, referral to a nephrologist. The ADA guidelines recommend good glycemic and blood pressure control and the use of medications that are kidney protective. Medications shown to slow progression of CKD include renin-angiotensin system inhibitors, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists and, more recently, non-steroidal mineralocorticoid receptor antagonists. Novel agents with different mechanisms of action are also in development that have the potential to further slow or prevent disease progression when used with currently recommended therapies.

Determining the incidence of interstitial pneumonitis and chronic kidney disease following full intensity haemopoetic stem cell transplant conditioned using a forward-planned intensity modulated total body irradiation technique

PURPOSE/OBJECTIVE

Total body irradiation (TBI) remains a key component of conditioning for allogeneic haemopoietic stem cell transplant (HSCT), with interstitial pneumonitis (IP) and chronic kidney disease (CKD) important late sequelae. We undertook a retrospective service evaluation of TBI patients treated with a forward-planned intensity modulated radiotherapy technique (FP IMRT).

MATERIAL/METHODS

74 adult patients were identified; all received step and shoot FP IMRT TBI, 14.4 Gy in 8 fractions over 4 days. Mean doses to the lungs and kidneys were 12-12.5 Gy. Toxicities were defined as per CTCAE v4.0: IP as multilobar infiltrates on CT with symptoms of dyspnoea, and renal dysfunction as an Estimated Glomerular Filtration rate (eGFR) < 60 ml/min/1.73 m2 for > 3 months. Secondary endpoints were overall survival (OS), progression free survival (PFS), cumulative incidence of non-relapse mortality (NRM), relapse risk and of acute and chronic GvHD.

RESULTS

Patients received treatment for the following diagnosis: ALL/LBL (n = 37); AML (n = 33), CML-BC (n = 2) and High grade NHL (n = 2). The rate of IP due to any cause was 30%; positive microbiological evidence in 73% (16 /22). Idiopathic IP was seen in 8%, with only 4% (n = 3) having IP Grade ≥ 3. Two (4%) of 52 long term survivors developed CKD, one with thrombotic microangiopathy. 4 year NRM was 16% (CI 11-32%); no treatment related deaths in matched sibling or umbilical cord blood HSCT.

CONCLUSION

FP IMRT TBI, reducing dose to the lungs and kidneys, has lower rates of idiopathic IP and CKD compared to the literature. This technique is safe and effective conditioning for full intensity HSCT.

[Prevalence and risk factors of chronic kidney disease in the comprehensive care program DiabetIMSS]

BACKGROUND

The aim of this paper is to determine prevalence and risk factors of chronic kidney disease (CKD) in the comprehensive care program DiabetIMSS.

METHODS

Cross-sectional study in 488 patients with type 2 diabetes mellitus (DM2) included in the program DiabetIMSS. Sociodemographic, clinical, biochemical, and kidney function variables were collected.

RESULTS

Prevalence of CKD was 32% [early nephropathy (EN) 19% and overt nephropathy (ON) 13%]. Patients with more severe nephropathy significantly (p < 0.05) had: older age [normal kidney function (NKF) 54±11, EN 54±10, ON 63±9, years)], cardiovascular disease (NKF 1%, EN 5%, ON 11%), hypertension (NKF 65%, EN 63%, ON 85%), longer duration of DM2 (NKF 5%, EN 5%, ON 9%,) and of hypertension (NKF 5%, EN 6%, ON 9%), glycemic lack of control (NKF 46%, EN 62%, ON 60%), hyperuricemia (NKF 7%, EN 13%, ON 23%), anemia (NKF 1%, EN 4%, ON 10%) and metabolic syndrome (NKF 79%, EN 82%, ON 93%). Uncontrolled hypertension and DM2, cardiovascular disease and hyperuricemia significantly predicted the presence of nephropathy

CONCLUSIONS

A third of patients attending to DiabetIMSS had CKD and has not been previously diagnosed. Multiple risk factors are present in this high-risk population; their identification and control are extraordinarily important. Moreover, educative interventions for primary health-care professionals to improve health of this kind of patients are needed.

Refractory intraoperative hypotension with elevated serum tryptase

Severe intraoperative hypotension has been reported in patients on angiotensin-converting enzyme inhibitors and angiotensin II receptor subtype 1 antagonists. We describe a patient on lisinopril who developed refractory intraoperative hypotension associated with increased serum tryptase level suggesting mast cell activation (allergic reaction). However, allergology workup ruled out an allergic etiology as well as mastocytosis, and hypotension recalcitrant to treatment was attributed to uninterrupted lisinopril therapy. Elevated serum tryptase was attributed to our patient's chronic renal insufficiency.