Diabetic End-stage Kidney Disease Research Articles

A Rare Anatomic Variant of the Superficial Palmar Branch of the Radial Artery Used for Arteriovenous Fistula Creation

Anatomical knowledge regarding the variant branching patterns of the radial artery is considerably crucial for interventionalists, vascular, and plastic surgeons. We report a case of a rare variant branching pattern where the superficial palmar branch of the radial artery originated from the radial artery in the forearm instead of the wrist with a subcutaneous course in a 52-year-old patient with diabetic end-stage kidney disease who required haemodialysis initiation. This variant branch was used as inflow for the creation of the arteriovenous fistula for haemodialysis access.

Diabetic kidney disease: Are the reported associations with single-nucleotide polymorphisms disease-specific?

BACKGROUNDThe genetic backgrounds of diabetic kidney disease (DKD) and end-stage kidney disease (ESKD) have not been fully elucidated.AIMTo examine the individual and cumulative effects of single-nucleotide polymorphisms (SNPs) previously associated with DKD on the risk for ESKD of diabetic etiology and to determine if any associations observed were specific for DKD.METHODSFourteen SNPs were genotyped in hemodialyzed 136 patients with diabetic ESKD (DKD group) and 121 patients with non-diabetic ESKD (NDKD group). Patients were also re-classified on the basis of the primary cause of chronic kidney disease (CKD). The distribution of alleles was compared between diabetic and non-diabetic groups as well as between different sub-phenotypes. The weighted multilocus genetic risk score (GRS) was calculated to estimate the cumulative risk conferred by all SNPs. The GRS distribution was then compared between the DKD and NDKD groups as well as in the groups according to the primary cause of CKD.RESULTSOne SNP (rs841853; SLC2A1) showed a nominal association with DKD (P = 0.048; P > 0.05 after Bonferroni correction). The GRS was higher in the DKD group (0.615 ± 0.260) than in the NDKD group (0.590 ± 0.253), but the difference was not significant (P = 0.46). The analysis of associations between GRS and individual factors did not show any significant correlation. However, the GRS was significantly higher in patients with glomerular disease than in those with tubulointerstitial disease (P = 0.014) and in those with a combined group (tubulointerstitial, vascular, and cystic and congenital disease) (P = 0.018).CONCLUSIONOur results suggest that selected SNPs that were previously associated with DKD may not be specific for DKD and may confer risk for CKD of different etiology, particularly those affecting renal glomeruli.

POS-714 POST-TRANSPLANT OUTCOMES IN RECIPIENTS OF LIVING DONOR KIDNEYS AND INTENDED RECIPIENTS OF LIVING DONOR KIDNEYS

Although kidney transplant recipients (KTR) from living donors demonstrate superior post-transplant outcomes compared to deceased donor (DD) recipients, the relative contribution of recipient factors versus donor factors to outcome differences remains unclear. Comparing outcomes in DD recipients with only potential living donors (DD1) to those with actualized living donors (LD) and DD recipients without potential living donors (DD0) may help inform this question. We hypothesized that graft outcomes in the two DD groups (DD0 and DD1) will be similar, but inferior to the LD group. This was a retrospective cohort observational study of KTR presenting to our centre for evaluation between 01/01/06 and 31/12/18, and received a transplant during that time. They were followed to 31/08/19. KT candidates were classified based on whether they identified a potential living donor at evaluation (LD, DD1) or not (DD0), and their ultimate donor source (LD or DD1). Primary outcome was 5-year death-censored graft survival, adjusted for donor and recipient age, race, cause of end-stage kidney disease (ESKD), peak panel-reactive antibody (PRA), dialysis duration, acute rejection (AR), and delayed graft function (DGF). Within-group and between-group comparisons were made using paired/unpaired student t-test or chi-square/Fisher’s exact test. Graft survival was compared by Kaplan-Meier methodology and log-rank test, with independence of predictor variables by multivariate Cox proportional hazards. Significance was taken as p<0.05. There were 471 KTR (LD=152, DD1=85, DD0=234), excluding DD0 candidates becoming LD (N=8). The most common immunosuppressive regimen was tacrolimus, MPA, and prednisone. DD0 and DD1 did not differ in organ characteristics. LD had a higher 5-year eGFR (59.7 v 53.5 and 52.0 ml/min/1.73m2 for LD, DD1, DD0 respectively, p=0.009) and fewer graft losses (N=10, 10, 49). The 5-year graft survival is shown in Figure 1. DD0 trended inferior to DD1 (p=0.07) and was inferior to LD (p=0.002) while DD1 was not (p=0.19). By multivariate Cox regression analysis, LD demonstrated superior graft survival to combined DD (DD0+DD1) (HR 0.40 [95% CI 0.19-0.84], p=0.016) and DD0 (HR 0.34 [0.16-0.72], p=0.005) but not DD1 (p=0.72). AR, DGF, and diabetic ESKD were also significant across models. Adding peak PRA and dialysis duration rendered DD type insignificant. DD recipients are not all the same. DD1 may exhibit less inferior outcomes to LD than DD0 even with biologically equal DD organs. Not having an identified living donor at initial evaluation is a surrogate for factors risking graft survival that require further attention. Distinguishing DD0 from DD1 as a simple pre-transplant variable may permit clinicians to effectively target biological-social interventions and improve overall DD graft survival. Information about potential but non-actualized living donors must transfer to the DD recipient’s post-transplant chart.

Experience of Magnesium and L-Carnitine Combine Use for Correction of Structural and Functional Heart Changes in Type 2 Diabetic Patients with End-Stage Kidney Disease

Introduction and purpose: It is important today to develop new pathogenetic strategies to reduce cardiovascular risk in type 2 diabetic patients with end-stage kidney disease (ESKD). The purpose of the study was to evaluate the efficacy of combine use of magnesium aspartate and L-Carnitine on character of heart changes in dynamics of complex treatment of the patients with diabetic kidney disease (DKD) undergoing hemodialysis (HD). Material and methods: 42 type 2 diabetic ESKD patients were included in this prospective cohort study (male/female, 26/16; age, 59.5±0.7 years; HD duration, 31.2±4.6 months; diabetes mellitus duration, 174,6±7,8 months). The patients were divided into two groups: the 1st (main) group (n=22) was treated by combination of magnesium aspartate (0.5 g/day orally) by three 2-months’ courses/year and L-carnitine (1 g/day parenterally after each HD session) throughout the year; the 2nd (comparison) group (n=20) was only on the basic therapy. The observation time was 12 months. A complete echocardiography and ultrasound scanning of common carotid arteries (CCA) were performed. Results: During follow up period we found the reduction of the left atrium (p=0.008) and left ventricle (LV) diameters (p=0.004), decrease of LV mass index for 17,1% (p=0.005) and prevalence of pseudonormal and restrictive types of LV diastolic dysfunction for 53.3% (p=0.026), increase of the LV ejection fraction for 5.4% (p=0.004), and decrease the mean pulmonary artery pressure for 13% (p=0.009) in the main group. The annual incidence of both mitral and aortic valve calcification in the 2nd group was 10%, in the 1st group – 0%. After 12 months of treatment, increase of the CCA intima-media thickness (p=0.23) was recorded in the comparison group only. Conclusions: The combine use of magnesium and L-carnitine as part of a 12-month complex therapy provides an effective reduction ofLV hypertrophy, improves its systolic and diastolic function, reduces pulmonary hypertension, and prevents the progression of cardiac valve calcification and atherosclerotic damage.

The Contribution of Kidney Disease to Cognitive Impairment in Patients with Type 2 Diabetes.

This review focuses on the relationships between diabetes, cognitive impairment, and the contribution of kidney disease. We review the independent contributions of parameters of kidney disease, including albuminuria, glomerular filtration, bone/mineral metabolism, and vitamin D synthesis, on cognitive performance in patients with diabetes. Potential pathophysiologic mechanisms underlying these associations are discussed highlighting gaps in existing knowledge. Finally, effects of the dialysis procedure on the brain and cognitive performance are considered. Emphasis is placed on novel non-invasive screening tools with the potential to preserve cerebral perfusion during hemodialysis and limit cognitive decline in patients with diabetic ESKD. Patients with type 2 diabetes and advanced chronic kidney disease suffer a higher prevalence of cognitive impairment. This is particularly true in patients with diabetes and end-stage kidney disease (ESKD).

Ocular manifestations in patients with diabetes with end-stage renal disease

PURPOSE: Diabetic nephropathy is the most common cause of kidney failure and end-stage kidney disease. The present study was undertaken to find ocular changes and complications associated with diabetic end-stage kidney disease. MATERIALS AND METHODS: A 1-year cross-sectional study was conducted in the department of ophthalmology at a tertiary care hospital in South India between January 2008 and December 2008 on 50 patients with diabetes mellitus undergoing renal hemodialysis. Patients were subjected to general physical examination, systemic examination, and ocular examination. Best-corrected visual acuity, intraocular pressure, and detailed examination of anterior and posterior segments were assessed. RESULTS: Male (74%) preponderance was observed, and 50% of the patients had age more than 60 years. Thirty-two (32%) of the patients had duration of renal dialysis CONCLUSION: Patients with diabetic end-stage kidney diseases are at high risk of ocular morbidities. Timely screening and treatment may help to reduce the ocular morbidities in this group.

Pancreas allocation and diabetic end-stage kidney disease

Pancreas allocation and diabetic end-stage kidney disease

Some profiles of diabetic CKD patients with AVF on haemodialysis

Background: Diabetes mellitus is one of the major chronic non communicable diseases that affect millions globally. Diabetic nephropathy is a serious complication of diabetes mellitus, often leading to end stage kidney disease (CKD). Objectives: The aim of this study was to assess some profiles of diabetic end stage kidney disease patients with AVF on haemodialysis at baseline and adequacy of treatment after three months follow up regarding different clinical and laboratory parameters. Methodology: The current prospective study was carried out in the haemodialysis unit in AL-Hussein Teaching Hospital (Iraq / Thi-Qar) from April to July 2016. The number of patients included in the study was (24) patients. Results: The majority of patients were not educated and 50 % of them were smokers. The adherence rate of the patients with haemodialysis schedule was 50%. The prevalence of HCV infection was significantly higher among adherent than non-adherent patients. Conclusion: The management of diabetic end stage kidney disease patients with AVF on maintenance haemodialysis is considered inadequate and there was a high rate of acquiring viral hepatitis C infection after beginning sessions of hemodialysis.

Preferred haemodialysis vascular access for diabetic chronic kidney disease patients: a systematic literature review.

Vascular access problems are one of the main concerns in the diabetic end-stage kidney disease (ESKD) population. However, the optimal strategy for the establishment of vascular access in this population remains to be solved. We performed a systematic review in order to clarify the most advisable approach of vascular access planning in diabetic patients with ESKD. MEDLINE, EMBASE and CENTRAL databases were searched for English-language articles without time restriction through focused, high-sensitive search strategies. We included all studies providing outcome data on diabetics starting chronic haemodialysis treatment on the basis of the type of primary placed vascular access. A total of 13 studies comprising over 2,800 participants with diabetes were reviewed in detail and included in the review. We found that diabetic patients using a dialysis catheter apparently experience a higher risk of death and infection compared with patients who successfully achieved and maintained an arteriovenous fistula as dialysis access. The comparison between the use of a graft or an autogenous fistula as dialysis access generated conflicting results. Primary patency rates appeared to be lower in diabetics versus non-diabetics. Our study suggests that diabetic ESKD patients with dialysis catheters incur a higher risk of death in comparison to those who achieve an arteriovenous access. It is however unclear whether this is caused by residual selection bias or by a true advantage of native vascular access.

Is it time to increase access to transplantation for those with diabetic end-stage kidney disease?

Keddis et al. present a large, single-center experience that demonstrates improvement over time in survival of patients with diabetes and end-stage kidney disease who receive a kidney transplant. We discuss how these data should prompt transplant programs to consider providing greater access to transplantation for their patients with diabetes.

Diabetic nephropathy: the role of inflammation in fibroblast activation and kidney fibrosis

Kidney disease associated with diabetes mellitus is a major health problem worldwide. Although established therapeutic strategies, such as appropriate blood glucose control, blood pressure control with renin–angiotensin system blockade, and lipid lowering with statins, are used to treat diabetes, the contribution of diabetic end-stage kidney disease to the total number of cases requiring hemodialysis has increased tremendously in the past two decades. Once renal function starts declining, it can result in a higher frequency of renal and extra-renal events, including cardiovascular events. Therefore, slowing renal function decline is one of the main areas of focus in diabetic nephropathy research, and novel strategies are urgently needed to prevent diabetic kidney disease progression. Regardless of the type of injury and etiology, kidney fibrosis is the commonly the final outcome of progressive kidney diseases, and it results in significant destruction of normal kidney structure and accompanying functional deterioration. Kidney fibrosis is caused by prolonged injury and dysregulation of the normal wound-healing process in association with excess extracellular matrix deposition. Kidney fibroblasts play an important role in the fibrotic process, but the origin of the fibroblasts remains elusive. In addition to the activation of residential fibroblasts, other important sources of fibroblasts have been proposed, such as pericytes, fibrocytes, and fibroblasts originating from epithelial-to-mesenchymal and endothelial-to-mesenchymal transition. Inflammatory cells and cytokines play a vital role In the process of fibroblast activation. In this review, we will analyze the contribution of inflammation to the process of tissue fibrosis, the type of fibroblast activation and the therapeutic strategies targeting the inflammatory pathways in an effort to slow the progression of diabetic kidney disease.

APOL1 allelic variants are associated with lower age of dialysis initiation and thereby increased dialysis vintage in African and Hispanic Americans with non-diabetic end-stage kidney disease

The APOL1 G1 and G2 genetic variants make a major contribution to the African ancestry risk for a number of common forms of non-diabetic end-stage kidney disease (ESKD). We sought to clarify the relationship of APOL1 variants with age of dialysis initiation and dialysis vintage (defined by the time between dialysis initiation and sample collection) in African and Hispanic Americans, diabetic and non-diabetic ESKD. We examined APOL1 genotypes in 995 African and Hispanic American dialysis patients with diabetic and non-diabetic ESKD. The mean age of dialysis initiation for non-diabetic African-American patients with two APOL1 risk alleles was 48.1 years, >9 years earlier than those without APOL1 risk alleles (t-test, P=0.0003). Similar results were found in the non-diabetic Hispanic American cohort, but not in the diabetic cohorts. G1 heterozygotes showed a 5.3-year lower mean age of dialysis initiation (t-test, P=0.0452), but G2 heterozygotes did not show such an effect. At the age of 70, 92% of individuals with two APOL1 risk alleles had already initiated dialysis, compared with 76% of the patients without APOL1 risk alleles. Although two APOL1 risk alleles are also associated with ∼2 years increased in dialysis vintage, further analysis showed that this increase is fully explained by earlier age of dialysis initiation. Two APOL1 risk alleles significantly predict lower age of dialysis initiation and thereby increased dialysis vintage in non-diabetic ESKD African and Hispanic Americans, but not in diabetic ESKD. A single APOL1 G1, but not G2, risk allele also lowers the age of dialysis initiation, apparently consistent with gain of injury or loss of function mechanisms. Hence, APOL1 mutations produce a distinct category of kidney disease that manifests at younger ages in African ancestry populations.

Identifying High Risk Groups and Quantifying Absolute Risk of Cancer After Kidney Transplantation: A Cohort Study of 15 183 Recipients

Transplant recipients have increased cancer risk, but data on risk variation across different patient groups are sparse. Rates and standardized rate ratios (SRR) of cancer (all sites, excluding nonmelanocytic skin and lip cancer) compared to the general population were calculated, using Australia and New Zealand Dialysis and Transplant Registry data. Within the transplant population, risk factors were identified (hazard ratios: HR; 95% CI) and absolute risk estimated for recipient groups. A total of 1642 (10.8%) of 15 183 recipients developed cancer. Risk was inversely related to age (SRR 15-30 children, 2 if >65 years). Females aged 25-29 had rates equivalent to women aged 55-59 from the general population. Age trend for lymphoma, colorectal and breast risk was similar; melanoma showed less variability across ages, prostate showed no risk increase. Within the transplanted population, risk was affected by age differently for each sex (p = 0.007), elevated by prior malignancy (HR 1.40; 1.03-1.89), white race (HR 1.36; 1.12-1.89), but reduced by diabetic end-stage kidney disease (ESKD) (HR 0.67; 0.50-0.89). Cancer rates in kidney recipients are similar to nontransplanted people 20-30 years older, but absolute risk differs across patient groups. Men aged 45-54 surviving 10 years have cancer risks varying from 1 in 13 (non-white, no prior cancer, diabetic ESKD) to 1 in 5 (white, prior cancer, other ESKD).