Diabetic End-stage Renal Disease Patients Research Articles

Status and trends in epidemiologic characteristics of diabetic end-stage renal disease: an analysis of the 2021 Korean Renal Data System.

Korean Renal Data System (KORDS) is a nationwide end-stage renal disease (ESRD) registry database operated by the Korean Society of Nephrology (KSN). Diabetes mellitus is currently the leading cause of ESRD in Korea; this article provides an update on the trends and characteristics of diabetic ESRD patients. The KORDS Committee of KSN collects data on dialysis centers and patients through an online registry program. Here, we analyzed the status and trends in characteristics of diabetic chronic kidney disease stage 5D (CKD 5D) patients using data from 2001 to 2021. In 2021, the dialysis adequacy of hemodialysis (HD) was lower in diabetic CKD 5D patients than in nondiabetic CKD 5D patients, while that of peritoneal dialysis (PD) was similar. Diabetic CKD 5D patients had a higher proportion of cardiac and vascular diseases and were more frequently admitted to hospitals than nondiabetic CKD 5D patients, and the leading cause of death was cardiac disease. From 2001 to 2020, diabetic CKD 5D patients had a higher mortality rate than nondiabetic CKD 5D patients, but in 2021 this trend was reversed. Diabetic PD patients had the highest mortality rate over 20 years. The mortality rate of diabetic HD patients was higher than that of nondiabetic HD patients until 2019 but became lower starting in 2020. There was a decreasing trend in mortality rate in diabetic CKD 5D patients, but cardiac and vascular diseases were still prevalent in diabetic CKD 5D patients with frequent admissions to hospitals. More specialized care is needed to improve the clinical outcomes of diabetic CKD 5D patients.

Impact of initial dialysis modality on the survival of patients with ESRD: a propensity-score-matched study

BackgroundStudies comparing the survival of hemodialysis (HD) and peritoneal dialysis (PD) patients are controversial. This study evaluated the impact of initial dialysis modality on the survival of patients with end-stage renal disease (ESRD) in a matched-pair cohort.MethodsA retrospective cohort study was performed on ESRD patients who initiated renal replacement treatment between January 1, 2010, and December 31, 2018. Propensity score matching was applied to balance the baseline conditions, and multivariate Cox regression analysis was applied to compare mortality between HD and PD patients and evaluate correlations between mortality and various baseline characteristics. Subgroup analysis was performed with respect to diabetes status.ResultsThere were 739 patients in our center in the Chinese National Renal Data System (CNRDS) between 2010 and 2018. Of these, 125 PD patients were matched with 125 HD patients. The 1-, 2-, and 3-year survival rates were 96.5%, 90.7%, and 82.5%, respectively, in the HD group and 99.5%, 97.8%, and 92.5%, respectively, in the PD group (log-rank P < 0.001). Among the propensity score-matched cohorts, no significant differences in Kaplan–Meier curves were observed between the two groups (log-rank P = 0.514). Age at dialysis initiation, CCI, congestive heart failure and cerebrovascular disease were risk factors in the multivariable-adjusted model. In subgroups defined by diabetes status, the Kaplan‒Meier survival curve showed that PD survival was significantly higher than that of HD (log-rank P = 0.022).ConclusionsHD and PD were not significantly different regarding the survival of patients with ESRD. PD was associated with better survival in diabetic ESRD patients.

Comparison of Hearing Abnormalities in Non-Diabetic and Diabetic End-Stage Renal Disease Patients Undergoing Hemodialysis

Background and Aim: Hearing loss is a highly prevalent symptom in patients with chronic kidney diseases (CKD). Comorbidities such as Diabetes Mellitus is known as the most common cause of CKD and a significant risk factor for sensorineural hearing loss (SNHL). The aim of this study was to compare SNHL among diabetic with non-diabetic hemodialysis patients.&#x0D; Methods: In this study, 33 diabetic patients on hemodialysis were selected from Hami center, Arak, Iran. Non-diabetic subjects were 31 hemodialysis patients without diabetes were matched for age, duration of CKD and hemodialysis. Data were obtained via questionnaire, patients’ files, physical examination, otoscopy and tympanometry. Hearing was analyzed using pure-tone audiometry for both groups.&#x0D; Results: In the study, 66.2% of diabetic patients and 52.1% of non-diabetic subjects had SNHL. Results showed that diabetic patient has 1.3 times more likely to have hearing impairment. This difference was not statistically significant. Bilateral mild SNHL was the most prevalent in both groups. No significant difference was reported in SNHL prevalence, mean thresholds of hearing and ear laterality between the groups. Gender and age had a significant effect on hearing loss after adjusting covariables. No significant association was found between diabetes and hearing loss.&#x0D; Conclusion: SNHL was more common in hemodialysis patients with diabetes. Patients with diabetes had poorer hearing thresholds compared to non-diabetic group, with no significant difference between groups. The periodical assessment of hearing and extending audiological care in this high-risk population is recommended due to long-term irreversible symptoms of the disease.&#x0D; Keywords: Diabetes mellitus; hearing loss; end-stage renal disease

MO641IMPACT OF MAGNESIUM AND L-CARNITINE ADMINISTRATION ON 3-YEAR SURVIVAL IN DIABETIC PATIENTS WITH END-STAGE RENAL DISEASE

Abstract Background and Aims According to population registries, the survival of diabetic patients with end-stage-renal disease (ESRD) remains low today. In this context, it is reasonable to develop new therapeutic strategies based on advances in science of the important role of magnesium (Mg) and L-carnitine deficiency (via inflammation and endothelial dysfunction) in mechanisms of cardiovascular remodeling, high morbidity and mortality rates. Thus, the purpose of the present study was to evaluate the effect of Mg and L-carnitine supplementation on 3-year survival and development of the cardiovascular complications in diabetic hemodialysis (HD) patients. Method 48 type 2 diabetic ESRD patients were included in this prospective cohort study (male/female, 29/19; age, 59.9±0.6 years; HD duration, 34.8±4.8 month; diabetes mellitus duration, 174.7±7.1 month). The study was performed in accordance with the provisions of the Declaration of Helsinki last revision. Depending on the treatment programme, patients were divided into two groups: the 1st (main) group (n=24) in addition to basic treatment (hypoglycemic, antihypertensive therapy, according to indications - correction of anemia, hyperparathyroidism, hyperphosphatemia) was treated by combination of magnesium aspartate (0.5 g/day orally) and L-carnitine (1 g/day parenterally after each HD session (three times weekly); the 2nd (comparison) group (n=24) was only on the basic therapy. Complex treatment lasted 12-months; administration of L-carnitine was performed continuously throughout the year, while magnesium aspartate – by three 2-months’ courses/year. The follow up period in both groups was 36 months. Quantitative data are expressed as means±SEM, qualitative ones – as %. Kaplan-Meier method and Log-rank test were used to estimate survival of HD patients, χ2-test – to compare the frequency values. Results The cumulative proportion of survivors at the end of follow-up was 60.4%; however, after 36 months, the survival rate of diabetic HD patients who received a combination of magnesium aspartate and L-carnitine as part of their modified treatment was significantly higher (75 vs. 45.8%; Log-rank=2.07, p=0.038) compared to patients who were on basic therapy (Figure). Survival time in main and comparison groups was 31.9±1.7 and 26.4±2.2 months respectively. It is noteworthy, that throughout the year (from 10 to 22 months), no completed events were recorded in subjects who underwent Mg and L-carnitine supplementation. Conclusion (1) The combined use of magnesium aspartate and L-carnitine in addition to the basic 12-month treatment provides an effective reduction of cardiovascular complications and promotes 3-year survival of diabetic HD patients. (2) The results obtained substantiate the advisability of using repeated courses of Mg and L-carnitine administration 1 years after the end of the primary modified treatment to improve the prognosis in these ESRD patients.

Comorbidity Profiles among Obese–Diabetic End-Stage Renal Disease Patients: Data from REIN Registry of PACA Region of France

IntroductionThe proportion of new dialysis patients with comorbidities increased by an average of 5.6% per year in the Provence-Alpes-Côte d’Azur (PACA) region, with major increases in obese, cancer, and diabetic patients. This study aimed to describe comorbidity profiles among obese–diabetic end-stage renal disease (ESRD) patients in the Renal Epidemiology and Information Network (REIN) registry of the PACA region of France on December 31, 2018.MethodsData for this retrospective cross-sectional study were retrieved from the REIN registry of the PACA region. Data were analyzed using two models. Firstly, the ESRD patients were divided into two groups and binary logistic regression model used for the analysis of the data. Secondly, ESRD patients were divided into four groups and multinomial logistic regression model used. Univariate analysis was performed for group comparison using x2 and t-tests, while binary logistic and multinomial logistic regression models were used for multivariate analysis to derive ORs and 95% CIs.ResultsAmong the 4,491 ESRD patients in this study, 623 were obese–diabetic and 3,868 nonobese–nondiabetic and obese only/ diabetic only. Obese–diabetic ESRD patients were younger (<75 years, OR 0.46, p<0.001), smoked less (OR 0.51, p<0.001), were mainly dialyzed at centers (OR 1.29, p=0.014), and less likely to be on the renal transplant waiting list (OR 0.46, p<0.001) compared to the other group. Obese–diabetic ESRD patients also had more comorbidities, including cardiovascular diseases (OR 1.38, p=0.028), coronary insufficiency (OR 1.49, p=0.001) and chronic obstructive pulmonary disease (OR 1.75, p<0.001), but had fewer cases of cancer (OR 0.68, p=0.024) compare to the other group.ConclusionObese–diabetic patients with ESRD have many specific characteristics. These patients were younger, but had more cardiovascular comorbidities and were less likely to be on the waiting list for transplantation. They should receive special attention and be the subject of prevention and therapeutic education.

Non-traditional Risk Factors of Cardiovascular Disease and Coenzyme Q10 Therapy in Hemodialysis Patients

Background: Inflammatory markers increase in end-stage renal disease (ESRD), especially in diabetic patients, and are positively correlated with cardiovascular mortality. Coenzyme Q10 (CoQ10), an agent with antioxidant properties, may be effective in reducing cardiovascular complications in hemodialysis patients. This study aimed to investigate the effects of CoQ10 supplementation on plasma C-reactive protein (CRP), homocysteine, and albumin in hemodialysis patients. Methods: Forty diabetic ESRD patients on hemodialysis for at least six months were evaluated in a double-blinded randomized clinical trial. The patients were randomly assigned to one of the two groups to receive either CoQ10 100 mg daily or placebo. In all patients, the serum levels of homocysteine, albumin, and CRP were measured before and after six months. Results: The mean age of the patients was 60.3 ± 9.1 years, and 57.5% of the participants were female. There was no statistical difference between the two groups at baseline. Furthermore, no significant difference was observed in serum albumin (P = 0.843), CRP (P = 0.214), and homocysteine (P = 0.21) at the end of the intervention between the groups. Conclusions: This study showed that in patients with ESRD, using CoQ10 supplementation has minimal beneficial effects on serum albumin, CRP, and homocysteine levels.

Should Pre-Transplant Hemoglobin A1c Be Used to Predict Post-Transplant Compliance in End-Stage Renal Disease Patients Undergoing Kidney Transplantation?

BackgroundPatient compliance with immunosuppressive therapy after transplant has impacts on both graft and patient outcomes. For diabetic end-stage renal disease (ESRD) patients who are undergoing evaluation for kidney transplantation in our program, hemoglobin A1c (HbA1c) level of >10% is used as a flag that the patient may be at risk for noncompliance and that more comprehensive psychosocial screening is needed prior to transplant. We evaluated the association between pre-transplant HbA1c level and post-transplant compliance, as no study to date has looked at this in the transplant population.Material/MethodsThe charts of 392 patients who received a kidney transplant at a single institution between July 2008 and June 2012 were retrospectively reviewed. One hundred and sixty-five diabetic patients who received a kidney transplant alone were included in the final analysis. Our predictive variable was HbA1c level greater than 7.7% based on previous reports in the diabetic population. Outcome measures were graft survival, rejection episodes, unexplained low immunosuppressant levels, and documented noncompliance.ResultsThere were no statistically significant differences between the HbA1c groups of ≤7.7% and >7.7% in outcomes of failed grafts (22.0% and 17.8%, p=0.2), rejection episodes (15.0% and 6.7%, p=0.3), unexplained low immunosuppressant level (46.6% and 37.9%, p=0.3), and documented noncompliance (25.0% and 16.7%, p=0.4).ConclusionsIn diabetic ESRD patients selected for renal transplantation, elevated pre-transplant HbA1c levels, defined as HbA1c >7.7%, are not predictive of post-transplant medication compliance. We advocate that this group of patients should not be denied transplant solely on their elevated pre-transplant HbA1c.

SO006DIPEPTIDYL PEPTIDASE-4 INHIBITOR PROTECTS FROM PERITONEAL FIBROSIS--- A TRANSLATIONAL RESEARCH FROM CLINICAL OBSERVATION TO ANIMAL STUDY

Abstract Background and Aims The increasing prevalence rate of end-stage renal disease (ESRD) has emerged as a global health burden. Peritoneal dialysis (PD) possesses the survival and convenient advantage for ESRD during the first 2 years of dialysis treatment. However, long-term PD and hyperglycemia have been identified to frequently result in peritoneal fibrosis (PF) as subsequently to lead the failure of peritoneal function. Therefore, how to prevent PF is an important issue, especially in diabetic ESRD patients. Method To explore the effective protection in PD patients, Taiwan National Health Insurance Research Database was utilized to conduct the retrospective population-based cohort study from 1997 to 2013. A total of 19,828 diabetic ESRD patients with PD were analyzed the incidence of PD failure in the user and nonuser of dipeptidyl peptidase-4 (DPP4) inhibitors. On the other hand, the pathological role of DPP4 was further verified by cellular model and animal model of PF induced by chlorhexidine gluconate (CG). Results The rate of PD failure was significantly lower in diabetic ESRD patients with than without receiving DPP4 inhibitors (p&amp;lt;0.0001). Among all collected types of antidiabetic drugs, diabetic ESRD patients with DPP4 inhibitors treatment had the lowest rate of PD failure. In cellular study, the high concentration of glucose induced the increase of DPP4 protein levels, accumulating with the epithelial–mesenchymal transition (EMT), inflammation and the generation of oxidative stress in the mesothelial cells. However, sitagliptin treatment remarkably suppressed high concentration of glucose-inducing cellular damage. Additionally, in vivo study, sitagliptin treatment significantly decreased DPP4 activity, reversed EMT process via attenuating TGF-β/ Smad3 axil, ameliorated angiogenesis, reduced oxidative stress generation and inflammation through inhibiting NF-κB/ MyD88 signaling, followed by protected peritoneal integrity and function against CG-inducing PF in rats. Conclusion DPP4 contributed to the peritoneal fibrosis and functional impairment, whereas DPP4 inhibitors were suggested as a clinical protective strategy for extending PD. Figure:

SUN-240 INFLAMATORY MARKERS AND COENZYME Q10 THERAPY IN HEMODIALYSIS PATIENTS

Inflammatory markers are increased in end stage renal disease (ESRD) especially diabetic patients and are positively correlated to cardiovascular mortality. Coenzyme Q10 (CO-Q10) a substance with antioxidant properties, may be effective in reducing cardiovascular complications in hemodialysis patients. The aim of this study was to investigate effects of CO-Q10 supplementation on plasma C-reactive protein, homocysteine and albumin in hemodialysis patients. Forty diabetic ESRD patients with at least 6 months on hemodialysis were evaluated in a double blind randomized clinical trial. The patients were randomly assigned into one of the two groups receiving CO-Q10 100 mg daily and placebo. In all patients serum levels of homocysteine, albumin and CRP were measured before and after 6 months. Mean age of the patients was 60.3 ± 9.1 years and 57.5 % were male. There was no statistically difference between two groups at baseline. Furthermore, no significant difference was observed in serum albumin (P=0.843), CRP (P=0.214) and homocysteine (P=0.21) at the end of intervention between groups. This study showed that in patients with ESRD, using CO-Q10 supplementation has minimal beneficial effects on serum albumin, CRP and homocysteine levels.

Ocular Pulse Amplitude in Non-Diabetic Patients with End Stage Renal Disease and Normal Individuals Using Dynamic Contour Tonometry.

Ocular Pulse Amplitude (OPA) is the fluctuation of IOP with the cardiac cycle which is equal to the difference between systolic and diastolic IOP. These variations in IOP are thought to be caused by the blood volume that is pumped into the eye, mainly the choroidal bed during each cardiac cycle. In patients with end stage renal disease (ESRD), Choroidal perfusion has been found to be reduced as determined by Indocyanine Green Angiography (ICG) which is an invasive procedure. OPA is recorded by Dynamic Contour Tonometer (DCT) which represents a potential new technology for measuring choroidal blood flow indirectly & non-invasively especially in patients with suspected compromise in perfusion as in ESRD. In this study we postulate that measurement of OPA can be used to assess the choroidal perfusion inpatients with ESRD. To measure OPA in non-diabetic patients with ESRD on hemodialysis and to compare it with that of OPA in age matched normal individuals. It was a prospective Cross-sectional study and was done in a clinical set up during the period of January 2013 to October 2013. OPA among 44exposed and 44 non exposed individuals were measured using Dynamic Contour Tonometry (DCT) and analysis done. The mean OPA in non diabetic patients with ESRD was 1.945mm Hg (CI:1.847 - 2.043) and the mean OPA in age matched normals was 2.16mm Hg (CI: 2.08- 2.24). OPA in non diabetic ESRD patients was statistically significantly lower than that of age matched normals (p=0.03). There was no correlation between OPA and other parameters like age, gender, intraocular pressure, blood pressure or serumcreatinine levels.

Pancreas Retransplant After Pancreas Graft Failure in Simultaneous Pancreas-kidney Transplants Is Associated With Better Kidney Graft Survival.

Background.Simultaneous pancreas-kidney (SPK) transplant is usually the best option for the diabetic end-stage renal disease patient. There is limited information about kidney graft outcomes in SPK recipients with isolated pancreas graft failure who do versus do not undergo pancreas retransplantation.Methods.Patients were divided into 2 groups based on whether they underwent pancreas retransplant (ReTx+) or not (ReTx−). Kidney graft function and survival were the primary endpoints.Results.One hundred and nine patients satisfied our selection criteria, 25 in ReTx+ and 84 in ReTx−. Mean interval from SPK to pancreas failure was significantly shorter in the ReTx+ compared with the ReTx− group, 19.3 ± 36.7 versus 45.7 ± 47.0 months (P = 0.01), respectively. There was no significant difference in kidney graft follow-up post SPK between 2 groups (P = 0.48). At last follow-up, 15 of the 25 (60%) of the repeat pancreas graft had failed, with a mean graft survival among these failed pancreas graft of 2.6 ± 2.7 years, ranging from 0 to 8.1 years. Uncensored kidney graft failure was significantly lower in the ReTx+ group compared with the ReTx− group, 44% versus 67% (P = 0.04). Death-censored kidney graft failure was also lower in the ReTx+ group, 24% versus 48% (P = 0.04). The difference in patient survival did not reach statistical significance. In adjusted Cox regression analysis, rejection as a cause of pancreas failure was associated with increased risk of death-censored kidney graft failure, and pancreas retransplantation was associated with decreased risk of kidney graft failure. A similar pattern was seen after 1:1 matching for the interval between SPK and pancreas graft failure.Conclusions.Even though ReTx+ patients accept the risks associated with repeat pancreas surgery, providers should consider this option in suitable otherwise healthy patients.

Burnt-out diabetes in diabetic nephropathy patients on maintenance haemodialysis

Background: Diabetic nephropathy contributes to about 50% of end-stage renal disease (ESRD) worldwide. Diabetic ESRD patients experience spontaneous resolution of hyperglycaemia with normalisation of blood glucose and glycosylated haemoglobin leading to discontinuation of antidiabetic medicines, which progress to burnt-out diabetes state. The occurrence of burnt-out diabetes state needs to be identified for reducing the occurrence of hypoglycaemic episodes in diabetes patients on maintenance haemodialysis (MHD). Methods: A cross-sectional study was conducted in ESRD patients on MHD at the dialysis unit, the Department of Nephrology at Sri Venkateswara Institute of Medical Sciences, Tirupati, during the period January–April 2016. The diabetic ESRD patients on MHD were further subgrouped as burnt-out and non-burnt-out patients. Results: Among the patients with diabetes, burnt-out state was observed in 12 (23%) and non-burnt out were of 40 (77%) patients. The serum triglycerides, very low-density lipoprotein cholesterol, low-density lipoprotein cholesterol and parathyroid hormone levels were found to be increased, whereas body mass index, blood urea, serum high-density lipoprotein (HDL) and 25 hydroxy vitamin D (25 OHD3) levels were found to be decreased in burnt-out diabetic patients compared with non-burnt-out diabetic patients which were not statistically significant except for urea and HDL. Conclusion: Approximately, one-fourth of our patients were belonging to burnt-out diabetes state. If burnt-out diabetes state is recognised, unnecessary administration of insulin and other drugs which precipitate hypoglycaemia can be avoided so that the future risk of cardiovascular disease and mortality is minimised.

Long non-coding RNA MALAT1 and microRNA-499a expression profiles in diabetic ESRD patients undergoing dialysis: a preliminary cross-sectional analysis

Background: Circulating non-coding RNAs (ncRNAs) have been implicated in health and disease. This study aimed to evaluate the serum expression profile of microRNA-499a (miR-499a) and its selected bioinformatically predicted partner long-ncRNA MALAT1 (metastasis-associated lung adenocarcinoma transcript 1) in diabetes-related end-stage renal disease (ESRD) patients and to correlate the expressions with the patients' clinicolaboratory data.Subjects and methods: Real-time quantitative polymerase chain reaction was applied in diabetics with and without ESRD (n = 90 for each).Results: Serum MALAT1 expression levels were increased in the ESRD group relative to diabetics without ESRD with median (quartile) values of 10.5 (1.41–126.7) (p < .001). However, miR-499a levels were decreased in more than half of ESRD patients with a median of 0.96 (0.13–3.14). Both MALAT1 and miR-499a expression levels were inversely correlated in the ESRD patient-group.Conclusions: MALAT1 up-regulation and miR-499 down-regulation might be involved in diabetic nephropathy-related ESRD pathogenesis. Functional validation studies are warranted to confirm the MALAT1/miR-499a partnership.

The rate of progression of type 2 diabetes mellitus to end stage renal disease – A single centred retrospective study from Malaysia

IntroductionIn Malaysia, 61% of dialysis cases are secondary to diabetes. To date, we are still lacking of data on the rate of progression of type 2 diabetes mellitus (T2DM) to end stage renal disease (ESRD) in Malaysia. Materials and methodsThis was a retrospective study conducted at nephrology unit of a tertiary hospital in Kedah. All diabetic ESRD patients who fulfilled the inclusion criteria were identified and recruited for analysis. ResultsThe mean duration of DM to ESRD was found to be 14.37 ± 4.42 years. Mean duration for the onset of diabetic nephropathy was 8.73 ± 3.37 years. There was a relative short duration from diabetic nephropathy to ESRD noted, which was 5.63 ± 2.06 years. The mean duration of DM to ESRD for patients receiving RAAS blocker was found to be 18.23 ± 2.38 years as compared to 11.41 ± 2.94 years for those who did not (95% CI: -0.64 to -2.46). For different type of RAAS blockers, namely ACE inhibitor and angiotensin receptor blocker (ARB), there was no significant difference observed pertaining to mean duration of DM to ESRD; 17.89 ± 1.97 years for ACEi and 19.00 ± 4.16 years for ARB (95% CI: -4.74 to 2.52). DiscussionTime frame from diabetic nephropathy to ESRF among Malaysian population was shorter as compared to findings from other countries with an average period of 15 to 25 years. RAAS blockers should be initiated early in diabetic patients.

Predictors of complication following lower extremity amputation in diabetic end-stage renal disease.

Patients with diabetic end-stage renal disease (ESRD) are at increased risk of lower extremity amputation (LEA) and postoperative complications compared to those without diabetic ESRD. This study sought to determine the factors that influence complications following LEA in patients with diabetic ESRD. A total of 41 patients with diabetic ESRD (total of 46 amputations) who underwent LEA were enrolled in this study. The electronic medical records were retrospectively reviewed to identify the predictors of postoperative complications. The outcomes were divided into three categories: no complications, minor complications (wounds requiring only local care or oral antibiotics), and major complications (requiring surgical intervention, further amputations, or inducing life-threatening morbidities and mortalities). Multivariate logistic regression analysis demonstrated that underlying sepsis (P=0.007) was the only significant risk factor for major complications, with an odds ratio demonstrating an 8.16 times increased risk of requiring another surgery or mortality compared to those without sepsis. Preoperative sepsis is an independent risk factor for major complications after LEA in patients with diabetic ESRD. We advise particular caution when performing LEA in diabetic ESRD patients who are also septic. Early amputation, prior to the development of sepsis, is preferable.

Diabetes mellitus, superoxide dismutase and peroxisome proliferator activated receptor gamma polymorphisms modify the outcome of end-stage renal disease patients of Han Chinese origin.

Increased oxidative stress significantly modifies the outcome of patients with diabetes mellitus (DM) and end-stage renal disease (ESRD), and is counteracted by antioxidative capacity. We aimed to investigate whether antioxidant single nucleotide polymorphisms (SNPs) influence the outcome of ESRD individuals and the influences exerted by DM, which has not been tested before. We prospectively enrolled multi-centre ESRD patients of Han Chinese origin between 2002 and 2003, recording their antioxidant (superoxide dismutase [SOD2], glutathione peroxidase [GPX1]) and peroxisome proliferator activated receptor-γ (PPAR-γ) genotyping results, and stratified based on DM. They were followed up until 2008, with risk factors for mortality analyzed by Cox proportional hazard regression. We discovered that diabetic ESRD carriers of CC genotype of SOD2 exon 2 had an increased risk of mortality compared to non-diabetic ones with other genotypes (hazard ratio [HR] 4.04, P=0.04), while GPX1 SNPs had no influence. Interactions between SOD2 and PPAR-γ SNPs regarding the mortality influence were also detected (for SOD2 CC genotype x PPAR-γ exon 6 CT genotype, HR 3.19, P=0.008), suggesting the importance of considering a combination panel of SNPs on patient survival. This might be the largest study focusing on the relationship between antioxidant SNPs and the outcomes of diabetic ESRD patients of Han Chinese origin. More studies are needed to validate our findings.

Endovascular Distal Plantar Vein Arterialization in Dialysis Patients With No-Option Critical Limb Ischemia and Posterior Tibial Artery Occlusion: A Technique for Limb Salvage in a Challenging Patient Subset

Purpose: To detail a percutaneous technique for distal plantar venous arterialization in diabetic, end-stage renal disease (ESRD) patients with no-option critical limb ischemia (CLI). Technique: After failure of standard intraluminal recanalization attempts, a subintimal approach through the posterior tibial artery (PTA) is begun using a 0.014-inch, 190- or 300-cm-long guidewire supported by a 2-×20-mm, low-profile balloon catheter positioned a short distance behind the narrow “U-shaped” loop in the guidewire. Typically, heavy calcification in the distal tortuous segment of the PTA prevents reentry to the arterial true lumen; however, an entry in the distal lateral or medial plantar vein from a subintimal channel in the plantar artery can be intentionally pursued as a bailout technique, pointing the tip of the guidewire opposite to the arterial wall calcifications. Venous access is confirmed by contrast injection through the balloon catheter. Once the guidewire is advanced in the distal lateral or medial plantar vein and a plantar arteriovenous fistula (AVF) has been created, the AV anastomosis and the occluded PTA segment are dilated with 0.014-inch balloon catheters. The technique has been attempted in 9 consecutive diabetic, ESRD patients (mean age 69 years; 5 men) with no-option CLI; an AVF was created between the PTA and plantar vein in 7 patients. The mean TcPO2 at 1 month was 30±17 mm Hg (vs 7.3±2.2 at baseline). Six ulcers healed over an average of 21±4 weeks. Three of the 9 patients had below-knee amputations. Conclusion: Although further investigations are required, distal plantar venous arterialization may represent a promising technique to improve recanalization rates and limb salvage in diabetic ESRD patients with extremely calcified PTA occlusions.

Roles of triglyceride and phosphate in atherosclerosis of diabetic hemodialysis patients.

Background: A growing number of patients with End-Stage Renal Disease (ESRD) are undergoing long-term hemodialysis (HD). HD needs a vascular access (VA) and complications of VA account for a sizable proportion of its costs. One of the important cardiovascular diseases (CVD) is atherosclerosis, which is a major cause of premature deaths in the world. So, it is essential to find the risk factors to treat them before they cause an obvious CVD. Methods: We analyzed data from 174 ESRD patients who were candidate for Arterio Venous Fistula (AVF) creation from April 2008 to March 2009 in Hasheminejad Kidney Center by convenient sampling. X-ray images were used and C 4.5 algorithm of data mining techniques revealed the roles of two risk factors for atherosclerosis of diabetic ESRD patients. Pearson coefficient was also used to measure the correlation between the parameters. Results: Diabetic patients had significantly more calcified arteries in their forearm X-ray than other patients (p<0.001). Occurrence of atherosclerotic CVD in diabetic HD patients has an adverse relation compared with the controlled levels of their plasma levels of Triglyceride (TG) and Phosphorus. We found an inverse effect of TG and phosphorus plasma levels on the atherosclerotic involvement of radial and ulnar arteries in diabetic HD patients. We observed that the prevalence of radial and ulnar arteries calcification in these patients is lower when they have higher plasma levels of TG and phosphorous. Conclusion: This study investigates the role of high plasma levels of TG and phosphorous in the development of atherosclerosis in diabetic HD patients. Although many studies showed that hypertriglyceridemia plays a promoting role in the development of CVD, our study also found an inverse effect of plasma levels of TG on the atherosclerotic involvement of radial and ulnar arteries in diabetic patients, and therefore our results support this suspicion that hypertriglyceridemia plays a significant role in developing atherosclerosis.

Dietary Approaches in the Management of Diabetic Patients with Kidney Disease.

Chronic kidney disease (CKD) is one of the most prevalent complications of diabetes, and patients with diabetic kidney disease (DKD) have a substantially higher risk of cardiovascular disease and death compared to their non-diabetic CKD counterparts. In addition to pharmacologic management strategies, nutritional and dietary interventions in DKD are an essential aspect of management with the potential for ameliorating kidney function decline and preventing the development of other end-organ complications. Among DKD patients with non-dialysis dependent CKD, expert panels recommend lower dietary protein intake of 0.8 g/kg of body weight/day, while higher dietary protein intake (>1.2 g/kg of body weight/day) is advised among diabetic end-stage renal disease patients receiving maintenance dialysis to counteract protein catabolism, dialysate amino acid and protein losses, and protein-energy wasting. Carbohydrates from sugars should be limited to less than 10% of energy intake, and it is also suggested that higher polyunsaturated and monounsaturated fat consumption in lieu of saturated fatty acids, trans-fat, and cholesterol are associated with more favorable outcomes. While guidelines recommend dietary sodium restriction to less than 1.5–2.3 g/day, excessively low sodium intake may be associated with hyponatremia as well as impaired glucose metabolism and insulin sensitivity. As patients with advanced DKD progressing to end-stage renal disease may be prone to the “burnt-out diabetes” phenomenon (i.e., spontaneous resolution of hypoglycemia and frequent hypoglycemic episodes), further studies in this population are particularly needed to determine the safety and efficacy of dietary restrictions in this population.

Preoperative Evaluation in Patients With End-Stage Renal Disease and Chronic Kidney Disease.

Optimal preoperative management of dialysis patients remains challenging. Patients with end-stage renal disease (ESRD) have higher mortality in the perioperative setting compared with non-ESRD patients. However, it is well established that dialysis should be done on the day before surgery. Additional dialysis session prior to surgery does not improve outcomes. All dialysis patients should undergo blood work to check electrolytes and especially serum potassium prior to any surgery. Some medications, including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics, should be stopped prior to surgery to minimize hemodynamic changes during surgery. The dialysis access should be carefully examined for any signs of infection. The arteriovenous fistula or graft should be evaluated for patency. Glycemic control in diabetic ESRD and chronic kidney disease patients is very important, and clinicians should be aware of the risk of bleeding and the appropriate analgesics that can be used in dialysis patients in the perioperative setting. In conclusion, preoperative evaluation in patients with ESRD should be a multidisciplinary approach.