Diabetic Uremic Patients Research Articles

Impact of kidney size on the outcome of diabetic patients receiving hemodialysis.

IntroductionDiabetic patients normally have enlarged or normal-sized kidneys throughout their lifetime, but some diabetic uremic patients have small kidneys. It is uncertain if kidney size could have any negative impact on outcome in hemodialysis patients.MethodsThis longitudinal, observational cohort study recruited 301 diabetic hemodialysis patients in 2015, and followed until 2019. Patients were stratified into two subgroups according to their kidney sizes before dialysis, as small (n = 32) or enlarged or normal (n = 269). Baseline demographic, hematological, biochemical, nutritional, inflammatory and dialysis related data were collected for analysis.ResultsPatients with small kidney size were not only older (P<0.001) and had lower body mass index (P = 0.016), but had also higher blood uric acid concentration (P<0.001) compared with patients with enlarged or normal kidney size. All patients received adequate doses of hemodialysis since the Kt/V and urea reduction ratio was 1.7±0.3 and 0.7±0.1, respectively. Patients with small size kidneys received higher erythropoietin dose than patients with enlarged or normal kidney size (P = 0.031). At the end of analysis, 92 (30.6%) patients expired. Kaplan-Meier analysis revealed no survival difference between both groups (P = 0.753). In a multivariate logistic regression model, it was demonstrated that age (P<0.001), dialysis duration (P<0.001), as well as blood albumin (P = 0.012) and low-density lipoprotein (P = 0.009) concentrations were significantly correlated with mortality.ConclusionsSmall kidney size on starting hemodialysis was not related with an augmented risk for death in diabetic patients receiving hemodialysis. Further studies are necessary.

Teaching NeuroImage: Reversible Symmetric Basal Ganglia Lesions in a Patient With Diabetes Undergoing Dialysis

A 50-year-old woman with diabetes and renal disease on hemodialysis presented with 1 month of involuntary movements, dysarthria, and gait disturbance. Examination revealed bradykinesia, dystonia, and choreoathetosis. Brain MRI showed symmetric basal ganglia lesions (Figure 1). Basic metabolic panel was stable from baseline with normal bicarbonate but elevated creatinine, blood urea nitrogen, and glucose. Serum and CSF testing was otherwise unremarkable. Repeat MRI 3 months later showed spontaneous lesion regression (Figure 2); however, her symptoms persisted. Findings were attributed to a well-described, but poorly understood, syndrome of basal ganglia injury in diabetic uremic patients due to metabolic and vascular dysregulation.1,2

The role of glycated albumin as a marker of glycemic state in type 2 diabetic patients under hemodialysis

Background: Glycated albumin (GA) and glycated hemoglobin (HbA1c) levels are affected not only by plasma glucose levels but also by albumin metabolism and hemoglobin metabolism, respectively. Our study is aiming to evaluate the role of (GA) as an indicator of the glycemic state and its correlation with HbA1c in hemodialysis patients with diabetes mellitus. Research Design and Methods: Our study is a cohort prospective study done on 50 chronic uremic diabetic patients 23 males and 27 females at Al-Azhar Assuit University Hospital, from August 2016 to February 2017. All the studied patients were on regular HD 3 times/week, 4 hours session. Multiple regression analysis was done to assess the correlation between glycated albumin and HbA1c as indicators of glycemic state. Patients with pregnancy, nephrotic syndrome, neoplastic disorders, and anemia due to causes other than chronic renal disease as hemolytic anemia, chronic liver diseases, thyroid disorders, and those under immunosuppressive therapy were excluded. Results: GA had had a highly significant predictor for PG (p-value = 0.001) VS HbA1c%, which was had a significant predictor (p-value = 0.021). Conclusion: Our study suggested that while HbAlc is considered the gold standard test in estimating the glycemic state in diabetic patients, GA can be used as an indicator of the glycemic state in uremic patients on regular HD.

The survival advantage of pancreas after kidney transplant.

Patient survival after pancreas after kidney transplant (PAK) has been reported to be inferior to patient survival after simultaneous pancreas-kidney transplant (SPK). The authors examine national data to further explore allograft (kidney and pancreas) and patient survival after PAK. Kaplan-Meier and Cox proportional hazard models were used to analyze Organ Procurement and Transplantation Network data from 1995 to 2010. The analysis compared PAK and SPK candidates and recipients. Kaplan-Meier analysis results showed that PAK after either a living or a deceased donor kidney transplant is associated with increased kidney graft survival compared with recipients with type 1 diabetes who received only a kidney. The best kidney allograft survival was for patients who received a living donor kidney followed by PAK. Receiving a living donor kidney was associated with increased pancreas allograft survival compared with receiving a deceased donor kidney. PAK transplant recipients who receive both organs have a survival advantage compared with uremic candidates who receive neither (SPK waitlist). Compared with uremic diabetic waitlist patients, SPK and PAK recipients showed similar overall patient survival. Successful PAK offers a survival advantage compared with receiving neither a kidney nor a pancreas transplant. These data also suggest that receiving a pancreas (after kidney) transplant may have a protective effect on the kidney allograft.

Isolated pancreas rejections do not have an adverse impact on kidney graft survival whereas kidney rejections are associated with adverse pancreas graft survivalin simultaneous pancreas kidney transplantation.

Diabetic Kidney Disease is associated with excessive mortality and morbidity. Simultaneous pancreas kidney transplantation (SPK) significantly improves quality of life and increases life expectancy of uremic diabetic patients. It is not known whether pancreas and kidney rejections in these transplant patients is concordant or discordant. We analyzed clinical data on all SPK transplants performed between 2003 and 2014 at Indiana University to assess the impact of isolated or combined pancreas and kidney rejections on patient and allograft outcomes. The primary outcome of interest was kidney graft rejection within 1year of pancreatic rejection and kidney survival in SPK patients with and without pancreatic rejection. Mean age of patients was 44 ± 9years; 61.9% were males; 88% were Caucasians. A total of 23.8% of cases had rejection [8.7% pancreatic rejection alone (PA), 4.4% had concordant pancreas and kidney (PK) rejection, and 10.7% had kidney rejection alone(KA)]. PK had a worse effect on kidney graft survival than PA (p = 0.019). Neither pancreas rejection nor kidney rejection had an adverse effect on patient survival. However, both pancreas graft failure and kidney graft failure adversely affected patient survival. Tacrolimus levels were not significantly different in all groups over a 10year period (p = 0.4584). Concordant pancreas kidney rejection is synergistically deleterious to kidney graft survival. Graft failure, not graft rejection, is adversely associated with patient survival.

Pancreas transplantation: review.

ABSTRACTVascularized pancreas transplantation is the only treatment that establishes normal glucose levels and normalizes glycosylated hemoglobin levels in type 1 diabetic patients. The first vascularized pancreas transplant was performed by William Kelly and Richard Lillehei, to treat a type 1 diabetes patient, in December 1966. In Brazil, Edison Teixeira performed the first isolated segmental pancreas transplant in 1968. Until the 1980s, pancreas transplants were restricted to a few centers of the United States and Europe. The introduction of tacrolimus and mycophenolate mofetil in 1994, led to a significant outcome improvement and consequently, an increase in pancreas transplants in several countries. According to the International Pancreas Transplant Registry, until December 31st, 2010, more than 35 thousand pancreas transplants had been performed. The one-year survival of patients and pancreatic grafts exceeds 95 and 83%, respectively. The better survival of pancreatic (86%) and renal (93%) grafts in the first year after transplantation is in the simultaneous pancreas-kidney transplant group of patients. Immunological loss in the first year after transplant for simultaneous pancreas-kidney, pancreas after kidney, and pancreas alone are 1.8, 3.7, and 6%, respectively. Pancreas transplant has 10 to 20% surgical complications requiring laparotomy. Besides enhancing quality of life, pancreatic transplant increases survival of uremic diabetic patient as compared to uremic diabetic patients on dialysis or with kidney transplantation alone.

Neuroimaging Findings in Hypoglycemia Triggered Syndrome of Acute Bilateral Basal Ganglia Lesions in Patients Treated With Regular Dialysis: Two Case Reports

The syndrome of bilateral basal ganglia lesions in diabetic uremic patients is a rare disorder with only few cases described in the literature, predominantly Asian patients. It has characteristic clinical and imaging features consisting of acute hyperkinetic or hypokinetic extrapyramidal disorder in association with uniform neuroimaging findings of bilateral symmetrical basal ganglia changes in diabetics undergoing hemodialysis. Its pathophysiology remains largely unknown. Uremic toxins, metabolic acidosis and diabetic microangiopathy are among the factors believed to contribute to its pathogenesis. Here we report two patients with uremia and diabetes, who developed the syndrome of acute bilateral basal ganglia lesions after an incidence of severe hypoglycemia. We would like to emphasize the importance of appropriate diagnose and management of the condition in uremic patients and also consider hypoglycemia as a candidate trigger factor.

Erythrocyte glutathione transferase activity: a possible early biomarker for blood toxicity in uremic diabetic patients

Erythrocyte glutathione transferase (e-GST) displays increased activity in patients with renal damage and positive correlation with homocysteine (Hcy) in patients under maintenance hemodialysis. Here, we determined e-GST, Hcy, and erythrocyte catalase (e-CAT) in 328 patients affected by type 2 diabetes mellitus (T2DM), 61 diabetic non-nephropathic patients and 267 affected by diabetes and by chronic kidney disease (CKD) under conservative therapy subdivided into four stages according to K-DOQI lines. e-GST activity was significantly higher in all T2DM patients compared to the control group (7.90 ± 0.26 vs. 5.6 ± 0.4 U/g(Hb)), and we observed an enhanced activity in all subgroups of CKD diabetic patients. No significant correlation or increase has been found for e-CAT in all patients tested. Mean Hcy in diabetic patients is higher than that in healthy subjects (33.42 ± 1.23 vs. 13.6 ± 0.8 μM), and Hcy increases in relation to the CKD stage. As expected, a significant correlation was found between e-GST and Hcy levels. These findings suggest that e-GST hyperactivity is not caused directly by diabetes but by its consequent renal damage. e-GST, as well as Hcy, may represent an early biomarker of renal failure.

Uremic Encephalopathy with Basal Ganglia Lesions in a Diabetic Predialysis Patient

Syndromes associated with acute bilateral lesions of the basal ganglia in diabetic uremic patients are uncommon, and usually have reversible clinical and imaging findings. Such syndromes are seen almost exclus ively in patients with diabetes mellitus and renal failure. Previously reported cases have described diabetic men with uremia on dialysis. Here, we report a case of uremic encephalopathy with lesions of the basal ganglia in a diabetic predialysis patient. A 44-year-old man with uremic encephalopathy presented with dysarthria, chorea, and right upper extremity paresthesia. Magnetic resonance imaging of the brain showed classic findings of hyper intensityin the bilateral basal ganglia. The patient had no fam ily history of psychiatric or neurological disease. Laboratory findings revealed elevated levels of blood urea nitrogen, creatinine, and glucose. Haloperidol and ropinirole therapy was continued, resulting in significant improvement without dialysis. The p atient recovered from his episode without apparent sequelae.

Uremic Encephalopathy with Basal Ganglia Lesions in a Diabetic Predialysis Patient

Syndromes associated with acute bilateral lesions of the basal ganglia in diabetic uremic patients are uncommon, and usually have reversible clinical and imaging findings. Such syndromes are seen almost exclus ively in patients with diabetes mellitus and renal failure. Previously reported cases have described diabetic men with uremia on dialysis. Here, we report a case of uremic encephalopathy with lesions of the basal ganglia in a diabetic predialysis patient. A 44-year-old man with uremic encephalopathy presented with dysarthria, chorea, and right upper extremity paresthesia. Magnetic resonance imaging of the brain showed classic findings of hyper intensityin the bilateral basal ganglia. The patient had no fam ily history of psychiatric or neurological disease. Laboratory findings revealed elevated levels of blood urea nitrogen, creatinine, and glucose. Haloperidol and ropinirole therapy was continued, resulting in significant improvement without dialysis. The p atient recovered from his episode without apparent sequelae.

Oral Health Status in Haemodialysis Patients

To assess the oral and dental manifestations in non- diabetic and diabetic uraemic patients who were undergoing haemodialysis and to estimate and compare the salivary pH in these two groups. Ninety Seven uraemic patients who were undergoing maintenance haemodialysis were included in the study. Subjective and objective findings were evaluated and recorded in a specially designed proforma. Predialytic unstimulated whole salivary pH was recorded by using pH-measuring strips. Dental health assessment consisted of DMFT and CPITN indices. A subjective oral manifestation of dysguesia was found to be more significant in non-diabetic patients (p<0.008). Statistically, a high significance was observed with mucosal petechiae in 31.9% patients of diabetic group .The overall DMFT score was significantly higher in diabetic group. A moderate significance was found with a CPI score of 5 (p<0.015). The pH of saliva was significantly higher among diabetic patients. The diabetic subjects who were on haemodialysis were at a high risk for developing periodontal disease and they exhibited a potential threat for dental decay and xerostomia. A lower salivary pH and a poor glycaemic control may affect their oral health. Further research is required to clarify the combined influence of diabetic nephropathy on oral health.

Toward personalized hemodialysis by low molecular weight amino-containing compounds: future perspective of patient metabolic fingerprint.

L-carnitine deficiency is commonly observed in chronic hemodialysis patients, and this depletion may cause clinical symptoms like muscle weakness, anaemia, and hypotension. We pursued a targeted metabonomics investigation in 28 hemodialysis patients (13 non diabetics and 15 diabetics) and in 10 age-matched healthy controls, on plasma levels of all carnitine esters and of several amino acids. Samples were taken before and after the first hemodialysis treatment of the week. Multiplexed data were collected in LCMRM (Multiple Reaction Monitoring) and analysed by unsupervised multivariate analysis. In diabetic uremic patients, we observed lower values of propionylcarnitine than in other groups, while acylcarnitine concentration was higher in uremics compared to controls. The hemodialysis session induced a decline in free, short-chain, medium-chain and dicarboxylic acylcarnitines, whereas the long chain acylcarnitines remained unaffected. Plasma levels of amino acid proline, ornithine, citrulline and serine were significantly elevated in uremic patients before dialysis compared to controls. For most tested plasma amino acids, a significant reduction after hemodialysis session was found. Our study is the first that investigated on possible modifications of the system of carnitine in diabetic patients in hemodialysis not only in relation to the condition of deficiency but also compared to lipid and glucose homeostasis alteration typical of diabetics. We proposed the application of targeted metabolic fingerprint in the management of the hemodialysis patients.

Association of adiponectin with cardiovascular events in diabetic and non-diabetic hemodialysis patients

Adiponectin is a novel collagen-like protein synthesized by white adipose tissue. Its levels are decreased in obesity, type-2 diabetes and insulin-resistant states, and are increased in chronic renal failure. It has anti-inflammatory and anti-atherogenic properties. This study was planned to evaluate the levels of adiponectin in uremic patients with and without diabetes and to find any relationship between adiponectin levels and some cardiovascular risk factors, and to determine the possible predictive value of adiponectin for cardiovascular complications (CVC). The study included 100 subjects, 20 of them were healthy subjects and served as the control group (group I), 40 were uremic non-diabetic patients (group II) (half of them were without CVC, group IIA, and the other half were patients with CVC, group IIB) and, lastly, 40 uremic diabetic patients (group III) (half of them were without CVC, group IIIA, and the other half were patients with CVC, group IIIB). All subjects were subjected to complete clinical examination, including determination of mean arterial blood pressure (MABP), body mass index (BMI), waist to hip ratio, routine laboratory investigations, fasting plasma glucose, fasting plasma insulin, lipid profile (cholesterol, TG, LDL, HDL), determination of insulin resistance by homeostasis model assessment index (HOMA-IR) and estimation of serum levels of adiponectin. There was a significant increase in serum adiponectin levels in all the uremic patients (group II and group III) when compared with the control (group I) group, P <0.01; also, serum adiponectin levels were significantly decreased in uremic diabetic patients (group III) when compared with uremic non-diabetic patients (group II), P <0.01; but this was still higher than in the controls. The patients with CVC, whether uremic non-diabetic (group IIB) or uremic diabetic (group IIIB), had a significant decrease in serum adiponectin levels when compared with patients without CVC (group IIA and group IIIA), P <0.01. Serum adiponectin has a significant positive correlation with HDL and a significant negative correlation with MABP, BMI, plasma insulin, HOMA-IR, LDL, TG and cholesterol in all the patients. Therefore, it can be concluded that adiponectin levels in uremic patients, whether diabetic or non-diabetic, may be a good indicator of cardiovascular disease risk.

Effect of serum electrolyte and bicarbonate concentration changes during hemodialysis sessions on heart rate variability

Heart rate variability (HRV) is decreased in dialysis patients, and decreased HRV is an independent risk factor for sudden cardiac death. We aimed to determine the effect of sudden changes in serum electrolyte, bicarbonate concentration and blood pressure on HRV during hemodialysis (HD) sessions in chronic HD patients. The study population included 75 HD patients (mean age 44.5 ± 10.3 years; 53% female, 13% diabetic) and 35 healthy volunteers (mean age 42.44 ± 11.5 years, 62% female). HRV indexes were analyzed from 24-hour ECG recordings. The time-domain HRV indexes (SDNN, SDANN, RMSSD, pNN50 [%] and HRV TAI) were calculated from these recordings. Pre- and post-HD blood samples were drawn from an arterial line to calculate Na+, K+, Ca2+, iCa2+ and HCO3- concentration gradients. All HRV indexes were significantly lower in dialysis patients than in healthy volunteers (p<0.05).The detected SDNN and HRV TAI values were lower in diabetic patients than in nondiabetics. While K+ concentration was decreased, Ca2+ and bicarbonate increased significantly during HD. HRV decreased in chronic HD patients. The decrease in HRV in diabetic uremic patients was higher than in uremic patients without diabetes. The change of serum electrolyte and bicarbonate concentrations during HD did not affect HRV.

Uremic Encephalopathy with Atypical Magnetic Resonance Features on Diffusion-Weighted Images

Uremic encephalopathy is a well-known disease with typical MR findings including bilateral vasogenic or cytotoxic edema at the cerebral cortex or basal ganglia. Involvement of the basal ganglia has been very rarely reported, typically occurring in uremic-diabetic patients. We recently treated a patient who had non-diabetic uremic encephalopathy with an atypical lesion distribution involving the supratentorial white matter, without cortical or basal ganglia involvement. To the best of our knowledge, this is only the second reported case of non-diabetic uremic encephalopathy with atypical MR findings.

Efficacy of Epigallocatechin-3-Gallate and Amla (Emblica officinalis) Extract for the Treatment of Diabetic-Uremic Patients

Uremic patients with diabetes suffer from high levels of oxidative stress due to regular hemodialysis therapy (neutrophil activation induced by hemo-incompatibility between the hemodialyser and blood) and complications associated with diabetes. Several plasma biomarkers were screened in 13 uremic diabetic patients after receiving the mixture of (-)-epigallocatechin gallate (EGCG), a major component of green tea extract, and Amla extract (AE), from Emblica officinalis, the Indian gooseberry, for 3 months. We found that oral administration of a 1:1 mixture of EGCG and AE for 3 months significantly improved antioxidant defense as well as diabetic and atherogenic indices in uremic patients with diabetes. Furthermore, no significant changes in hepatic function, renal function, or inflammatory responses were observed. These results suggest that a 1:1 combination of EGCG and AE is a safe and effective treatment for uremic patients with diabetes.

Association of Erythropoietin, Adiponectin and Leptin levels with Anemia in uremic diabetic patients (Under hemodialysis):

Background: End stage renal disease in patients with diabetes mellitus has been called a medical catastrophe of worldwide dimensions .It was recognized that anemia is a complication of diabetes, particularly in patients with diabetic kidney diseases. The purpose of the present study is to determine whether erythropoietin, adiponectin, and leptin levels correlate with anemia in uremic diabetic patients (under hemodialysis).Patients and Methods: The studied groups were comprised of (30) diabetic patients(9 patients with type1 and 21 type2 diabetes) with renal failure (group2) who had been under hemodialysis compared with (30) healthy controls (group1). Blood film was obtained in addition to blood tests include fasting serum glucose (FSG), glycosylated hemoglobin (A1c), insulin, urea, creatinine, uric acid, estimated glomerular filtration rate (eGFR), serum erythropoietin (EPO), Adiponectin (ADPN),and leptin.Results: It was found that uremic diabetic patients in group2(G2) had higher FSG, A1c, insulin and higher levels of urea, creatinine, uric acid and lower levels of eGFR when compared to healthy controls (P &lt;0.05). Anemia was confirmed in the diabetic patients by Hemoglobin (Hb) and hematocrit (Hct) that were lower than healthy control (group1) (G1) (P&lt;0.05).EPO, ADPN levels were increased in uremic diabetic patients as compared to control subjects (P &lt;0.05). While, leptin levels were higher in type2 diabetes when compared to type1 diabetes and control subjects (group1) (P &lt;0.05). There were positive significant correlations between (FSG and A1c), (Hb and Hct), (EPO and leptin), (EPO and Hct), (ADPN and urea). In addition there were significant negative correlations between (FSG and EPO), (A1c and leptin), (ADPN and leptin).Creatinine was negatively associated with Hb and Hct. ADPN was negativelyassociated with Hb in uremic diabetics.Conclusions: Anemia is a common accompaniment to diabetes, particularly in those with renal failure or under hemodialysis .Adipocytokines like leptin and adiponectin may involved with anemia in these patients. Leptin in the present study was positively associated with EPO levels (the hormone that stimulates red blood cells production in the bone marrow). ADPN was negatively associated with Hb. These elevated levels of ADPN may antagonize EPO and leptin to increase the hemopoiesis rate and Hb levels in uremic diabetic patients in addition to other factors involved with diabetes.

Kidney-Pancreas Transplantation Does Not Improve Retinal Arterial Flow Velocities in Type 1 Diabetic Uremic Patients

Kidney-Pancreas Transplantation Does Not Improve Retinal Arterial Flow Velocities in Type 1 Diabetic Uremic Patients

A comparative study of serum myeloperoxidase activity in type 2 diabetes and diabetic nephropathy

Inflammatory burden is high in End Stage Renal Disease (ESRD) patients. In Diabetic ESRD patients, the balance between pro- and anti-oxidant activities is shifted towards an oxidative stress. Myeloperoxidase (MPO), a bactericidal enzyme plays an active role in induction and evolution of the endothelial dysfunction associated with Type 2 Diabetes Mellitus (DM). However, whether MPO can serve as a marker in diabetic ESRD patients is doubtful. Hence, the present study was undertaken. The Fasting Blood Glucose (FBG), Serum Creatinine, Blood Urea Nitrogen (BUN) and Serum Myeloperoxidase levels were estimated in three different groups with 30 subjects each. The Control group includes healthy individuals, group I constitutes Type 2 diabetes with no nephropathy and group II includes Type 2 diabetes with nephropathy patients. Glomerular Filtration Rate (GFR) was calculated using Cockcroft Gault formula corrected for the Body Surface Area. Statistical software, namely, SPSS 15.0, Stata 8.0, MedCalc 9.0.1 and Systat 11.0 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables etc. Reference Ranges for MPO were established in our study. An increase in MPO levels was noticed in Group I, whereas a differential behaviour of MPO levels was noted in group II. Uremic diabetic nephropathy patients with a low MPO level may be at a lesser risk for any cardiac event compared to those uremic patients with high MPO levels. Hence, MPO may be taken as a biomarker to predict coronary events in diabetic ESRD.

Insulin therapy in renal disease

Diabetes mellitus (DM) is the main cause of end-stage renal disease (ESRD). Conversely, chronic renal failure (CRF) is also associated with diverse alterations in carbohydrate and insulin metabolism. CRF-induced metabolic disorders should be borne in mind when treating diabetic patients, to ensure the introduction of adequate therapy adjustments that are in line with the onset of renal function decline. Moreover, several specific therapies employed in CRF may also influence pharmacological therapy of DM in uraemic patients. Adequate glycaemic control has also been associated with a reduction in the onset and progression of diabetic nephropathy as well as in the morbidity and mortality in uraemic diabetic patients during dialysis. Intensive insulin therapy can notably improve glycemic control and it should be considered part of the management of insulin-treated CRF diabetic patients. Insulin analogues have been recently evaluated in CRF diabetic patients, with encouraging results. In this study, we review the more relevant aspects related to insulin therapy in diabetic patients with different degrees of renal failure and in patients with ESRD, both in conservative therapy and dialysis.