End-stage Diabetic Nephropathy Research Articles

Progress in the Study of Diabetic Nephropathy Markers

Diabetic nephropathy (DN) is the principal consideration of end-stage diabetic nephropathy in China, second only to chronic glomerulonephritis. It is the most common complication of diabetes and the cause of death in diabetic patients. The clinical manifestations of DN are proteinuria, edema, hypertension, and progressive renal damage, and its continuous development can turn into nephrotic syndrome and uremia. It has been reported that urinary microalbumin, cystatin C and homocysteine are related to the diagnosis of renal diseases. In addition, pathological examination of renal biopsy, as the golden standard, plays a vital role in clinical diagnosis of DN. In the meantime, with the rise of biomarkers research, such as Genetic Markers, miRNAs and AGEs, we can evaluate the renal function of diabetic patients by detecting these markers as early as possible. Taking into account the above information, we focus on research advances in the association of microalbuminuria, urinary inhibitory C, serum homocysteine, renal biopsy and biomarkers with DN.

Epidemiological characteristics, complications of haemodialysis patients with end-stage diabetic nephropathy in a tertiary hospital in Guizhou, China: a cross-sectional survey

Epidemiological characteristics, complications of haemodialysis patients with end-stage diabetic nephropathy in a tertiary hospital in Guizhou, China: a cross-sectional survey

Genetic drivers of heterogeneity in type 2 diabetes pathophysiology

Type 2 diabetes (T2D) is a heterogeneous disease that develops through diverse pathophysiological processes1,2 and molecular mechanisms that are often specific to cell type3,4. Here, to characterize the genetic contribution to these processes across ancestry groups, we aggregate genome-wide association study data from 2,535,601 individuals (39.7% not of European ancestry), including 428,452 cases of T2D. We identify 1,289 independent association signals at genome-wide significance (P < 5 × 10−8) that map to 611 loci, of which 145 loci are, to our knowledge, previously unreported. We define eight non-overlapping clusters of T2D signals that are characterized by distinct profiles of cardiometabolic trait associations. These clusters are differentially enriched for cell-type-specific regions of open chromatin, including pancreatic islets, adipocytes, endothelial cells and enteroendocrine cells. We build cluster-specific partitioned polygenic scores5 in a further 279,552 individuals of diverse ancestry, including 30,288 cases of T2D, and test their association with T2D-related vascular outcomes. Cluster-specific partitioned polygenic scores are associated with coronary artery disease, peripheral artery disease and end-stage diabetic nephropathy across ancestry groups, highlighting the importance of obesity-related processes in the development of vascular outcomes. Our findings show the value of integrating multi-ancestry genome-wide association study data with single-cell epigenomics to disentangle the aetiological heterogeneity that drives the development and progression of T2D. This might offer a route to optimize global access to genetically informed diabetes care.

State of the Retina and Visual Functions before and after Pancreatic Transplantation (Clinical Case)

In this report, we reflected a clinical case of the course of the proliferative stage of diabetic retinopathy in a patient suffering from type 1 diabetes mellitus (DM) and end-stage diabetic nephropathy (DN) before and after simultaneous pancreas and kidney transplantation. As a result of successful surgical treatment of DM and DN was achieved physiological normoglycemia (change in fasting blood glucose from 11 to 5.1 mmol/l, glycated hemoglobin level from 9.2 to 5.7 %) and relief of uremic syndrome (change in serum creatinine from 632 to 77,5 µmol/l, urea from 13 to 6 mmol/l, glomerular filtration rate from 7.1 to 83.5 ml/min/1.73 m2). By the end of the first year of the post-transplantation period according to ophthalmoscopy data on the fundus no regression of the initial and addition of new diabetic changes was recorded and according to special instrumental methods of research was recorded a partial improvement hemoperfusion in superficial (an increase in the whole perfusion density: OD — from 24 to 35 %; OS — from 23 to 33 %) and deep (increase in the whole perfusion density: OD — from 5 to 13 %; OS — from 4 to 6 %) capillary plexus, a decrease in the central thickness of the retina (OD — from 269 to 257 µm; OS — from 271 to 253 µm) with resorption of intraretinal fluid in the right eye, improvement of the visual acuity (OD — from 0.5 to 0.7; OS — 0.6 to 0.7) and light sensitivity (macula light sensitivity threshold: OD — from 16.5 to 21.8 dB; OS — from 22.1 to 25.4 dB) of both eyes.

Safety and efficacy of hemodialysis and peritoneal dialysis in treating end-stage diabetic nephropathy: a meta-analysis of randomized controlled trials.

Present investigation aims to elucidate safety and efficacy of hemodialysis as well as peritoneal dialysis in treating end-stage diabetic nephropathy. We searched various databases for articles from the database starting date to October 2019. The analysis involved studies that contained outcomes of hemodialysis and peritoneal dialysis in the treatment of end-stage diabetic nephropathy. A total of 12 randomized controlled trials (RCTs) with 932 participants were collected. Meta-analysis results suggested that comparing with peritoneal dialysis group, hemodialysis group had a higher incidence of cardiovascular and cerebrovascular events and bleeding complications. There was no statistically significant difference regarding the infection (P = 0.71) or malnutrition (P = 0.53) incidence between the two forms of dialysis. Hemodialysis could better improve the levels of albumin [mean difference (MD) = 6.80, 95% CI = (4.17-9.44)] and hemoglobin [MD = 3.40, 95% CI = (0.94-5.86)] than peritoneal dialysis after 3months or more. In treating end-stage diabetic nephropathy patients, peritoneal dialysis had a lower incidence of cardiovascular and cerebrovascular events, as well as bleeding complication than hemodialysis. However, hemodialysis could better improve albumin and hemoglobin levels than peritoneal dialysis after 3months.

Targeting Predialysis Glucose up to 180 mg/dl Reduces Glycemic Variability in End Stage Diabetic Nephropathy.

Glycemic variability plays a major role in the development as well as the progression of cardiovascular disease in diabetes. We compared the mean plasma glucose and glycemic variability (GV) parameters on and off hemodialysis (HD) in patients with End-Stage Diabetic Nephropathy (ESDN) and End-Stage Renal Disease (ESRD). Cross-sectional study. We included 23 ESDN and 6 ESRD patients who underwent continuous glucose monitoring (CGM) (iPro2) for 6 days and a glucose-free dialysate for 4 hours thrice weekly. EasyGV software was used to calculate the variability parameters {mean glucose, Time in range (TIR), Time above and below range (TAR/TBR), CV (Coefficient of Variation) and MAGE}. The quantitative data variables were expressed by using mean and SD. Unpaired t-test was used to compare the two groups. P value <0.05 was considered significant. In the ESDN group, TIR was significantly lower whereas TAR and TBR were significantly higher on HD day. MAGE (101.88 ± 40.5 v/s 89.46 ± 30.0, P < 0.007) and CV (29.41% v/s 21.67%) were higher on HD day. Subjects with pre-HD glucose values ≥180 mg/dl (Group B, n = 24) had a rapid drop with a delayed higher rise in glucose values than those with pre-HD glucose values <180 mg/dl (Group A, n = 27). Ten patients had 13 episodes of hypoglycemia. The CGM parameters were not different in the ESRD group. Targeting a pre- HD glucose value <180 mg/dl could be a good strategy to prevent larger fluctuation during and post HD.

Pancreas transplantation for cystic fibrosis: A frequently missed opportunity.

Cystic fibrosis (CF) is an inherited autosomal recessive disorder. Despite optimized therapy, the majority of affected individuals ultimately die of respiratory failure. As patients with CF are living longer, extra-pulmonary manifestations may develop including pancreatic failure, which manifests as exocrine insufficiency, and CF-related diabetes (CFRD). Both of these can be managed through pancreas transplantation. Pancreas transplantation is usually performed in combination with another organ, most often with a kidney transplant for end-stage diabetic nephropathy. In the CF patient population, the two settings where inclusion of a pancreas transplant should be considered would be in combination with a lung transplant for CF pulmonary disease, or in combination with a liver for CF-related liver disease with cirrhosis. This report will discuss this topic in detail, including a review of the literature regarding combinations of lung/pancreas and liver/pancreas transplant.

A complex case of refractory hypercalcaemia, end-stage diabetic nephropathy with pituitary mass and hypopituitarism– is there a unifying diagnosis?

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Immediate post-operative complications (I): Post-operative bleeding; vascular origin: Thrombosis pancreatitis.

Simultaneous pancreas-kidney transplantation is the treatment of choice for insulin-dependent diabetes that associates end-stage diabetic nephropathy, since it achieves not only a clear improvement in the quality of life, but also provides a long-term survival advantage over isolated kidney transplant. However, pancreas transplantation still has the highest rate of surgical complications among organ transplants. More than 70% of early graft losses are attributed to technical failures, that is, to a non-immunological cause. The so-called technical failures include graft thrombosis, bleeding, infection, pancreatitis, anastomotic leak and pancreatic fistula. Pancreatic graft thrombosis leads these technical complications as the most frequent cause of early graft loss. Currently most recipients receive postoperative anticoagulation with the aim of reducing the rate of thrombosis. Hemoperitoneum in the early postoperative period is a frequent cause of relaparotomy, but it is not usually associated with graft loss. The incidence of hemoperitoneum is clearly related to the use of anticoagulation in the postoperative period. Post-transplant pancreatitis is another cause of early postoperative complications, less frequent than the previous. In this review, we analyze the most common surgical complications that determine pancreatic graft losses.

Effects of Hemodialysis and Peritoneal Dialysis on Glycometabolism in Patients with End-Stage Diabetic Nephropathy

Objective: The objective is to study the fluctuation pattern of blood glucose spectrum in patients with end-stage diabetic nephropathy (ESDN) receiving hemodialysis (HD) and peritoneal dialysis (PD), respectively, and to compare the influences of these 2 dialysis methods on glycometabolism. Methods: Sixty-four dialysis patients with ESDN were recruited, including 35 HD patients and 29 PD patients. The 24-h blood glucose on dialysis days of the 2 groups was monitored by the continuous glucose monitoring system, and the relevant glycometabolism indexes were recorded and compared. Results: The control of blood glucose in both groups was not satisfactory. At the same blood glucose level, the dosage of exogenous insulin needed by patients in the PD group was larger than that in the HD group (p < 0.05). However, the fluctuation of blood glucose and consequently the incidence of hyperglycemia and hypoglycemia in HD group were greater than that in PD group (p < 0.05). The patients’ blood glucose levels decreased progressively during the course of HD. The mean blood glucose (MBG) values estimated by glycosylated hemoglobin (HbA1c) in both groups were lower than the actual measured blood glucose values (p < 0.05). Preliminary correlation analysis showed that the deviation of the MBG values estimated by HbA1c was positively correlated with the degree of anemia. Conclusion: HD patients have larger glycemic variability as compared with PD patients, while PD patients have overall increased blood glucose levels. Hypoglycemic programs should be made according to the corresponding changes in blood glucose. The HbA1c value of dialysis patients has a large deviation, so it is necessary to explore its influencing factors and develop more accurate blood glucose assessment indicators.

ACCOMPLISHMENT OF ISCHEMIA-FREE KIDNEY TRANSPLANTATION USING NORMOTHERMIC MACHINE PERFUSION

Background: Ischemia-reperfusion injury (IRI) has been considered an inevitable event in organ transplantation since the first successful kidney transplant was performed in 1954. To avoid IRI, we have established a novel procedure called ischemia-free organ transplantation. Here, we describe the first case of ischemia-free kidney transplantation (IFKT). Materials and Methods: The kidney graft was donated by a 19-year-old brain dead donor. The recipient was a 47-year-old man with end-stage diabetic nephropathy. The graft was procured, preserved and implanted without cessation of blood supply using normothermic machine perfusion. Results: The graft appearance, perfusion flow and urine production suggested the kidney was functioning well during the whole procedure. The creatinine dropped rapidly to normal range within three days post-transplantation. The levels of serum renal injury markers were low post-transplantation. No rejection, vascular or infectious complications occurred. The patient had an uneventful recovery. Conclusion: This paper marks the first case of IFKT in humans. This innovation might offer a unique solution to optimize transplant outcomes in kidney transplantation.

P0761STUDY ON THE MECHANISM OF MICROINFLAMMATION WITH UREMIA CAUSED BY LACTOBACILLUS ACTIVATION OF INTESTINAL MACROPHAGES BY MINCLE

Abstract Background and Aims My previous studies have found that Intestinal macrophages in the uremic rats are polarized towards a proinflammatory phenotype and had dysfunction of phagocytosis leading to aggravate microinflammation and assist bacterial translocation in uremia resulting in microinflammation. However, it is still unclear what kind of mechanism of action of intestinal bacteria activates intestinal macrophages and thus participates in the occurrence and development of microinflammation in uremia. Method Male Sprague-Dawley rats were randomly divided into two groups: sham, uremia. The macrophage ultrastructure was examined by transmission electron microscopy. Immunochemistry was used to analyze the expression of macrophage-inducible C-type lectin (Mincle). RT-PCR and western blot were employed to assess the mRNA and protein expression of toll-like receptor 4 (TLR4). Results Our RCT study found that the number of Lactobacilli in the intestines of patients with end-stage diabetic nephropathy was significantly higher than that in non-diabetic patients(Figure 1). The plasma levels of endotoxin, CRP, IL-6, and TNF-a in the uremia group were greater than those in the sham group (p&amp;gt;0.05)(Table 1).Compared with the sham group, the uremic macrophages showed fewer cytoplasmic protrusions and pseudopodia(Figure 2) and the uremia group exhibited macrophages with higher staining intensities for Mincle and higher mRNA and protein expression of TLR4(Figure 3-5). Conclusion Studies have shown that Lactobacillus planta can directly activate Mincle. The relationship between Mincle and the activation of intestinal macrophages was verified. The solution to this scientific problem will not only clarify the molecular mechanism of intestinal bacteria in controlling the activation of intestinal macrophages, but also link the immune regulation of intestinal macrophages with the micro-inflammation of uremia so as to clarify the micro-inflammation state of uremia.

SUN-153 STUDY ON THE MECHANISM OF MICROINFLAMMATION WITH UREMIA CAUSED BY LACTOBACILLUS ACTIVATION OF INTESTINAL MACROPHAGES BY MINCLE

My previous studies have found that Intestinal macrophages in the uremic rats are polarized towards a proinflammatory phenotype and assist bacterial translocation in uremia resulting in microinflammation. However, it is still unclear what kind of mechanism of action of intestinal bacteria activates intestinal macrophages and thus participates in the occurrence and development of microinflammation in uremia. Male Sprague-Dawley rats were randomly divided into two groups: sham, uremia. The macrophage ultrastructure was examined by transmission electron microscopy. Immunochemistry was used to analyze the expression of macrophage-inducible C-type lectin (Mincle). RT-PCR and western blot were employed to assess the mRNA and protein expression of toll-like receptor 4 (TLR4). Our RCT study found that the number of Lactobacilli in the intestines of patients with end-stage diabetic nephropathy was significantly higher than that in non-diabetic patients. (the proportion could even reach 50%) (Figure1).Table 1Body weight, hematocrit, and blood chemistry resultsGroup (n = 10)Body weight (g)Creatinine (µmol/L)Urea (mmol/L)Endotoxin (Eu/mL)CRP(mg/mL)IL-6 (pg/mL)TNF-α (pg/mL)sham560.4 ±16.631.5 ±6.76.05 ±0.850.016 ± 0.0052.48 ±0.2818.26 ±3.7220.9 ±0.28Uremia516.6 ±14.5*95.7 ±35.6*18.10 ±8.50*0.033 ±0.009*5.2 ±0.77*31.07 ±10.06*30.4 ± 7.73*Data are presented as the mean ±SD.*p < 0.05 vs. the sham group Open table in a new tab Data are presented as the mean ±SD. *p < 0.05 vs. the sham group Compared to the sham group, the intestinal mucosa in the uremia group exhibited small and irregular microvilli, lightly-stained tight junctions, and obscure desmosome junctions between epithelial cells; in addition, more vacuolated mitochondria appeared in the uremia group (Figure 2). Compared to the sham group, intestinal macrophages of uremic rats showed fewer cytoplasmic protrusions and pseudopodia, decreased electron density, and greater numbers of organelles (especially lysosomes) from ruptured macrophages in the intercellular space (Figure 3)The expression of Mincle on the surface of intestinal macrophages is increased(Figure 4-5). The fold-change in TLR4mRNA and the expression levels of TLR4 protein in the intestinal segments were greater in the uremia group than in the sham group (p < 0.05 vs. the sham group jejunum; Figure 6) Studies have shown that Lactobacillus planta can directly activate Mincle. Our RCT study found that the relative abundance of Lactobacillus in patients with end-stage diabetic nephropathy was significantly higher. The relationship between Mincle and the activation of intestinal macrophages was verified. The solution to this scientific problem will not only clarify the molecular mechanism of intestinal bacteria in controlling the activation of intestinal macrophages, but also link the immune regulation of intestinal macrophages with the micro-inflammation of uremia so as to clarify the micro-inflammation state of uremia.

Comparative study on the efficacy of peritoneal dialysis and hemodialysis in patients with end-stage diabetic nephropathy.

Objective:Diabetic nephropathy is a serious threat to human health, and its incidence is on the rise. End-stage diabetic nephropathy (ESDN) requires extra investigation due to its complexity and severity, as well as serious concurrent diseases. Our objective was to compare the efficacy of hemodialysis (HD) and peritoneal dialysis (PD) in the treatment of ESDN.Methods:Clinical data of 84 patients with ESDN admitted to our hospital from June 2016 to June 2018 were retrospectively analyzed. The patients were divided into an HD group that received hemodialysis and a PD group that received peritoneal dialysis. Their general conditions, biochemical indicators, residual renal function and incidence of complications were recorded and compared between the two groups.Results:(1) No significant difference in diastolic blood pressure, systolic blood pressure, body weight, or urine output was detected between the two groups at the beginning of dialysis (P>0.05). (2) Compared to the PD group, the HD group had significantly lower total cholesterol (TC) and triglyceride (TG) (P<0.05), and significantly higher total protein (TP) and albumin (ALB) after treatment (P<0.05). (3) The two groups also showed significant difference in residual renal function after treatment (P<0.05). (4) The HD group had significantly higher systolic pressure than the PD group after treatment (P<0.05). And more cases of infection were observed in the PD group than the HD group (P<0.05).Conclusion:Both HD and PD are used for treatment of ESDN, and can achieve similar calcium and phosphorus control. Compared to HD, PD has less adverse effect on hemodynamics and better preserves residual renal function, but is more likely to cause malnutrition and disorders of lipid metabolism. Therefore, choice of dialysis method should be based on specific conditions of each patient.

MON-199 KIDNEY TRANSPLANTATION IN MULTIPLE MYELOMA: CASE REPORTS

Renal transplantation is traditionally contraindicated in Multiple Myeloma (MM) due to increased risk of post-transplant disease recurrence and associated complications. However, with recent advances in MM treatment modalities and overall survival, renal transplant centers are reporting increasing success in carefully selected groups of patients with treated plasma cell dyscrasias. We hereby present our experience through 3 case reports. A 72-year-old Caucasian male with IgG smoldering MM, and end stage diabetic nephropathy, received prophylactic Bortezomib chemotherapy for high lambda light chain burden, 6 months prior to an ABO incompatible living related kidney transplant in 2015. A stable renal function and ongoing hematological remission without further maintenance therapy was achieved for the next 24 months. MM progression in the form of gastrointestinal amyloidosis and plasma cell infiltration of his renal allograft was diagnosed 2 years post transplant. This was successfully mitigated with further cycles of Bortezomib containing chemotherapy, stabilizing his serum creatinine around 180umol/L. A 68-year-old Caucasian male, with stage 3 lambda light chain MM and end stage cast nephropathy was evaluated for renal transplantation. Hematological remission was achieved through Bortezomib based induction and subsequent autologous stem cell transplant, with thalidomide maintenance therapy. Unfortunately, no suitable living related donor was available, and he received a cadaveric renal transplant 2.5 years later in 2017. 10 months post transplant, he was diagnosed with CMV pneumonitis, and required CMV immunoglobulin therapy as a consequence of residue hypogammaglobulinemia secondary to his MM. His renal function has remained stable post transplant with a baseline serum creatinine of 120umol/L. A 49-year-old Greek female, with end stage cast nephropathy secondary to stage 3 kappa light chain MM. Remission of her myeloma was achieved through Bortezomib containing induction therapy followed by an autologous stem cell transplant. She subsequently underwent a successful ABO incompatible living related kidney transplant 10 months later in 2018. Her allograft function has remained stable with a serum creatinine of 90umol/L. Sustained renal allograft function can be achieved in MM patients with hematological remission, improving quality of life off dialysis whilst broadening myeloma treatment options previously limited by end stage renal failure. Logistically, living related donors provide a favorable option, significantly reducing the duration of wait time and risk of further deterioration. Unique complications associated with underlying MM, in the form of disease recurrence or increased predisposition to opportunistic infections can occur post renal transplant. However, early recognition and mitigation will ensure perseverance of allograft function.

The 2017 Banting Memorial Lecture The diabetic lower limb - a forty year journey: from clinical observation to clinical science.

A series of clinical research projects conducted over the past 40 years, all of which were informed by clinical observation or discussions with people with diabetes and staff colleagues are described in this review. A study of necrobiosis lipoidica diabeticorum confirmed that this rare skin complication occurs predominantly in young women with Type 1 diabetes and other microvascular complications. Biopsies of necrobiotic lesions showed destruction of superficial nerve fibres by inflammatory tissue, which likely causes the sensory loss in lesions that is pathognomonic of the condition. The development of corneal confocal microscopy as a new non-invasive surrogate marker of peripheral neuropathy in diabetes is described next and several small studies of the use of this new technique in clinical research are reported. The influence of blood glucose instability on the genesis of neuropathic pain is then explained, with results suggesting that the stability of glycaemic control may be more important than the level of control achieved. Lastly, in neuropathy, studies of gustatory sweating are discussed, including the observation that sweating in the head and neck region is more common in people with end-stage diabetic nephropathy than in those with neuropathy. The disappearance of gustatory sweating after renal transplantation suggests a metabolic cause and for those with troublesome sweating, use of the anticholinergic, anti-muscarinic, topical cream glycopyrrolate is confirmed in a randomized control trial. In the area of diabetic foot research, distended dorsal foot veins were observed to be a clinical sign of sympathetic autonomic neuropathy: raised venous Po2 and Doppler abnormalities of blood flow are highly suggestive of arteriovenous shunting. A series of studies of the abnormalities of pressures and loads under the neuropathic diabetic foot are described: high dynamic plantar pressures are highly predictive of subsequent ulceration in the neuropathic foot. Lastly, a number of recent studies on unsteadiness and gait abnormalities when climbing and descending stairs are described. It is hoped that the art of clinical observation survives in the highly technological 21st century.

Diabetológia és szervátültetés

Diabetes increases the risk of different kidney diseases. The most important is diabetic nephropathy, however, ischemic kidney disease, chronic pyleonephritis and papilla necrosis may also develop. The prognosis of diabetic nephropathy has improved recently, however, it is still the primary cause of dialysis and transplantation. Cardiovascular diseases predict mostly mortality in diabetic patients, however, cerebrovascular insults and peripheral obstructive arterial diseases necessitating lower limb amputations are also important. Diabetic retinopathy is almost always present with diabetic nephropathy. Diabetic neuropathy may also develop, furthermore vascular complications often combine. All these urge complex workup, follow-up and early treatment. If transplantation is indicated, preemptive operation should be preferred, and living donation shows the best outcomes. Different forms of carbohydrate disorder may occur after transplantation: new-onset diabetes or diabetes known before transplantation may progress. Renal transplantation with pancreas transplantation may be indicated in type 1 diabetes with end-stage diabetic nephropathy, most often simultaneously. This may result in normoglycemia and insulin-independence and the progression of other complications may also halt. Transplant associated hyperglycemia occurs in most of the patients early, however, it is often transitory. Despite stabilization of the patient and of the immunosuppressive therapy, about one third of the patients may develop posttransplant diabetes. Insulin secretion disorder is the primary cause, but insulin resistance is also needed. Insulin administration may help, however, other antidiabetics can also be useful. Carbohydrate metabolism should be checked in both cadaveric and living donors. The authors make an attempt to summarize the above conditions with Hungarian relevance as well. Orv Hetil. 2018; 159(46): 1930-1939.

Ischaemic Monomelic Neuropathy in a Diabetic Patient after Brachio-Basilic Arteriovenous Fistula Creation

Introduction: The number of people with diabetes is increasing in every country. Recent estimates put the prevalence at 8.3% of adults, with a predicted rise to 10.1 in 2035 [1]. Although less than 1% of patients with diabetes require definitive haemodialysis, this still represents a significant number who may require arteriovenous fistula creation. Presentation: We report a case of IMN occurring in a patient with end stage diabetic nephropathy following brachio-basilic arteriovenous fistula creation for chronic maintenance haemodialysis. Discussion: Ischaemicmonomelic neuropathy (IMN) has developed as a distinct clinical entity involving dysfunction of multiple peripheral nerves following vascular access. Symptom onset is usually immediate, and neurological symptoms are dominant, generally in the absence of significant clinical ischaemia. Acute neurological symptoms may be disabling and irreversible, but prompt ligation of arteriovenous fistula can prevent permanent disability. Conclusion: Ischaemicmonomelic neuropathy (IMN) is a rare but serious complication of vascular access for arteriovenous fistula for haemodialysis and should be considered in the differential diagnosis of hand dysfunction following such surgery. While the condition is not preventable or predictable, prompt recognition and treatment can lead to prevention of permanent disability.

Blood glucose fluctuations in hemodialysis patients with end stage diabetic nephropathy

ObjectiveTo characterize blood glucose fluctuation during hemodialysis in patients with end stage diabetic nephropathy (ESDN) by a continuous glucose monitoring system (CGMS), and aim to improve blood glucose control in this patient population. MethodsForty-six patients with or without type 2 diabetes mellitus (T2DM), receiving hemodialysis, were recruited in this study. Thirty-six patients had end stage diabetic nephropathy (ESDN group), the other ten patients had end stage renal disease without diabetes (ESRD group). A continuous glucose monitoring system (CGMS) was employed to monitor glycemic fluctuation for 72hours. Blood samples were collected and analyzed. ResultsMean, standard deviation (SD), maximum, and mean amplitude glycemic excursion (MAGE) of blood glucose and the ratio of blood glucose readings that was greater than 13.9mmol/L of ESDN group, were significantly greater than those of ESRD group (p<0.01 for all) during 72hours of observation. The mean blood glucose was significantly lower, while SD and MAGE were significantly higher in ESDN group on hemodialysis day than on days off hemodialysis (p<0.05), while these were not been observed in ESRD group. Though mean, SD, and MAGE of blood glucose during hemodialysis were significantly lower than those of peri-hemodialysis in both groups (p<0.01 or p<0.05, respectively), they were significantly higher in ESDN group than that in ESRD group (p<0.05). The mean blood glucose value calculated from HbA1c did not reflect the actual mean blood glucose measured by CGM in both groups, and gave an inaccurate impression of a significantly lower mean glucose. ConclusionsESDN patients had larger glycemic fluctuations as compared with ESRD patients. Hemodialysis caused reduction in mean, SD, and MAGE, which in turn caused bigger glycemic fluctuations on hemodialysis day. The HbA1c in ESDN patients gave an inaccurate value, which did not truly reflect blood glucose status for a prolonged period.

Early Complications Related to the Transplanted Kidney After Simultaneous Pancreas and Kidney Transplantation

ObjectiveSimultaneous pancreas and kidney transplantation (SPKTx) is the most often performed multiorgan transplantation. The main source of complication is transplanted pancreas; as a result, early complications related to kidney transplant are rarely assessed. The aim of this study was to evaluate prevalence, types, and severity of postoperative complications due to kidney graft among the simultaneous pancreas and kidney recipients. MethodsComplications related to transplanted kidney among 112 SPKTx recipients were analyzed. The indication for SPKTx was end-stage diabetic nephropathy due to long-lasting diabetes type 1. The cumulative survival rates for kidney graft function and cumulative freedom from complication on days 60 and 90 after transplantation were assessed. Severity of complications was classified according to the modified Dindo-Clavien scale. ResultsThe 12-month cumulative survival rate for kidney graft was 0.91. Cumulative freedom from complication on the 60th day after transplantation was 0.84. The rates for II, IIIA, IIIB, IVA, and IVB severity grades were: 34.9%, 4.3%, 26.1%, 26.1%, and 8.6%, respectively. Acute tubular necrosis and rejection were the most frequent (43.4%) cause of complication. The most frequent reasons for graft nephrectomy were infections (2/7; 28.6%) and vascular thrombosis due to atherosclerosis of recipient iliac arteries (2/7; 28.6%). The most severe (IVB) complications were caused by fungal infection. ConclusionRate and severity of complications due to renal graft after SPKTx was low; however, to prevent the most serious ones reduction of fungal infection was necessary.