Frequency of Hypoglycemia Assessed by Continuous Glucose Monitoring in Advanced CKD.

BACKGROUND: Hypoglycemia represents a risk for serious morbidity. We evaluated the prevalence and risk factors of hypoglycemia by continuous glucose monitoring (CGM) in patients with CKD with or without diabetes. METHODS: In this cross-sectional study, outpatients with CKD stages G3-G5 (including hemodialysis) and type 2 diabetes without CKD were enrolled and underwent intermittently scanned CGM measurements for 7 days. The burden of CGM-measured hypoglycemia was assessed using the 7-day sum of area over the curve with glucose levels <70 mg/dl and the sum of time spent <54 mg/dl. RESULTS: A total of 366 participants (148 participants with CKD and diabetes, 115 with CKD and without diabetes, and 103 without CKD and with diabetes) were included. Glucose levels of <54 mg/dl were observed in 41% of participants with CKD and diabetes, 48% of participants with CKD and without diabetes, and 14% of participants with diabetes and without CKD. However, only two participants reported hypoglycemic symptoms during CGM measurements, which were confirmed and documented by capillary blood glucose measurements. Between-group differences of 7-day area over the curve (<70 mg/dl) were as follows: hemodialysis group versus CKD stage G4 and G5 groups, -0.25 min·mg/dl per hour (95% confidence interval [CI], -6.40 to -0.59) P <0.001; CKD stage G4 and G5 groups versus CKD stage G3 group, -0.08 min·mg/dl per hour (95% CI, -0.0 to -0.50) P =0.15; and CKD stage G3 group versus diabetes without CKD group, -0.14 min·mg/dl per hour (95% CI, -0.0 to -0.20) P =0.01. In addition, the subgroup analysis of the diabetic or nondiabetic and at daytime or nighttime showed that the 7-day area over the curve (<70 mg/dl) and time spent (<54 mg/dl) was larger with worse kidney function. CONCLUSIONS: The lowering level of kidney function was strongly associated with the burden of hypoglycemia in patients with CKD.

Transarterial Interventional Therapy for Non-functioning Hemodialysis Access.

Transarterial vascular access interventional therapy (VAIVT) for non-functioning hemodialysis access has advantages over the venous approach because natural venous outflow through the fistula as well as the stump at the fistula site in total occlusion can be observed, and most strictures and/or occlusions can be treated via one access route. The brachial arterial approach is essential, but the radial arterial approach at the wrist is also necessary for certain patients. The transarterial approach can be applied to all VAIVTs; however, additional venous access is necessary in cases requiring a large device and those with unsuccessful traversal of the occluded segment via the arterial route. The high origin of the radial artery is a disadvantage of the transbrachial approach, and local hematomas are the most frequent complications.

A case of apolipoprotein E Toyonaka and homozygous apolipoprotein E2/2 showing non-immune membranous nephropathy-like glomerular lesions with foamy changes.

A 47-year-old Japanese man with mild proteinuria was treated with an ACE inhibitor and antiplatelet agent for 7 years. However, urinary protein levels increased and renal biopsy was performed. Eight out of 20 glomeruli showed global or segmental sclerosis with foamy changes or bubbles, but with a different appearance to typical foam cells or lipoprotein thrombi. "Spike" formation, as observed in membranous nephropathy (MN), was segmentally detected in methenamine silver-stained sections. In an immunofluorescence study, weak linear patterns for IgG and scanty deposits for C3 were observed in glomeruli, but were not specific for immunogenetic MN. An electron microscopy study showed highly dense deposits in the subepithelial, subendothelial, and mesangial areas, in which microbubbles appeared under a higher magnification. Since this case exhibited hypertriglyceridemia and cholesterolemia with high serum apolipoprotein E (apoE) clinically and homozygous apoE2/2 by apoE phenotype and genotype analyses, apoE2 homozygote glomerulopathy was diagnosed and various lipid-lowering agents, e.g., probucol, fenofibrate, and ezetimibe, were administered. However, renal dysfunction gradually developed and peritoneal dialysis was initiated 11 years after the diagnosis. ApoE Toyonaka (Ser197Cys) and homozygous E2/2 were recently identified by direct DNA sequencing. Therefore, non-immune MN-like lesions may develop with the combination of these apoE mutations.

Percutaneous transluminal angioplasty of a non-mainstream venous route to restore an occluded hemodialysis fistula.

PURPOSE: To report the usefulness of percutaneous transluminal angioplasty (PTA) of a non-mainstream venous route in an occluded native hemodialysis fistula when a mainstream outflow vein could not be traversed. MATERIALS AND METHODS: This cohort included seven patients with an occulted hemodialysis fistula with difficulty in traversing via a mainstream route. A non-mainstream vein near the occluded portion was traversed until it connected with a proximal large-sized vein and the route was dilated using a 4- or 5-mm balloon catheter. Metallic stent placement was performed, if necessary. Technical aspects and long-term patency was evaluated. RESULTS: PTA could be performed in all patients; however, stent placement was required in two because of residual stenosis and clotting. The clinical success rate of fistula restoration was 100 %. Fistula dysfunction recurred in six patients 17-668 days (mean ± standard deviation 229.3 ± 225.0) later. PTA was repeated in four patients, but not in two. The mean duration of the primary patency was 336.6 ± 417.2 days (range 17-1,190) and that of the secondary patency was 897.1 ± 801.4 days (range 17-2,230). CONCLUSION: PTA of a non-mainstream venous route is useful for restoring an occluded hemodialysis fistula when the mainstream outflow vein cannot be traversed.

Technical success rates and long-term patency of endovascular treatment for occluded native hemodialysis fistulas: comparison between thrombotic occlusion and nonthrombotic occlusion.

PURPOSE: This study evaluated the technical success and long-term patency of endovascular treatment for occluded native hemodialysis fistulas caused by thrombotic occlusion (TO) and nonthrombotic occlusion (NTO). MATERIALS AND METHODS: This cohort included 96 consecutive occlusions (70 TOs and 26 NTOs) at the forearm. Clinical success and patency rates of endovascular treatment were calculated and compared between the TO and NTO groups. RESULTS: Overall clinical success rate was 91.6%; and primary, assisted primary, and secondary patency rates at 1, 2, and 3 years were 49.6%, 30.7%, and 28.3%, respectively; 73.8%, 48.3%, and 48.3%, respectively; and 80.7%, 72.3%, and 66.2%, respectively. Clinical success rates of the TO and NTO groups were 91.4% and 92.3%, respectively. The 1-, 2-, and 3-year primary, assisted primary, and secondary patency rates of the TO group were 54.4%, 29.3%, and 25.6%, respectively; 70.7%, 49.4%, and 49.4%, respectively, and 78%, 68.8%, and 64,2%, respectively. Those of the NTO group were 38.9%, 32.4%, and 32.4%, respectively; 81.2%, 47.3%, and 40.6%, respectively; and 87%, 80.3%, and 70.2%, respectively. There were no significant differences between the clinical success and patency rates of the two groups. CONCLUSION: Occluded native hemodialysis fistulas were restored with high frequency, without significant differences between clinical success and patency in the TO and NTO groups.

Dietary sodium restriction restores nocturnal reduction of blood pressure in patients with primary aldosteronism.

The purpose of this study was to elucidate the effects of dietary sodium restriction on diurnal blood pressure (BP) variation in primary aldosteronism. We studied the diurnal variation in the systemic hemodynamic indices and in baroreflex sensitivity (BRS). In 13 subjects with aldosterone-producing adenomas (2 males; mean age, 39+/-2 years), intra-arterial pressure was monitored telemetrically on a normal salt diet (NaCl 10-12 g/day). Non-dippers were defined as those with a nocturnal reduction in systolic BP (SBP) of less than 10% of daytime SBP. Ten subjects showed a non-dipper pattern. Six of these "non-dippers" underwent repetitive hemodynamic studies on the last day of a 1-week low salt diet regimen (NaCl 2-4 g/day). Stroke volume was determined using Wesseling's pulse contour method, calibrated with indocyanine green dilution. BRS was calculated every 30 min as delta pulse interval/delta SBP on spontaneous variations. Nocturnal reduction of SBP was 4.1% on the normal salt diet. With sodium restriction, urinary sodium excretion decreased from 187+/-8 to 46+/-8 mmol/day, and body weight decreased from 57.9+/-2.1 to 56.6+/-1.9 kg. Night-time BP significantly decreased with dietary modification from 154+/-7/88+/-4 to 140+/-6/78+/-4 mmHg, whereas daytime BP was unaltered. With sodium restriction, cardiac index and stroke index decreased throughout the day. No significant difference was seen in either daytime or nighttime BRS between the two diets. We conclude that the non-dipper pattern is common in patients with an aldosterone-producing adenoma on a normal salt intake, and under such conditions, volume expansion appears to play a major role in the impairment of nocturnal BP reduction.

Unilateral stent implantation for renal function in bilateral atherosclerotic renovascular hypertension--a case report.

Renal artery stenting improves or preserves renal function in patients with bilateral renovascular disease and chronic renal insufficiency. An 80-year-old male was admitted to the hospital for elevated blood pressure accompanied by congestive heart failure. He had renal insufficiency and severe hypertension secondary to bilateral atherosclerotic renal artery stenosis. Unilateral renal artery stenting in the left kidney resulted in the recovery of renal function, whereas renal artery stenting in the right kidney was technically difficult due to a tortuous aorta. After the left unilateral stent implantation, the serum creatinine concentration decreased from 2.0 to 1.3 mg/dL, and control of his blood pressure required fewer antihypertensive drugs, namely a calcium antagonist, an angiotensin-converting enzyme inhibitor, and diuretics. Fifteen months after stenting, renal scintigraphy demonstrated improved function of the right kidney, despite severe renal artery stenosis, as well as improved function of the left kidney. Renal angioplasty or stenting should be attempted in bilateral atherosclerotic renovascular hypertension with renal insufficiency, even though it may only be successful unilaterally.