Stroke and diabetic ketoacidosis--some diagnostic and therapeutic considerations.

Cerebrovascular insult (CVI) is a known and important risk factor for the development of diabetic ketoacidosis (DKA); still, it seems that the prevalence of DKA among the patients suffering CVI and its influence on stroke outcome might be underestimated. Diabetic ketoacidosis itself has been reported to be a risk factor for the occurrence of stroke in children and youth. A cerebral hypoperfusion in untreated DKA may lead to cerebral injury, arterial ischemic stroke, cerebral venous thrombosis, and hemorrhagic stroke. All these were noted following DKA episodes in children. At least some of these mechanisms may be operative in adults and complicate the course and outcome of CVI. There is a considerable overlap of symptoms, signs, and laboratory findings in the two conditions, making their interpretation difficult, particularly in the elderly and less communicative patients. Serum pH and bicarbonate, blood gases, and anion gap levels should be routinely measured in all type 1 and type 2 diabetics, regardless of symptomatology, for the early detection of existing or pending ketoacidosis. The capacity for rehydration in patients with stroke is limited, and the treatment of the cerebrovascular disease requires intensive use of osmotic and loop diuretics. Fluid repletion may be difficult, and the precise management algorithms are required. Intravenous insulin is the backbone of treatment, although its effect may be diminished due to delayed fluid replenishment. Therefore, the clinical course of diabetic ketoacidosis in patients with CVI may be prolonged and complicated.

Predictive value of serum myeloperoxidase activity for thrombosis of arteriovenous fistulas.

Myeloperoxidase is a proinflammatory protein that appears as a result of increased oxidative stress. It plays an important role in the promotion and progression of atherosclerosis. The aim of this study was to determine the importance of MPO as a predictive parameter for thrombosis of arteriovenous fistula (AVF). The study involved monitoring patients with AVFs for hemodialysis over a period of 2 years. There were 41 patients, 19 (46%) men and 22 (54%) women, with mean age of 65 ± 12.7 years. Routine laboratory analyses were carried out in all respondents, including determination of MPO concentration. Gender, demographic and anthropometrical characteristics, smoking, alcohol consumption, as well as the presence of diabetic nephropathy, as an etiological factor of kidney disease, were recorded. The group of patients who developed initial thrombosis of the AVFs had significantly different values for leukocytes (8.5 ± 3.8 vs. 7.3 ± 2.1, P = 0.024), erythrocytes (2.8 ± 0.27 vs. 3.2 ± 0.65; P = 0.019), hemoglobin (88.5 ± 81 vs. 99.1 ± 6.02; P = 0.041), and myeloperoxidase (19.3 ± 4.67 vs. 11.1 ± 4.43; P = 0.007) when compared with the group without fistula thrombosis. Diabetic nephropathy (P = 0.02) characterized the group of patients with thrombosis of the fistula. Diabetic nephropathy (B = 2.53, P = 0.049) and MPO (B = 0.03, P = 0.029) were statistically significant predictors of fistula thrombosis. In our study, MPO and diabetic nephropathy were predictors of thrombosis of the AVF.

Residual renal function and erectile dysfunction in patients on hemodialysis.

INTRODUCTION: Residual renal function and erectile dysfunction are important parameters of quality of life in dialysis patients. GOAL: The purpose of our investigation was to determine correlations between erectile dysfunction and residual diuresis in patients on hemodialysis. METHODS: The survey was organized as a cross-sectional study in men aged up to 65 years on hemodialysis. All respondents voluntarily completed the questionnaire of the International Index of Erectile Function (IIEF)-5. Demographic and anthropometric characteristics, the duration of dialysis, smoking, alcohol consumption, residual renal function, comorbidity, and routine biochemical parameters were determined for all patients. The adequacy of dialysis was calculated as Kt/V. Based on residual renal function, the patients were divided into a group without residual diuresis and a group with preserved residual renal function. RESULTS: Nearly two-thirds of our patients did not have preserved diuresis, while 82.8% of our respondents had erectile dysfunction. Patients with preserved residual renal function were heavier (P = 0.047) and had higher body mass index (P = 0.047), but the prevalence of cardiovascular disease (P < 0.0001) and erectile dysfunction (P < 0.0015) was lower, compared to patients without residual diuresis. The regression model also demonstrated a statistically significant relationship between the residual diuresis and the total IIEF score (b = 4.74; P < 0.001). CONCLUSION: Hemodialysis patients with preserved diuresis retain erectile function better.

Impact of metabolic syndrome and malnutrition on mortality in chronic hemodialysis patients.

OBJECTIVE: Metabolic abnormalities contribute to increases in the mortality rate of patients on hemodialysis. Here, we estimate the importance and influence of metabolic syndrome and malnutrition on mortality rate. DESIGN: This was a follow-up study. METHODS: We examined the demographic characteristics of time on dialysis, body mass index, indications for hospitalization, treatment outcomes, and biochemical parameters over a 4-year period. RESULTS: Whereas 31.7% of patients had metabolic syndrome, 26.7% showed evidence of malnutrition. More than two thirds of the malnourished patients died. Many patients (46%) with malnutrition were hospitalized because of problems with vascular access, whereas hospitalization of half of the examined patients with metabolic syndrome was attributable to cardiovascular disorders. Differences between groups in the parameters of anemia, total proteins, albumin, and low-density lipoprotein cholesterol also occurred, with the lowest values in malnourished patients. Glycemia, total cholesterol, and fibrinogen were significantly higher in patients with metabolic syndrome, whereas those with malnutrition had a markedly higher concentration of C-reactive protein. The mean survival was 24 months with metabolic syndrome and 17.5 months with malnutrition, which was significantly shorter. CONCLUSIONS: More than half of the examined patients had metabolic abnormalities. Patients with malnutrition had a lower rate of survival compared with those who had metabolic syndrome. Two thirds of our malnourished patients died, and the total rate of mortality in the examined sample was 38%.

Influence of the level of renal insufficiency on endoscopic changes in the upper gastrointestinal tract.

AIM: Lesions of the gastrointestinal tract are frequent finding in uremic patients but their actual nature is not completely clear. The aim of this study was to detect any correlation between endoscopic lesions of patients with different levels of renal insufficiency. METHODS: This prospective study involved 244 cases, with dyspeptic difficulties including 124 patients in different stages of renal insufficiency, and a control group of 120 patients with normal renal function. Upper esophagogastroscopy was performed in all patients because of the appearance of dyspeptic difficulties. Helicobacter pylori infection was detected by the urease test. RESULTS: H. pylori infection (P=0.009), gastric erosions (P=0.019), gastric ulcer (P=0.002), and duodenal ulcer (P<0.001) were more common in the control group of patients. Significant negative correlations were found between the level of renal insufficiency and H. pylori infection (Kendall's tau=-0.346; P=0.003), stomach erosions (Kendall's tau=-0.272; P=0.019), stomach ulcer (Kendall's tau=-0.347; P=0.003), and duodenal ulcer (Kendall's tau=-0.531; P<0.001). CONCLUSIONS: In patients with end stage renal disease, endoscopic lesions of the gastrointestinal tract are detected less frequently in relation to patients without kidney disease.

The influence of atherosclerosis and plasma D-dimer concentration in patients with a functioning arteriovenous fistula for maintenance hemodialysis.

OBJECTIVE: The aim of this study was to deduce the influence of atherosclerosis and plasma D-dimer concentration on the functioning of arteriovenous fistulae for hemodialysis. METHODS: The study was organized as a prospective and non-randomized investigation in the "Kragujevac" Clinical Center. The 81 examined patients, 49 (60.5%) males and 32 (39.5%) females, were divided into a group (n = 36) requiring several attempts to create arteriovenous fistulae for hemodialysis and a group (n = 45) with no complications of arteriovenous fistulae for hemodialysis. The demographic structure, etiology of renal disease, biochemical parameters and concentration of D-dimer were analyzed at the beginning of the study and 1 year later, as well as the existence of tissue calcification and Duplex ultrasound parameters of the carotid artery. RESULTS: The patients with arteriovenous fistulae complications were significantly older (58.4 +/- 12.9 vs. 52.3 +/- 11.6 years; P = 0.026). High venous pressure (98.6 +/- 29.98 vs. 80 +/- 33.57 mmHg; P = 0.005) and soft-tissue calcification (P = 0.03) were correlated with the occurrence of arteriovenous fistula complications. The greatest risk for failure of fistula was within the first month after creation of the anastomosis (failure rate was 0.235). The hemoglobin concentration (89 +/- 14.0 vs. 96.6 +/- 17.7 g/l; P = 0.048) was lower, and concentration of D-dimer at the end of the study was higher (219.56 +/- 193.05 vs. 332.03 +/- 149.48; P = 0.012) in patients with vascular access complications. By Cox regression analysis, the concentration of fibrin D-dimer at the end of the study was shown to be a significant predictor of fistula survival (beta = 0.002; P = 0.006). CONCLUSIONS: Complications of arteriovenous fistulae were more often recorded in older patients. The greatest risk for fistula functioning was within the first month after creation of the anastomosis. Vein pressure and anemia were important indicators of arteriovenous fistula complications. D-dimer was a significant marker of arteriovenous fistula thrombosis.

Severity of angina as a predictor of quality of life changes six months after coronary artery bypass surgery.

BACKGROUND: Although the fact that chest pain has a negative influence on the quality of life is well known, it is not completely clear whether the preoperative severity of angina can be a predictor of the quality of life change after coronary artery bypass grafting (CABG). METHODS: We studied 243 consecutive patients who underwent elective CABG. The Nottingham Health Profile Questionnaire part 1 was used as the model for determination of quality of life. We distributed the questionnaire to all patients before and six months after coronary artery bypass surgery. Two hundred and twenty-six patients filled in the postoperative questionnaire. Severity of angina was estimated by Canadian Cardiovascular Society (CCS) classification of angina. RESULTS: Quality of life (before and after CABG surgery) in all sections was significantly worse in patients with higher CCS angina class (p < 0.001). The CCS angina class was 1.89 +/- 0.97 at baseline and improved to 0.46 +/- 0.75 (p < 0.001) after CABG. Six months after the operation, quality of life significantly improved in patients with all classes of angina (p < 0.01). The improvement in quality of life was related to higher CCS angina class in sections of physical mobility (r = 0.4, p < 0.001), energy (r = 0.31, p < 0.001), and pain (r = 0.48, p < 0.001). High CCS angina class before CABG was an independent predictor of quality of life improvement after coronary artery bypass surgery in sections of physical mobility (p = 0.005; odds ratio [OR] = 2.11; confidence interval [CI] 1.25 to 3.55), energy (p = 0.021; OR = 1.77; CI 1.09 to 2.87), and pain (p < 0.001; OR = 3.99; CI 2.2 to 7.22). CONCLUSIONS: Patients with higher CCS angina class had worse preoperative and postoperative quality of life. Patients with preoperative higher CCS angina class had greater improvement in sections of physical mobility, energy, and pain. High CCS angina class before CABG was the independent predictor of quality of life improvement six months after CABG.