Diabetic patients treated with dialysis: complications and quality of life.

AIMS/HYPOTHESIS: The aim of this study was to describe the prevalence of complications, health-related quality of life (HRQOL) and the influence of beliefs about control over health in diabetic dialysis patients. METHODS: Of 53 eligible diabetic patients on chronic dialysis during January 2004 in our clinic, 38 (76%) completed a kidney-specific (Kidney Disease Quality of Life) and a generic (SF-36) questionnaire and were characterised in terms of cardiovascular diseases and diabetic complications. Matched groups of non-diabetic dialysis patients (n = 40) and diabetic patients with a long duration of diabetes and normal kidney function (n = 38) served as controls. Generic HRQOL was compared with matched data from a survey on the Danish general population (n = 2248). RESULTS: Micro- and macrovascular complications were significantly more frequent in diabetic dialysis patients than in diabetic patients without renal disease. Self-rated physical health was significantly worse (p < 0.01) in diabetic dialysis patients (35 +/- 9 [mean +/- SD]) compared with non-diabetic dialysis patients (41 +/- 10), diabetic patients with normal kidney function (45 +/- 12) and the matched general population (47 +/- 19). The diabetic dialysis patients had similar levels of kidney-specific quality of life and mental health compared with the control groups. Reduced physical health was predicted by the presence of end-stage renal disease, diabetes and short time spent in education. Among the diabetic patients, those who believed more on their own ability to control their diabetes and less on chance reported better mental health and were less likely to be on dialysis. CONCLUSIONS/INTERPRETATIONS: Diabetic dialysis patients are characterised by a high prevalence of diabetic complications, reduced self-rated physical health but relatively good mental health.

Improved survival rate in patients with diabetes and end-stage renal disease in Denmark.

AIMS/HYPOTHESIS: We investigated the survival rate of Danish diabetic patients with end-stage renal disease (ESRD) between 1990 and 2005 and evaluated possible predictors of survival rate. MATERIALS AND METHODS: Data were obtained from the Danish National Register on Dialysis and Transplantation and from the Scandiatransplant database. Survival rates in different patient groups and association with age, sex, calendar time, waiting-list status and renal transplantation were evaluated using a multivariate Cox regression model. RESULTS: During the study period 8,421 patients (13% type 1 diabetic, 9% type 2 diabetic and 78% non-diabetic) started renal replacement therapy. The overall survival rate improved by 15% per five calendar years (hazard ratio [HR]=0.85, 95% CI: 0.81-0.88). The percentage of patients within each group who received renal transplantation was: type 1 diabetic: 26%, type 2 diabetic: 5%, non-diabetic: 24%. The survival rate of transplanted patients with diabetes mellitus (types 1 and 2) compared with non-diabetic patients at 1 year was: 95 vs 93%, at 5 years: 80 vs 85% and at 10 years: 52 vs 71%. Among diabetic patients survival rate was better in transplanted than in waiting-list patients (HR = 0.21, 95% CI 0.13-0.34), whereas the survival rate in waiting-list patients seemed to be superior to the survival rate among non-transplantation candidates (HR = 0.75, 95% CI 0.53-0.1.02, p = 0.07). CONCLUSIONS/INTERPRETATION: The survival rate of diabetic patients with ESRD has improved during the last 15 years. Although some selection bias may exist, significantly improved survival rate was observed among transplanted patients compared with dialysis patients on the waiting-list for transplantation. Renal transplantation should therefore be offered to diabetic patients with ESRD whenever possible.

Stabilized incidence of diabetic patients referred for renal replacement therapy in Denmark.

Despite an improvement in diabetes care during the last 20 years, the number of diabetic patients starting renal replacement therapy (RRT) has continued to increase in the Western world. The aim was to study the incidence of patients starting RRT in Denmark from 1990 to 2004. Data were obtained from The Danish National Registry; Report on Dialysis and Transplantation, where all patients actively treated for end-stage renal disease have been registered since 1990. The incidence of end-stage renal disease increased until 2001. Thereafter the incidence stabilized on 130 per million people (pmp). The number of diabetic patients starting RRT increased steadily from: 52 (number of patients) in 1990, 113 in 1995, 150 in 2000, 168 in 2001, and 183 in 2002. However, during the years 2003 and 2004 this number was significantly reduced by 15% to 156 and 155, respectively. This was mainly due to a 22% reduction in the number of non-insulin- treated (type II) diabetic patients (number of patients): 98, 82, and 76 in 2002, 2003, and 2004, respectively. The mean age in the background population, the mean age in diabetic patients starting RRT and the incidence of type I and type II diabetes increased during the study period. The encouraging stabilization in the incidence of diabetic patients referred for RRT observed in Denmark could be the result of implementation of a multifactorial and more intensive renoprotective intervention in patients with diabetes and chronic progressive renal disease.

Impaired vascular function during short-term poor glycaemic control in Type 1 diabetic patients.

AIM: To study the effects of short-term poor glycaemic control on vascular function in Type 1 diabetic patients. METHODS: Ten Type 1 diabetic patients, with diabetes duration of less than 10 years and normal urinary albumin excretion and ophthalmoscopy, were studied. All patients were examined after 48 h of good vs. poor glycaemic control within a 3-week period. Blood glucose was measured seven times daily for 2 days before each examination. External ultrasound was used to measure the dilatory response of the brachial artery to post-ischaemic increased blood flow (endothelium-dependent dilation) and to nitroglycerin (endothelium-independent dilation). Plasma concentration of von Willebrand factor antigen, adhesion molecules, vascular endothelial growth factor, homocystein and cholesterol were also measured. RESULTS: The median blood glucose levels in the 48 h before the examinations were [median (range), good vs. poor control]: 6.3 (5.0-7.6) vs. 15.9 (11.3-17.8) (mmol/l). The flow-associated vasodilation (% of baseline) was reduced during poor control: 102.7 (94.7-110.8) vs. 104.0 (99.6-118.5) (P < 0.05) as were the nitroglycerin-induced dilation (% of baseline): 114.5 (103.3-127.9) vs. 120.2 (106.8-148.0) (P < 0.05). P-von Willebrand factor antigen was high during poor control (kIU/l): 1.14 (0.73-1.84) vs. 0.86 (0.72-1.39) (P < 0.05) and so was P-vascular endothelial growth factor (ng/l): 288 (133-773) vs. 254 (90-383) (P < 0.05). CONCLUSIONS: Short-term (48 h) hyperglycaemia in Type 1 diabetic patients may disturb vascular function, possibly mediated through smooth muscle cell dysfunction as well as endothelial dysfunction. We suggest that prolonged and repeated episodes of hyperglycaemia could possibly lead to permanent vascular dysfunction and thereby development and progression of vascular complications in diabetes.

Hemodynamic changes during a single treatment with the molecular adsorbents recirculating system in patients with acute-on-chronic liver failure.

The aim of this pilot study is to evaluate the circulatory safety of treatment with the molecular adsorbents recirculating system (MARS) by determining the effect on systemic hemodynamics of a single MARS treatment in patients with acute-on-chronic liver failure (AOCLF). In eight patients admitted with AOCLF, a single 10-hour MARS treatment was performed. Systemic hemodynamic variables were determined before and during treatment. Bilirubin and urea were monitored as measures of protein-bound and water-soluble toxins. During MARS treatment, mean arterial pressure increased from 67 +/- 9 to 76 +/- 6 mm Hg (P < .05). Systemic vascular resistance index increased from 757 +/- 134 to 884 +/- 183 dyne x s/cm(5)/m(2) (P < .05), whereas cardiac index remained constant (5.9 +/- 0.7 v 6.0 +/- 1.1 L/min/m(2)). No episode of dialysis-induced hypotension was observed. Systemic oxygen consumption remained constant (92 +/- 30 v 93 +/- 11 mL/min/m(2)). Bilirubin levels decreased from 537 +/- 192 to 351 +/- 106 micromol/L (P < .05), and urea levels, from 19.1 +/- 13.9 to 6.7 +/- 5.1 mmol/L (P < .05). In conclusion, MARS treatment proved safe in critically ill patients with no attributing side effects.

Cerebral blood flow velocity increases during a single treatment with the molecular adsorbents recirculating system in patients with acute on chronic liver failure.

The aim of this uncontrolled pilot study is to determine the effect of treatment with the molecular adsorbents recirculating system (MARS) on cerebral perfusion in patients with acute on chronic liver failure (AOCLF). In 8 patients (median age, 44 years; range, 35 to 52 years) admitted with AOCLF, a single 10-hour MARS treatment was performed. Hepatic encephalopathy (HE) was graded according to the Fogarty criteria. Changes in cerebral perfusion were determined by transcranial Doppler as mean flow velocity (V(mean)) in the middle cerebral artery. Arterial ammonia and bilirubin levels were monitored as a measure of the capability of the MARS to remove water-soluble and protein-bound toxins. During MARS treatment, HE grade improved in 3 patients and remained unchanged in 5 patients (P =.11). V(mean) increased from 42 cm/sec (range, 26 to 59 cm/sec) to 72 cm/sec (range, 52 to 106 cm/sec; P <.05), whereas arterial ammonia level decreased from 88 micromol/L (range, 45 to 117 micromol/L) to 71 micromol/L (range, 26 to 98 micromol/L; P <.05) and bilirubin level from 537 micromol/L (range, 324 to 877 micromol/L) to 351 micromol/L (range, 228 to 512 micromol/L; P <.05). In conclusion, cerebral perfusion is increased and levels of ammonia and bilirubin are reduced during MARS treatment in patients with AOCLF.