The reduction in insulin requirement in renal insufficiency is similar in Type 1 and insulin-treated Type 2 diabetic patients. In subjects with Type 2 diabetes, the residual insulin secretion has no impact on the reduction in insulin requirement dependent on the GFR.

Despite improvements in dialysis therapy, the mortality rate of patients with end stage renal disease (ESRD) has remained high. A relatively high proportion of uremic patients dies within one year after the initiation of dialysis treatment. The aim of this study was to evaluate predictors for this early mortality in patients with ESRD. A total of 66 uremic patients were included in the study. Patients were divided in those who survived < 1 year (n = 17) and those who survived > or = 1 year (n = 49). We compared the prevalence of diabetes and hypertension and of vascular diseases as well as the prevalence of heart insufficiency (EF < 30%) and left ventricular hypertrophy (LVH). Additionally, we estimated the laboratory parameters serum creatinine, creatinine clearance, BUN, cholesterol, triglycerides, fibrinogen, serum protein, serum albumin and hemoglobin, and evaluated the indications for the initiation of dialysis therapy in both patient groups. The patients with survival < 1 year were significantly older (64+/-12 vs. 54+/-14 years, p<0.01) and showed a lower BMI (22+/-3 vs. 25+/-3, p<0.01) than those who survived > 1 year. The prevalence of diabetes (70% vs. 31%, p<0.05), cardiac insufficiency (70% vs. 16%, p<0.025), cardiovascular disease (65% vs. 28%, p<0.05) and peripheral vascular diseases (70% vs. 28%, p<0.05) was significantly higher in the patients with early mortality. The prevalence of hypertension was similar in both groups, however, the prevalence of LVH was significantly higher in the patients who survived < 1 year (88% vs. 37%, p<0.05). Laboratory parameters were not significantly different in the two groups of patients, with the exception of serum albumin, which was significantly lower in the patients with early mortality (3.5+/-0.6 vs. 3.9+/-0.4 g/l, p<0.02). Hyperhydration was the most common indication for the start of dialysis in patients with early mortality (59% vs. 13%, p<0.025). Cardiac insufficiency was the most common cause of death in these subjects (n = 10, 59%). Six individuals (12%) died within four weeks after initiating dialysis therapy. Thus, there are several predictors for early mortality in end-stage renal disease patients, including high age, low BMI, the presence of diabetes, coronary heart disease, heart insufficiency and LVH, as well as low serum albumin levels. A relatively high percentage of patients die shortly after the start of dialysis therapy. Heart insufficiency is the most common cause of early death in these patients.

An inverse relationship between plasma insulin levels and homocysteine (Hcy) concentrations in type 2 diabetic patients has been previously reported (1) and discussed (2,3). An association between hyperinsulinemia and elevated Hcy levels has been found (4), and others (5) have observed that acute hyperinsulinemia reduces plasma Hcy levels in healthy men. In addition, it has been documented that plasma Hcy could be affected by both metabolic control and duration of disease in type 2 diabetic patients (6). By using the clamp technique, others have found that acute hyperinsulinemia did not influence plasma Hcy levels in patients with type 2 diabetes (7). Although hyperhomocysteinemia has been widely accepted as a risk factor for premature atherosclerosis (8), the complex relationship among insulin levels, insulin resistance, and plasma Hcy has yet to be entirely elucidated.As part of a screening procedure for detecting subjects with clinical characteristics of the metabolic syndrome in Hungary, we measured total plasma Hcy levels (Abbott IMx) in hyperinsulinemic subjects with different stages of glucose intolerance. In a cohort of middle-aged (40-60 years) hyperinsulinemic subjects (38 men and 53 women, [means ± SD] age 47.6 ± 4.3 years, BMI 34.6 ± 4.9 kg/m 2 , waist-to-hip ratio 0.92 ± 0.07, fasting plasma insulin level Ͼ15 µU/ml and/or postprandial [120 min after oral glucose tolerance test with 75 g glucose] plasma insulin level Ͼ45 µU/ml, actual blood pressure 146 ± 16/87 ± 9 mmHg, serum LDL cholesterol level 3.73 ± 1.09 mmol/l, HDL cholesterol level 1.12 ± 0.30 mmol/l, triglycerides level 2.97 ± 2.38 mmol/l, and uric acid level 279 ± 79 µmol/l), the plasma Hcy, vitamin B 12 , and folic acid levels were simultaneously determined. Subjects were classified as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT) or diabetes; subgroups were matched for age, sex, BMI, and actual blood pressure. No antidiabetic or lipid-lowering drugs were used by the patients screened. Normal values of plasma Hcy, folic acid, and vitamin B 12 levels in a nondiabetic and nonhyperinsulinemic control group (19 men and 28 women aged 45.0 ± 7.8 years) were also measured.Although fasting plasma insulin levels were comparable, postprandial values were significantly higher in subjects with IGT or diabetes than in those with NGT. Plasma Hcy levels were not elevated and did not increase significantly with different stages of glucose intolerance in hyperinsulinemic subjects. Folic acid and vitamin B 12 levels were also comparable in the investigated subgroups (Table 1). In addition, no significant difference (P Ͼ 0.05) was observed between hyperinsulinemic subjects (n = 91) and control subjects (n = 47) when plasma Hcy (9.28 ± 3.81 vs. 9.63 ± 2.70 µmol/l, respectively), folic acid (8.5 ± 5.9 vs. 7.5 ± 2.1 ng/ml), and vitamin B 12 levels (423 ± 141 vs. 356 ± 121 pg/ml) were compared. Plasma Hcy levels were significantly (P Ͻ 0.001) higher in hyperinsulinemic men (11.34 ± 4.72 µmol/l, n = 38, age 48.1 ± 4.1 years) than in hype...

BackgroundThe purpose of the present study was to check the validity of data collected in BIOREG, the Austrian register for biological treatment in rheumatology, and to elucidate eventual differences with respect to disease activity (DA) in patients with rheumatoid arthritis (RA) on established biological DMARDs (bDMARDs) before inclusion into the register (EST) and beginners at the time point of inclusion (NEW) after 1 year of treatment.MethodsRA patients with a complete follow-up of 1 year in BIOREG were divided into EST and NEW and compared with respect to DA, remission rates, concomitant synthetic DMARDs (csDMARDs) and glucocorticoid therapy (GC) at baseline and after 1-year follow-up. Safety concerns are listed. Descriptive statistics are applied.ResultsFor 346 RA patients (284 EST, 62 NEW) out of 970 RA patients included into BIOREG, a full data set for a 1-year follow-up was available. No differences in DA were observed after 1 year as expressed by DAS28 or RADAI-5, and small differences as expressed by remission rates according to DAS28, RADAI-5 or Boolean criteria (namely approximately 1/2, 1/3 to 1/4 and 1/4 to 1/5 of the patients respectively). Sixty-four adverse events (AEs) were noted in 56 (20 %) of EST and 20 in 19 (31 %) of NEW patients. Malignancy occurred in four patients. After 1 year, 48 % of EST patients but only 16 % of NEW patients were on bDMARD monotherapy.ConclusionRegarding DA, the date collected in BIOREG appeared to be valid. After 1 year of bDMARD therapy, all patients, whether EST or NEW, achieved a similar level of DA. AEs occurred more frequently during the early phase of bDMARD treatment. Austrian rheumatologists initiate bDMARD therapy in patients with lower disease levels than in other European countries, leading to high remission rates.

Diabetes is known to be a risk factor for the severity of anemia in non-dialyzed patients with renal failure. The aim of this study was to evaluate differences in hemoglobin (Hb) response to erythropoietin (EPO) in diabetic and nondiabetic patients on chronic hemodialysis (CHD). Sixty-four patients on CHD were included in the study: 24 type 2 diabetics (mean age, 59+/-11 years; 10 men, 14 women) and 40 nondiabetics (age, 53+/-14 years; 21 men, 19 women). All patients received a fixed dose of 50 mg ferric saccharate and EPO per week, dosed individually to achieve a target Hb level of 12 g/dl. Hb levels, ferritin, transferrin saturation (TSAT), EPO requirement (IU/kg/week), folic acid, vitamin B12 and C-reactive protein (CRP) were measured every two months. Additionally, the incidence of infectious diseases during the observation period of six months was evaluated, and a univariate correlation analysis of CRP and EPO requirements was performed in both groups. Patients with and without diabetes were divided into two groups each: those with normal CRP and those with elevated CRP. The EPO requirements of these groups were compared. Under identical iron substitution the mean Hb level increased more, but not significantly, in non-diabetic patients than in diabetic patients. After 6 months the mean Hb levels were 12.1+/-1.2 versus 11.5+/-1.2 g/dl (NS), although the actual EPO requirement was higher in diabetic than in non-diabetic subjects (244+/-122 versus 183+/-118 IU/kg/week; p<0.05). CRP after 6 months was significantly higher in diabetic than in non-diabetic patients (2.6+/-2.2 versus 1.5+/-1.3 mg/dl; p<0.05), as was the incidence of infectious disease (n/patient/month) (0.24 versus 0.08; p<0.05). The correlation coefficient between CRP and EPO requirements was statistically significant in both diabetic (r=0.547 p<0.01) and non-diabetic subjects (r=0.577; p<0.001). All other laboratory indices were similar in both groups. In the diabetic patients with normal CRP (n=6) the Hb levels achieved after six months were similar to those of non-diabetic patients (n=10) with normal CRP (11.9+/-1.1 versus 12.1+/-1.2%), and the required EPO was comparable. We conclude that the Hb response to EPO is reduced in diabetic patients on CHD. This elevated EPO requirement may be explained by a greater prevalence of infectious diseases, characterized by a significantly higher CRP level, in these patients. Other causes for the elevated EPO requirement could be excluded.