Impact of End‐Stage Renal Disease and Dialysis on Glycemic Control

Mak, Robert H.

doi:10.1046/j.1525-139x.2000.00007.x

Cited by 96 publications

(102 citation statements)

References 52 publications

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“…A significant percentage of diabetic patients have ESKD, however, and poor glycemic control has been shown to be a predictor of mortality in diabetic patients starting hemodialysis (3). Maintaining euglycemia may also be more difficult in patients with ESKD, as it has been suggested ESKD itself may induce insulin resistance (4).…”

mentioning

confidence: 99%

Adequacy of Glycemic Control in Hemodialysis Patients With Diabetes

et al. 2006

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OBJECTIVE -We sought to measure the prevalence of inadequate glycemic control in prevalent hemodialysis patients with diabetes and to examine independent predictors of inadequate glycemic control in these patients. RESEARCH DESIGN AND METHODS-This is a cross-sectional study of prevalent hemodialysis patients with diabetes in southeastern Ontario (n ϭ 100). Data were collected by chart review and interview. The outcome variable was inadequate glycemic control defined as HbA 1c (A1C) Ͼ0.07. Other measured variables were diabetes type, diabetes duration, diabetes physician, blood glucose monitoring, diabetes medications, BMI, time on dialysis, and other demographic, clinical, and laboratory variables.RESULTS -Fifty-four patients had A1C Ͼ0.07. In bivariate analysis, these patients had a longer diabetes duration (23.6 vs.14.7 years, P Ͻ 0.001), higher proportion with insulin use (81.5 vs. 58.7%, P ϭ 0.012), higher proportion with microvascular complications (66.7 vs. 43.5%, P ϭ 0.017), and lower erythropoietin (EPO) dose (7.0 vs. 11.9 ϫ 10 3 units/week, P Ͻ 0.01) than patients with adequate glycemic control. There was no difference between the two groups in terms of macrovascular complications (59.3 vs. 65.2%, P ϭ 0.54). In multiple logistic regression controlling for age and diabetes type, the diabetes duration (odds ratio 1. showed that maintaining blood glucose at normal or near-normal levels can reduce the incidence of microvascular complications in patients with type 1 and type 2 diabetes, respectively (1,2). Both trials excluded patients with end-stage kidney disease (ESKD) from the study population. A significant percentage of diabetic patients have ESKD, however, and poor glycemic control has been shown to be a predictor of mortality in diabetic patients starting hemodialysis (3). Maintaining euglycemia may also be more difficult in patients with ESKD, as it has been suggested ESKD itself may induce insulin resistance (4).Using HbA 1c (A1C) as a marker of long-term glycemic control in patients with ESKD was problematic in the past, as carbamylated hemoglobin formed in the uremic milieu interfered with older assays that relied on ion exchange for determination of A1C (5,6). Newer chemical and immunoassays do not have this problem (7,8).A study conducted prior to the results of the DCCT and UKPDS trials did demonstrate an increase in both micro-and macrovascular complications in diabetic patients with poor glycemic control on chronic dialysis (hemodialysis or peritoneal dialysis) but utilized one of these older A1C assays (9). It also set a cutoff for adequate glycemic control of A1C Ͻ0.10, well above modern guidelines (10,11). Since the publication of the DCCT and UKPDS trials, there have been no studies showing how patients with diabetes on hemodialysis have fared in terms of adequacy of glycemic control and whether there are any differences between those who do and do not have adequate control.The primary objective of this study was to measure the prevalence of inadequate glycemic control in prevalent hemod...

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confidence: 99%

Adequacy of Glycemic Control in Hemodialysis Patients With Diabetes

et al. 2006

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“…In CRF patients a decreased food intake can be due to many factors, such as: uraemic dysgeusia; inadequate compliance to dietary restrictions; psychosocial factors; drugs; chronic inflammation; gastrointestinal alterations (delayed gastric emptying, abdominal distension due to dialysis fluid, impairment of gastric myoelectric activity) (Mak, 2000); anorectic effect of dialytic fluid (Manno et al 2001). Prolonged glucose infusion beyond the peritoneum reduces food intake and induces endocrine alterations that further reduce nutrient ingestion (Mak, 2000).…”

Section: Reduced Nutrient Intakementioning

confidence: 99%

“…Prolonged glucose infusion beyond the peritoneum reduces food intake and induces endocrine alterations that further reduce nutrient ingestion (Mak, 2000).…”

Section: Reduced Nutrient Intakementioning

confidence: 99%

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Pathophysiological and clinical aspects of malnutrition in chronic renal failure

2005

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Kidney diseases are the ninth leading cause of death in the USA. In these patients cardiovascular mortality is greater than in the general population. This observation, not completely explained by the so-called ‘traditional’ cardiovascular risk factors, lead the authors to postulate other ‘emerging’ ones found in chronic renal failure patients. Among these new findings, nutritional status, considered as the balance existing between nutrient requirements and intakes, plays an important role for the development of cardiovascular diseases. In fact several nutritional parameters are widely known as pathophysiological determinants of cardiovascular disturbances, which are based on accelerated atherosclerosis, due especially to enhanced oxidative stress and endothelial dysfunction. Chronic renal failure is a clinical condition that from many points of view seems to be a chronic inflammatory state, and many studies confirm this observation. This influences nutritional status especially in dialysis patients. Malnutrition is related in turn to accelerated atherosclerosis thus leading to a postulated ‘malnutrition, inflammation, atherosclerosis’ (MIA) syndrome in which malnutrition, inflammation and atherosclerosis contribute to an elevated cardiovascular mortality rate. The present review explores this issue, first by describing epidemiological aspects of malnutrition in chronic renal failure patients and then by analysing the specific biochemical and metabolic features of these patients.

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“…Although most patients with chronic renal failure have impaired glucose tolerance, the kidneys play a major role in insulin breakdown, therefore many patients see an improvement in glycemic control when they progress to hemodialysis. 12 As well, because glycosuria and osmotic diuresis account for most of the fluid and electrolyte losses seen in DKA, anuric patients may be somewhat protected from dehydration and shock, although still subject to hyperkalemia and metabolic acidosis. This said, substantial volume loss, as described in Case 2, can still occur due to a prolonged decrease in oral intake or increased insensible water losses related to tachypnea and fever.…”

Section: Dka and Hemodialysismentioning

confidence: 99%