Bernhard Schmekal

Long-term impact of chronic hemodialysis on glycemic control and serum lipids in insulin-treated type 2-diabetic patients.

There are only a few data in the literature concerning metabolic control in insulin-treated diabetic patients with end stage renal disease (ESRD). The aim of the study was to find out the long-term impact of hemodialysis on glycemic control and lipid values in type 2 diabetic patients. Twenty insulin-treated type 2 diabetic patients (age 62 ± 9 years, f:m = 6:14) were evaluated. We compared HbA1c, fasting blood glucose (FBG), body weight, serum lipids, insulin requirement, and blood-pressure (BP) 12 and 6 months before dialysis, at the start of dialysis, and 6 as well as 12 months after the start. Results: The mean HbA1c- and FBG-values were not significantly different before and after the start of dialysis therapy. The average insulin requirement was 26 ± 10 IU/day in the predialysis period, 25 ± 12 IU/day at the start, and 24 ± 13 as well as 22 ± 13 IU/day after the start of dialysis. The mean cholesterol level fell significantly from 199 ± 63 and 190 ± 49 mg/dL in the predialysis phase to 167 ± 62 and 157 ± 38 mg/dL after dialysis began. The triglyceride concentrations decreased only slightly after the start of dialysis. The incidence of hypoglycemia (n/patient/month) was markedly lower in the predialysis phase (0.4 vs. 0.6, NS) than after start of dialysis. In patients with residual diuresis (< 500 mL urine/day) the needed insulin doses decreased significantly by 29% compared to patients with higher residual diuresis, whose insulin requirement remained unchanged. In summary, hemodialysis had no significant long-term effect on glycemic control in insulin-treated type 2 diabetic patients, but incidence of hypoglycemia tended to be higher under hemodialysis than in the predialysis period. Lipid levels tended to be lower after the initiation of dialysis therapy. Insulin requirement under hemodialysis decreased only in patients with loss of residual urine volume (below 500 mL urine/day).

Skin Tuberculosis with Atypical Mycobacteria 8 Years after Combined Pancreas-Kidney Transplantation

We report on a Mycobacterium marinum infection in a diabetic woman 8 years after undergoing a combined pancreas-kidney transplantation. This is, to our knowledge, the first case report on an isolated skin infection with atypical mycobacteria after simultaneous pancreas-kidney transplantation. A genetic probe categorization revealed an infection with M. marinum. Skin tuberculosis caused by M. marinum is an uncommon complication in kidney or pancreas-kidney transplant recipients, hence the diagnosis can be delayed.

Causes and Prognosis of Nontraumatic Acute Renal Failure Requiring Dialysis in Adult Patients with and without Diabetes

Despite advanced techniques of renal replacement therapy the overall mortality of patients with ARF is still high. The majority of patients with ARF requiring dialysis are those with nontraumatic ARF. In a retrospective study we compared the causes of nontraumatic ARF, the risk factors for the development of renal failure and the mortality rates in patients with and without diabetes mellitus who received dialysis therapy in the years 1991–2000. A total of 232 patients were included in the study, 34 (14.6%) of them with and 198 patients (85.4%) without diabetes. The predominant causes of nontraumatic ARF like congestive heart failure (26.4 vs. 13.6, p < 0.05) and hypotension/hypovolemia (20.6 vs. 7.6%, p < 0.05) occurred more frequently in diabetic patients. The prevalence of sepsis (8.8 vs. 10.1%, NS), malignancy/hypercalcemia (5.8 vs. 11.6%, NS) and other causes of nontraumatic ARF were similar in both groups. The prevalence of hepato‐renal syndrome (5.8 vs. 13.6%, p < 0.05) and acute kidney graft failure (2.9 vs. 15.1%, p < 0.05) was higher in the nondiabetic individuals. Patients with diabetes showed more often chronic predictors for the onset of ARF like pre‐existing hypertension (93.6 vs. 51.0%, p < 0.05), congestive heart failure (44.1 vs. 14.6%, p < 0.005), pre‐existing renal insufficiency (76.4 vs. 46.9%, p < 0.05) and ACE‐inhibitor therapy (32.3 vs. 9.6%, p < 0.005). Additionally, the prevalence of multiple organ failure (MOF) as prognostic factor was significantly higher in the diabetic patients (47.0 vs. 21.7%, p < 0.05). The mean number of dialyses therapy was 4.7 vs. 4.5 per patient. The overall mortality was 41.1 vs. 44.% (NS). In conclusion, the prevalence of the most common causes of nontraumatic ARF was different between the patients with and without diabetes. The diabetic individuals had more frequently predictors for the onset of ARF. The overall mortality was approximately the same in both groups.

PREDIALYSIS MANAGEMENT AND PREDICTORS FOR EARLY MORTALITY IN UREMIC PATIENTS WHO DIE WITHIN ONE YEAR AFTER INITIATION OF DIALYSIS THERAPY

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 ≥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.

Impact of smoking on progression of vascular diseases and patient survival in type-1 diabetic patients after simultaneous kidney–pancreas transplantation in a single centre

We evaluated the impact of smoking on the progression of macro‐angiopathy as well as patient and graft survival in 35 type‐1 diabetic patients with simultaneous kidney–pancreas transplantation (SKPT). According to their smoking history, the patients were divided into smokers (n = 12) and nonsmokers (n = 23). Mean observation period was 80 (12–168) vs. 84 (12–228) months. The prevalence of vascular diseases as well as the incidence of vascular complications during the observation period was evaluated in each group. Graft‐ and patient survival were calculated. The prevalence of all vascular diseases was higher in the smokers with prior SKPT at the start as also at the end of study; however, the differences were not significant. In addition, the incidence of vascular complications (stroke, myocardial infarction and amputation) during the follow‐up period was higher in the smoking group. Taking all vascular complications together (events/patient/year) the difference was significant (0.105 vs. 0.066, P < 0.05). One‐ and  5‐year patient survival was 100% and 75% for smokers vs. 100% and 91% for nonsmokers.  One‐ and 5‐year pancreas graft survival at the same time was 100% and 75% in living smokers as well as 100% and 83% in the nonsmokers: We conclude that smoking after SKPT is associated with a progression of macro‐angiopathy. Additionally, mortality after SKPT tends to be higher in smoking patients.

Spontaneous remission of therapy-resistant minimal change nephritis in an adult woman 12 years after onset of the disease.

ZusammenfassungEine 23 Jahre alte Frau wurde wegen schwerer Ödeme im Rahmen einer steroid-resistenten Minimal Change Nephritis (MCN) stationär aufgenommen; die Diagnose war vor 9 Jahren mittels Nierenbiopsie gestellt worden. Eine Steroidtherapie führte bei der Patientin zu einer kompletten Remission der Erkrankung. 7 Jahre später, die Patientin war inzwischen 22 Jahre alt, kam es zu einem Relaps mit schwerem nephrotischem Syndrom. Eine Kombinationstherapie mit Prednisolone and Cylosporine A (CSA) führte nur zu einer partiellen Rückbildung der Proteinurie, die Ödeme persistierten. Konsequenterweise lehnte die Patientin nach 3 Monaten die weitere Einnahme von CSA wegen Erfolglosigkeit ab. Bei der Aufnahme in unserem Krankenhaus, 1 Jahr später im Dezember 2000, zeigte die Patientin ein schweres nephrotisches Syndrom mit peripheren Ödemen und Lungenödem, trotz hoher Furosemidgabe. Die Urin-Eiweißausscheidung betrug 12,5 g/Tag, das Serum-Kratinin war auf 1,4 mgdl erhöht, die Serum-Proteinkonzentration auf 47 g/l reduziert. Eine nochmals durchgeführte Nierenbiopsie bestätigte erneut die Diagnose MCN. Die Patientin erhielt wiederum eine Steroid-Bolustherapie über 4 Wochen und eine immunsuppressive Therapie mit CSA über 6 Wochen, beide Therapien blieben ohne Erfolg. Weitere Theapieregime mit Mofetil Mycophenolat, Azathioprin, Chloerambucil und Cyclosphopsphamid über einen Zeitraum von jeweils 6–12 Wochen waren ebenso ineffektiv und wurden zugleich schlecht vertragen. Die Proteinurie blieb hoch mit > 10 g/Tag. In weiterer Folge litt die Patientin vor allem an schweren Ödemen trotz Furosamidinfusionen. Es erfolgte daher auch 2–4 mal monatlich eine maschinelle Ultrafiltration mit einer Fresenius-Dialysemaschine. 3 Monate nach der letzten immunsuppressiven Therapie verschwanden die Ödeme spontan, die diuretische Therapie konnte beendet werden. Serum-Kreatinin war 0,8 mg/dl, die Eiweißausscheidung im Urin blieb noch hoch mit 9,8 g/Tag, aber die Serum-Protein-Konzentration war mit 65 g/l bereits normal. 3 Monate später war die Eiweißausscheidung bereits auf 0,48 g/Tag reduziert und alle anderen Laborbefunde normal. Inzwischen befindet sich die Patientin bereits über 3 Jahre in kompletter Remission ohne jegliche Therapie.SummaryA 23-year old woman was admitted to our hospital because of severe edema due to steroid resistant minimal change nephritis (MCN). The diagnosis was proven by renal biopsy nine years ago. At that time, steroid therapy led to a complete remission. Seven years later, patient was 22 years old, a relapse with severe nephrotic syndrome occurred. The diagnosis MCN was confirmed by a second renal biopsy. A combined therapy with prednisolone and cyclosporine A (CSA) led only to a partial reduction of protein excretion, the edema did not disappear. After 3 months, patient declined further therapy with CSA. On admission to our hospital, one year later in December 2000, the woman showed a severe nephrotic syndrome with edema and fluid lung, despite high doses of furosemide. Urinary protein excretion was 12.5 g/day, serum creatinine was increased to 1.4 mg/dl, the serum protein was reduced to 47 g/l. A repeated renal biopsy confirmed again the diagnosis MCN. Once again, a steroid bolus monotherapy over 4 weeks and an immunosuppressive therapy with CSA over 6 weeks had no effect on proteinuria. Further therapy regimes with mofetil mycophenolat, azathioprine, chlorambucil and cyclophosphamide over a period of 6–12 weeks of each regime was not well tolerated, proteinuria remained high with > 10 g/day. Moreover the patient suffered from severe edema despite furosemide infusions. Therefore, an additional mechanical ultrafiltration was performed 2–4 times monthly. Three months after the last immunosuppressive therapy the edema disappeared spontaneously, the diuretic therapy could be stopped. Serum creatinine was 0.8 mg/dl, protein in urine was still high with 9.8 g/day but serum protein for the first time was normal with 65 g/l. Three months later, the protein excretion was reduced to 0.48 g/l, and all other laboratory data were normal. Meanwhile, the woman has now enjoyed a complete second spontaneous remission for a period of three years.

Rate of Decline of GFR and Progression of Vascular Disease in Type 2 Diabetic Patients with Diabetic or Vascular Nephropathy during the Last Three Years before Starting Dialysis Therapy

Background: The progression of chronic renal insufficiency depends on the type of primary renal disease and blood pressure (BP) levels. We investigated the rate of decline of glomerular filtration rate (GFR) during 3 years prior to the start of dialysis therapy in type 2 diabetic patients with diabetic nephropathy (dNP) or vascular nephropathy (vNP). The aim of the study was to determine differences in the progression of renal insufficiency and the prevalence of vascular diseases in the two patient groups. Methods: In a retrospective study, we investigated type 2 diabetic patients with chronic renal insufficiency who were undergoing regular controls in our outpatient care unit for at least 3 years prior to the start of dialysis. We evaluated only patients who had already died under chronic dialysis therapy, and whose diagnosis of primary renal disease was histologically conformed at autopsy. A total of 40 type 2 diabetic patients were included in the study. Of these, 28 patients had dNP (age 62 ± 8 years) and 12 had vNP (age 70 ± 7 years). The following parameters were determined at 3- to 6-month intervals: body weight, BP, HbA1c, serum creatinine (Cr), Cr clearance (Cockroft formula), cholesterol and triglycerides. The prevalence of vascular disease in the two groups was also assessed. Results: The average decrease in Cr clearance was 7.7 ± 2.4 ml/min/year in patients with dNP and 7.7 ± 2.1 ml/min/year in those with vNP (NS). During the entire observation period, mean HbA1c values (7.0 ± 0.8 vs. 6.8 ± 0.6%), systolic BP (137 ± 8 vs. 138 ± 11 mm Hg) and diastolic BP (86 ± 4 vs. 87 ± 7 mm Hg), cholesterol and triglycerides did not differ significantly in the two groups. The prevalence of vascular disease 3 years prior to and at the start of dialysis therapy was similar in patients with dNP and vNP. Conclusion: The progression of dNP and vNP is similar at least during 3 years before the start of dialysis therapy. Vascular risk factors and the prevalence of vascular diseases were not significantly different in the two patient groups. However, diabetic patients with ESRD secondary to dNP were significantly younger than those with vNP.

Different Risk Factors and Causes for Early Death after Initiating Dialysis in Diabetic and Non-Diabetic Patients

The mortality of patients with end-stage renal disease (ESRD) is especially high after the start of dialysis therapy, especially in diabetic patients. A part of these patients die within three months after initiating renal replacement therapy (RRT). In the present retrospective study we evaluated all patients with ESRD requiring RRT who died within 3 months after initiating the first RRT. A total of 42 patients who died such early after the start of dialysis treatment during the years 1995–2001 were included in the study. Of them, 28 subjects (age 66 + 11 years) were diabetics and 14 non-diabetics (age 76 + 10 years). Indications for the start of dialysis were end-stage renal failure (creatinine clearance < 10–12 mL/min or < 12–14 mL/min in diabetic patients) or fluid lung associated with chronic renal failure (creatinine clearance < 20 mL/min). Hyperhydration with fluid lung was the most common indication for dialysis therapy in patients with diabetes (64.3% versus 14.3%, p < 0.05). The vascular risk factors blood pressure and serum-lipids were similar in both groups; however, diabetic patients were younger than non-diabetic subjects. The prevalence of vascular diseases tended to be higher in the diabetic group, but difference was not significant (see ). Severe heart failure (NYHA stage III-IV) was more common among diabetics (42.8% versus 14.3%, p < 0.05). The incidence of sepsis (17.9% versus 14.3%) did not significantly differ between the groups. The most common cause of death was cardiovascular events in both diabetic and non-diabetic patients (71.5% and 64.2%, respectively). Heart failure was a more common cause of death in diabetic patients (39.2% versus 21.4%, NS). In conclusion, early death after the initiation of dialysis treatment was more common in patients with type 2 diabetes, though, the diabetic patients were less old. In the diabetic group fluid lung was more often indication for initiating dialysis therapy than in the non-diabetic group. In both, diabetic and non-diabetic patients, the most common causes of death are cardiovascular events.