Authors: Taner Basturk MD, Abdulkadir Unsal MD

Summary: The objective of this paper is to detect the incidence of insulin resistance in Chronic Kidney disease patients and the presence of impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and diabetes mellitus in patients with/without insulin resistance.

Methods: 113 patients with CKD were enrolled. Biochemical parameters were investigated.

Results: IFG was found 59.3% of patients with CKD. Age(p:0,012), BMI(p:0,036), TG(p:0.008), HbA1c(p:0.002),hs-CRP(p:0.015) levels were higher in patients with IFG. According to the results of Oral glucose tolerance test (OGTT), 69% of patients with CKD had a detected carbohydrate metabolism disorder, 9.7% had diabetes melitus, 59.3% had IGT. In patients with IFG 13.6%had diabetes melitus, 31.8% IGT, in patients without IFG 4.2% had diabetes melitus and 29.8% IGT.  The mean HOMA-IR and insulin levels were 3.03±1,97/11.9±7.13.  Insulin resistance was detected 23% of patients with CKD. In patients with insuline resistance; FBG (p:0.003), serum insulin (p:0.001), TG (p:0.05) and HbA1c(p:0.004) levels were elevated. 31.3% of patients with IFG were found to be Insulin resistant.

Conclusion: Carbohydrate metabolism disorder and insulin resistance are found in patients with CKD. Most patients with CKD who are elderly, obesity or overweight offer targets for additional risk factors. For these reasons, screening for diabetes melitus may be recommended.

Key words: Chronic kidney disease, carbohydrate metabolism disorder, insulin resistance.

Authors: Magda Bayoumi PhD RN

Summary:Along with basic survival and other clinical outcomes, patients’ quality of life is an important indicator to reflect the needs of these patients. Human needs are classified in Maslows’ hierarchy, where the most essential basic physiological need provides the base, and self actualisation is at the top of pyramid.

The aim of this study is to identify the patients’ needs who are on maintenance haemodialysis using concept of Maslows’ hierarchy.

Method:  the descriptive study was conducted in the dialysis unit of Suez Canal University Hospitals. The study included 50 patients attending the dialysis unit.

Results: the findings showed that the patients’ highest need was for self-esteem (92.0%), whereas the lowest was for love and belonging (38.0%). Statistically significant relationships were revealed between the identified love and belonging needs and patients’ age and the duration of dialysis (p=0.008). The total needs score was lower with longer duration of dialysis (59.6±7.3), compared to those with a duration less than 24 months (65.7±8.1), p=0.02.

Conclusion: Based on the main study findings it is concluded that haemodialysis patients’ highest need was for self-esteem, and the lowest was for love and belonging. These needs increased with longer duration of dialysis. Nurses need to be aware of these findings in order to be able to supply the necessary support to help the patient regain his/her self-concept

Key words: End Stage Renal Disease, Haemodialysis, Maslows’ Hierarchy, Needs.

Authors: Debbie Benner MA, RD, CSR; Allen R. Nissenson MD; David Van Wyck MD

Summary: As with other disease states, mineral and bone disorder (MBD) management is challenging and may benefit from more systematic management. To evaluate the effectiveness of a focused campaign to improve MBD outcomes, we compared the percent of patients meeting 2003 K/Dialysis, Outcomes, Quality Initiative,(DOQI) -recommended MBD targets between baseline and 18 months after programme initiation. The four components of the clinical campaign were: (1) a set of grids allowing simultaneous evaluation of MBD test results, (2) a weighted, facility-level cumulative scoring system representing % of patients within KDOQI-recommended MBD targets, (3) team involvement, and (4) patient education. Eighteen months after programme initiation, the percent of patients simultaneously meeting all 2003 KDOQI targets increased 7% and the percent meeting calcium and phosphorus targets increased 24% and 8%, respectively. These findings suggest that a coordinated clinical campaign with effective tools, outcome tracking and sharing, and team involvement is an effective strategy to improve MBD outcomes.

Key words: MBD outcomes, team involvement, patient education, MBD scorecard, KDOQI

Authors: Muhammad M Javaid MBBS, B.Sc, MRCP UK, Antigoni Grigoriou MBBS, Dimitrios Katsianos MBBS, Sui Phin Kon MBBS, MD, FRCP.

Summary: Acute myocardial infarction is relatively uncommon in patients under the age of 40 years. Unlike the older patients where rupture of coronary artery atherosclerotic plaque is the main underlying pathology, the pathogenesis in younger patients can be varied and may require different diagnostic and therapeutic approaches. Hypercoagulable state associated with nephrotic syndrome and antiphospholipid syndrome can lead to the development of occlusive coronary artery thrombus in absence of atherosclerotic coronary artery disease. Acute myocardial infarction in such a setting can sometimes be the first manifestation of an underlying disease. We describe a case of myocardial infarction in a young man with both nephrotic and antiphospholipid syndromes and present a brief literature review.

Key words: Acute myocardial infarction, antiphospholipid syndrome, nephrotic syndrome

Authors: Rumeyza Kazancioglu.MD; Derya Topcuoglu.RN, Nese Kiricimli.RN; Arzu Cinkilic RN; Huseyin Celik.MD.

Summary: Standard peritoneal equilibrium test (PET) is an implementation that requires hard work for peritoneal dialysis staff. We analysed the efficacy of the fast PET and compared its results with standard PET. 49 patients on peritoneal dialysis therapy were included in the study. For standard PET, glucose, urea and creatinine values of dialysate were analysed at 0, 2nd 4th hours, and the patient’s serum glucose, urea and creatinine values were analysed at 2nd hour. In the fast PET, urea, glucose and creatinine values in plasma and dialysate were analysed at the 4th hour only. The results of both methods were compared with Pearson correlation and kappa tests. According to the standard PET, low transport in 5 patients, low-average transport in 17 patients, high-average transport in 23 patients and high transport types in 4 patients were identified. Fast PET results were similar in 46 (94%) patients (r=0.77, p=0,0001). Kappa (κw) analysis of results of both PETs was also statistically significant (p=0,0001). This study showed that the peritoneal transport type may be determined more easily, practically and faster.

Key Words: Treatment, Peritoneal Dialysis, Treatment Outcomes

Authors:  Franca Pasticci RD, BSc Dietetics; Anna Laura Fantuzzi RD, BSc Dietetics; Marisa Pegoraro RN; Margaret McCann RGN, RNT, BNS Hons., MSc, FFNMRCSI.  Giorgio Bedogni MD.

Summary: Nutrition is a critical issue in the management of patients with stage 5 chronic kidney disease (CKD). Malnutrition is common among these patients and affects their survival and quality of life. A basic knowledge of the nutritional management of stage 5 CKD is essential for all members of the nephrology team to improve patient care.  This article demonstrates that the needs of haemodialysis patients are more complex than those receiving peritoneal dialysis.

Keywords: Chronic kidney disease; dialysis; nutrition; patient care team.

Authors: Shah Sweni MD, Ramachandran Meenakshisundaram MD,  R Sakthirajan MD, Chinnasamy Rajendiran MD,  Ponniah Thirumalaikolundusubramanian MD.

Summary: Background: Poisoning cases are likely to develop into acute renal failure (ARF) and may be due to multiple mechanisms/aetiologies. Hence one has to carefully observe and treat these cases.

Objective: To find the prevalence of ARF among acute poisoning cases, identify the underlying causes and analyse the outcome.

Material and methods: In this prospective analytical study 1,250 cases that were admitted in Poison Control, Training and Research Centre of Government General Hospital, Madras Medical College over a period of consecutive 12 months were monitored and evaluated for development of ARF. Patients with history of diabetes/ hypertension, known chronic kidney disease, chronic NSAID’s therapy, those on drugs that increase serum creatinine by inhibiting creatinine secretion and other co-morbid illnesses were excluded. Data were analysed statistically.

Results: Among subject groups, 32 cases developed ARF. 28 were due to snake bite and the rest due to chemical poisons. Five in the former and seven in the latter expired. Among cases bitten by snake, only 22 (7%) cases bitten by Russell Viper developed renal failure. Copper sulphate and rat killer poisonings were the commonest causes of chemical induced ARF, whereas dichromate, indigenous medicines and vasmol 33 (para phenelyne diamine ) were the least causes for ARF. None of our patients with organophosphate developed ARF. Similarly none among the 150 admitted for overdose of medicines (tablets) developed ARF.

Conclusion: The prevalence of ARF among the cases of poisoning was 2.5%.The commonest predisposing factor for ARF in bites & stings was haemolysis, and that of chemical poisoning was direct nephrotoxicity. Early recognition and appropriate measures reduce the occurrence of ARF.

Keywords:  Renal failure,  Poison, Snake bite, Dialysis, Chemicals

Authors: Rebecca Walker  BSc. Food Science, PGDip Dietetics. Hayley James BSc App.Psychology, MSc Health Psychology. Aine Burns  MD  FRCP MSc. Med Ed.

Summary: Background: Chronic Kidney Disease (CKD) is associated with the development of serious co-morbidities.  Patients with CKD are encouraged to adhere to regimens to lower this risk. This study aimed to explore the experiences of patients attempting to integrate lifestyle changes into their lives.

Method: Face-to-face recorded interviews were conducted with 9 consenting patients with CKD stage 4 under the care of a consultant nephrologist. Each recording was analysed by two independent investigators using thematic analysis.

Results: Five themes emerged: Self in relation to others, Control, Adherence, Beliefs about treatment and illness and Uncertainty. Participants highlighted the importance of personal support and recounted their sense of being a burden on close family. They described how they approached disclosure about their condition, their beliefs regarding treatment and their decision making processes and how these factors impacted on adherence to behaviour change.

Conclusion: Practical support from family and healthcare professionals, a willingness to disclose their condition and help to make good decisions in difficult circumstances were identified as important factors in supporting success with behaviour change.

Key words: adherence, behaviour change, chronic kidney disease stage 4, qualitative, thematic analysis.

Author: Titus Augustine MBBS; MS; FRCSEd

Summary: Simultaneous Pancreas and Kidney transplantation (SPK) in the 21st century is a proven therapeutic intervention for diabetics with renal failure. While it is a major invasive procedure, successful transplantation leads to an overall improvement in the quality of life of the recipient, freedom from insulin and dialysis, along with stabilization and improvement in several of the multisystem complications associated with long term diabetes. It is also associated with improved longevity when compared to diabetics who have had a kidney transplant alone. The combined transplant could be considered a curative procedure albeit at the expense of long term immunosuppression. In essence, successful SPK transplantation may be considered the gold standard against which all other therapeutic interventions may be measured in a diabetic with renal failure.

Key words: Transplantation, Diabetic, Immunosuppression, Rejection, Treatment, Chronic Kidney Disease

Authors: Kate Bramham MRCP, Daghni Rajasingham FRCOG

Summary: With appropriate multidisciplinary team care most women with diabetes, with or without nephropathy will have successful pregnancy outcomes; however pregnancy complications are increased compared to normal individuals, particularly in those with poor glycaemic control. Women with more severe renal impairment, especially those with hypertension and proteinuria at are highest risk of worse pregnancy outcomes and deterioration in pre-existing renal function. Pre-pregnancy counselling should be offered to all women with diabetes in order to optimise diabetic care, and inform women of potential complications. Pregnancy is an indicator of long-term health, and should be utilised in the future management of women with diabetes.

Key words: Diabetes, Kidney disease, Pregnancy

Author: Edwina A Brown,DM FRCP

Summary: Patients with chronic kidney disease, particularly those with diabetes, often have a heavy burden of vascular comorbidity and hence a poor overall prognosis. Unfortunately, patients and their healthcare teams often have unrealistic expectations about outcomes and receive ineffective and often harmful interventions towards their end of life. We need to move away from death being perceived as a failure and realise, instead, that our goal of care at the end of life is to achieve as good a quality of life for the patient as possible. To be able to achieve this, it is important to be realistic about prognosis, be able to recognise predictors of poor outcome, and then be able to discuss these with the patient and their family to ensure symptom control, avoid interventions that could do harm and then as the end approaches, determine the wishes of the patient regarding preferred place of care for their inevitable death

Key words: Chronic Kidney Disease, Diabetic, Palliative Care

Author: John D Dean MD FRCP

Summary: Diabetes and Chronic Kidney Disease are two of the commonest long term conditions. One fifth of patients with diabetes will have CKD, and diabetes is the commonest cause of advanced kidney disease. For most patients these co morbidities will be managed in primary care with the focus on cardiovascular prevention. Many patients with more advanced disease and complications require joint care from multidisciplinary specialist teams in diabetes and renal disease to ensure that care is consistent and coordinated. Models of joint speciality care, include joint registry management, parallel clinics, shared consulting and case discussion, but require more evaluation than has currently been performed. These underpin more informal interactions between the specialist teams. A local model of care for diabetes and renal disease that incorporates the roles of primary care, members of multidisciplinary teams, and speciality care should be agreed, resourced appropriately and its effectiveness monitored.

Key words: Diabetes Mellitus, Chronic Kidney Disease, Integrated care, Primary Care, Specialist Care

Authors: Christopher Hill MB, MRCP, Damian Fogarty BSc, MD, FRCP

Summary: Background: Globally diabetic kidney disease is the leading cause of renal failure responsible for almost half of all patients needing renal replacement therapy (RRT). Aim of this review: To establish trends in end-stage renal disease (ESRD) due to diabetes in United Kingdom (UK).

Method: The UK Renal Registry electronically captures clinical information on renal replacement patients in UK renal units publishing annual reports on trends in RRT, clinical markers of care and survival statistics. Using these reports we summarise incidence, prevalence, and survival of ESRD patients with diabetes over last 15 years.

Results: In 1995 RRT initiated in 89 patients per million population (pmp) in UK. The proportion of new patients with diabetes was 13.8% (crude incidence rate 12.3pmp). In 2009 25.3% new ESRD patients had diabetes (unadjusted incidence rate 27.6pmp), 9 units reporting that over 30% of new patients have diabetes.

Conclusion: ESRD due to diabetes has increased over last 10-15 years with older patients and more comorbidity. Patients with diabetes now survive longer on RRT compared with 1990s, many are offered renal transplantation.

Key words: diabetic nephropathy; dialysis; incidence; renal replacement therapy; transplantation.

Authors: Rebecca Suckling MB Bs BSc MRCP & Hugh Gallagher MA MSc FRCP PhD

Summary: The prevalences of chronic kidney disease (CKD) and diabetes mellitus are increasing worldwide. Kidney disease and diabetes are important risk factors for cardiovascular disease and all three conditions are key components of the multiple morbidities increasingly evident as population age in the developed world. Shared risk factors, both traditional and non-traditional, contribute to these associations, and are important targets for public health and both primary and secondary care. Prevention and early detection in combination with a holistic approach to vascular care will be key to improving outcomes and reducing costs. Routine reporting of eGFR to aid early identification, risk stratification through quantitative proteinuria testing, appropriate use of renin-angiotensin system antagonists and optimal blood pressure control are important strategies to improve the care of people with or at risk of kidney disease.

Key words: chronic kidney disease, diabetes mellitus, cardiovascular disease, epidemiology

Author: Catherine A Hamilton ClinDip, MPharm, MRPharmS

Summary: Effective and appropriate control of blood glucose can significantly reduce the risk of diabetic complications and all cause mortality in patients with diabetes mellitus and recent years have seen a number of new anti-diabetic medications marketed. However, approximately 30% of patients with diabetes mellitus develop progressive renal insufficiency limiting the selection of agents that can safely be used. Whilst older agents such as metformin and the sulphonylureas remain the mainstay of initial treatment, the elimination and adverse effects profile of a number of these drugs can be a concern in patients with renal impairment. Additionally, use of the newer agents is often limited by a lack of long-term safety data, particularly in this patient group. Treatment guidelines for anti-diabetic therapy rarely consider safe and efficacious management of those patients with renal insufficiency.

Key words: Diabetic, Treatment, Chronic Kidney Disease, Proteinuria, Acute Renal Failure

Author: Beverley Meaney RGN.

Summary: Patients on renal replacement therapy especially haemodialysis (HD) are at high risk of foot ulcers which can lead to amputation. With the increasing numbers of diabetic patients now presenting with renal failure, renal nurses are in a pivotal position to educate patients and initiate and oversee good foot care. This paper describes the risk factors for these patients and discusses general care for prevention and treatment of these factors. Factors such as regular screening which can be done easily and effectively in an HD setting where patients attend regularly is the first method towards prevention. Care and treatment of foot wounds based on results from the author’s unit are discussed. The creation of a diabetic care programme for the author’s HD unit resulted in a more holistic approach to the care of the renal diabetic patient with special attention to foot care, leading in an improved standard of care and better management of the patients’ diabetes. This paper offers information from this programme and a summary of risks and treatments to assist those caring for renal diabetic patients.

Key words: Diabetes, foot care, ulceration, amputation

Author: Gurch Randhawa PhD, FFPH

Summary: It is widely acknowledged within the UK that there significant inequalities in renal health and transplant services – in relation to demand for, access to, and waiting times for these services – between minority ethnic groups in particular. This phenomena is not unique to the UK and affects many other countries who have a strong tradition of immigration. The solutions to reducing these inequalities are multi-faceted and require both short-term and long-term policy and resource-driven initiatives. In the short term, there is an urgent need to increase the number of organ donors from minority ethnic groups which will positively impact upon improved access to transplantation and contribute to reduced waiting times. The increase in donor registration can only be achieved if there are evidence-based, concerted and adequately resourced efforts to engage with minority ethnic communities at grass-roots level. In the long term, public health interventions are required that pro-actively seek to prevent and manage long-term conditions among the UK’s multi-ethnic and multi-faith population, thereby reducing the demand for transplantation.

Key words: Chronic Kidney Disease, Diabetic, ethnicity,Transplantation

Authors: Katherine Reid, MA, D.Clin Psy; Marianne Morris, BSc, MSc, PhD; Margaret Cormack BA, MA, MPsychol, PhD; Karen Marchant, MSc, RN

Summary:The psychological process of adjusting to diabetic kidney disease has been afforded little attention within previous literature. This study aimed to explore the process of adjusting to diabetic kidney disease (DKD) as a secondary condition to type 1 diabetes. A qualitative method was used in the study design. Eleven participants were interviewed using a semi-structured and exploratory approach. Through inductive thematic analysis three super-ordinate themes were identified from the data: coming to an understanding over time, managing the impact of DKD and facing the future. The themes demonstrate that the DKD population has complex physical and psychological needs at all stages of their condition. Making sense of kidney disease as a secondary condition and integration of this information with existing beliefs was integral to the adjustment process. Attempts to manage uncertainty and change included asserting control of the situation and use of cognitive strategies. The results support the use of psychological models of adjustment in conceptualising the process of adjustment and suggest the need for psychological interventions to support this population.

Key words: Chronic Kidney Disease, Diabetic, Psychosocial

Authors: Alice Smith BSc MSc PhD; James Burton, BA(Hons), MBChB(Hons), MRCP, DM. NIHR

Summary: Physical inactivity is well recognised as a major health issue in today’s society. Regular exercise is important in maintaining health and preventing chronic disease, it is increasingly accepted as a valuable therapeutic intervention in many long term conditions. Unfortunately the role of physical activity in renal disease has been largely overlooked and provision of exercise advice and rehabilitation programmes for kidney patients lags well behind that of cardiology and pulmonary services. Research indicates that exercise can impact positively upon many of the health issues associated with declining renal function and renal replacement therapy, as concluded by a recent Cochrane review on the topic. As exercise should be integral to the management of diabetes, the issue is particularly relevant for patients with diabetic kidney disease. This article summarises what is known about the main effects of exercise training in chronic kidney disease and diabetic kidney disease, and suggests how adaptations in the attitudes and approaches of the multidisciplinary renal and diabetes healthcare teams can help patients to enjoy the diverse benefits of an appropriately active lifestyle.

Key words: Chronic Kidney Disease, Diabetic Kidney Disease, Exercise, Physical Activity

Authors: Kathryn K. Stevens BSc, MB. ChB., MRCP; Rajan K Patel MB. Ch.B., PhD., MRCP; Alan G Jardine, MB.Ch.B., MD, FRCP

Summary:New onset diabetes after transplantation (NODAT) has serious consequences for the patient in terms of overall survival, graft function and graft survival. The incidence of NODAT and impaired glucose tolerance has probably been underestimated previously due to lack of a universal diagnostic definition. Many risk factors have been identified, a proportion of which are modifiable. Early identification of those who are at high risk of NODAT and strategies to reduce risk will help to reduce the morbidity and mortality resulting from this condition. Where prevention is not possible, stringent management strategies are essential.
Although this article focuses on NODAT in the renal transplant recipient and considers the scale of the problem, impact on patient and transplant survival, determinants and risk factors for, and the management of, impaired glucose tolerance and NODAT, much of it will also be applicable to other types of solid organ transplantation.

Key words: Diabetes mellitus, NODAT, renal transplantation, survival

Author: Paul E Stevens, MB BS. BSc FRCP

Summary: Anaemia is a common finding in people with diabetes and chronic kidney disease and failure of the kidney to produce erythropoietin in response to a falling haemoglobin concentration is a key component, correlating with the degree of albuminuria, renal dysfunction and iron deficiency. Anaemia in diabetes is associated with a number of adverse outcomes, including increased risk of all cause and cardiovascular mortality. Whether or not anaemia is a marker or mediator of adverse outcome still remains to be completely resolved. Treatment of anaemia in diabetes has quality of life benefits and reduces transfusion requirements. Correction of anaemia to normal haemoglobin concentrations is associated with significant adverse cardiovascular outcomes and is not recommended, escalating doses of erythropoiesis stimulating agents should be avoided. The treatment of anaemia in people with diabetes and chronic kidney disease should begin with optimisation of iron stores. An aspirational haemoglobin concentration range of 10-12 g/dL with anaemia management balances proven benefits of anaemia treatment with potential cardiovascular risk.

Key words: Anaemia. Diabetes, Chronic kidney disease, Cardiovascular disease, Quality of life, Mortality, Hospitalisation, Iron, Erythropoietin, Erythropoiesis stimulating agents

Author: Jonathan Valabhji MD. FRCP

Summary: There is a much higher incidence of diabetic foot disease in those with concurrent renal disease and outcomes, including amputation and mortality, are generally poorer. The risk factors contributing to the higher incidence of foot disease in those with both diabetes and renal disease are outlined, and the evidence explored demonstrating higher incidence of foot disease across categories of renal disease, including impaired renal function, haemodialysis, continuous ambulatory peritoneal dialysis, renal transplantation, and simultaneous pancreas and kidney transplantation. Three major pathological aspects of diabetic foot disease in which concurrent renal disease either contributes to a higher incidence, or modifies the clinical manifestations and outcomes, are described: ulceration; Charcot neuroarthropathy; and necrotic toes. Pathophysiology, clinical features and management strategies for these three conditions are described. Finally, the evidence for preventative strategies for foot disease is explored, and the important role of speed of access to specialist multidisciplinary diabetic foot services discussed.

Key words: Infection, Diabetic foot, Ulceration, Charcot, Osteomyelitis, Necrotic toes

Author: Fiona Willingham BSc (Hons) RD.

Summary: Diabetes Mellitus is one of the major causes of chronic kidney disease and end stage renal disease. Diet and lifestyle modification are vital components of optimal treatment for both conditions. This article will address appropriate and often diverse treatment for each individual, understanding that advising changes which positively impact both conditions is a major challenge for health care professionals working within either speciality. It will also highlight where overlap can be contradictory rather than complementary, and offers practical guidance to support patients in making the necessary lifestyle changes to have maximal positive impact upon both conditions and their overall health.

Key words: Chronic kidney disease, Diabetes, Nutrition, Advice