RESUMEN
BACKGROUND: The prognostic importance of several hematological parameters has been scarcely investigated in type 2 diabetes. So, we aimed to evaluate their prognostic importance for development of complications in a cohort of type 2 diabetes. METHODS: In a prospective study, 689 individuals with type 2 diabetes had blood red cell, platelet and leukocyte parameters obtained at baseline. Multivariate Cox analyses examined the associations between several hematological parameters (including neutrophyl-to-lymphocyte, lymphocyte-to-monocyte, platelet-to-lymphocyte, and monocyte-to-HDL ratios) and the occurrence of microvascular (retina, renal and peripheral neuropathy) and cardiovascular complications (total cardiovascular events [CVEs], and major adverse CVEs [MACEs]), and all-cause and cardiovascular mortality. Improvements in risk discrimination were assessed by C-statistics and Integrated Discrimination Improvement (IDI) index. RESULTS: During a median follow-up of 10.5 years, 212 patients had a CVE (174 MACEs), 264 patients died (131 cardiovascular deaths); 206 had a renal, 161 a retinopathy and 179 patients had a neuropathy outcome. In multivariate-adjusted analyses, the lymphocytes count and lymphocyte-to-monocyte ratio were protective (hazard ratios [HRs]: 0.77 and 0.72, respectively), whereas the neutrophyl-to-lymphocyte and platelet-to-lymphocyte ratios were associated with increased risks (HRs: 1.19 and 1.17) for all-cause mortality. For cardiovascular mortality, the monocytes count, the neutrophyl-to-lymphocyte and monocyte-to-HDL ratios were associated with increased risks and the lymphocyte-to-monocyte ratio was protective. Higher lymphocyte-to-monocyte ratio was protective for renal failure outcome. However, none of them improved risk discrimination. CONCLUSIONS: Low lymphocytes count and leukocyte ratios that mainly included lymphocytes were predictors of macrovascular complications and mortality in individuals with type 2 diabetes. However, they did not improve risk prediction over traditional risk factors.
Asunto(s)
Plaquetas , Diabetes Mellitus Tipo 2/sangre , Angiopatías Diabéticas/sangre , Eritrocitos , Leucocitos , Anciano , Brasil/epidemiología , Causas de Muerte , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidad , Angiopatías Diabéticas/diagnóstico , Angiopatías Diabéticas/mortalidad , Nefropatías Diabéticas/sangre , Nefropatías Diabéticas/diagnóstico , Nefropatías Diabéticas/mortalidad , Neuropatías Diabéticas/sangre , Neuropatías Diabéticas/diagnóstico , Neuropatías Diabéticas/mortalidad , Retinopatía Diabética/sangre , Retinopatía Diabética/diagnóstico , Retinopatía Diabética/mortalidad , Recuento de Eritrocitos , Femenino , Humanos , Recuento de Linfocitos , Linfocitos , Masculino , Persona de Mediana Edad , Recuento de Plaquetas , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Factores de TiempoRESUMEN
Patients with type 2 diabetes (T2D) and Latin American subjects in particular are at an increased risk of developing severe COVID-19 and mortality. Altered renal function and lower magnesium levels have been reported to play important roles in the pathophysiology of T2D. The aim of the study was to investigate the relationship between renal function, serum magnesium levels and mortality in T2D patients with COVID-19. In this retrospective study, we characterized 118 T2D and non-diabetic subjects hospitalized with COVID-19. Patients were clinically characterized and electrolyte, renal function and inflammatory markers were evaluated. Patients were grouped according to their estimated glomerular filtration rate (eGFR <60 mL/min per 1.73 m2). T2D patients had lower eGFR and serum magnesium levels when compared to non-diabetics (59.7 ± 32.8 vs. 78.4 ± 33.8 mL/min per 1.73 m2, P = 0.008 and 1.9 ± 0.3 vs. 2.1 ± 0.3 mEq/L, P = 0.012). Survival was worse in T2D patients with eGFR levels less than 60 mL/min per 1.73 m2 as estimated by Kaplan-Meier analyses (log-rank test <0.0001). The Cox model for T2D patients showed that eGFR (HR 0.970, 95% CI 0.949 to 0.991, P = 0.005) and magnesium (HR 8.025, 95% CI 1.226 to 52.512, P = 0.030) were associated with significantly increased risk of death. Reduced eGFR and magnesium levels were associated with increased mortality in our population. These results suggest that early assessment of kidney function, including magnesium levels, may assist in developing effective treatment strategies to reduce morbidity and mortality among Latin American COVID-19 patients with T2D.
Asunto(s)
COVID-19 , Diabetes Mellitus Tipo 2 , Riñón/fisiopatología , Magnesio/sangre , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , COVID-19/sangre , COVID-19/complicaciones , COVID-19/diagnóstico , COVID-19/mortalidad , Estudios de Casos y Controles , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidad , Nefropatías Diabéticas/sangre , Nefropatías Diabéticas/complicaciones , Nefropatías Diabéticas/diagnóstico , Nefropatías Diabéticas/mortalidad , Femenino , Tasa de Filtración Glomerular/fisiología , Mortalidad Hospitalaria , Humanos , Riñón/metabolismo , Masculino , Persona de Mediana Edad , Pronóstico , Insuficiencia Renal Crónica/sangre , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/mortalidad , Estudios Retrospectivos , SARS-CoV-2/fisiología , Análisis de SupervivenciaRESUMEN
BACKGROUND: The prognostic importance of an increased visit-to-visit blood pressure variability (BP-VVV) for the future development of micro- and macrovascular complications in type 2 diabetes has been scarcely investigated and is largely unsettled. We aimed to evaluate it in a prospective long-term follow-up study with 632 individuals with type 2 diabetes. METHODS: BP-VVV parameters (systolic and diastolic standard deviations [SD] and variation coefficients) were measured during the first 24-months. Multivariate Cox analysis, adjusted for risk factors and mean BP levels, examined the associations between BP-VVV and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications (total cardiovascular events [CVEs], major adverse CVEs [MACE] and cardiovascular and all-cause mortality). Improvement in risk discrimination was assessed by the C-statistic and integrated discrimination improvement (IDI) index. RESULTS: Over a median follow-up of 11.3 years, 162 patients had a CVE (132 MACE), and 212 patients died (95 from cardiovascular diseases); 153 newly-developed or worsened diabetic retinopathy, 193 achieved the renal composite outcome (121 newly-developed microalbuminuria and 95 deteriorated renal function), and 171 newly-developed or worsened peripheral neuropathy. Systolic BP-VVV was an independent predictor of MACE (hazard ratio: 1.25, 95% CI 1.03-1.51 for a 1-SD increase in 24-month SD), but not of total CVEs, cardiovascular and all-cause mortality, and of any microvascular outcome. However, no BP-VVV parameter significantly improved cardiovascular risk discrimination (increase in C-statistic 0.001, relative IDI 0.9%). CONCLUSIONS: Systolic BP-VVV was an independent predictor of MACE, but it did not improve cardiovascular risk stratification. The goal of anti-hypertensive treatment in patients with type 2 diabetes shall remain in controlling mean BP levels, not on decreasing their visit-to-visit variability.
Asunto(s)
Presión Sanguínea , Enfermedades Cardiovasculares/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Angiopatías Diabéticas/epidemiología , Nefropatías Diabéticas/epidemiología , Neuropatías Diabéticas/epidemiología , Anciano , Brasil/epidemiología , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/fisiopatología , Causas de Muerte , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidad , Diabetes Mellitus Tipo 2/fisiopatología , Angiopatías Diabéticas/diagnóstico , Angiopatías Diabéticas/mortalidad , Angiopatías Diabéticas/fisiopatología , Nefropatías Diabéticas/diagnóstico , Nefropatías Diabéticas/mortalidad , Nefropatías Diabéticas/fisiopatología , Neuropatías Diabéticas/diagnóstico , Neuropatías Diabéticas/mortalidad , Neuropatías Diabéticas/fisiopatología , Progresión de la Enfermedad , Femenino , Humanos , Incidencia , Riñón/fisiopatología , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Sístole , Factores de TiempoRESUMEN
BACKGROUND: The aim of this study was to examine the relationship of albuminuria to cardiovascular disease outcomes in diabetic patients undergoing treatment for stable coronary artery disease. METHODS AND RESULTS: We analyzed data from 2176 participants of the Bypass Angioplasty Revascularization Investigation in type-2 diabetes (BARI-2D) trial, a randomized clinical trial comparing Percutaneous coronary intervention/Coronary artery bypass grafting (PCI/CABG) to medical therapy for people with diabetes. The population was stratified by baseline spot urine albumin-creatinine ratio (uACR) into normal (uACR <10 mg/g), mildly (uACR ≥10 mg/g < 30 mg/g), moderately (uACR ≥30 mg/g < 300 mg/g) and severely increased (uACR ≥300 mg/g) groups, and outcomes compared between groups. Death, myocardial infarction (MI) and/or stroke were experienced by 489 patients at a mean follow-up of 4.3 ± 1.5 years. Compared with normal uACR, mildly increased uACR was associated with a 1.4 times (P = 0.042) increase in all-cause mortality. Additionally, nonwhites with type-II diabetes and stable coronary artery disease who had mildly increased albuminuria had a Hazard ratio (HR) of 3.3 times (P = 0.028) for cardiovascular death, 3.1 times for (P = 0.002) all-cause mortality, and two times for (P = 0.015) MI during follow-up. CONCLUSIONS: Mildly increased albuminuria is a significant predictor of all-cause mortality in those with type-II diabetes mellitus and stable coronary artery disease, as well as for cardiovascular events those who are nonwhites.
Asunto(s)
Albuminuria/etnología , Fármacos Cardiovasculares/uso terapéutico , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/terapia , Diabetes Mellitus Tipo 2/etnología , Nefropatías Diabéticas/etnología , Intervención Coronaria Percutánea , Anciano , Albuminuria/diagnóstico , Albuminuria/mortalidad , Brasil/epidemiología , Fármacos Cardiovasculares/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/etnología , Enfermedad de la Arteria Coronaria/mortalidad , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidad , Nefropatías Diabéticas/diagnóstico , Nefropatías Diabéticas/mortalidad , Europa (Continente)/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etnología , Infarto del Miocardio/mortalidad , América del Norte/epidemiología , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/etnología , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
A lesão no pé de pacientes com diabetes é um importante problema de saúde pública que frequentemente está associado a amputações em membros inferiores e mortalidade nessa população. Objetivos: Investigar os fatores de risco associados a mortalidade em pacientes com pé diabético infectado submetidos a amputação maior. Métodos: Estudo observacional, retrospectivo e caso-controle. Amostra composta por 78 pacientes com pé diabético e úlcera infectada submetidos a amputação maior em um serviço de cirurgia vascular em um hospital universitário no período de 5 anos. Resultados: A média de idade da amostra estudada foi de 63,8 ± 10,5 anos, com 54 (69,2%) pacientes do sexo masculino, com creatinina sérica média de 2,49 ± 2,4 mg/dL e hemoglobina sérica média de 7,36 ± 1,7 g/dL. Houve 47,4% de reinternação. Foi realizada amputação transtibial em 59,0% e transfemoral em 39,7% da amostra estudada. Nesta amostra, 87,2% dos pacientes apresentaram cultura positiva, predominantemente monomicrobiana (67,9%), e 30,8% presentaram infecção hospitalar da úlcera. Os gêneros de bactérias mais frequentes foram Acinetobacter spp. (24,4%), Morganella spp. (24,4%) e Proteus spp. (23,1%). Nenhum gênero bacteriano foi identificado como fator de risco para óbito. O nível de creatinina ≥ 1,3 mg/dL (OR 17,8; IC 2,1-150) e a amputação transfemoral (OR 4,5; C: 1,3-15,7) foram fatores de risco para o óbito. Conclusões: Os níveis séricos de creatinina ≥ 1,3 mg/dL e amputação transfemoral foram fatores de risco para óbito
Foot ulcers in patients with diabetes are a major public health problem and are often associated with lower limbs amputation and mortality in this population. Objectives: To investigate the risk factors associated with mortality in patients with infected diabetic foot ulcers and major lower limb amputations. Methods: This was an observational, retrospective, case-control study with a sample of 78 patients with infected diabetic foot ulcers who had major lower limb amputations at a Vascular Surgery Service at a university hospital. Results: The mean age of the study sample was 63.8 ± 10.5 years, 54 (69.2%) were male, mean serum creatinine was 2.49 ± 2.4 mg/dL and mean serum hemoglobin was 7.36 ± 1.7 g/dL.There was a 47.4% rate of readmissions to the same hospital.Transtibial amputation was performed in 59.0%; and transfemoral amputation in 39.7% of the sample. In this sample, 87.2% had a positive culture, predominantly (68.0%) monomicrobial and nosocomial infection of ulcers was observed in 30.8%. The most common bacterial genera were Acinetobacter spp. (24.4%), Morganella spp. (24.4%) and Proteus spp. (23.1%). No bacterial genus was identified as a predictor of death. Creatinine level ≥ 1.3 mg/dL (OR 17.8; IC 2.1-150) and transfemoral amputation (OR 4.5; IC: 1.3-15.7) were associated with death. Conclusions: Serum creatinine levels ≥ 1.3 mg/dL and transfemoral amputation were risk factors for death
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Factores de Riesgo , Pie Diabético/mortalidad , Amputación Quirúrgica , Infección de Heridas , Comorbilidad , Infección Hospitalaria/complicaciones , Úlcera del Pie/complicaciones , Extremidad Inferior , Diabetes Mellitus/mortalidad , Nefropatías Diabéticas/mortalidad , Estudio Observacional , Infecciones , Antibacterianos/uso terapéuticoRESUMEN
OBJECTIVE: A common belief is that only a minority of patients with type 1 diabetes (T1D) develop advanced kidney disease and that incidence is higher among men and lower in those diagnosed at a younger age. However, because few patients with T1D survived to older ages until recently, long-term risks have been unclear. RESEARCH DESIGN AND METHODS: We examined the 50-year cumulative kidney complication risk in a childhood-onset T1D cohort diagnosed during 1950-80 (n = 932; mean baseline age 29 years, duration 19 years). Participants comprised 144 who died prior to baseline, 130 followed with periodic surveys, and 658 followed with biennial surveys and a maximum of nine examinations for 25 years. Micro- and macroalbuminuria were defined as an albumin excretion rate of 20-199 and ≥200 µg/min, respectively, and end-stage renal disease (ESRD) was defined as dialysis or kidney transplantation. Cumulative incidence was estimated at 10-year intervals between 20 and 50 years, duration and compared by calendar year of diabetes onset. RESULTS: By 50 years, T1D duration, ESRD affected 60% of the cohort; macroalbuminuria, 72%; and microalbuminuria, 88%. Little evidence existed for declines in cumulative incidence in recent cohorts, except for ESRD (microalbuminuria 3% increase, macroalbuminuria no change; ESRD 45% decrease by 40 years of T1D duration). Onset before age 6 years was associated with the lowest risk; incidence generally did not differ by sex. CONCLUSIONS: Some degree of kidney disease in T1D is virtually universal at long durations and not declining, which has major implications for formulating health care and research strategies. ESRD has declined, but continues to affect >25% of the population by 40 years, duration.
Asunto(s)
Diabetes Mellitus Tipo 1/complicaciones , Fallo Renal Crónico/etiología , Adulto , Distribución por Edad , Edad de Inicio , Albuminuria/etiología , Albuminuria/mortalidad , Albuminuria/orina , Estudios de Cohortes , Diabetes Mellitus Tipo 1/mortalidad , Diabetes Mellitus Tipo 1/orina , Nefropatías Diabéticas/etiología , Nefropatías Diabéticas/mortalidad , Nefropatías Diabéticas/orina , Femenino , Humanos , Incidencia , Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/orina , Modelos Logísticos , Masculino , Distribución por Sexo , Análisis de Supervivencia , Adulto JovenAsunto(s)
Humanos , Persona de Mediana Edad , Angiopatías Diabéticas/tratamiento farmacológico , Nefropatías Diabéticas/complicaciones , Hipertensión/tratamiento farmacológico , Fallo Renal Crónico/complicaciones , Antihipertensivos/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Literatura de Revisión como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Metaanálisis como Asunto , Resultado del Tratamiento , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/mortalidad , Diabetes Mellitus Tipo 1/prevención & control , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/mortalidad , Diabetes Mellitus Tipo 2/prevención & control , Angiopatías Diabéticas/complicaciones , Nefropatías Diabéticas/mortalidad , Nefropatías Diabéticas/prevención & control , Antagonistas de Receptores de Angiotensina/uso terapéutico , Hipertensión/complicaciones , Hipertensión/mortalidad , Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/prevención & controlRESUMEN
OBJECTIVE: The goal of the study was to determine whether complications of diabetes well-known to be associated with death such as cardiovascular disease and renal failure fully explain the higher rate of death in those who have undergone a lower-extremity amputation (LEA). RESEARCH DESIGN AND METHODS: This was a longitudinal cohort study of patients cared for in the Health Improvement Network. Our primary exposure was LEA and outcome was all-cause death. Our "risk factor variables" included a history of cardiovascular disease (a history of myocardial infarctions, cerebrovascular accident, and peripheral vascular disease/arterial insufficiency), Charlson index, and a history of chronic kidney disease. We estimated the effect of LEA on death using Cox proportional hazards models. RESULTS: The hazard ratio (HR) for death after an LEA was 3.02 (95% CI 2.90, 3.14). The fully adjusted (all risk factor variables) LEA HR was diminished only by â¼22% to 2.37 (2.27, 2.48). Furthermore, LEA had an area under the receiver operating curve (AUC) of 0.51, which is poorly predictive, and the fully adjusted model had an AUC of 0.77, which is better but not strongly predictive. Sensitivity analysis revealed that it is unlikely that there exists an unmeasured confounder that can fully explain the association of LEA with death. CONCLUSIONS: Individuals with diabetes and an LEA are more likely to die at any given point in time than those who have diabetes but no LEA. While some of this variation can be explained by known complications of diabetes, there remains a large amount of unexplained variation.
Asunto(s)
Amputación Quirúrgica/mortalidad , Angiopatías Diabéticas/mortalidad , Anciano , Pie Diabético/mortalidad , Pie Diabético/cirugía , Nefropatías Diabéticas/mortalidad , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Reino Unido/epidemiologíaRESUMEN
Chronic kidney disease (CKD) leads to renal failure and the need for renal replacement therapy (RRT). Secondary prevention may postpone CKD for many years. This retrospective study sought to analyze prognostic factors and estimate the mortality of patients with CKD secondary to diabetes mellitus and to hypertension that initiate RRT through non-elective hemodialysis at an emergency hospital unit in Rio de Janeiro, from hospital admission until transfer to referral units. The mortality rate was 35.1%. The study detected a significant difference between the survival curves according to disease etiology (log-rank and Peto, p=0.02) and the presence of functional arteriovenous fistulae (log-rank, p=0.0099; Peto, p=0.0090). Multivariate analysis (Cox model) revealed a 7% increase in the risk of death (p=0.002) by one-year increment in age; the presence of a functional fistule was associated to an 81% reduction in the risk of death (p=0.03). About one third of patients with CKD followed by hypertension or diabetes that initiate renal replacement therapy through non-elective hemodialysis die before being transferred to a referral unit, indicating low access to secondary prevention in CKD, including surgery for arteriovenous fistula creation.
Asunto(s)
Insuficiencia Renal Crónica/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Nefropatías Diabéticas/mortalidad , Femenino , Humanos , Hipertensión/complicaciones , Masculino , Persona de Mediana Edad , Pronóstico , Diálisis Renal , Insuficiencia Renal Crónica/etiología , Insuficiencia Renal Crónica/terapia , Estudios Retrospectivos , Adulto JovenRESUMEN
A doença renal crônica (DRC) leva à falência renal e à necessidade de terapia renal substitutiva (TRS). A prevenção secundária pode retardar em muitos anos a evolução da doença. O presente estudo, retrospectivo, objetivou analisar os fatores prognósticos e estimar a mortalidade de portadores de doença renal crônica (DRC) secundária à hipertensão ou diabetes que iniciam a TRS por hemodiálise de emergência, desde a admissão hospitalar até a transferência para clínica-satélite ou óbito, no Rio de Janeiro. A taxa de mortalidade foi de 35,1%. Houve diferença significativa entre as curvas de sobrevida até o óbito, por doença de base (log-rank e Peto, p = 0,02) e por presença de fístula funcional (log-rank, p = 0,0099; Peto, p = 0,0090). A análise multivariada (modelo de Cox) mostrou aumento no risco de óbito de 7% (p = 0,002) por ano de idade; a presença de fístula funcional foi associada a uma redução de 81% no risco (p = 0,03). Conclui-se que um terço dos pacientes portadores de DRC por hipertensão e diabetes, que iniciam a TRS de forma não planejada, morrem no período entre a admissão hospitalar e a transferência para clínicas-satélites, o que indica baixo acesso à prevenção secundária na DRC, inclusive à cirurgia para a confecção da fístula arteriovenosa.
Chronic kidney disease (CKD) leads to renal failure and the need for renal replacement therapy (RRT). Secondary prevention may postpone CKD for many years. This retrospective study sought to analyze prognostic factors and estimate the mortality of patients with CKD secondary to diabetes mellitus and to hypertension that initiate RRT through non-elective hemodialysis at an emergency hospital unit in Rio de Janeiro, from hospital admission until transfer to referral units. The mortality rate was 35.1%. The study detected a significant difference between the survival curves according to disease etiology (log-rank and Peto, p=0.02) and the presence of functional arteriovenous fistulae (log-rank, p=0.0099; Peto, p=0.0090). Multivariate analysis (Cox model) revealed a 7% increase in the risk of death (p=0.002) by one-year increment in age; the presence of a functional fistule was associated to an 81% reduction in the risk of death (p=0.03). About one third of patients with CKD followed by hypertension or diabetes that initiate renal replacement therapy through non-elective hemodialysis die before being transferred to a referral unit, indicating low access to secondary prevention in CKD, including surgery for arteriovenous fistula creation.
Asunto(s)
Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Insuficiencia Renal Crónica/mortalidad , Nefropatías Diabéticas/mortalidad , Hipertensión/complicaciones , Pronóstico , Diálisis Renal , Insuficiencia Renal Crónica/etiología , Insuficiencia Renal Crónica/terapia , Estudios RetrospectivosRESUMEN
AIM: Diabetic nephropathy (DN) is a frequent complication in patients with long-standing type 1 diabetes mellitus (DM1). The objective of this study was to assess the prevalence of DN in DM1 patients diagnosed during childhood and its association with clinical and metabolic variables, such as age at diagnosis of DM1, glucose control, dyslipidemia, hypertension and the occurrence of diabetic retinopathy (DR). METHODS: The medical records of 205 patients admitted to the Pediatric Endocrinology Division at the Hospital das Clinicas da Universidade Federal de Minas Gerais, in Belo Horizonte, Brazil, were analyzed. For the analysis of survival and prognostic factors, the Kaplan-Meyer method and the COX regression model were used. RESULTS: The mean disease duration was 11.32 +/- 4.02 years and the mean age at diagnosis was 6.10 +/- 3.54 years. Microalbuminuria was present in 11.2% of them, proteinuria in 6.8% and end-stage renal disease (ESRD) in 2.9%. There was a significant association between the occurrence of microalbuminuria or proteinuria and poor glucose control (p=0.025 and p=0.005, respectively), higher LDL cholesterol levels (p=0.006 and p=0.004, respectively) and age greater than 6 years at diagnosis (p=0.049 and p=0.05, respectively). Proteinuria was also associated to the occurrence of DR (p=0.016). CONCLUSION: Our data showed that the prevalence of DN was higher than expected in this young population studied, especially considering the most severe forms. Clinical and laboratory factors associated to ND were: poor long-term glucose control, higher levels of LDL-C, higher age at diagnosis and the occurrence of DR.
Asunto(s)
Diabetes Mellitus Tipo 1/complicaciones , Nefropatías Diabéticas/etiología , Adolescente , Adulto , Edad de Inicio , Albuminuria/etiología , Niño , Estudios de Cohortes , Nefropatías Diabéticas/epidemiología , Nefropatías Diabéticas/mortalidad , Retinopatía Diabética/etiología , Femenino , Humanos , Masculino , Prevalencia , Proteinuria/etiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Despite a better management of the variables that influence the development of diabetic nephropathy there is a progressive increase in the prevalence of terminal renal failure among diabetics, whose cause is not clear. AIM: To study in a group of patients in hemodialysis, the quality of diabetes control previous to the entry to dialysis, their physical condition and their evolution. MATERIAL AND METHODS: Diabetic patients with at least three months of hemodialysis answered a questionnaire about diabetes control quality previous to dialysis and had physical and laboratory assessment. They were followed for at least four years thereafter. RESULTS: Fifty seven patients aged 62+/-11 years were studied. Eighty four percent had some degree of disability. Eighty seven percent had high blood pressure and 73% had to enter dialysis as an emergency. Mean glycosilated hemoglobin was 7.7% and 58% had a dialysis dose with a Kt/Vofless than 1.2. Fifty eight percent died during follow up. No relationship between mortality and age, blood pressure, glycosilated hemoglobin of Kt/V, was observed. CONCLUSIONS: There is an inadequate management of blood glucose and blood pressure of diabetic patients before entry to dialysis. They are referred inverted exclamation markate to the nephrologist, the dialysis dose is insufficient and they have a high mortality.
Asunto(s)
Glucemia/análisis , Nefropatías Diabéticas/terapia , Fallo Renal Crónico/terapia , Diálisis Renal , Chile/epidemiología , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Nefropatías Diabéticas/sangre , Nefropatías Diabéticas/mortalidad , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Hemoglobina Glucada/análisis , Humanos , Fallo Renal Crónico/sangre , Fallo Renal Crónico/mortalidad , Masculino , Persona de Mediana Edad , Diálisis Renal/mortalidad , Resultado del TratamientoRESUMEN
Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.
Asunto(s)
Diabetes Mellitus Tipo 1/cirugía , Trasplante de Islotes Pancreáticos/métodos , Trasplante de Riñón/métodos , Trasplante de Páncreas/métodos , Adulto , Enfermedad Crónica , Diabetes Mellitus Tipo 1/mortalidad , Angiopatías Diabéticas/etiología , Angiopatías Diabéticas/mortalidad , Nefropatías Diabéticas/etiología , Nefropatías Diabéticas/mortalidad , Neuropatías Diabéticas/etiología , Neuropatías Diabéticas/mortalidad , Rechazo de Injerto , Humanos , Terapia de Inmunosupresión , Trasplante de Islotes Pancreáticos/efectos adversos , Trasplante de Islotes Pancreáticos/mortalidad , Trasplante de Riñón/efectos adversos , Páncreas/irrigación sanguínea , Trasplante de Páncreas/efectos adversos , Trasplante de Páncreas/mortalidad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
O transplante simultâneo de pâncreas/rim tem indicações específicas, riscos e benefícios. O procedimento, cada vez mais realizado, traz vantagens se comparado ao paciente em diálise, em relação à qualidade de vida, anos de vida ganhos e evolução das complicações crônicas. Se o paciente tiver a opção de realizar o transplante de rim com doador vivo, que apresenta sobrevida semelhante do enxerto e do paciente aos dez anos, o procedimento deverá ser considerado. O transplante de pâncreas após rim, quando efetivo, pode melhorar a evolução das complicações cardiovasculares, mas em contrapartida provoca maior mortalidade nos primeiros meses após a cirurgia. O transplante isolado de pâncreas também ocasiona a maior mortalidade pós-operatória, resultado da complexidade do procedimento e da imunossupressão. O transplante de ilhotas tem sua indicação para um seleto grupo de diabéticos com instabilidade glicêmica.
Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.
Asunto(s)
Adulto , Humanos , Diabetes Mellitus Tipo 1/cirugía , Trasplante de Islotes Pancreáticos/métodos , Trasplante de Riñón/métodos , Trasplante de Páncreas/métodos , Enfermedad Crónica , Diabetes Mellitus Tipo 1/mortalidad , Angiopatías Diabéticas/etiología , Angiopatías Diabéticas/mortalidad , Nefropatías Diabéticas/etiología , Nefropatías Diabéticas/mortalidad , Neuropatías Diabéticas/etiología , Neuropatías Diabéticas/mortalidad , Rechazo de Injerto , Terapia de Inmunosupresión , Trasplante de Islotes Pancreáticos/efectos adversos , Trasplante de Islotes Pancreáticos/mortalidad , Trasplante de Riñón/efectos adversos , Trasplante de Páncreas/efectos adversos , Trasplante de Páncreas/mortalidad , Páncreas/irrigación sanguínea , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
Background: Despite a better management of the variables that influence the development of diabetic nephropathy there is a progressive increase in the prevalence of terminal renal failure among diabetics, whose cause is not clear. Aim: To study in a group of patients in hemodialysis, the quality of diabetes control previous to the entry to dialysis, their physical condition and their evolution. Material and methods: Diabetic patients with at least three months of hemodialysis answered a questionnaire about diabetes control quality previous to dialysis and had physical and laboratory assessment. They were followed for at least four years thereafter. Results: Fifty seven patients aged 62±11 years were studied. Eighty four percent had some degree of disability. Eighty seven percent had high blood pressure and 73 percent had to enter dialysis as an emergency. Mean glycosilated hemoglobin was 7.7 percent and 58 percent had a dialysis dose with a Kt/Vofless than 1.2. Fifty eight percent died during follow up. No relationship between mortality and age, blood pressure, glycosilated hemoglobin of Kt/V, was observed. Conclusions: There is an inadequate management of blood glucose and blood pressure of diabetic patients before entry to dialysis. They are referred ¡ate to the nephrologist, the dialysis dose is insufficient and they have a high mortality.
Asunto(s)
Femenino , Humanos , Masculino , Persona de Mediana Edad , Glucemia/análisis , Nefropatías Diabéticas/terapia , Fallo Renal Crónico/terapia , Diálisis Renal , Chile/epidemiología , Diabetes Mellitus Tipo 1/complicaciones , /complicaciones , Nefropatías Diabéticas/sangre , Nefropatías Diabéticas/mortalidad , Progresión de la Enfermedad , Estudios de Seguimiento , Hemoglobina Glucada/análisis , Fallo Renal Crónico/sangre , Fallo Renal Crónico/mortalidad , Diálisis Renal/mortalidad , Resultado del TratamientoRESUMEN
BACKGROUND: Inverse associations between risk factors and mortality have been reported in epidemiological studies of patients on maintenance hemodialysis (MHD). OBJECTIVE: The aim of this prospective study was to estimate the effect of the dual variable pulse pressure (PP) - body mass index (BMI) on cardiovascular (CV) events and death in type 2 diabetic (T2D) subjects on MHD in a Caribbean population. METHODS: Eighty Afro-Caribbean T2D patients on MHD were studied prospectively from 2003 to 2006. Proportional-hazard modeling was used. RESULTS: Of all, 23.8% had a high PP (PP > or = 75th percentile), 76.3% had BMI < 30 Kg/m(2), 21.3% had the dual factor high PP - absence of obesity. During the study period, 23 patients died and 13 CV events occurred. In the presence of the dual variable and after adjustment for age, gender, duration of MHD, and pre-existing CV complications, the adjusted hazard ratio (HR) (95% CI) of CV events and death were respectively 2.7 (0.8-8.3); P = 0.09 and 2.4 (1.1-5.9); P = 0.04. CONCLUSIONS: The dual factor, high PP - absence of obesity, is a prognosis factor of outcome. In type 2 diabetics on MHD, a specific management strategy should be proposed in nonobese subjects with wide pulse pressure in order to decrease or prevent the incidence of fatal and nonfatal events.
Asunto(s)
Presión Sanguínea , Índice de Masa Corporal , Enfermedades Cardiovasculares/etiología , Diabetes Mellitus Tipo 2/fisiopatología , Nefropatías Diabéticas/terapia , Diálisis Renal , Anciano , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/fisiopatología , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/mortalidad , Nefropatías Diabéticas/etiología , Nefropatías Diabéticas/mortalidad , Nefropatías Diabéticas/fisiopatología , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Indias Occidentales/epidemiologíaRESUMEN
AIM: To analyse the risk factors for the development of micro- and macroalbuminuria and mortality rates in a cohort of normoalbuminuric Type 2 diabetes mellitus (DM) patients. METHODS: In this prospective study, 193 Type 2 DM patients with urinary albumin excretion (UAE) < 20 microg/min, 96 men (50%), aged 56.5 +/- 9 years, were followed for a mean period of 8 +/- 3 years. UAE and estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease) were measured. The outcomes were development of persistent micro- and macroalbuminuria and mortality. RESULTS: Twenty patients were lost to follow-up. Of the 173 remaining patients, 33 (19%) died. The Cox analysis [hazard ratio (HR), 95% confidence interval] revealed that the baseline significant predictors of mortality were higher UAE [above median (5 microg/min); HR 2.7, 1.2-6.1; P = 0.02], male sex (HR 3.9, 1.7-9.2; P = 0.002), age (HR 1.6, 1.3-1.9; P = 0.0001), and fasting plasma glucose (HR 1.2, 1.1-1.3; P = 0.004). Smoking and eGFR were not significant in this model. Follow-up renal data were available for 158 patients: 34 (22%) progressed to microalbuminuria and seven (4%) to macroalbuminuria, and the baseline predictors were a higher UAE (> 5 microg/min, HR 2.5, 1.2-5.1; P = 0.02), presence of diabetic retinopathy (HR 2.5, 1.3-5.0; P = 0.009), fasting glucose (HR 1.1, 1.0-1.2; P = 0.015), and male sex (HR 2.2, 1.1-4.7; P = 0.04), independently of smoking and hypertension. Lower GFR (HR 0.98, 0.97-1.00; P = 0.07) was of borderline significance. CONCLUSIONS: In normoalbuminuric Type 2 DM patients, the development of micro- or macroalbuminuria and mortality rates was independently and positively associated with higher levels of albuminuria, although still in the traditionally established normal range.
Asunto(s)
Albuminuria/metabolismo , Diabetes Mellitus Tipo 2/complicaciones , Nefropatías Diabéticas/metabolismo , Enfermedades Renales/diagnóstico , Albuminuria/fisiopatología , Brasil/epidemiología , Estudios de Cohortes , Diabetes Mellitus Tipo 2/metabolismo , Diabetes Mellitus Tipo 2/mortalidad , Nefropatías Diabéticas/mortalidad , Nefropatías Diabéticas/fisiopatología , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular , Humanos , Enfermedades Renales/mortalidad , Enfermedades Renales/fisiopatología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Resultado del TratamientoRESUMEN
UNLABELLED: Diabetic nephropathy (DN) is the main cause of chronic kidney disease (CKD) in developed countries. OBJECTIVE: To observe if there was an increase in the prevalence of diabetes mellitus (DM) of CKD in the last 20 years and to analyze comparatively the survival on dialysis of diabetic and non-diabetic patients. METHODS: Retrospective analysis of patients kept on dialysis in the west region of Paraná State in the period between 1985-2005. Survival analysis was performed using Kaplan-Meier Curves. RESULTS: In the period, 645 patients were admitted to dialysis. In 16.1% DM was the cause of the CKD. It was observed a progressive increase in the prevalence of DM as a cause of CKD. Patient survival was lower in diabetics. CONCLUSIONS: The prevalence of DM as a cause of CKD increased in the last 20 years in our region. The survival rates were lower in diabetic than in non-diabetic patients.
Asunto(s)
Nefropatías Diabéticas/mortalidad , Fallo Renal Crónico/mortalidad , Diálisis Renal/estadística & datos numéricos , Adulto , Brasil/epidemiología , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/mortalidad , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/mortalidad , Nefropatías Diabéticas/complicaciones , Nefropatías Diabéticas/epidemiología , Femenino , Humanos , Estimación de Kaplan-Meier , Fallo Renal Crónico/epidemiología , Fallo Renal Crónico/etiología , Trasplante de Riñón , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , UremiaRESUMEN
A nefropatia diabética (ND) é a principal causa de insuficiência renal crônica terminal (IRCT) nos países desenvolvidos. OBJETIVOS: Observar se ocorreu aumento da prevalência de diabete melito (DM) como causa de IRCT nos últimos 20 anos e comparar a sobrevida em diálise dos diabéticos e não diabéticos. MÉTODOS: Análise retrospectiva dos pacientes mantidos em diálise na região Oeste do Paraná no período de 1985 a 2005. A estimativa de sobrevida foi realizada pela Curva de Sobrevida de Kaplan-Meier. RESULTADOS: Durante este período, foram admitidos em diálise 645 pacientes. Em 16,1 por cento deles o DM foi a causa da IRCT. Observou-se aumento na prevalência de DM como causa de IRCT. A sobrevida dos pacientes em diálise foi inferior nos diabéticos. CONCLUSÕES: A prevalência de DM como causa de IRCT aumentou progressivamente nos últimos 20 anos em nossa região. A sobrevida de pacientes diabéticos em diálise foi menor que a dos não-diabéticos.
Diabetic nephropathy (DN) is the main cause of chronic kidney disease (CKD) in developed countries. OBJECTIVE: To observe if there was an increase in the prevalence of diabetes mellitus (DM) of CKD in the last 20 years and to analyze comparatively the survival on dialysis of diabetic and non-diabetic patients. METHODS: Retrospective analysis of patients kept on dialysis in the west region of Paraná State in the period between 19852005. Survival analysis was performed using Kaplan-Meier Curves. RESULTS: In the period, 645 patients were admitted to dialysis. In 16.1 percent DM was the cause of the CKD. It was observed a progressive increase in the prevalence of DM as a cause of CKD. Patient survival was lower in diabetics. CONCLUSIONS: The prevalence of DM as a cause of CKD increased in the last 20 years in our region. The survival rates were lower in diabetic than in non-diabetic patients.
Asunto(s)
Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nefropatías Diabéticas/mortalidad , Fallo Renal Crónico/mortalidad , Diálisis Renal/estadística & datos numéricos , Brasil/epidemiología , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/mortalidad , /complicaciones , /mortalidad , Nefropatías Diabéticas/complicaciones , Nefropatías Diabéticas/epidemiología , Estimación de Kaplan-Meier , Trasplante de Riñón , Fallo Renal Crónico/epidemiología , Fallo Renal Crónico/etiología , Prevalencia , Estudios Retrospectivos , UremiaRESUMEN
Among patients on hemodialysis, the mortality rate is higher in individuals with diabetes than in nondiabetic individuals, especially due to cardiovascular causes. The objective of the present study was to evaluate the role of echocardiographic abnormalities to predict mortality in diabetic patients starting hemodialysis. A 4.25-year prospective study was carried out with 40 diabetic and 28 nondiabetic patients starting hemodialysis in five dialysis centers in the metropolitan area of Porto Alegre, Brazil, between August 1996 and June 1999. Cardiovascular status was evaluated based on World Health Organization criteria, resting electrocardiogram (ECG), myocardial scintigraphy (at rest and after dipyridamole administration), and M-mode and Doppler echocardiography. Left ventricular diastolic function was classified into the following filling patterns: normal, impaired relaxation, pseudonormal, or restrictive. The survival rate was analyzed by Kaplan-Meier curves and predictors of death by Cox's proportional-hazards model. At the end of the study, the overall mortality rate was higher in patients with diabetes [19/40 (47.5%)] than in those without diabetes [2/28 (7.1%), P=.0013, log rank test]. Pseudonormal and restrictive filling patterns (HR: 3.2; 95% CI: 1.2-8.8; P=.02) and presence of diabetes (HR: 4.7; 95% CI: 1.03-21.4; P=.04) were associated with mortality. In conclusion, left ventricular diastolic dysfunction (LVDD) was the main predictor of mortality in this cohort of diabetic and nondiabetic patients starting dialysis. Intensive treatment of cardiovascular risk factors before the start of dialysis and during the treatment might reduce the mortality rate in diabetic patients.