Background
Inflammation, oxidative stress (OS), atherosclerosis and resistant hypertension (RH) are common features of chronic kidney disease (CKD) leading to a higher risk of death from ...cardiovascular disease. These effects seem to be modulated by impaired anti-oxidant, anti-inflammatory and reverse cholesterol transport actions of high-density lipoprotein cholesterol (HDL). HDL prevents and reverses monocyte recruitment and activation into the arterial wall and impairs endothelial adhesion molecule expression. Recently, monocyte count to HDL-cholesterol ratio (MHR) has emerged as a potential marker of inflammation and OS, demonstrating to be relevant in CKD. Our research was aimed to assess, for the first time, its reliability in RH.
Methods
We performed a retrospective study on 214 patients with CKD and arterial hypertension who were admitted between January and June 2019 to our Department, 72 of whom were diagnosed with RH.
Results
MHR appeared inversely related to eGFR (ρ = − 0.163;
P
= 0.0172). MHR was significantly higher among RH patients compared to non-RH ones (12.39 IQR 10.67–16.05 versus 7.30 5.49–9.06;
P
< 0.0001). Moreover, MHR was significantly different according to the number of anti-hypertensive drugs per patient in the whole study cohort (
F
= 46.723;
P
< 0.001) as well as in the non-RH group (
F
= 14.191;
P
< 0.001). Moreover, MHR positively correlates with diabetes mellitus (ρ = 0.253;
P
= 0.0002), white blood cells (ρ = 0.664;
P
< 0.0001) and C-reactive protein (ρ = 0.563;
P
< 0.0001).
Conclusions
MHR may be a reliable biomarker due to the connection between HDL and monocytes. Our study suggests that MHR is linked with the use of multiple anti-hypertensive therapy and resistant hypertension in CKD patients, and can be a useful ratio to implement appropriate treatment strategies.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The causes and metabolic consequences of lipohypertrophy (LH) from incorrect insulin injection techniques have been well-known for a long time and are the subject of countless publications. However, ...only some researchers propose structured research modalities for LH and programs to teach patients how to prevent them and minimize their effects, thus contributing to complete rehabilitation. Experts and scientific societies have produced consensus documents and recommendations to spread the culture of LH and its complications among clinicians. However, they should go deeper into LH detection methods. This short article analyzes the recent literature on the best way to explore and find more or less evident LH lesions by using a structured and validated clinical methodology to benefit the many clinicians without access to technological equipment such as ultrasonography. This text also aims to bring awareness that since the last published recommendations on injection techniques, new needles for insulin injection, more technologically advanced and suitable for specific populations, have come to market but still need a thorough evaluation.
The number of adult individuals with insulin-treated diabetes mellitus (DM) is steadily increasing worldwide. The main local complications of insulin injection are lipohypertrophies (LHs), i.e., ...subcutaneous nodules consisting of aggregates of macro-adipocytes and fibrin. These nodules result from errors repeatedly made by patients while injecting insulin. Despite being very common, LH lesions/nodules due to incorrect insulin injection techniques are often flat and hardly visible and thus require thorough deep palpation examination and ultrasonography (US) for detection. Identifying LHs is crucial, especially in elderly and frail subjects, because they may eventually result in poor diabetes control due to associated unpredictable insulin release patterns. Raising awareness of the adequate detection of LHs and their clinical consequences is crucial and urgent. A call to action is required on this topic at all levels of undergraduate and postgraduate education.
Diabetes mellitus (DM) and hypertension (HT) are characterized by cell damage caused by inflammatory and metabolic mechanisms induced by alteration in reduction-oxidative status. Serum advanced ...oxidation protein products (AOPP) are new markers of protein damage induced by oxidative stress. We evaluated serum levels of AOPP in a cohort of patients with DM and HT, with or without renal complications, compared with a control healthy population.
The study group comprised of 62 patients with type 2 DM and 56 with HT. The 62 patients affected by DM were further distinguished in 24 subjects without renal impairment, 18 with diabetic nephropathy (DN), 20 with chronic kidney disease (CKD) stage 2-3 secondary to DN. The subgroup of 56 patients with primary HT comprised 26 subjects without renal complications and 30 with CKD (stage 2-3) secondary to HT. Thirty healthy controls, matched for age and sex, were recruited among blood donors.
Increased AOPP levels were found in DM patients compared with healthy subjects, although not significantly. This index was higher and more significant in patients with DN and CKD secondary to DN than in DM patients without nephropathy (
< 0.05) or controls (
< 0.0001). Patients with HT and with kidney impairment secondary to HT also had significantly higher AOPP serum levels than controls (
< 0.01 and
< 0.0001, respectively). There were no significant differences in mean AOPP levels among DM and HT patients.
Our study showed that oxidative stress was higher in diabetic or hypertensive subjects than in healthy controls and, in particular, it appeared to be more severe in patients with renal complications. We suggest that the assessment of AOPP in diabetic and hypertensive patients may be important to predict the onset of renal failure and to open a new perspective on the adoption of antioxidant molecules to prevent CKD in those settings.
Introduction
Lipohypertrophies (LHs) due to incorrect insulin injection techniques have been described in the literature for decades. Their rate averages 38%, but this is still controversial because ...of the vast range reported by different publications, most of which fail to describe the selected detection protocol and therefore are not entirely reliable. We still need to identify the real LH rate, and only consistently using a standardized method in a large cohort of insulin-treated (IT) patients make this possible.
Methods
Our group performed thorough clinical skin examinations on patients suffering from type 2 diabetes mellitus (T2DM): 1247 IT T2DM outpatients were examined according to a standardized protocol, previously published elsewhere, as well as an ultrasound scan of the same skin areas to assess the degree of concordance between the two methods and to evaluate the demographic, clinical, and behavioral risk factors (RF) as well as metabolic consequences of identified LHs.
Results
The concordance between the two methods was 99%. Identified risk factors for LHs were needle reuse, failure to rotate injection sites, and ice-cold insulin injections. High HbA1c values, wide glycemic variability, and longstanding proneness to hypoglycemia with a high rate of ongoing hypoglycemic events proved to be significantly associated with LHs, too; the same applied to cardiovascular and renal complications as well as to living alone and being retired.
Conclusions
Based on a strict well-structured methodology, our data confirmed what has already been reported in the literature on factors leading to, or associated with, LHs and, for the first time in adults, indicated cryotrauma from ice-cold insulin injections and specific social conditions as factors facilitating LH occurrence. HCPs should therefore plan a yearly clinical examination of all injection sites to improve patient quality of life through better glucose control and a reduced rate of hypoglycemic events.
Trial Registration
Trial registration no. 127-11.01.2019, approved by the Scientific and Ethics Committee of Campania University “Luigi Vanvitelli,” Naples, Italy.
Introduction
End-stage renal disease (ESRD) is associated with increased cardiovascular mortality (CVM) and diabetes mellitus (DM), which in many cases is treated with insulin. Skin lipohypertrophy ...(LH) very often occurs in insulin-treated (IT) patients as a consequence of inadequate injection technique and is one of the most prominent contributors to hypoglycemia (HYPO), glycemic variability (GV), and poor metabolic control (PMC).
Method
The aim of our multicenter observational study was to assess LH prevalence at self-injection sites and any possible factors predicting high LH/HYPO rates and GV in 296 dialyzed ITDM patients characterized by 64 ± 7 years of age, 7 ± 2 years disease duration, 2.6 ± 2.2 years dialysis duration, preferred pen utilization (80%), and basal-bolus regimen (87.4%) with self-injections (62.6%) largely surpassing caregiver-assisted ones (16.9%), and a mix of the two injection methods (20.5%).
Results
LH was detected in 57% of patients. Univariate analysis followed by backwards stepwise multivariate logistic regression function showed increased odds for developing LH in patients characterized by needle reuse, smaller injection areas, missed injection site rotation, higher HbA1c levels, and more prominent rates of HYPO and GV.
Conclusion
This was the first time such observation was made. It is now time for further studies aimed at providing evidence also in ESRD ITDM patients for the cause–effect relationship among wrong injection behavior, LH, and poor metabolic control and for the long-term preventative role of suitable educational countermeasures.
The cardiovascular risk factor homocysteine is mainly bound to proteins in human plasma, and it has been hypothesized that homocysteinylated proteins are important mediators of the toxic effects of ...hyperhomocysteinemia. It has been recently demonstrated that homocysteinylated proteins are elevated in hemodialysis patients, a high cardiovascular risk population, and that homocysteinylated albumin shows altered properties.
Aim of this work was to investigate the effects of homocysteinylated albumin - the circulating form of this amino acid, utilized at the concentration present in uremia - on monocyte adhesion to a human endothelial cell culture monolayer and the relevant molecular changes induced at both cell levels.
Treated endothelial cells showed a significant increase in monocyte adhesion. Endothelial cells showed after treatment a significant, specific and time-dependent increase in ICAM1 and VCAM1. Expression profiling and real time PCR, as well as protein analysis, showed an increase in the expression of genes encoding for chemokines/cytokines regulating the adhesion process and mediators of vascular remodeling (ADAM17, MCP1, and Hsp60). The mature form of ADAM17 was also increased as well as Tnf-α released in the cell medium. At monocyte level, treatment induced up-regulation of ICAM1, MCP1 and its receptor CCR2.
Treatment with homocysteinylated albumin specifically increases monocyte adhesion to endothelial cells through up-regulation of effectors involved in vascular remodeling.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
BACKGROUND AND AIMS
Patients with type 2 diabetes mellitus (T2DM) often discontinue sodium–glucose cotransporter-2-inhibitors (SGLT2 i) despite high efficacy and safety due to genital ...infection (GI).
SGLT2i, also called gliflozins, represent the newest class of anti-hyperglycemic agents 1 whose effects depend on the ability to dramatically reduce the threshold for maximum glucose tubular resorption rate in patients with type 2 diabetes mellitus (T2DM), with consequently enhanced glycosuria. Due to elevated urinary glucose output, T2DM increases the risk for urinary tract infections (UTIs) and non-sexually transmitted genital infections (GIs) 15. Massive glycosuria might, indeed, already cause commensal genital microorganism overgrowth in people with T2DM 16 and is likely to increase the risk for GIs and UTIs when further aggravated by SGLT2i. To assess real-life GI risk profile in post-menopausal T2DM patients educated on strict hygiene-based prevention practices (SHBPPs) due to their intrinsic GI susceptibility.
METHOD
21 post-menopausal T2DM patients willing to follow SHBPPs were randomly assigned to three different SGLT2-Is (intervention group, IG, n = 318) or other drugs (control group, CG, n = 403) for 3 months. Before and after treatment, they underwent routine lab tests and completed a specific questionnaire. The present study was carried out by a network of five identically organized outpatient diabetes care units (DCUs) previously documented to attain the same performance levels and to come from a single institution. For the study, we specifically prepared the Female Genital Infection Symptoms Questionnaire (FGISQ) based on GIPR recommendations and checked for appropriate question comprehension and answer concordance as described below by previously administering it to 40 post-menopausal women with T2DM three times at 5-day intervals. Answer concordance was 97%. Based on a specific nurse’s inquiry and help request rate by patients completing the test, question comprehension was 98%. FGISQ consisted of sections A and B (Figure 1/A and 1/B). In greater detail, we changed question n.5 from Section A by considering that some women had Figure 1A: Female Genital Infection Symptoms Questionnaire. Part A (FGISQ-A) is addressed to the general prevention recommendations of GIs in women, taken from the recommendations (reference number 28, and Supplementary data, Table S1A, supplementary material), only six of which have been transformed into general questions. Part B (FGISQ-B), investigating GI symptoms and sexual habits is unscored and resumes GIPR questions 5 and 8 (see supplementary material), kept sexually active, and question n.8 to assess the intensity of eventually occurring GI symptoms. We also refrained from formulating any question related to recommendation n.9 as useless (all were post-menopausal, indeed).
RESULTS: GIs more often occurred (9.6%; P < 0.001) among IG women non-adhering to SHBPPs (41.5%) versus the 2.9% of adhering ones. Conversely CG women had superimposable GI rates (2.7% versus 3.1%, respectively, p n.s.) whether or not adhering to SHBPPs (51.4% versus 49.6%, respectively, p n.s.). The typical profile of women on SGLT2-Is at higher risk for GIs included (i) poor adherence to SHBPPs, (ii) older age, (iii) higher BMI, (iv) poor glucose control as witnessed by high HbA1c levels, and (v) antihypertensive drug utilization.
CONCLUSION
Physicians should consider the importance of strict hygiene control in their post-menopausal T2DM patients undergoing SGLT2-I treatment and thus utilize better-focused education strategies in that specific subgroup to prevent or rehabilitate from repeated GIs.
Few studies address alteration of sexual function in women with diabetes and chronic kidney disease (CKD). Quality of life surveys suggest that discussion of sexual function and other reproductive ...issues are of psychosocial assessment and that education on sexual function in the setting of chronic diseases such as diabetes and CKD is widely needed. Pharmacologic therapy with estrogen/progesterone and androgens along with glycemic control, correction of anemia, ensuring adequate dialysis delivery, and treatment of underlying depression are important. Changes in lifestyle such as smoking cessation, strength training, and aerobic exercises may decrease depression, enhance body image, and have positive impacts on sexuality. Many hormonal abnormalities which occur in women with diabetes and CKD who suffer from chronic anovulation and lack of progesterone secretion may be treated with oral progesterone at the end of each menstrual cycle to restore menstrual cycles. Hypoactive sexual desire disorder (HSDD) is the most common sexual problem reported by women with diabetes and CKD. Sexual function can be assessed in women, using the 9-item Female Sexual Function Index, questionnaire, or 19 items. It is important for nephrologists and physicians to incorporate assessment of sexual function into the routine evaluation protocols.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Abstract
Background and Aims
We know that lung and kidney are intimately related from a functional standpoint, both in physiological conditions and in diseases. The close relationship between lung ...and kidney (kidney-lung link) is evidence of a homeostatic connection between all organs and systems in an attempt to maintain the body system balance. In a recent review 1 we emphasized the importance to search for the clinical signs of a disease not only in the primary affected organ but also in organ functionally related.
Method
For this purpose we examined 81 hemodialyzed patients, with a mean age of 66.6 ± 13 years (28 f and 53 M), undergoing hemodialysis treatment (mean dialysis: 96 ± 34 months), with regard to smoking habits (47 non-smokers and 34 smokers with an average of 19.8 cigarettes per day: pack / years: 33.4 ± 2.9). Pulmonary function test (PFT) and clinical signs were evaluated. we excluded 6 patients (4 males and 2 females) in the smoking group with obstructive spirometric pattern (detected by a FEV1.0/FVC ratio lower than 70 absolute value), so that the final non-smoking group consisted of 47 patients and the smoking-group by 28 smokers: both groups matched for anthropomorphic data.
Results
The mean values of PFT were globally no different between smokers with normal PFT and non smokers are summarized in Table 1: Although the never-smoking group was nearly twice as large as the smokers, and PFT were similar and normal, respiratory symptoms were predominant: daily cough (49 yes; 26 no); chronic phlegm (51 yes; 24 no).
Conclusion
in dialysis patients, cough and phlegm are common symptoms, regardless of smoking and spirometric values. Probably these results are the consequence of synergistic effects between lungs and kidneys, as recently demonstrated 2. Hence the need to evaluate dialysis patients from the clinical-functional point of view of both, kidneys and lungs, in order to evaluate the appropriate, personalized, therapeutic strategy according to the last evidences of the literature 3.
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