Immunogenetic susceptibility to diabetes mellitus in patients with liver disease

Background/Aim: Genetic, environmental, metabolic and infectious influences, such as hepatitis C virus (HCV) infection, are thought to impact on the development of diabetes in patients with liver disease. As specific human leucocyte antigen (HLA) alleles provide the major genetic risk factors for type 1 diabetes, our aim was to investigate whether HLA class I and II alleles constitute additional risk factors for diabetes in patients with liver disease. Methods: We evaluated two independent databases of 193 and 728 adult patients with chronic liver disease for the diagnosis of diabetes and the presence of specific HLA subtypes. Results: In each database, 24 and 19% of patients met criteria for diabetes. In the first database, specific class I and II alleles were observed more frequently in diabetics compared with non‐diabetics: Cw7 (50 vs. 32%, P=0.04), DR51 (17 vs. 3%P=0.003) and DQ6 (37 vs. 18%, P=0.02). In the second database, DQ6 was observed in 16% of diabetics vs. 8% of non‐diabetics (P=0.04). The DR2–DR51–DQ6 haplotype was higher in patients with diabetes in both databases (22 vs.7%, P=0.02 and 12 vs. 5%, P=0.02). In a subgroup analysis of patients with HCV infection, increased frequencies of Cw7, DR2/DR51, DQ6 and DR2–DR51–DQ6 were also observed to be higher in subjects with diabetes compared with those without diabetes. Conclusions: Patients with chronic liver disease, especially those with HCV infection, have an immunogenetic risk for diabetes characterized by the presence of Cw7, DR51, DQ6 and DR2–DR51–DQ6.     

Iron deficiency in chronic kidney disease patients with diabetes mellitus

Backgrounds

Iron deficiency has been studied extensively in patients with chronic kidney disease on hemodialysis therapy. However, few studies looked at iron treatment in the non-dialysis chronic kidney disease population.

糖尿病合并下肢动脉性病变的药物治疗

糖尿病患者合并下肢动脉病变（PAD）较非糖尿病患者患病率更高、进展速度更快、病变更严重。PAD的内科治疗一方面强调心血管危险因素的全面干预,另一方面是针对间歇性跛行症状的药物治疗,其中己酮可可碱、西洛他唑、沙格雷酯、前列腺素E能改善行走距离,提高生活质量。     

前列地尔治疗老年糖尿病合并慢性肾脏病患者的效果分析

目的探讨前列地尔联合常规治疗对老年2型糖尿病(T2DM)合并慢性肾脏病(CKD)患者的治疗效果。方法人选2014年2月至2016年2月在攀枝花市中心医院内分泌科治疗的90例老年T2DM合并CKD患者,采用数字表法随机分为前列地尔组和对照组,每组45例。对照组给予常规治疗,前列地尔组在常规治疗基础上加用前列地尔10μg/d,静脉推注,1次/d,2周为1个疗程,共治疗3个疗程。比较两组患者血脂、血糖、肝功能、肾功能等指标。所有数据采用SPSS 16.0软件进行统计学分析。计量资料用均数±标准差(±s)表示,两组比较采用t检验。计数资料用百分率表示,组间比较用χ~2检验。结果两组患者治疗前空腹血糖(FPG)、糖化血红蛋白(HbAlc)、甘油三酯(TG)、总胆固醇(TC)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、同型半胱氨酸(Hcy)、血β2微球蛋白(β2-MG)、尿白蛋白排泄率(UAER)、血肌酐(SCr)、估算肾小球滤过率(eGFR)差异均无统计学意义(P0.05)。治疗后,前列地尔组患者的TG、TC、LDL-C、Hcy、β2-MG、UAER显著低于对照组,差异具有统计学意义(P0.05)。两组患者治疗前后的凝血酶原时间(PT)、血小板(PLT)、活化部分凝血活酶时间(APTT)差异无统计学意义(P0.05)。两组不良反应发生率差异无统计学意义(χ~2=0.212,P=0.645)。结论前列地尔联合常规治疗能显著降低老年T2DM合并CKD患者尿蛋白水平,对患者的肾功能具有一定的保护作用。     

Liver disease in patients with diabetes mellitus

Diabetes mellitus is a growing health concern in our society. In addition to the well-known cardiovascular, renal, and ophthalmologic complications of diabetes, liver-related complications occur commonly and are often underrecognized. The ensuing article will review the relationship between diabetes mellitus and two common liver diseases: chronic hepatitis C and nonalcoholic fatty liver disease. The association with diabetes and cirrhosis, acute liver failure, hepatocellular carcinoma, and outcomes following orthotopic liver transplantation will also be discussed.     

利拉鲁肽治疗非酒精性脂肪性肝病合并2型糖尿病患者血脂、血管内皮功能和肝纤维化指标的变化*

目的 探讨应用利拉鲁肽治疗非酒精性脂肪性肝病(NAFLD)合并2型糖尿病(T2DM)患者血脂、血管内皮功能和血清肝纤维化指标的变化。方法 2014年1月～2018年12月我院收治的NAFLD合并T2DM患者90例,被随机分为对照组45例和观察组45例,分别给予二甲双胍或二甲双胍联合利拉鲁肽治疗12周。检测空腹血糖(FPG)、餐后 2 h 血糖(2hPPG)和糖化血红蛋白(HbA1c),使用高分辨超声诊断仪检测肱动脉内径变化,记录血管舒张内径达到最大值所需的时间(T₁)和舌下含化硝酸甘油后血管达最大内径所需的时间(T₂),计算肱动脉血流介导的内皮依赖性血管舒张功能(EDR)和硝酸甘油介导的内皮非依赖性血管舒张功能(END)。采用放射免疫分析法检测血清透明质酸(HA)、 层粘连蛋白(LN)、 IV型胶原(CIV)和 III型前胶原(PIIIP)。结果 在治疗结束时,观察组和对照组FPG分别为(7.3±1.9)mmol/L对(8.6±1.8)mmol/L,2hPPG分别为(9.8±2.3)mmol/L对(11.4±2.2)mmol/L,HbA1c水平分别为(7.2±1.0)%对(8.3±1.2)%,差异显著(P＜0.05);血清TC分别为(4.8±0.9)mmol/L对(5.6±1.2)mmol/L、TG分别为(1.5±0.4)mmol/L对(2.0±0.6)mmol/L、LDL-C分别为(2.0±0.6)mmol/L对(2.9±0.7)mmol/L和HDL-C分别为(1.6±0.3)mmol/L对(1.3±0.2)mmol/L,差异显著(P＜0.05);T₁分别为(56.1±6.5)s对(62.9±5.8)s,EDR分别为(7.8±1.0)%对(5.2±0.8)%和END分别为(21.3±2.9)%对(17.2±2.5)%,差异显著(P＜0.05);血清HA分别为(70.3±9.2)ng/ml对(85.9±10.3)ng/ml, CIV分别为(50.2±0.7)ng/ml对(67.3±0.9)ng/ml和PIIIP分别为(6.2±0.6)ng/ml对(8.3±0.5)ng/ml,差异显著(P＜0.05)。结论 应用利拉鲁肽治疗NAFLD合并2 型糖尿病患者能有效降低血糖,改善血管内皮功能,纠正脂代谢紊乱,对预防糖尿病患者大血管并发症可能有益。     

Prevention and treatment of ischemic heart disease in patients with diabetes mellitus

The incidence of cardiovascular diseases among diabetic patients is so high that diabetes mellitus is currently defined as a cardiovascular disease equivalent. Furthermore, diabetic patients who develop acute coronary syndromes have a poorer short-term and long-term prognosis, so primary and secondary preventive measures are critically important in this population subgroup.There is substantial evidence that pharmacological therapy for primary and secondary cardiovascular prevention is more effective in diabetic patients than in non-diabetics. This article reviews the evidence of the efficacy of pharmacological prevention therapies in diabetic patients in favor of an aggressive pharmacological preventive strategy. Every diabetic patient without known cardiovascular disease should be treated with angiotensin-converting enzyme inhibitors and statins. High-risk patients should also receive low-dose aspirin.Compared with non-diabetics, diabetic patients who develop acute coronary events benefit more from the addition of intensive antithrombotic therapy to aspirin treatment. Diabetic patients presenting with non-ST segment elevation syndromes have better outcomes when treated with clopidogrel or glycoprotein IIb/IIIa inhibitors, and diabetics presenting with ST-segment elevation or left bundle-branch block have a greater survival benefit when given thrombolytic therapy compared with non-diabetic patients.Unless formal contraindications are present, diabetic patients with ischemic heart disease, particularly those with previous myocardial infarction, should always be treated with aspirin, betablockers, angiotensin converting enzyme inhibitors, and statins, regardless of lipid levels, left ventricular systolic function or the presence of congestive heart failure.     

慢性阻塞性肺病合并糖尿病患者免疫功能变化及其意义

目的 研究慢性阻塞性肺疾病合并糖尿病的免疫功能变化并探讨临床意义.方法 78例COPD稳定期病例分为COPD合并糖尿病(COPD+DM)组和COPD组,同时选择20例健康人作为对照组,分别测定周血细胞免疫、和体液免疫.结果 COPD+ DM组IgA、IgG、IgM、CD4+水平均低于COPD组和对照组,CD8+水平高于COPD组和对照组,CD4 +/CD8+倒置更为明显,差异均有统计学意义(P＜0.05),而CD3+水平在各组之间无差异(P＞0.05).结论 糖尿病加重COPD免疫功能失调,控制糖尿病对于提高COPD免疫功能有重要意义.     

Nonalcoholic fatty liver disease and diabetes mellitus: pathogenesis and treatment

Nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM) frequently coexist as they share the pathogenic abnormalities of excess adiposity and insulin resistance. Although type 1 diabetes mellitus (T1DM) is due to a relative lack of insulin, an increased prevalence of obesity and insulin resistance in this population means that NAFLD also commonly coexists with this condition. Both T2DM and NAFLD are associated with adverse outcomes of the other; T2DM is a risk factor for progressive liver disease and liver-related death in patients with NAFLD, whereas NAFLD may be a marker of cardiovascular risk and mortality in individuals with T2DM. Nonalcoholic steatohepatitis-a histological subtype of NAFLD characterized by hepatocyte injury and inflammation-is present in approximately 10% of patients with T2DM and is associated with an increased risk for the development of cirrhosis and liver-related death. Current treatment strategies aim to improve insulin resistance via weight loss and exercise, improve insulin sensitivity by the use of insulin-sensitizing agents (for example, pioglitazone) and reduce oxidative stress by the use of antioxidants, such as vitamin E. Pioglitazone and vitamin E supplementation show the most promise in improving hepatic steatosis and inflammation but have not yet been demonstrated to improve fibrosis, and concern remains regarding the toxicity of long-term use of both of these agents.     

Management of chronic constipation in patients with diabetes mellitus

Aim

The aim of this review is to provide an overview of the clinical assessment and evidence-based treatment options for managing diabetes-associated chronic constipation.

Methods

A literature search of published medical reports in English language was performed using the OVID Portal, from PUBMED and the Cochrane Database of Systematic Reviews, from inception to October 2015. A total of 145 abstracts were identified; duplicate publications were removed and 95 relevant full-text articles were retrieved for potential inclusion.

Results

Chronic constipation is one of the most common gastrointestinal symptoms in patients with diabetes, and occurs more frequently than in healthy individuals. Treatment goals include improving symptoms and restoring bowel function by accelerating colonic transit and facilitating defecation. Based on guidelines and data from published literature, food and dietary change with exercise and lifestyle change should be the first step in management. For patients recalcitrant to these changes, laxatives should be the next step of treatment. Treatment should begin with bulking agents such as psyllium, bran or methylcellulose followed by osmotic laxatives if response is poor. Lactulose, polyethylene glycol and lactitol are the most frequently prescribed osmotic agents. Lactulose has a prebiotic effect and a carry-over effect (continued laxative effect for at least 6 to 7 days, post cessation of treatment). Stimulants such as bisacodyl, sodium picosulphate and senna are indicated if osmotic laxatives are not effective. Newer agents such as chloride-channel activators and 5-HT4 agonist can be considered for severe or resistant cases.

Conclusion

The primary aim of intervention in diabetic patients with chronic constipation is to better manage the diabetes along with management of constipation. The physician should explain the rationale for prescribing laxatives and educate patients about the potential drawbacks of long-term use of laxatives. They should contact their physician if short-term use of prescribed laxative fails to provide relief.

     

Survival benefit of nephrologic care in patients with diabetes mellitus and chronic kidney disease

BACKGROUND: The association of nephrologic care and survival in patients with diabetes mellitus and chronic kidney disease is unknown. METHODS: Using data from 1997 to 2000, we conducted a retrospective cohort study of Veterans Health Administration clinic users having diabetes mellitus and stage 3 or 4 chronic kidney disease. The baseline period was 12 months and median follow-up was 19.3 months. Degree of consistency of visits to a nephrologist, defined as the number of calendar quarters in which there was 1 visit or more (range, 0-4 quarters), and covariates were calculated from the baseline period. The outcome measure was dialysis-free death. RESULTS: Of 39,031 patients, 70.0%, 22.4%, and 7.6% had early stage 3, late stage 3, and stage 4 chronic kidney disease, respectively, and 3.1%, 9.5%, and 28.2%, respectively, visited a nephrologist. Dialysis-free mortality rates were 9.6, 14.1, and 19.4, respectively, per 100 person-years. More calendar quarters with visits to a nephrologist were associated with lower mortality: adjusted hazard ratios were 0.80 (95% confidence interval, 0.67-0.97), 0.68 (95% confidence interval, 0.55-0.86), and 0.45 (95% confidence interval, 0.32-0.63), respectively, when the groups having 2, 3, and 4 visits were compared with those who had no visits. One visit only was not associated with a difference in mortality when compared with no visits (adjusted hazard ratio,1.02; 95% confidence interval, 0.89-1.16). CONCLUSIONS: The consistency of outpatient nephrologic care was independently associated in a graded fashion with lower risk of deaths in patients with diabetes and moderately severe to severe chronic kidney disease. However, only a minority of patients had any visits to a nephrologist.