Una aproximación al trasplante renal anticipado de donante cadáver. Estudio de cohortes emparejadas

IntroductionCurrently, kidney transplantation is the treatment of choice for patients with kidney disease who require replacement therapy. Dialysis is a necessary step, but not mandatory prior to transplantation. There is the possibility of pre-emptive transplantation or transplantation in pre-dialysis, that is, without previous dialysis. The aim of the present study is to evaluate the result of our experience with a pre-emptive kidney transplant from a deceased donor.Materials and methodsRetrospective, observational, matched cohort study. We compared 66 pre-emptive with 66 non pre-emptive recipients, who received a first renal graft performed at our centre, matched by age and gender of donors and recipients, time of transplant, immunological risk, immunosuppression and cold ischaemia time.Early graft loss, incidence of acute rejection, delayed graft function, renal function at 12 and 36 months and graft and recipient survival were assessed in this period.ResultsThe percentage of recipients who presented early graft loss, delayed graft function and acute rejection was similar in both groups. No differences were observed in their renal function at 12 and 36 months after transplantation, as well as the actuarial survival of patients (P = 0.801) and grafts (P = 0.693) in the studied period. The total calculated cost of the period on dialysis for the control group was 8,033,893.16 euros.ConclusionsPre-emptive transplantation can yield comparable outcomes to those for post-dialysis kidney transplantation, and results in better quality of life for patients with end-stage kidney disease, as well as a reduced cost.     

A learning curve for living donor liver transplantation

BackgroundThe number of living donor liver transplantations performed has increased rapidly in many Eastern transplant centres. However, the impact of the transplant centres’ experience and learning on the transplant outcomes are not well established. Aim of the study was to evaluate the learning curve for living donor liver transplantation in our centre.MethodsData from 156 recipients and 156 donors who underwent surgery were reviewed. Intraoperative data and postoperative outcomes of both donors and recipients were retrospectively analysed. Recipients and donors were divided into three groups that consisted of 52 consecutive cases each.ResultsSurgical duration and intraoperative blood loss during donor surgery were decreased significantly between the earlier and the more recent cases (423 ± 39 vs. 400 ± 44 min and 959 ± 523 vs. 731 ± 278 mL, respectively; P < 0.01). Rates of postoperative complications and functional changes were not statistically different amongst the three donor groups. Immediate complication rate of the first 52 recipients was higher than those of the second and third cohorts. Long-term survival rates of the three recipient groups were similar.ConclusionsThe learning curve greatly influenced immediate outcomes of recipients during the early transplant period. However, it had little influence on donor outcome; long-term outcome improvement of recipients did not depend on the accumulation of experience alone.     

Impact of the 2018 French two-score allocation scheme on the profile of heart transplantation candidates and recipients: Insights from a high-volume centre

BackgroundIn 2018, a new cardiac allograft allocation scheme, based on an individual scoring system, considering the risk of death both on the waiting list and after heart transplantation, was implemented in France.AimTo assess the impact of this new scheme on the profile of transplantation candidates and recipients.MethodsIn this single-centre retrospective study, we included consecutive patients listed and/or transplanted between 01 January 2012 and 30 September 2021 at La Pitié-Salpêtrière Hospital. Baseline characteristics of patients were retrieved from the national CRISTAL registry and were compared according to the type of allocation scheme (before or after 2018).ResultsA total of 1098 newly listed transplantation candidates and 855 transplant recipients were included. One-year mortality rates after listing and after transplantation were 12.4% and 20%, respectively. At listing, the proportion of candidates on inotropes significantly declined following the scheme update (26.3 versus 20.9%; P = 0.038), reflecting a change in medical practice. At transplantation, recipients had worse kidney function (estimated glomerular filtration rate < 60 mL/min/1.73 m²: old scheme, 29.7%; new scheme, 46.4%; P < 0.001) and were more likely to be on extracorporeal membrane oxygenation support (33.5% versus 28.1%; P = 0.080) under the new scheme, reflecting the prioritization of more severe patients. Outcomes after transplantation were not significantly influenced by the allocation system.ConclusionsThe implementation of the 2018 French allocation scheme had a limited impact on the profile of transplantation candidates, but selected more severe patients for transplantation without significant impact on outcomes after transplantation.     

Renal safety of intensive cholesterol-lowering treatment with rosuvastatin: a retrospective analysis of renal adverse events among 40,600 participants in the rosuvastatin clinical development program

ObjectiveIntensive lowering of low-density lipoprotein cholesterol (LDL-C) with statins reduces cardiovascular risk but can cause liver-, muscle-, and possibly renal-related adverse events (AEs). We assessed the effects of rosuvastatin on the risk of developing renal impairment or renal failure among participants in the rosuvastatin clinical development program.MethodsThe analysis was based on AE data reported by investigators from 36 studies that included 40,600 participants who did not have advanced, pre-existing renal disease. Rates of renal AEs were determined based on time to first occurrence of renal impairment or renal failure.ResultsRenal impairment or renal failure was reported in 536 study participants during 72,488 patient-years of follow-up. Renal event rates were higher in patients with history of heart failure (n = 5011), hypertension (n = 21,864), diabetes (n = 5165), or estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² (n = 9507) at baseline but did not differ with rosuvastatin compared with placebo or with rosuvastatin 40 mg compared with rosuvastatin 10 mg. Relative risk (RR) estimates obtained from pooled analysis of placebo-controlled trials were RR: 1.03 (95% CI: 0.86–1.23, p = 0.777) for any reported renal impairment or renal failure event, RR: 1.02 (95% CI: 0.76–1.37, p = 0.894) for serious renal AEs, and RR: 0.70 (95% CI: 0.36–1.35, p = 0.282) for renal AEs leading to death.ConclusionThese findings suggest that intensive LDL-C-lowering treatment with rosuvastatin does not affect the risk of developing renal insufficiency or renal failure in patients who do not have advanced, pre-existing renal disease.     

Practical application of the French two-score heart allocation scheme: Insights from a high-volume heart transplantation centre

BackgroundIn 2018, a cardiac allocation scheme based on an individual score considering the risk of death both on the waitlist and after heart transplantation was implemented in France.AimsTo analyse the practical application of the pre- and post-transplant risk score in a French high-volume heart transplantation centre.MethodsAll consecutive adult patients listed for a first non-combined heart transplantation between 02 January 2018 and 30 June 2022 at our centre were included. Baseline characteristics of candidates and recipients were retrieved from the national CRISTAL registry. Both scores were calculated at listing and at transplant.ResultsOverall, 364 patients were included. During follow-up, 257 patients (70.6%) were transplanted, and 57 (15.6%) died or were removed from the waitlist. Post-transplant 3-month survival was 84.8%. Total bilirubin and natriuretic peptides had the most important weight in the pretransplant risk score. This score had a major impact on waitlist outcomes: quartile 1 was characterized by low access to heart transplantation (58.2%) and risk of death on the waitlist (9.9%) compared with quartile 4 (heart transplantation rate 74.1%, mortality on the waiting list > 20%). According to the post-transplant risk score, a minimal number of candidates were considered ineligible for heart transplantation (< 1%), but 12.4% were contraindicated to at least one donor category. The number of contraindicated donor categories had a significant impact on waitlist outcomes. Although adequately calibrated, the post-transplant score had a limited discrimination (area under the curve 0.65, 95% confidence interval 0.59–0.71).ConclusionOur results highlight the major impact of pre- and post-transplantation risk scores on waitlist outcomes following the allocation scheme update.     

Taxa de filtração glomerular: que fórmula deverá ser usada em doentes com enfarte agudo do miocárdio?

IntroductionThere is disagreement regarding the best method for assessing renal dysfunction in patients with myocardial infarction (MI). This study aims to compare two commonly used formulas for measuring glomerular filtration rate (GFR) (Cockcroft-Gault [CG] and modification of diet in renal disease [MDRD]) in terms of predicting extent of coronary artery disease (CAD) and short- and long-term cardiovascular risk.MethodsWe studied 452 patients admitted to a cardiac intensive care unit (ICU) with MI (age 69.01 ± 13.64 years; 61.7% male, 38.5% diabetic) and followed for two years. CG and MDRD GFR estimates were compared in terms of prediction of CAD extent, in-hospital mortality risk and cardiovascular risk during follow-up.ResultsGFR <60 ml/min/1.73 m² using the MDRD formula was associated with a tendency for more extensive CAD (2.70 affected segments vs. 2.20, p = 0.052) and higher two-year mortality risk (p < 0.001, OR 3.84, 95% CI 2.04-7.22) and risk for reinfarction (p < 0.001, OR 4.09, 95% CI 2.00-8.39), decompensated heart failure (DHF) (p < 0.001, OR 3.95, 95% CI 2.04-7.66) and combined cardiovascular endpoints (p = 0.001, OR 2.47, 95% CI 1.47-4.17). Using the CG formula, GFR < 60 ml/min/1.73 m² only predicted higher risk for DHF (p = 0.016, OR 4.5, 95% CI 1.11-16.57), despite a tendency for more overall combined cardiovascular endpoints (p = 0.09, OR 2.84). Both formulas predicted in-hospital mortality.Discussion/ConclusionsThis study confirmed the value of GFR in predicting various cardiovascular endpoints in patients with MI. Compared to the CG formula, the MDRD formula was significantly more accurate in predicting the severity of CAD and two-year CV risk in patients admitted to the ICU with MI.     

The association of tooth scaling and decreased cardiovascular disease: a nationwide population-based study

ObjectivePoor oral hygiene has been associated with an increased risk for cardiovascular disease. However, the association between preventive dentistry and cardiovascular risk reduction has remained undetermined. The aim of this study is to investigate the association between tooth scaling and the risk of cardiovascular events by using a nationwide, population-based study and a prospective cohort design.MethodsOur analyses were conducted using information from a random sample of 1 million persons enrolled in the nationally representative Taiwan National Health Insurance Research Database. Exposed individuals consisted of all subjects who were aged ≥ 50 years and who received at least 1 tooth scaling in 2000. The comparison group of non-exposed persons consisted of persons who did not undergo tooth scaling and were matched to exposed individuals using propensity score matching by the time of enrollment, age, gender, history of coronary artery disease, diabetes, hypertension, and hyperlipidemia.ResultsDuring an average follow-up period of 7 years, 10,887 subjects who had ever received tooth scaling (exposed group) and 10,989 age-, gender-, and comorbidity-matched subjects who had not received tooth scaling (non-exposed group) were enrolled. The exposed group had a lower incidence of acute myocardial infarction (1.6% vs 2.2%, P < .001), stroke (8.9% vs 10%, P = .03), and total cardiovascular events (10% vs 11.6%, P < .001) when compared with the non-exposed group. After multivariate analysis, tooth scaling was an independent factor associated with less risk of developing future myocardial infarction (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.57-0.85), stroke (HR, 0.85; 95% CI, 0.78-0.93), and total cardiovascular events (HR, 0.84; 95% CI, 0.77-0.91). Furthermore, when compared with the non-exposed group, increasing frequency of tooth scaling correlated with a higher risk reduction of acute myocardial infarction, stroke, and total cardiovascular events (P for trend < .001).ConclusionTooth scaling was associated with a decreased risk for future cardiovascular events.     

Early HHV-6 replication is associated with morbidity non-related to CMV infection after kidney transplantation

Human herpesvirus type 6-(HHV-6) has been associated with morbidity after liver transplantation.ObjectiveThe aim of this study was to determine the HHV-6 seroprevalence among donorrecipient pairs, analyze the incidence of early active infection, its clinical manifestation, interaction with CMV, and the related morbidity in the first year after kidney transplantation.Methods46 donor-recipient pairs had IgG evaluated by ELISA before transplantation: HHV-6-(Pambio – USA) and CMV-(Roche – USA). A frozen whole blood sample collected weekly (from the 1^st to the 6^th week) was retrospectively tested for HHV-6 viral load (VL) determination by real time quantitative PCR (qPCR, Nanogen – Italy). Patients were preemptively surveyed for CMV by pp65 antigenemia (Ag, APAAP, immunohistochemistry, Biotest – Germany) from the 4^th to the 12^th week after transplantation. Active infection was defined as qPCR-HHV6+ (viral-load/mL-VL) and Ag+ (+cells/100.000 granulocytes), for HHV-6 and CMV, respectively. DCMV was defined as simultaneous positive antigenemia and suggestive signs/symptoms. Concerning +qPCR-HHV6, associated factors, clinical manifestation, interaction with CMV and morbidity were searched.ResultsPre-transplant HHV-6 seroprevalence was significantly higher among kidney recipients compared to their donors (82.6×54.8%; p = 0.005 [3.9 (1.4–10.4)]). Active infection by this virus occurred in 26.1% (12/46), with no association with previous IgG (p = 0.412). Median VL was 125 copies/mL (53–11.264), and the median Ag was 21 +cells (2–740). There was no association between HHV-6 and CMV activation after transplantation (p = 0.441), neither concerning DCMV (p = 0.596). Median highest Ag+ and days of ganciclovir treatment were similar between qPCR-HHV6 + or ? (p = 0.206 and p = 0.124, respectively). qPCR-HHV6+ was associated with higher incidence of bacterial (p = 0.009) and fungal (p = 0.001) infections, and higher number (p = 0.001) of hospital admission and longer duration of hospitalization over the first 6 and 12 months post-transplantation (p = 0.033 and p = 0.001).ConclusionLatent HHV-6 infection is more common among recipients than donors before transplantation. Early active infection by this pathogen after transplantation does not increase DCMV incidence or severity during the first 3 months of follow-up. However, early HHV-6 replication is associated with other infections and hospitalizations in the first year.     

The increasing incidence of infective endocarditis in Denmark, 1994–2011

BackgroundLittle updated population-based evidence exists of temporal trends in infective endocarditis (IE).MethodsFor the 1994–2011 period, we used Danish nationwide registries to identify cases with first-time IE and to estimate the population size. We calculated the incidence rate of IE in 3-year intervals. To evaluate time trends in incidence, we used the 1994–1996 period as reference and computed incidence ratios and 95% confidence intervals (CI) as the incidence in each of the subsequent 3-year intervals divided by the incidence in the reference period.ResultsWe identified 5486 incident IE patients (65% men) and the mean age at diagnosis was 63 years. Men tended to be younger at diagnosis than women; 62 years vs. 65 years. Mean age at IE diagnosis steadily increased from 57 years in 1994–1996 to 65 years in 2009–2011. The IE incidence rate increased from 3.93 per 100,000 person-years in 1994–1996 to 7.55 per 100,000 person-years in 2009–2011, corresponding to an incidence ratio of 1.92 (95% CI: 1.74–2.12). The increase in incidence over time was more pronounced in men (2.28, 95% CI: 2.02–2.59) than in women (1.39, 95% CI: 1.18–1.64). We observed no increase in incidence over time for subjects younger than 50 years, whereas the incidence increased substantially over time for elderly patients, with the highest incidence ratio of 3.38 (95% CI: 2.55–4.52) for patients more than 80 years at IE onset.ConclusionThe incidence of IE increased over time particularly among men and for the older age groups.     

Acute exacerbation of chronic hepatitis B virus infection in renal transplant patients

IntroductionThere is scarce information regarding clinical evolution of HBV infection in renal transplant patients.AimsTo evaluate the prevalence of acute exacerbation in HBV-infected renal transplant patients and its association with the time after transplantation, presence of viral replication, clinical evolution, and use of antiviral prophylaxis.Materials and methodsHBV infected renal transplant patients who underwent regular follow-up visits at 6-month intervals were included in the study. The criteria adopted to characterize exacerbation were: ALT >5× ULN and/or >3× baseline level. Predictive factors of exacerbation evaluated were age, gender, time on dialysis, type of donor, post-transplant time, ALT, HBeAg, HBV-DNA, HCV-RNA, immunosuppressive therapy, and use of antiviral prophylaxis.Results140 HBV-infected renal transplant patients were included (71% males; age 46 ± 10 years; post-renal transplant time 8 ± 5 years). During follow-up, 25% (35/140) of the patients presented exacerbation within 3.4 ± 3 years after renal transplant. Viral replication was observed in all patients with exacerbation. Clinical and/or laboratory signs of hepatic insufficiency were present in 17% (6/35) of the patients. Three patients died as a consequence of liver failure. In univariate analysis variables associated with exacerbation were less frequent use of prophylactic/preemptive lamivudine and of mycophenolate mofetil. Lamivudine use was the only variable independently associated with exacerbation, with a protective effect.ConclusionsAcute exacerbation was a frequent and severe event in HBV-infected renal transplant patients. Prophylactic/preemptive therapy with antiviral drugs should be indicated for all HBsAg-positive renal transplant patients.     

Low levels of insulin-like growth-factor-binding protein-1 (IGFBP-1) are prospectively associated with the incidence of type 2 diabetes and impaired glucose tolerance (IGT): The Söderåkra Cardiovascular Risk Factor Study

AimTo explore the association between baseline levels of insulin-like growth-factor-binding protein-1 (IGFBP-1), a marker of insulin sensitivity, and the development of type 2 diabetes or impaired glucose tolerance (IGT) in a specifically defined middle-aged population.MethodsThis cross-sectional population-based screening study was conducted in 1989–1990 and included baseline data for 664 non-diabetic subjects aged 40–59 years. Clinical data were collected and blood samples analyzed for blood glucose, serum lipids and insulin. Blood specimens were frozen at baseline and later analyzed for IGF-I, IGFBP-1 and C-reactive protein (CRP). At the follow-up in 2006, the incidence of type 2 diabetes and IGT was reported based on primary-care medical records.ResultsDuring the 17-year observation period, 42 subjects (6.3%) developed type 2 diabetes/IGT. Those in the lowest quintile of IGFBP-1 (≤24 μg/L) at baseline had a diabetes incidence of 12.6% while, in the highest quintile of IGFBP-1 (≥59 μg/L), the incidence was 1.5%. Cox's proportional-hazards model regression analyses were used to determine the incidence of type 2 diabetes/IGT, corrected for age and gender, in relation to IGFBP-1, CRP and waist circumference. Subjects in the lowest IGFBP-1 quintile showed an independently increased risk of type 2 diabetes/IGT [hazards ratio (HR): 3.54; 95% CI 1.18–10.6; P = 0.024]. For CRP and waist circumference, the corresponding figures were HR: 6.81; 95% CI 2.50–18.6; P < 0.001 and HR: 3.33; 95% CI 1.47–7.6; P = 0.004, respectively.ConclusionLow levels of IGFBP-1 predicted the long-term development of type 2 diabetes or IGT in a middle-aged population. The association was independent of CRP and abdominal obesity.     

Waist circumference cut-off values to predict the incidence of hypertension: an estimation from a Brazilian population-based cohort

Background and aimsCentral obesity is a key component in the definition of the metabolic syndrome, but the cut-off values proposed to define abnormal values vary among different guidelines and are mostly based on cross-sectional studies. In this study, we identify the best cut-off values for waist circumference (WC) associated with the incidence of hypertension.Methods and resultsParticipants for this prospectively planned cohort study were 589 individuals who were free of hypertension and selected at random from the community of Porto Alegre, Brazil. Hypertension was defined by a blood pressure measurement ≥ 140/90 mmHg or the use of blood pressure lowering drugs. A logistic regression model established the association between WC and the incidence of hypertension. A receiver operating characteristics (ROC) curve analysis was used to select the best WC cut-off point to predict the incidence of hypertension. During a mean follow-up of 5.5 ± 0.9 years, 127 subjects developed hypertension. The hazard ratios for the development of hypertension, adjusted for age, baseline systolic blood pressure, alcohol consumption, gender and scholarship were 1.02 (95% CI; 1.00–1.04; P = 0.02) for WC. The best cut-off WC values to predict hypertension were 87 cm in men and 80 cm in women, with an area under the curve of 0.56 (95% CI; 0.47–0.64; P = 0.17) and 0.70 (95% CI; 0.63–0.77; P < 0.001), respectively.ConclusionExcess visceral adiposity is a major risk factor for hypertension in individuals living in communities in Brazil, and this risk begins at lower values of WC that those recommended by some guidelines.     

Angiotensin-converting enzyme gene single polymorphism as a genetic biomarker of diabetic peripheral neuropathy: longitudinal prospective study

BackgroundIdentifying patients at risk of developing diabetic peripheral neuropathy (DPN) is of paramount importance in those with type 2 diabetes mellitus (T2DM) to provide and anticipate secondary prevention measures as well as intensify action on risk factors, particularly so in primary care. Noteworthy, the incidence of DPN remains unknown in our environment.Aims(i) To analyze a single angiotensin-converting enzyme (ACE) gene polymorphism (D/I) as a genetic marker of risk of developing DPN, and (ii) to determine the incidence of DPN in our environment.Research design and methodsLongitudinal study with annual follow-up for 3 years involving a group of T2DM (N = 283) randomly selected. ACE gene polymorphism distribution (I = insertion; D = deletion) was determined. DPN was diagnosed using clinical and neurophysiology evaluation.ResultsBaseline DPN prevalence was 28.97% (95% CI, 23.65–34.20). ACE polymorphism heterozygous genotype D/I presence was 60.77% (95% CI, 55.05–66.5) and was independently associated with a decreased risk of DPN (RR, 0.51; 95% CI, 0.30–0.86). DPN correlated with age (P < 0.001) but not with gender (P = 0.466) or time of evolution of T2DM (P = 0.555). Regarding end point, DPN prevalence was 36.4% (95% CI, 30.76–42.04), and accumulated incidence was 10.4% 3 years thereafter. In the final Poisson regression analysis, the presence of heterozygous genotype remained independently associated with a decreased risk of DPN (RR, 0.71; (95% CI, 0.53–0.96). DPN presence remained correlated with age (P = 0.002), but not with gender (P = 0.490) or time of evolution (P = 0.630).ConclusionsIn our series, heterozygous ACE polymorphism (D/I) stands as a protective factor for DPN development. Accumulated incidence of DPN was relevant. Further prospective studies are warranted.     

Elevated circulating soluble form of CD40 ligand in patients with cardiac syndrome X

ObjectivesMarkers of non-specific inflammation, such as C-reactive protein (CRP) or leukocyte count are increased in end-stage renal disease patients. Recent studies have shown positive associations between inflammatory markers and cardiovascular mortality in kidney transplant recipients, but these analyses had been limited by sample size. The aim of our study was to determine the association between pretransplant CRP levels and leukocyte counts with posttransplant outcome in a prospectively enrolled cohort of kidney transplant recipients.Methods459 consecutive patients transplanted from July 1995 to December 2007 were analyzed. Both markers were obtained prior to transplantation and patients were grouped according to baseline CRP levels (<5 mg/l or ≥5 mg/l) or leukocyte counts (<10,000/μl or ≥10,000/μl).ResultsMajor cardiac events were associated with elevated pretransplant CRP levels (p < 0.00003) but not leukocyte counts. Furthermore, more acute rejection episodes within 4 weeks or 6 months, as well as a lower probability of survival at 6 months were found in patients with elevated pretransplant CRP levels or leukocyte counts.ConclusionElevated pretransplant serum CRP level is a risk predictor for major cardiac events in renal transplant patients. It is also predictive, besides leukocyte counts, for acute rejection episodes. Elevated CRP levels and initial high leukocyte counts may prove to be useful markers for posttransplant course and warrant the close follow-up of such patients.     

Time to change the glomerular filtration rate estimating formula in primary care?

BackgroundThe most commonly used equation for estimated glomerular filtration rate (eGFR) is nowadays the four-variable Modification of Diet in Renal Disease (MDRD) equation. This formula was derived from patients with non-diabetic chronic kidney disease (CKD) with mean GFR 40 ml/min.MethodsWe compared the MDRD study equation and the recently developed Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation by applying the two formulas in 1747 middle-aged cardiovascular risk persons in primary care.ResultsThe prevalence of renal insufficiency defined as eGFR < 60 ml/min was 6.7% (95% CI 5.6–8.0) according to the MDRD formula, and 3.6% (95% CI 2.8–4.6) according to the CKD-EPI formula. The subjects who were classified as having CKD according to the MDRD equation, but no-CKD according to the CKD-EPI formula, were mostly women (86%) and slightly younger than the subjects having CKD according to both formulas.ConclusionThe characteristics of the subjects commonly treated in primary care resemble more closely the population from which the CKD-EPI than the MDRD study equation was derived from. Thus, we suppose that in general practice, the CKD-EPI equation is more suitable for estimating renal function than the MDRD equation.     

Diabetes, comorbidities and increased long-term mortality in older patients admitted for geriatric inpatient care

AimsTo study the specific impact of diabetes on long-term mortality in very old subjects with multiple comorbidities and functional disabilities.MethodsThe prevalence of vascular disorders, global comorbidity load (cumulative illness rating scale [CIRS]) and functional disabilities (activities of daily living [ADL] and Lawton's instrumental ADL [IADL] scores) were determined according to diabetes status in a cohort of 444 patients (mean age 85.3 ± 6.7 years; 74.0% women) admitted to our geriatric service. Also, the specific impact of diabetes on 4-year mortality was analyzed using Cox proportional-hazards models.ResultsDiabetic patients had higher BMI scores (27.1 ± 4.9 vs. 23.4 ± 4.7 kg/m² in controls; P < 0.001), and higher prevalences of hypertension (81.9% vs. 65.1%, respectively; P = 0.003) and ischaemic heart disease (33.7% vs. 22.2%, respectively; P = 0.033), but not of stroke and renal insufficiency. They also had more comorbidities (CIRS score excluding diabetes: 15.1 ± 4.5 vs. 13.8 ± 4.8, respectively; P = 0.016) and functional disabilities. Diabetes was associated with mortality (HR: 1.42, 95% CI: 1.02–1.99; P = 0.041) after adjusting for age, gender and BMI, and this persisted after adjusting for individual vascular comorbidities, but disappeared after adjusting for CIRS, ADL or IADL scores.ConclusionDiabetes was associated with 4-year mortality after adjusting for the inverse relationship between mortality and BMI. This association was better accounted for by the global comorbidity load and functional disabilities than by the individual vascular comorbidities. These findings suggest that the active management of all – rather than selected – comorbidities is the key to improving the prognosis for older diabetic patients.     

Sensitivity of A1C to diagnose diabetes is decreased in high-risk older Southeast Asians

ObjectiveTo determine the effect of ageing on the performance of glycosylated haemoglobin A1C (A1C) for the diagnosis of diabetes mellitus (DM) in Southeast Asians.MethodsA1C was measured in 511 subjects (mean age of 52.4 years; range 14–93) undergoing the 75-g oral glucose tolerance test (OGTT). Using receiver operating curve (ROC) analysis, the performance of A1C for the diagnosis of diabetes (using different standard criteria) was compared between 4 groups: < 45 (n = 156), 45–54 (n = 132), 55–64 (n = 122), ≥ 65 years (n = 101).ResultsSubjects aged ≥ 65 years had the highest false-negative rates with fasting plasma glucose (60.8%) and A1C (35.1%), the smallest area under ROC curve (0.723, 95% CI 0.627–0.820), the lowest sensitivity (58.7%, 95% CI 50.4–65.7) and specificity (71.1%, 95% CI 57.3–82.6) of A1C 6.5%, compared to the younger age groups.ConclusionOGTT is preferable for diagnosis of DM in older Southeast Asian adults.     

Risk factors of renal scars in children with acute pyelonephritis

ObjectiveThe aim of this study was to determine the association between previously documented risk factors such as recurrent pyelonephritis with the incidence of renal scarring after acute pyelonephritis in children.Material and methodsChildren with acute pyelonephritis who were admitted to the Department of Pediatrics of a teaching hospital during 2007–2009 were enrolled in this study. DMSA scans were obtained 4–6 months after the last episode of pyelonephritis in all patients.ResultsA total of 80 children with acute pyelonephritis were enrolled in this study. Most of them were girls (77.5%), with a median age of 12 months. Nearly half of the children (n = 44; 55%) had one or more renal scars. The distribution of gender, CRP level and leukocytosis did not differ significantly regardingthe absence or presence of renal scars (p > 0.05). Most of the scars occurred in children who had presented with bilateral pyelonephritis (69.4% vs. 18.2%, p = 0.001). Most of the patients with renal scars had a positive history of vesicoureteral reflux (VUR) (75% vs.13.6%, p = 0.001). The significant roles of recurrent pyelonephritis and presence of VUR were further confirmed by multivariate analysis.ConclusionsAccording to our findings, presence of VUR and recurrent pyelonephritis are independently associated with a higher incidence of renal scarring.     

Glycated apolipoprotein B and myocardial infarction

AimsTo evaluate the association of serum concentrations of glycated apolipoprotein B (ApoBg) with the incidence of myocardial infarction (MI) in subjects with and without diabetes.MethodsThe design is a nested case-control study. The cohort included 5632 subjects over 50 years of age attending the clinical laboratories of a small geographic area in southern Italy. After five years, 4563 subjects were traced and 103 had developed MI. We sampled from the cohort two controls for each incident case of MI, frequency matched for sex and diabetes. ApoBg was measured using a monoclonal antibody. Logistic regression was used for statistical analysis of the data.ResultsApoBg at baseline was higher in subjects who developed myocardial infarction than in controls in both non-diabetic and diabetic subjects (t test, P = 0.009 and P = 0.05 respectively). MI odds ratio in the third tertile of ApoBg was 2.01 (95 % CI 0.93–4.33) in non-diabetic and 2.88 (0.85–9.68) in diabetic subjects (chi-square test for trend; non-diabetics P = 0.03, diabetics P = 0.06). Serum triglycerides, cholesterol, HDL and LDL cholesterol, glucose and insulin were not associated with MI (P > 0.10).ConclusionApoBg at baseline is directly associated with the development of MI in the following five years in both diabetic and non-diabetic individuals.     

Intensive versus conventional glucose control in critically ill patients: A meta-analysis of randomized controlled trials

BackgroundCritically ill patients commonly develop hyperglycemia. It remains unclear, however, to what extent correcting hyperglycemia will benefit these patients. We performed this meta-analysis to evaluate the benefits and risks of intensive glucose control versus conventional glucose control in critically ill adult patients.MethodsA systematic literature search of MEDLINE, PubMed, and Cochrane databases (until June 2011) was conducted using specific search terms. Randomized controlled trials that compared intensive glucose control with a target glucose goal < 6.1 mmol/l (110 mg/dl) to conventional glucose control in adult intensive care patients were included. The random-effect model was used to estimate the pooled risk ratio of the two treatment arms.ResultsTwenty two studies that randomized 13,978 participants were included in the meta-analysis. Overall, intensive glucose control did not reduce the short-term mortality (RR = 1.02, 95% CI: 0.95–1.10, p = 0.51), 90 day or 180 day mortality (RR = 1.06, 95% CI: 0.99–1.13, p = 0.08), sepsis (RR = 0.96, 95% CI: 0.83–1.12, p = 0.59) or new need for dialysis (RR = 0.96, 95% CI: 0.83–1.11, p = 0.57). The incidence of hypoglycemia was significantly higher in intensive glucose control group compared with conventional glucose control group (RR = 5.01, 95% CI: 3.45–7.28, p < 0.00001).ConclusionsThis meta-analysis found that intensive glucose control in critically ill adults did not reduce mortality but is associated with a significantly increased risk of hypoglycemia.