Influence of hemodialysis on incretin hormones and insulin secretion in diabetic and non-diabetic patients.

BACKGROUND: Incretin hormones are secreted in the gut after a meal and stimulate insulin production. Both major incretins, that is, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), are eliminated by the kidneys. Little is known about the influence of end-stage renal disease (ESRD) on the incretin axis. The aim of the study was to assess the effect of the commencement of chronic hemodialysis (HD) therapy on serum GLP-1 and GIP, and insulin sensitivity in diabetic and non-diabetic patients. SUBJECTS AND METHODS: The study comprised 56 patients (23 F, 33 M; mean age 57 ± 14 years) with ESRD in the course of diabetic nephropathy (n = 23) and non-diabetic renal diseases (n = 34) who started chronic HD. Glucose metabolism, including incretin hormones concentration, was assessed before the first HD session and repeated after the first 6 months of the therapy. RESULTS: After 6 months of HD, a significant increase in fasting GLP-1 concentration was observed in both diabetic and non-diabetic patients [by 2.27 pmol/l (45 %) and 1.28 pmol/l (22 %), respectively, p = 0.0003]. Serum GIP increased significantly only in diabetic patients [by 30.9 pg/ml (55 %); p = 0.008]. No significant change of fasting glucose was found but HOMA-IR and serum insulin decreased significantly in diabetic patients (p = 0.01 and p = 0.008, respectively). In contrast, HOMA-B was unchanged in both groups. Changes of HOMA-IR did not significantly correlate with serum GLP-1 or GIP concentrations. CONCLUSION: Our results indicate that starting the hemodialysis therapy helps to restore the incretin axis in particular in patients with the diabetic kidney disease.

Three months of regular gum chewing neither alleviates xerostomia nor reduces overhydration in chronic hemodialysis patients.

INTRODUCTION AND AIMS: Gum chewing has been known to be a part of adjunctive medical therapy for cancer-related xerostomia. Nonadherence to fluid restriction in hemodialysis (HD) patients brought about by unrestricted thirst and xerostomia leads to excessive interdialytic weight gain (IWG). The effectiveness of gum chewing in reducing thirst in HD patients has till recently been evaluated by only a single study with short 2-week intervention period. The aim of the present study was to assess the effect of 3 months of regular use of sugar-free chewing gum on xerostomia, thirst, and hydration and nutritional status in HD patients. METHODS: A prospective pre/post (3 + 1 month[s]) study including 38 chronic HD patients (14 women, 17 men; mean age, 59 ± 10 years; time on dialysis, 48 ± 45 months) with mean mid-week IWG of >1 kg, persistent xerostomia, and/or thirst was conducted. Seven patients did not complete the study including 3 because of suspected side effects of gum chewing (diarrhea or paradoxically increased thirst). After a 2-week run-in period, the subjects received a specified number of packs of low-tack, sugar-free chewing gum and specially designed diaries. Basic biochemistry and multifrequency electric bioimpedance were performed a total of 8 times, that is, at baseline and after each month of the intervention period, both before and after dialysis. Questionnaires related to xerostomia and thirst were filled in by the patients at baseline, at the end of the intervention period, and 1 month later. Body weight (for IWG assessment) and blood pressure were measured at the start of each dialysis for the whole duration of the study. RESULTS: The mean number of chewing gum pellets used during the first and the third month of the study was 137 ± 56 and 139 ± 59, respectively. The patients did not report experiencing any changes in the intensity of xerostomia and thirst during the study. Total body water content assessed with bioimpedance did not decrease (41.9 ± 8.9 kg at baseline vs. 42.7 ± 9.1 kg at the end of the intervention period). Moreover, no changes in extracellular mass (31.9 ± 6.4 kg vs. 32.6 ± 6.6 kg), extracellular water (18.0 ± 5.2 kg vs. 18.3 ± 5.0 kg), and phase angle (4.6 ± 0.8 vs. 4.6 ± 0.8) were observed. Mean IWG between 2 mid-weekly HD sessions also did not change (2.3 ± 0.8 kg at baseline vs. 2.3 ± 0.9 kg at the end of the intervention period). No significant changes in thirst and xerostomia were observed 4 weeks after the end of the intervention period; however, mean IWG between 2 mid-weekly HD sessions increased to 2.8 ± 1.0 kg (P < .001). CONCLUSIONS: Regular gum chewing is known to be well tolerated by most HD patients; however, it does not lead to the alleviation of xerostomia or excessive thirst and does not reduce IWG or improve hydration status.

Pulmonary embolism and reactivation of tuberculosis during everolimus therapy in a kidney transplant recipient.

BACKGROUND: Proliferation signal inhibitors (PSIs) - sirolimus and everolimus - are commonly used in kidney transplant patients with co-existing neoplasms. These drugs may have prothrombotic activity, but aside from use in interventional cardiology, their clinical relevance has not been confirmed. In contrast to pulmonitis, an association of everolimus therapy with pulmonary embolism has never been documented. There have also been no reports on the increased risk of tuberculosis reactivation after an introduction of a PSI, and experience with everolimus dosing during antituberculosis treatment is very limited. CASE REPORT: A 72-year-old man, after kidney transplantation, had been converted to everolimus from tacrolimus after being diagnosed with basal cell carcinoma. One month later he was hospitalized with suspected pneumonia. Because of the lack of clinical improvement after antibiotic therapy, computed tomography (CT) angiography of the chest was performed and showed bilateral pulmonary embolism. Initially the patient responded well to the treatment, but shortly thereafter developed fever with rigors and chest pain. Eventually, after extensive diagnostic work-up, tuberculosis was diagnosed. During 6 months of pyrazinamide (PZA) and rifampicin (RFP) treatment, the repeated reduction of everolimus blood concentration was necessary, despite the substantial increase of the drug dose. CONCLUSIONS: This case shows that kidney transplanted patients treated with everolimus presenting symptoms of pneumonia should also be screened for pulmonary embolism. Patients treated with PSIs may be prone to reactivation of tuberculosis. When tuberculosis treatment is started, much larger doses of everolimus are required.

Pedometers as a means to increase spontaneous physical activity in chronic hemodialysis patients.

BACKGROUND: Pedometers are simple devices which measure spontaneous physical activity. In nonrenal disease populations, pedometers were successfully used to encourage patients to increase their habitual physical activity through self-monitoring of its intensity. Our aim was to investigate how an awareness of using pedometers helps in increasing daily spontaneous physical activity in patients on hemodialysis. METHODS: We studied 33 hemodialysis patients (16 women, 17 men; mean age 58.3 +/- 10.1 years; mean dialysis vintage 41.4 +/- 28.6 months). Daily walking activity was measured by pedometers 7 times over 4 months during 5 midweek interdialysis periods and 2 dialysis-free weekends. During the study, patients recorded their activities and pedometer readings. Blood count, serum albumin, electrolytes, lipids, C-reactive protein (CRP), interdialytic weight gain and erythropoiesis-stimulating agent dosages were also measured. Body composition was estimated with multifrequency phase-sensitive bioimpedance. The patients also filled in the SF-36 questionnaire. RESULTS: Total number of steps counted between 2 midweek dialysis sessions increased from a mean 9,337 +/- 5,317 to 11,921 +/- 5,909 (p=0.001). Number of steps during dialysis-free days increased, from 3,766 +/- 1,963 to 4,978 +/- 2,495 (p=0.0005). Total number of steps between midweek dialysis and dialysis after dialysis-free weekend break tended to increase from 20,974 +/- 10,696 to 22,080 +/- 11,631 (p=0.06). At study end, the number of steps taken during weekend days was greater than during between midweek dialysis sessions. Bioimpedance did not reveal significant changes of body composition. The patients had similar scores on physical functioning, general health and mental health perception and total SF-36 at the end of the study. CONCLUSION: Pedometers could serve as a simple means to increase spontaneous physical activity in patients on chronic hemodialysis.