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Clinical and laboratory features and risk factors for diabetic gastroparesis (DGP) were investigated in 226 diabetics on chronic dialysis; 106 subjects (43%) had DGP diagnosed by persistent vomiting improved with the use of prokinetic agents and 120 (control group) had no clinical DGP. Type 1 diabetics had DGP more frequently than type 2 diabetics (70 vs. 37%). The DGP group had longer duration of diabetes (21 +/- 8 vs. 13 +/- 6 years), higher frequency of diabetic orthostatic hypotension (95 vs. 33%), enteropathy (49 vs. 5%), blindness (52 vs. 23%), myocardial infarction (86 vs. 42%), extremity gangrene (54 vs. 27%) and cerebrovascular accidents (43 vs. 25%), lower serum albumin 32.3 +/- 3.9 vs. 35.4 +/- 3.8 g/l), urea (24.0 +/- 5.5 vs. 25.5 +/- 5.5 mmol/l) and creatinine (710 +/- 210 vs. 820 +/- 220 mumol/l), and higher serum TCO2 (20.9 +/- 3.1 vs. 19.8 +/- 2.7 mmol/l) than the control group (all differences significant at p +/- 0.004). Glycemic control was adequate in 24% of the DGP group subjects and 83% of the control subjects (p < 0.001). Annual hospitalization rate was 49 +/- 48 days/patient in the DGP group and 16 +/- 27 days/patient in the control group (p < 0.001). Median patient survival was 24 +/- 2 months in the DGP group and 61 +/- 9 months in the control group (p < 0.0001). Logistic regression identified long duration of diabetes and poor glycemic control as risk factors for DGP. In diabetics on dialysis, DGP is associated with high frequency of other diabetic complications, low serum albumin and creatinine, and high morbidity and mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

This study was conducted to determine the association between glycemic control and clinical outcomes of diabetic patients maintained on chronic dialysis. The study group consisted of 226 diabetics (60 Type I and 166 Type II) classified as having either good glycemic control (> 50% of blood glucose determinations within 3.3-11.1 mmol/L) or poor glycemic control (< 50% of blood glucose measurements > 3.3 and < 11.1 mmol/L). The following variables were analyzed in each group: demographics; vascular and diabetic complications; laboratory values; and patient survival. In comparison to diabetics with poor control (Type I, n = 44; Type II, n = 57), those with good control, either Type I (n = 16), or Type II (n = 109), were dialyzed for longer periods and had shorter hospitalizations, lower prevalence rates of myocardial infarctions, congestive heart failure, orthostatic hypotension, gastroparesis and enteropathy, and higher mean serum albumin. Mean patient survival by life-table analysis was as follows: Type I diabetics, good control 128.9 + 8.1 months, poor control 29.5 + 5.0 months, p = 0.0014. Type II diabetics, good control 56.9 + 6.8 months, poor control 22.8 + 4.6 months, p < 0.0001. Good glycemic control during the first 6 months of dialysis predicted long-term survival for Type II but not for Type I diabetics. Poor glycemic control is associated with increased morbidity from vascular and diabetic complications, malnutrition, and shortened survival in diabetics on chronic dialysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Eight diabetic men with poor glycemic control, probably worsened by severe congestive heart failure and gastroparesis, were sequentially dialyzed by CAPD and hemodialysis. Mean blood glucose concentration, blood glycosylated hemoglobin, and insulin dose were higher during CAPD than during hemodialysis. Among blood glucose determinations, however, the frequency of hypoglycemia (glucose less than 3.3 mmol/L) was higher during hemodialysis (13.2 +/- 8.9%) than during CAPD (2.8 +/- 2.1% p = 0.012), whereas the frequencies of hyperglycemia (glucose greater than 11.1 mmol/L) and euglycemia (glucose between 3.5 and 11.1 mmol/l) did not differ between the two dialysis modalities. Furthermore, hypoglycemia was severe during hemodialysis and was associated with two deaths. There were no deaths linked to abnormalities in blood glucose concentration during CAPD. When hypoglycemia is frequent in diabetics with poor glycemic control, CAPD is preferable to hemodialysis.

The authors analyzed the outcome of 56 episodes of cardiopulmonary resuscitation (CPR) in dialysis patients. Eleven patients (20%) left the hospital alive. Univariate analysis showed that a functional cause of cardiac arrest, absence of rib fractures, and the occurrence of cardiac arrest in the dialysis or intensive care units were associated with a favorable outcome. Logistic regression showed that the outcome of CPR was related to the presence of rib fractures, cause of arrest, degree of preexisting heart disease, and patient age. Despite the high incidence of rib fractures (77%), the outcome of CPR in dialysis patients is similar to its outcome in the general population.

The morbidity and mortality of 11 femoral neck fractures were analyzed to compare operative and conservative management of femoral neck fractures in dialysis patients. All fractures occurred in older men with severe cardiac, pulmonary, gastro-intestinal, and neurologic conditions and with advanced renal osteodystrophy. Six of the seven operated patients survived the surgery and achieved varying degrees of ambulation. Stability of the operated hip was excellent in each case. Post-operative complications included transient confusional state related to narcotics, pneumonia, decubitus ulcers, and severe hypoalbuminemia. All four patients who were managed conservatively died from complications of the fracture. Progressive deterioration was noted in each nonoperated patient, with confusion caused by narcotics and analgesics, pneumonia, hepatic coma, decubitus ulcers, severe depression, and severe hypoalbuminemia. Therefore, operative management was superior to conservative management for femoral neck fractures of patients receiving chronic dialysis with multiple medical problems and advanced renal osteodystrophy. Narcotics must be used with great caution, and efforts should be directed toward prevention of malnutrition and decubitus ulcers.

When serum glucose concentration is nearly normal, serum sodium concentration and tonicity are usually normal in ambulatory outpatient diabetics on chronic hemodialysis or peritoneal dialysis. In hyperglycemia, patients on hemodialysis do not undergo osmotic diuresis and are able to nearly normalize their serum tonicity by increasing the intake of water. Patients on peritoneal dialysis differ from hemodialysis patients because of continued loss of water in the peritoneal dialysate and achieve only partial correction of tonicity by water consumption. The model currently used to predict changes in serum sodium concentration and in tonicity from hyperglycemia assumes no changes in external balance of body water or solute during development of hyperglycemia and, therefore, is not applicable in ambulatory dialysis patients with intact thirst mechanism, because of water retention. In ambulatory patients on chronic dialysis, clinical manifestations of hyperglycemia include thirst, water intake, and weight gain. Neurologic manifestations due to hypertonicity are usually absent.

We analyzed routine serum potassium concentration measurements and conditions temporally associated with abnormalities in potassium concentration in outpatients on chronic hemodialysis (136 nondiabetics, 36 diabetics) and continuous ambulatory peritoneal dialysis (16 nondiabetics, 10 diabetics). The following potassium concentration frequencies were found: prehemodialysis, nondiabetics: normal 51.3%, severe hyperkalemia (greater than 6.0 mmol/l) 10%, severe hypokalemia (less than 3.0 mmol/l) 0.3%; diabetics: normal 57.8%, severe hyperkalemia 8.7%, severe hypokalemia 0.5%. Peritoneal dialysis, nondiabetics: normal 73.7%, severe hyperkalemia 0.6%, severe hypokalemia 4.9%; diabetics: normal 72.5%, severe hyperkalemia 0.9%, severe hypokalemia 2.9%. Normokalemia and severe hypokalemia were significantly (chi 2 test) more frequent in peritoneal dialysis than in prehemodialysis, whereas severe hyperkalemia was more frequent in prehemodialysis serum samples. No difference was found between nondiabetics and diabetics for either form of dialysis. 50% of prehemodialysis episodes of hyperkalemia were diet-induced. Hyperkalemic drugs and anuria were not associated with a higher risk of prehemodialysis hyperkalemia, but each one of 3 abnormalities, very high BUN (greater than 40 mmol/l), metabolic acidosis (TCO2 less than 15 mmol/l) and, in diabetics, severe hyperglycemia (serum glucose greater than 30 mmol/l), was associated with a statistically higher risk of hyperkalemia.

The abnormal cutaneous flora of hemodialysis (HD) patients might contribute to their frequent septic complications. We compared the effects of 13 wk of Betadine and 13 wk of Hibiclens on the skin flora of HD patients and personnel. Skin cultures were obtained weekly immediately prior to the disinfection, preceding each triweekly HD treatment, and monthly, at 2 and 4 hr postdisinfection. Total bacterial counts from predisinfection cultures were not significantly altered over either 13-wk treatment period. Hibiclens reduced total bacterial counts (p less than 0.01) and eradicated cutaneous staphylococci (p = 0.032) at both 2 and 4 hr postdisinfection significantly more than did Betadine. No reduction of staphylococcal sensitivity to either germicidal agent could be demonstrated. Neither agent was associated with severe adverse reactions and Hibiclens could not be detected in the blood. Hibiclens appears to offer short-term advantages over Betadine in the HD setting because of significantly longer duration of antibacterial activity.

The authors studied hyperglycemia occurring in insulin-dependent diabetic patients on chronic dialysis to determine the types of associated acid-base disorders, their treatment, and any differences from hyperglycemia in diabetic patients with intact renal function. Eighty-eight episodes of serum glucose greater than 25 mmol/L were observed, 23 in hemodialysis patients and 65 in patients on continuous peritoneal dialysis. Treatment consisted of low-dose insulin in 77 episodes and low-dose insulin plus saline in 11; no base was administered. Seventeen episodes (19%) presented with ketoacidosis. Arterial blood gas determinations were carried out at presentation in 37 of the episodes without ketoacidosis. Of these, 12 had respiratory alkalosis, six had respiratory acidosis and severe pulmonary edema, 14 had other single or mixed acid-base disorders, and only five had normal acid-base status. Insulin corrected the ketoacidosis in all instances and both pulmonary edema and respiratory acidosis in five of six instances. In eight cases metabolic alkalosis developed during treatment, without external acid loss. At the completion of treatment respiratory alkalosis was present in half the cases. No difference was noted between patients treated with hemodialysis or peritoneal dialysis. Insulin alone is sufficient for the management of hyperglycemia in dialysis patients. Certain acid-base disorders persist, but do not need further treatment. Hyperglycemia in patients on dialysis is characterized by infrequent development of metabolic acidosis and frequent presentation with respiratory alkalosis, by respiratory acidosis that is corrected by insulin, and by metabolic alkalosis developing during treatment without external cause.

We measured by affinity chromatography glycosylated hemoglobin levels in the blood of 43 diabetic and nondiabetic patients (139 measurements) on long-term dialysis therapy (continuous ambulatory peritoneal dialysis and hemodialysis) to determine the usefulness of this method of estimating glycemic control in diabetic persons on dialysis therapy. In nondiabetic patients, glycosylated hemoglobin levels were within the normal range (4.0% to 6.8% of total blood hemoglobin levels) for both continuous ambulatory peritoneal dialysis and hemodialysis. Glycosylated hemoglobin values correlated significantly with fasting blood glucose levels, serum urea levels, and serum total carbon dioxide content. By stepwise regression, fasting blood glucose values accounted statistically for .54 of the variability (R2) in glycosylated hemoglobin. The contribution of the other variables to this variability was minimal. In 9 diabetic patients (3 on hemodialysis), glycosylated hemoglobin levels correlated significantly with average daily blood glucose levels. Regression of the fasting blood glucose value on glycosylated hemoglobin was similar between continuous ambulatory peritoneal dialysis and hemodialysis. Measuring glycosylated hemoglobin levels by affinity chromatography is a suitable method for assessing glycemia in dialysis patients.