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Abstract In rare cases (1-8%) diabetic patients with end-stage renal disease (ESRD) suffer from diabetic nephropathy (dNP) due to pancreatic diabetes mellitus (PDM). Aim of this study was to investigate differences in the outcome of patients with PDM and those with type 2 diabetes. In a retrospective study we evaluated 96 diabetic patients, who started hemodialysis (HD) in our dialysis centre (1997-2005). In 12 patients PMD was diagnosed, and 84 patients had type 2 diabetes. In both groups we compared vascular risk factors and prevalence of vascular diseases at the start of dialysis. We also evaluated incidence of malnutrition, and 5-year survival in both patient groups. The vascular risk factors were similar in both patient groups, also the prevalence of vascular diseases at the initiation of HD was similar in both groups. In the patients with PDM the mean BMI (kg/m2) was lower (22 + 3 versus 25 + 3), and also their serum albumin was lower (2.7 + 0.3 versus 3.4 + 0.3 g/dl, p < 0.05). Four of these patients (33%) developed malnutrition (BMI < 18.5). In the patients with PDM the age adjusted 5-year survival was significantly lower (8% versus 27%, p < 0.05) than in the type 2 diabetic patients. Conclusions in HD-treated patients with type 2 diabetes or PDM the prevalence of vascular diseases was not significantly different. The lower survival of PDM patients can be related to poor nutrition status.

Aim: Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity and mortality. In the general population, an increased heart rate is associated with increased mortality. Only a few studies have investigated heart rate in RA patients and compared the results with patients that do not have RA (n-RA). Therefore, little is known as to whether an increased heart rate, at least in part, could explain the increased mortality found in RA patients. The aim of the present study was to investigate whether heart rate is increased in RA patients., Methods: In this cross-sectional study, heart rate was determined in a total of 282 patients (131 RA, 151 n-RA). In addition, non-invasive pulse wave analysis of the radial artery was performed to determine cardiac ejection duration using the Sphygmocor apparatus. Furthermore, the subendocardial viability ratio (SEVR), a marker of cardiac workload, was investigated, whereby higher values indicate a more favorable supply/demand relationship for the myocardium. Patients using chronotropic drugs were not included in the study., Results: Heart rate was virtually the same in RA patients (71.9 ± 11.2 beats/min [bpm]) as compared with controls (72.3 ± 11.7 bpm; P > 0.05). Also SEVR (RA 144 ± 25% vs. n-RA 147 ± 27%; P > 0.05) and ejection duration (RA 321 ± 24 ms vs. n-RA 318 ± 24 ms; P > 0.05) were comparable between the groups., Conclusion: It could not be shown that heart rate in RA patients differs significantly from heart rate in controls. Therefore, heart rate does not appear to explain or contribute to the increased cardiovascular risk found in RA patients., (© 2013 The Authors International Journal of Rheumatic Diseases © 2013 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.)

Both hemodialysis (HD) as well as peritoneal dialysis (PD), are efficient renal replacement therapies in uremic patients with and without diabetes. PD is less expensive dialysis modality and may provide a survival advantage over hemodialysis in first 2 to 4 years of treatment. Chronic ambulatory peritoneal dialysis (CAPD) as well as Continuous Cycler-Assisted Peritoneal Dialysis (CCPD) have additional advantages in patients with diabetes. PD therapy will be better tolerated than HD, the blood pressure is more stable and vascular access is not necessary. Preserving residual renal function (RRF) is of paramount importance to prolong the survival outcomes in PD patients. In insulin-dependent diabetic patients intraperitoneal insulin substitution can be used. The development of new, more biocompatible PD solutions holds promise for the future. Nevertheless, in many countries HD is further more favoured in the treatment of patients with ESRD.

Background: Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity. It was previously shown that the augmentation index (AIx), a marker of vascular dysfunction, is higher in RA patients without traditional cardiovascular risk factors than in healthy controls. In this study we determined whether the impact of RA on the AIx is diminished in the context of coexisting, strong cardiovascular risk factors., Patients and Methods: A total of 411 participants were included [203 with RA; 208 in the non-RA (n-RA) group]. Pulse-wave analysis was performed on the radial artery using applanation tonometry. The impact of RA on the AIx was determined in a single and in a multiple linear regression model., Results: The mean unadjusted AIx was 30.5 ± 9.0% for RA patients and 24.0 ± 11.0% for the n-RA group (P < 0.001). In the regression model, the following variables are statistically significant at approximately the same level (P < 0.001); the order of impact of these variables is age > diastolic blood pressure > sex > RA > height > smoking status. RA, height, and smoking had a nearly equal impact on the AIx., Conclusions: The AIx is increased in RA patients regardless of the coexistence of traditional cardiovascular risk factors, thereby reflecting vascular dysfunction in this population. The impact of RA on the vascular system is comparable to that of smoking., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: Uremic type 2 diabetic patients on hemodialysis need various types of antidiabetic therapies. The aim of the present study was to identify differences between patients on oral antidiabetic drug therapy or insulin substitution or diet therapy alone during their first year of hemodialysis., Patients and Methods: Sixty-four type 2 diabetic patients who had started hemodialysis (HD) at our dialysis center between 2003 and 2007 were included in the study. Kidney-transplanted patients (n = 1) and those with chronic infectious or malignant diseases (n = 4) were excluded. Patients were divided into three groups according to their antidiabetic therapy: group 1 consisted of patients on oral antidiabetic drug therapy (n = 12), group 2 of those on insulin therapy (n = 42), and group 3 of those being treated with diet alone (n = 10). At the start of HD and 12 months later, we measured fasting plasma glucose (FPG), HbA1c, the incidence of hypoglycemia (n/patient/month), cholesterol, triglycerides, body weight, and insulin requirements in the insulin-treated group. C-peptide was only measured at the start of dialysis. We evaluated changes in antidiabetic therapy during the first year on dialysis, and the prevalence of vascular disease in each group at the start of HD., Results: FPG and HbA1c values were similar in all groups at the start of HD and after 1 year. Hypoglycemia occurred more frequently in insulin-treated patients; however, the difference was not significant. Cholesterol levels were similar in all groups, whereas triglycerides were significantly lower in insulin-treated patients (138 ± 28 vs. 176 ± 46 mg/dl; P < 0.05). Body weight was similar in all groups. No significant change in body weight was observed in any group after 12 months on dialysis. At the start of HD, C-peptide levels were lower in insulin-treated patients than in the other groups (1.8 ± 0.9 ng/ml vs. 2.2 ± 1.1 and 2.4 ± 1.1 ng/ml; P < 0.05). During the first 12 months on HD, two patients from group 1 were shifted to group 3 (diet alone), while four patients could reduce their drug dosage (33%). However, two subjects became insulin-dependent. In group 2, insulin therapy could be terminated in two cases, while the insulin dose could be reduced in 20 patients (48%). In group 3, one patient was switched to oral antidiabetic therapy. The prevalence of vascular disease was slightly higher in group 3 (NS)., Conclusion: Within 1 year after the start of HD, the dose of sulfonylurea as well as insulin could be reduced in a large majority of patients. Metabolic control was similar in all groups. Only triglycerides were significantly lower in group 2. The frequency of hypoglycemia and the prevalence of vascular disease were just slightly higher in the group on insulin therapy.

Objecives: The clinical and histological diagnosis (gold standard) of diabetic nephropathy (dNP) and vascular nephropathy (vNP) were compared in type 2 diabetic patients with end-stage renal disease (ESRD)., Aim: The aim of the study was to investigate indication for renal biopsy in type 2 diabetic patients with renal disease., Design: Retrospective study in diabetic patients with clinical and histological diagnosis of renal disease., Patients and Methods: Eighty-four patients with type 2 diabetes and ESRD were investigated. Histological findings of the kidneys were available in all patients, 14 had undergone a renal biopsy before their first dialysis while a post-mortem kidney investigation was performed in 70 subjects. According to the histological findings, 66 patients had dNP and 18 subjects had vNP. The histological diagnosis was compared with the clinical diagnosis, and the sensitivity as well as the specificity of the clinical diagnosis of dNP and vNP were calculated., Results: The clinical diagnosis was not identical with the histological diagnosis in 10 cases. In the dNP group the diagnosis was 4 false positive and 3 false negative as in the vNP group 1 false positive and 2 false negative. The sensitivity of clinical diagnosis was 95% for dNP and 89% for vNP. Specificity was 78% for dNP and 97% for vNP., Conclusion: The sensitivity of the clinical diagnosis is very high for dNP as well as vNP. A renal biopsy is not required in the majority of type 2 diabetic patients with ESRD, especially in patients who exhibit all criteria for clinical diagnosis.

Pulse wave velocity (PWV), a marker of arterial stiffness, reflects vascular dysfunction and is associated with cardiovascular risk. Rheumatoid arthritis (RA) is associated with profound changes in vascular function and premature death, mainly caused by cardiovascular diseases. The aim of this study was to investigate arterial stiffness in the brachial artery (a muscular type of artery) as measured by PWV in women with longstanding RA and to compare the results with healthy controls and to patients with traditional cardiovascular risk factors without RA. A total of 80 female participants underwent non-invasive measurement of PWV. Participants were allocated to one of three groups: patients with longstanding RA (disease duration >5 years) without traditional cardiovascular risk factors (n = 30), patients with traditional cardiovascular risk factors (n = 20) and healthy controls (n = 30). Patients and controls were matched for age. PWV was significantly higher in RA patients (8.6 +/- 0.9 m/s) as compared with healthy controls (8.1 +/- 0.7 m/s; P = 0.02). PWV was virtually the same in RA patients and patients who had traditional cardiovascular risk factors (8.6 +/- 1.5 m/s; NS). PWV was also higher in this group as compared with healthy controls, but this difference did not reach statistical significance (NS). RA is associated with a higher PWV as compared with healthy controls and is comparable to patients with known traditional risk factors. This reflects vascular dysfunction in patients with RA.

Premature atherosclerosis is linked to inflammation. Arterial stiffness is a marker of vascular dysfunction. We tested the hypothesis that treatment with infliximab, which is effective in reducing inflammation in rheumatoid arthritis (RA) and ankylosing spondylitis (AS), also lowers the augmentation index (AIx) in patients with active disease. We also analyzed the subendocardial viability ratio (SEVR), which is a measure of myocardial perfusion relative to cardiac workload. Included in the study were 30 patients (17 RA, 13 AS). Conventional treatment failed in all patients. The AIx and SEVR were determined by radial applanation tonometry before and after treatment with infliximab, at baseline and at week 7. After treatment with infliximab, Disease Activity Score for 28 joints (RA patients), Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index (AS patients), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) improved significantly (p < 0.001). The AIx for all patients increased from 22.0 +/- 14.0% to 24.6 +/- 13.0% (p = 0.03). The increase in the RA sub-group (p = 0.01) was also significant. The SEVR decreased from 148.6 +/- 23.7% to 141.2 +/- 23.7% (p = 0.04). Infliximab did not reduce the AIx in patients with RA and AS, although there were clinical improvements and CRP and ESR decreased. Instead, the AIx increased. This could negatively influence cardiac workload.

Aim: To investigate relapse predictors in chronic hepatitis C (CHC) patients with end-of-treatment response (ETR), after pegylated interferon-alpha (PegIFN-alpha) and ribavirin treatment., Methods: In a retrospective study we evaluated a spectrum of predictors of relapse after PegIFN-alpha and ribavirin treatment in 86 CHC patients with ETR. Viral loads were determined with real-time reverse transcription polymerase chain reaction. Hepatitis C virus genotyping was performed by sequencing analysis. Patients with genotype 1 were treated for 48 wk with 180 microg PegIFN-alpha2a or 1.5 microg/kg PegIFN-alpha2b once weekly plus ribavirin at a dosage of 1000 mg/d for those under 75 kg or 1200 mg/d for those over 75 kg. Patients with genotypes 2 and 3 were treated for 24 wk with 180 microg PegIFN-alpha2a or 1.5 microg/kg PegIFN-alpha2b once weekly plus ribavirin at a dosage of 800 mg/d., Results: In all ETR patients, binary logistic regression analysis identified absence of complete early virological response (cEVR) (OR 27.07, 95% CI: 3.09-237.26, P < 0.005), serum alkaline phosphatase (ALP) levels prior to therapy < 75 U/L (OR: 6.16, 95% CI: 2.1-18.03, P < 0.001) and body mass index > 26 kg/m(2) (OR: 8.27, 95% CI: 2.22-30.84, P < 0.005) as independent predictors of relapse. When cEVR patients were analyzed exclusively, ALP prior to therapy < 75 U/L remained the only predictor of relapse., Conclusion: Lower levels of ALP prior to, during and after therapy seem to be associated with a higher risk of relapse in CHC patients with ETR.

Nephrogenic systemic fibrosis (NSF) is a rare and debilitating disease which affects patients with kidney failure. The most obvious manifestation is fibrosis of the skin, but it also frequently involves the locomotor system and the inner organs. An association has been found with the administration of gadolinium-containing contrast agents, which are given to provide enhanced contrast during magnetic resonance imaging. It is thought that unstable chelate complexes release toxic gadolinium. Other triggers or co-triggers may also be relevant. No effective treatment currently exists for NSF, so prevention of the disease is of the utmost importance. If gadolinium-containing contrast agents need to be administered to patients who have kidney failure, a cyclic agent should be used, and the dosage should be as low as possible. Although no proof is yet available that hemodialysis prevents NSF, it is effective in the clearance of gadolinium and should therefore be considered as a treatment immediately after the imaging.

Objective: There is growing evidence of premature atherosclerosis in patients with rheumatoid arthritis (RA), leading to a higher rate of cardiovascular events than in the general population. The augmentation index (AIx), a marker of arterial stiffness, is an indicator of vascular function. The aim of the study was as follows: (1) to investigate whether AIx is increased in RA patients without traditional cardiovascular risk factors and (2) to evaluate whether there is an interrelationship with large artery remodeling as ascertained by carotid ultrasound., Methods: Thirty-six RA patients (age, 46.4 +/- 7.7 years; 31 female) were recruited. Patients were eligible for analysis if they had no traditional cardiovascular risk factors. AIx was assessed noninvasively during pulse wave analyses. For large artery remodeling the intima-media thickness (IMT) was measured in both common carotid arteries with ultrasound. Results were compared with 36 age- and sex-matched controls., Results: AIx was statistically significantly higher in RA patients as compared with controls (27.4 +/- 9.4% versus 18.4 +/- 9.0%; P < 0.001). In addition, IMT was significantly higher in RA patients (0.73 +/- 0.16 mm versus 0.65 +/- 0.12 mm; P = 0.01). In RA patients there was a positive correlation between IMT and AIx (r[IMT; AIx] = 0.45; P = 0.008)., Conclusion: AIx, a marker of arterial stiffness, as well as IMT, a marker of large-artery remodeling, are increased in RA patients without traditional cardiovascular risk factors. Measuring AIx might assist in better assessing the increased cardiovascular risk in RA patients.

Background: B-type natriuretic peptide (BNP) plays a key role in the regulation of volume homeostasis, and elevated blood levels of BNP are associated with end-stage renal disease. Renal transplantation leads to a decrease of elevated BNP levels with established graft function. Assessment of N-terminal pro-BNP (NT-proBNP) is established as reflecting volume homeostasis, and we therefore studied the relationship between NT-proBNP and allograft function in a prospective study., Methods: NT-proBNP was assessed in 76 patients with end-stage renal disease undergoing renal transplantation. Patients were grouped according to immediate or delayed graft function. The degree of allograft function was assessed from the estimated glomerular filtration rate according to the MDRD formula., Results: In patients with immediate graft function (n = 48), median NT-proBNP decreased immediately after transplantation; in patients with delayed function (n = 28), median NT-proBNP first increased and then decreased as function improved. Patients with early acute rejection showed significantly higher NT-proBNP levels prior to transplantation than patients without rejection. NT-proBNP levels measured 2 or 3 weeks post-transplant were significantly correlated with the estimated glomerular filtration rate 1 year after transplantation., Conclusions: An association was observed between renal allograft function and post-transplant levels of NT-proBNP. The association was not found to be a useful general predictor for graft function in individual patients in a clinical setting, as the range of NT-proBNP levels measured was too wide.

No clear consensus exists on whether methotrexate (MTX) should be continued or whether this therapy should be discontinued for a few weeks in patients with rheumatoid arthritis (RA) undergoing surgery. Continued MTX therapy may impair wound healing, but discontinuation of the therapy may increase the risk of flares. In this article we review published data on the perioperative management of MTX in patients with RA undergoing elective orthopedic surgery. Eight papers on this topic could be identified. These studies compare continued vs. discontinued MTX therapy or MTX therapy vs. therapies other than MTX. Summing up the published data, continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares. None of the examined papers addresses the issue of safety in connection with comorbidities, age or high doses of MTX.

Background: During recent years, the number of patients with end-stage renal disease (ESRD) has been rising worldwide. Especially older patients and those with diabetes contribute to this rise. The aim of the present study was to evaluate whether patients older than 65 years with type 2 diabetes, who started first dialysis, have a higher prevalence of vascular diseases and co-morbidities, show a higher incidence of vascular complications and/or have a higher mortality rate than elderly non-diabetic patients with ESRD., Patients and Methods: In this study, 82 consecutive patients with ESRD, who had either type 2 diabetes or did not have diabetes and who had started chronic hemodialysis (HD) in our dialysis center during the years 1994 to 2002, were included. Patients were included when they were older than 65 years. Patients were divided into two groups: those with diabetes (DM) (n = 47) and those without diabetes (nDM) (n = 35). For both groups the number of co-morbidities as well as the prevalence of vascular diseases and vascular risk-factors at the start of HD was evaluated. In addition, the incidence of vascular complications was registered over a 3-year observation period. In both groups serum(S)-creatinine, blood urea nitrogen (BUN), creatinine clearance, hemoglobin, fasting blood glucose, HbA1c (in diabetic patients), cholesterol, triglycerides and phosphorus were evaluated., Results: At the start of HD the creatinine clearance was significantly higher in diabetic subjects (nDM 7.1 +/- 2.1 vs DM 9.5 +/- 4.4 ml/min/1.73 m2; p < 0.005). For S-creatinine the difference was not statistically significant (nDM 8.7 +/- 3.3 mg/dl vs DM 7.4 +/- 2.4; p = 0.07). Fasting blood glucose was significantly higher in diabetic patients (p < 0.001). BUN, hemoglobin, phosphorus and lipids were not significantly different in both groups. There was no statistically significant difference in systolic or diastolic blood pressure, but a higher amount of antihypertensive drugs were necessary in the DM group for blood pressure control (p < 0.01). In both groups there was a high prevalence of vascular diseases at the start of HD. In the diabetic patients the prevalence of peripheral vascular disease was significantly higher. Furthermore, in the first and second year significantly more vascular complications were observed in the DM group (p < 0.01). Survival was low in both groups. The 3-year survival was 20.0% in non-diabetic and 17.0% in diabetic patients (NS)., Conclusion: Patients older than 65 years with ESRD have a low survival with and without type 2 diabetes. The mortality rate was only slightly higher in the diabetic group and was not statistically significant. The prevalence of vascular diseases and co-morbidities is high in both groups; however, the incidence of cardiovascular complications was significantly higher in our diabetic patients.

We evaluated the impact of smoking on the progression of macro-angiopathy as well as patient and graft survival in 35 type-1 diabetic patients with simultaneous kidney-pancreas transplantation (SKPT). According to their smoking history, the patients were divided into smokers (n = 12) and nonsmokers (n = 23). Mean observation period was 80 (12-168) vs. 84 (12-228) months. The prevalence of vascular diseases as well as the incidence of vascular complications during the observation period was evaluated in each group. Graft- and patient survival were calculated. The prevalence of all vascular diseases was higher in the smokers with prior SKPT at the start as also at the end of study; however, the differences were not significant. In addition, the incidence of vascular complications (stroke, myocardial infarction and amputation) during the follow-up period was higher in the smoking group. Taking all vascular complications together (events/patient/year) the difference was significant (0.105 vs. 0.066, P < 0.05). One- and 5-year patient survival was 100% and 75% for smokers vs. 100% and 91% for nonsmokers. One- and 5-year pancreas graft survival at the same time was 100% and 75% in living smokers as well as 100% and 83% in the nonsmokers: We conclude that smoking after SKPT is associated with a progression of macro-angiopathy. Additionally, mortality after SKPT tends to be higher in smoking patients.

Infliximab is used in the treatment of various diseases, such as rheumatoid arthritis (RA), psoriasis, psoriatic arthritis (PA), Crohn's disease (CD) and ankylosing spondylitis (AS). In most countries, infliximab is given in hospitals or infusion centers, which are experienced in the management of infusion reactions. Because of this side effect, general practitioners (GPs) might refuse to administer infliximab in their offices. The aim of this study was to investigate the safety of infliximab administration in GPs' offices. Health system in the provincial state of Upper Austria (Austria) provides reimbursement of biological treatment only in outpatient care. Infliximab is due to cost effectiveness usually administered by GPs after a specific training and initialisation of treatment by specialists in the hospital. We sent out a form to 42 cooperating GPs, containing 20 questions concerning the administration of infliximab. Thirty-four forms were returned and evaluated. Altogether, 69 patients (2 patients per doctor mean) were treated with infliximab (1-42 months; 21 months mean). The overall observation period was 697 patients-months. During this period, 487 infusions (14.5 infusions per doctor mean) were administered. From five doctors, seven adverse events (AE) in six patients were reported. In all seven cases, infusion was discontinued; two had allergic reactions and five had nausea or cardiac symptoms, not definitely of allergic origin. Severe adverse events (SAE), defined as shock, emergency treatment or hospitalisation during or after infliximab administration were reported by two doctors. In contrast, SAE during the infusion of other drugs (e.g. analgetics, vitamins) were previously seen by 16 doctors, showing the overall possibility of infusion reactions with commonly prescribed drugs. Almost all (31/34) confirmed the overall safety of infliximab administration in GP's patient care. The administration of infliximab by specially trained general practitioners with background guidance through rheumatologist or gastroenterologist centers seems to be a safe and acceptable way to provide long-term treatment with infliximab to patients in need of biological treatment.