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Introduction: It is unclear whether kidney/pancreas (KP) transplantation will prevent the progression of peripheral arterial disease (PAD) in patients with insulin dependent diabetes (IDDM) and end‐stage renal disease. We sought to determine the pre‐ and posttransplant prevalence of symptomatic PAD and changes in carotid artery intima‐media thickness (IMT) in KP recipients. Methods: In this single center study, outcomes were compared between KP recipients with and without a history of PAD. A subset of recipients underwent pre‐ and posttransplant IMT measurements. Results: Among the study group (N = 107), 18 (17%) recipients admitted to a pretransplant history of symptomatic PAD, comprised 11 foot infections and 7 amputations (5 minor and 2 major). Baseline characteristics of age, gender, race, years of diabetes, dialysis history, smoking history, years of hypertension, and history of coronary artery disease (CAD) were equivalent between PAD and non‐PAD cohorts. At a median follow‐up of 60 months (IQR: 28, 110), 16 (15%) KP recipients had suffered a PAD event. In multivariate analysis, a pretransplant history of PAD (hazard ratio [HR] 9.66, p < 0.001) and CAD (HR 3.33, p = 0.04) were independent predictors of posttransplant PAD events. Among a subset of 20 recipients (3 with PAD), mean IMT measurements pretransplant and at a median of 24 (range 18–24) months posttransplant, showed no evidence of disease progression. Conclusion: Based on IMT measurements and clinical results, KP transplantation stabilized PAD in most patients, but did not alter outcomes of symptomatic PAD recipients. A pretransplant history of PAD and CAD was an independent predictor of posttransplant PAD events. [ABSTRACT FROM AUTHOR]

This article discusses the use of real-time continuous glucose monitoring (rtCGM) in the intensive care unit (ICU) as a means of managing hyperglycemia in hospitalized patients. Hyperglycemia is associated with complications, longer hospital stays, and higher mortality rates. The article highlights the benefits of rtCGM in minimizing patient contact and protecting healthcare workers during the COVID-19 pandemic. The study found that rtCGM was effective and feasible in critically ill patients undergoing major abdominal surgery, with comparable accuracy to traditional blood glucose monitoring methods. However, the study's use of arterial blood samples as a reference may limit its applicability to other hospital settings. Despite this limitation, the study supports the use of rtCGM as a valuable tool for glycemic control in high-risk hospitalized patients. Further research is needed to evaluate its efficacy on clinical outcomes and cost-effectiveness. [Extracted from the article]

Guidelines recommend basal bolus insulin for inpatient hyperglycemia management based on studies performed in patients with type 2 diabetes without any corticosteroid therapy. However, in the "real-world," corticosteroid use is common and complicates management. To better understand insulin use in corticosteroid related hyperglycemia, we conducted a large, retrospective study of patients who were: age >18 years, admission >48 hours, administered insulin >75% of admission, AND administered corticosteroids within the first 2 days of admission. Patients receiving IV insulin or no insulin within two days were excluded. Insulin therapy was categorized into 3 groups based on observed prescribing practices: (a) sliding scale (SS, n=481) (b) basal bolus (BB, n=356), (c) Basal plus (B+, n=386). Each group was analyzed for glucose control: days with hypoglycemia (any <70mg/dl), hyperglycemia (mean >180 mg/dl) or euglycemia (no hypo- or hyperglycemia) and clinical outcomes of length of stay (LOS), 30/60-day readmission, and hospital mortality. Patient and provider factors that influence choice of therapy were controlled using propensity score adjusted models. BB had fewer hyperglycemic days and lower LOS, albeit more hypoglycemia than SS. B+ had higher hyperglycemic and hypoglycemic days than SS. For corticosteroid related hyperglycemia, BB was a superior insulin regimen in reducing hyperglycemia and LOS. Disclosure: B. Patham: None. A. Vadhariya: None. M.L. Johnson: None. S.D. Yande: None. A.R. Sadhu: None. [ABSTRACT FROM AUTHOR]

Hyperglycemia is associated with increased morbidity and mortality in hospitalized patients and intensive insulin therapy has been shown to improve clinical outcomes. These improvements should translate into economic benefits. Previously, a few studies have demonstrated reduced costs and length of stay but in limited settings. The aim of this project was to test the hypothesis that achievement of strict glycemic control in a large ICU population would reduce both length of stay and costs. The study cohort included 6,719 patients aged ≥ 18 admitted between 2003-2005 at UCLA to any of five ICUs that received intervention from the TRIUMPH team or four control ICUs that did not. The TRIUMPH team used intensive insulin therapy and glucose targets defined by the 2004 AACE guidelines to manage the intervention group. Outcomes included length of stay (LOS), cost measures and mortality. To control for confounding time trends when comparing outcomes pre- vs. post-intervention, a quasi-experimental design was used. Changes among intervention group between the pre-intervention (2003-04) vs. post-intervention (2005) years were compared with the equivalent changes among control group. The change in a given outcome Y attributable to the intervention was calculated as the "difference-in-differences" (DID) estimate [(Y[sub intv, post] - Y[sub intv, pre]) - (Y[sub cont, post] - Y[sub cont. pre])], using regression methods to adjust for changes in patient case-mix. All of the outcomes showed greater improvements among the intervention group (Table). The average reduction of 1.19 ICU days per admission associated with the intervention was statistically significant, although the associated ICU cost savings of $5231 per admission was not. The mean glucose in the intervention group was reduced by 21.5 mg/dL, whereas the control group had a reduction of only 2.3 mg/dL. A dedicated program for glucose management of ICU patients can significantly reduce the ICU length of stay. This may potentially have also translated into a savings of $5,534,398 in our intervention patients. [ABSTRACT FROM AUTHOR]

The comprehensive care of the kidney transplant (KT) patient includes a broad clinical assessment to detect and stage metabolic disease both before and after transplantation. In this review, the metabolic consequences of KT in both the short and long term will be explored in the context of new data and a synthesis proposed based upon what has been studied for over two decades. A review of the changes in epidemiology introduces a discussion of the current state of the literature for the diagnosis and management of diabetes after KT, obesity and the metabolic syndrome.

Background: The effect of adrenal replacement therapy (ART) with hydrocortisone on critical endpoints such as infection and mortality in critically ill patients with cirrhosis remains unclear. We evaluated our indications for ART in patients with cirrhosis with clinical symptoms of adrenal insufficiency (AI), and examined the rate of peri-transplant fungal colonization and mortality associated with ART., Methods: Seventy-eight patients with cirrhosis admitted to our institution's surgical intensive care unit (ICU) over a 4-year period met criteria for AI by vasopressor requirement and baseline cortisol levels. Outcomes included disposition at 90-days, fungal colonization, and fungal infection in the presence or absence of ART., Results: In total, 56 patients received hydrocortisone (HC+) while 22 did not (HC-). The HC+ and HC- groups had comparable median Model for End-stage Liver Disease (MELD) scores (26.5 vs. 25, respectively; p=0.93), median ICU lengths of stay (23 vs. 20 days, respectively; p=0.54) and median cortisol levels (18 μg/dL for both, p=0.87). Fungal cultures (FC) from blood, urine or bronchoalveolar lavage/sputum were positive for 44% of HC+, and 40.9% of HC- (p=0.77) had mortality rates between HC+ and HC- groups that were not significantly different (60.7% vs. 50%, respectively; p=0.39; α=0.05). The 90-day outcomes for HC+ vs. HC- (39.3% vs. 50% discharged, respectively; p=0.39; α=0.05) and those surviving to transplant (17.9% vs. 36.4%, respectively; p=0.08; α=0.05) were not significantly different between the two groups., Conclusion: In this small single-center series, we found that steroid administration for AI does not affect the rate of fungal colonization/infection or mortality. Further prospective studies are required to determine the utility of ART and factors affecting the rate of FC and mortality in these patients.

Currently patients with diabetes comprise up to 25-30% of the census of adult wards and critical care units in our hospitals. Although evidence suggests that avoidance of hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL) is beneficial for positive outcomes in the hospitalized patient, much of this evidence remains controversial and at times somewhat contradictory. We have recently formed a consortium for Planning Research in Inpatient Diabetes (PRIDE) with the goal of promoting clinical research in the area of management of hyperglycemia and diabetes in the hospital. In this article, we outline eight aspects of inpatient glucose management in which randomized clinical trials are needed. We refer to four as system-based issues and four as patient-based issues. We urge further progress in the science of inpatient diabetes management. We hope this call to action is supported by the American Diabetes Association, The Endocrine Society, the American Association of Clinical Endocrinologists, the American Heart Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the Society of Hospital Medicine. Appropriate federal research funding in this area will help ensure high-quality investigations, the results of which will advance the field. Future clinical trials will allow practitioners to develop optimal approaches for the management of hyperglycemia in the hospitalized patient and lessen the economic and human burden of poor glycemic control and its associated complications and comorbidities in the inpatient setting.