Prevalence and associated factors of hospitalization for dysglycemia among elderly type 2 diabetes patients: A nationwide study

BACKGROUND The prevalence of older individuals with type 2 diabetes mellitus (T2DM) is increasing due to the aging population and improved medical care. These patients are very susceptible to disease and treatment-related hospitalizations, resulting in higher health care costs, morbidity, and decreased quality of life. However, data of treatment-related complications, especially dysglycemiarelated hospitalizations, are lacking. AIM To assess the prevalence and associated factors for dysglycemia-related hospitalizations among elderly diabetic patients in Thailand using nationwide patient sample. METHODS T2DM patients aged ≥ 65 years who received medical care at public hospitals in Thailand in the year 2014 were included. The prevalence of hospitalization due to dysglycemia within one year was examined. Multivariable logistic regression was performed to assess the independent factors associated with hospitalization due to hypoglycemia and hyperglycemia RESULTS A total of 11404 elderly T2DM patients were enrolled in this study. The mean age was 72.9 ± 5.5 years. The prevalence of hospital admissions due to diabetic ketoacidosis, hyperosmolar hyperglycemic state, hyperglycemic dehydration syndrome, and hypoglycemia among elderly T2DM patients in the year 2014 was 0.1%, 0.1%, 1.7% and 3.1%, respectively. Increased hospitalization due to hypoglycemia was associated with older age, female sex, had hypertension, dementia, lower body mass index, elevated hemoglobin A1C (HbA1C), decreased kidney function, insulin use. Increased hospitalization due to hyperglycemia was associated with dementia, depression, lower body mass index, elevated HbA1C, and insulin use. CONCLUSION The prevalence of dysglycemia-related hospitalization in elderly T2DM patients in Thailand was 4.9%. Close monitoring of blood glucose should be provided in high-risk patients for prevention and early detection for these complications.

Liver transplantation and atrial fibrillation:A meta-analysis

AIM To assess prevalence of pre-existing atrial fibrillation(AF) and/or incidence of AF following liver transplantation, and the trends of patient's outcomes overtime; to evaluate impact of pre-existing AF and post-operative AF on patient outcomes following liver transplantation. METHODS A literature search was conducted utilizing MEDLINE, EMBASE and Cochrane Database from inception throughMarch 2018. We included studies that reported:(1) prevalence of pre-existing AF or incidence of AF following liver transplantation; or(2) outcomes of liver transplant recipients with AF. Effect estimates from the individual study were extracted and combined utilizing randomeffect, generic inverse variance method of DerSimonian and Laird. The protocol for this meta-analysis is registered with PROSPERO(International Prospective Register of Systematic Reviews, No. CRD42018093644). RESULTS Twelve observational studies with a total of 38586 liver transplant patients were enrolled. Overall, the pooled estimated prevalence of pre-existing AF in patients undergoing liver transplantation was 5.4%(95%CI: 4.9%-5.9%) and pooled estimated incidence of AF following liver transplantation was 8.5%(95%CI: 5.2%-13.6%). Meta-regression analyses were performed and showed no significant correlations between year of study and either prevalence of pre-existing AF(P = 0.08) or post-operative AF after liver transplantation(P = 0.54). The pooled OR of mortality among liver transplant recipients with pre-existing AF was 2.34(2 studies; 95%CI: 1.10-5.00). In addition, pre-existing AF is associated with postoperative cardiovascular complications among liver transplant recipients(3 studies; OR: 5.15, 95%CI: 2.67-9.92, I2 = 64%). With limited studies, two studies suggested significant association between new-onset AF and poor clinical outcomes including mortality, cerebrovascular events, post-transplant acute kidney injury, and increased risk of graft failure among liver transplant recipients(P < 0.05).CONCLUSION The overall estimated prevalence of pre-existing AF and incidence of AF following liver transplantation are 5.4% and 8.5%, respectively. Incidence of AF following liver transplant does not seem to decrease overtime. Preexisting AF and new-onset AF are potentially associated with poor clinical outcomes post liver transplantation.

Rituximab or plasmapheresis for prevention of recurrent focal segmental glomerulosclerosis after kidney transplantation:A systematic review and meta-analysis

BACKGROUND Focal segmental glomerulosclerosis(FSGS)is one of the most common glomerular diseases leading to renal failure.FSGS has a high risk of recurrence after kidney transplantation.Prevention of recurrent FSGS using rituximab and/or plasmapheresis has been evaluated in multiple small studies with conflicting results.AIM To assess the risk of recurrence of FSGS after transplantation using prophylactic rituximab with or without plasmapheresis,and plasmapheresis alone compared to the standard treatment group without preventive therapy.METHODS This meta-analysis and systematic review were performed by first conducting a literature search of the MEDLINE,EMBASE,and Cochrane databases,from inception through March 2021;search terms included‘FSGS,’’steroid-resistant nephrotic syndrome’,‘rituximab,’and‘plasmapheresis,’.We identified studies that assessed the risk of post-transplant FSGS after use of rituximab with or without plasmapheresis,or plasmapheresis alone.Inclusion criteria were:Original,published,randomized controlled trials or cohort studies(either prospective or retrospective),case-control,or cross-sectional studies;inclusion of odds ratio,relative risk,and standardized incidence ratio with 95%confidence intervals(CI),or sufficient raw data to calculate these ratios;and subjects without interventions(controls)being used as comparators in cohort and cross-sectional studies.Effect estimates from individual studies were extracted and combined using a random effects model.RESULTS Eleven studies,with a total of 399 kidney transplant recipients with FSGS,evaluated the use of rituximab with or without plasmapheresis;thirteen studies,with a total of 571 kidney transplant recipients with FSGS,evaluated plasmapheresis alone.Post-transplant FSGS recurred relatively early.There was no significant difference in recurrence between the group that received rituximab(with or without plasmapheresis)and the standard treatment group,with a pooled risk ratio of 0.82(95%CI:0.47-1.45,I2=65%).Similarly,plasmapheresis alone was not associated with any significant difference in FSGS recurrence when compared with no plasmapheresis;the pooled risk ratio was 0.85(95%CI:0.60-1.21,I2=23%).Subgroup analyses in the pediatric and adult groups did not yield a significant difference in recurrence risk.We also reviewed and analyzed posttransplant outcomes including timing of recurrence and graft survival.CONCLUSION Overall,the use of rituximab with or without plasmapheresis,or plasmapheresis alone,is not associated with a lower risk of FSGS recurrence after kidney transplantation.Future studies are required to assess the effectiveness of rituximab with or without plasmapheresis among specific patient subgroups with high-risk for FSGS recurrence.

Prediction of mortality among patients with chronic kidney disease:A systematic review

BACKGROUND Chronic kidney disease(CKD)is a common medical condition that is increasing in prevalence.Existing published evidence has revealed through regression analyses that several clinical characteristics are associated with mortality in CKD patients.However,the predictive accuracies of these risk factors for mortality have not been clearly demonstrated.AIM To demonstrate the accuracy of mortality predictive factors in CKD patients by utilizing the area under the receiver operating characteristic(ROC)curve(AUC)analysis.METHODS We searched Ovid MEDLINE,EMBASE,and the Cochrane Library for eligible articles through January 2021.Studies were included based on the following criteria:(1)Study nature was observational or conference abstract;(2)Study populations involved patients with non-transplant CKD at any CKD stage severity;and(3)Predictive factors for mortality were presented with AUC analysis and its associated 95%confidence interval(CI).AUC of 0.70-0.79 is considered acceptable,0.80-0.89 is considered excellent,and more than 0.90 is considered outstanding.RESULTS Of 1759 citations,a total of 18 studies(n=14579)were included in this systematic review.Eight hundred thirty two patients had non-dialysis CKD,and 13747 patients had dialysis-dependent CKD(2160 patients on hemodialysis,370 patients on peritoneal dialysis,and 11217 patients on non-differentiated dialysis modality).Of 24 mortality predictive factors,none were deemed outstanding for mortality prediction.A total of seven predictive factors[N-terminal pro-brain natriuretic peptide(NT-proBNP),BNP,soluble urokinase plasminogen activator receptor(suPAR),augmentation index,left atrial reservoir strain,C-reactive protein,and systolic pulmonary artery pressure]were identified as excellent.Seventeen predictive factors were in the acceptable range,which we classified into the following subgroups:predictors for the non-dialysis population,echocardiographic factors,comorbidities,and miscellaneous.CONCLUSION Several factors were found to predict mortality in CKD patients.Echocardiography is an important tool for mortality prognostication in CKD patients by evaluating left atrial reservoir strain,systolic pulmonary artery pressure,diastolic function,and left ventricular mass index.

Associations of new-onset atrial fibrillation and severe visual impairment in type 2 diabetes:A multicenter nationwide study

BACKGROUND Many studies have demonstrated an association between type 2 diabetes mellitus(T2DM)and atrial fibrillation(AF).However,the potential independent contributions of T2DM and AF to the prevalence of visual impairment have not been evaluated.AIM To determine whether such an association between T2DM and incident AF with visual impairment exists,and if so,the prevalence and magnitude of this association.METHODS We conducted a nationwide cross-sectional study based on the DM/HT study of the Medical Research Network of the Consortium of Thai Medical Schools.This study had evaluated adult T2DM patients from 831 public hospitals in Thailand in the year 2013.T2DM patients were categorized into two groups:patients without and with incident AF.T2DM patients without AF were selected as the reference group.The association between incident AF and visual impairment among T2DM patients was assessed using multivariate logistic regression.RESULTS A total of 27281 T2DM patients with available eye examination data were included in this analysis.The mean age was 60.7±10.5 years,and 31.2%were male.The incident AF was 0.2%.The prevalence of severe visual impairment in all T2DM patients,T2DM patients without AF,and T2DM patients with incident AF were 1.4%,1.4%,and 6.3%,respectively.T2DM patients with incident AF were associated with an increased OR of 3.89(95%CI:1.17-13.38)for severe visual impairment compared with T2DM patients without AF.CONCLUSION T2DM patients with incident AF were independently associated with increased severe visual impairment.Therefore,early eye screening should be provided for these high-risk individuals.

Recovery after acute kidney injury requiring kidney replacement therapy in patients with left ventricular assist device: A metaanalysis

BACKGROUND Acute kidney injury(AKI)is a common and severe complication after left ventricular assist device(LVAD)implantation with an incidence of 37%;13%of which require kidney replacement therapy(KRT).Severe AKI requiring KRT(AKI-KRT)in LVAD patients is associated with high short and long-term mortality compared with AKI without KRT.While kidney function recovery is associated with better outcomes,its incidence is unclear among LVAD patients with severe AKI requiring KRT.AIM To identify studies evaluating the recovery rates from severe AKI-KRT after LVAD placement,which is defined by regained kidney function resulting in the discontinuation of KRT.Random-effects and generic inverse variance method of DerSimonian-Laird were used to combine the effect estimates obtained from individual studies.METHODS A total of 268 patients from 14 cohort studies that reported severe AKI-KRT after LVAD were included.Follow-up time ranged anywhere from two weeks of LVAD implantation to 12 mo.Kidney recovery occurred in 78%of enrollees at the time of hospital discharge or within 30 d.Overall,the pooled estimated AKI recovery rate among patients with severe AKI-KRT was 50.5%(95%CI:34.0%-67.0%)at 12 mo follow up.Majority(85%)of patients used continuous-flow LVAD.While the data on pulsatile-flow LVAD was limited,subgroup analysis of continuous-flow LVAD demonstrated that pooled estimated AKI recovery rate among patients with severe AKI-KRT was 52.1%(95%CI:36.8%-67.0%).Metaregression analysis did not show a significant association between study year and AKI recovery rate(P=0.08).There was no publication bias as assessed by the funnel plot and Egger's regression asymmetry test in all analyses.RESULTS A total of 268 patients from 14 cohort studies that reported severe AKI-KRT after LVAD were included.Follow-up time ranged anywhere from two weeks of LVAD implantation to 12 mo.Kidney recovery occurred in 78%of enrollees at the time of hospital discharge or within 30 d.Overall,the pooled estimated AKI recovery rate among patients with severe AKI-KRT was 50.5%(95%CI:34.0%-67.0%)at 12 mo follow up.Majority(85%)of patients used continuous-flow LVAD.While the data on pulsatile-flow LVAD was limited,subgroup analysis of continuous-flow LVAD demonstrated that pooled estimated AKI recovery rate among patients with severe AKI-KRT was 52.1%(95%CI:36.8%-67.0%).Metaregression analysis did not show a significant association between study year and AKI recovery rate(P=0.08).There was no publication bias as assessed by the funnel plot and Egger's regression asymmetry test in all analyses.CONCLUSION Recovery from severe AKI-KRT after LVAD occurs approximately 50.5%,and it has not significantly changed over the years despite advances in medicine.

Proton pump inhibitors and adverse effects in kidney transplant recipients: A meta-analysis

BACKGROUND The adverse renal effects of proton pump inhibitors (PPIs) are increasingly recognized in both the general population and patients with chronic kidney disease. Several pharmacokinetic studies have also raised concerns regarding the interaction between PPIs and immunosuppressive drugs in transplant patients. Whether the adverse effects of PPIs have a clinical significance in kidney transplant recipients remains unclear. We performed this meta-analysis to assess the risk of adverse effects in kidney transplant recipients on PPI compared with those without PPI exposure. AIM To investigate the risk of acute rejection, graft loss, hypomagnesemia, renal dysfunction, and overall mortality in kidney transplant recipients on PPI compared with those without PPI exposure. METHODS A systematic review was conducted in MEDLINE, EMBASE, and Cochrane databases from inception through October 2018 to identify studies that evaluated the adverse effects of PPIs in kidney transplant recipients, including biopsyproven acute rejection, graft loss, hypomagnesemia, renal function, and overall mortality. Effect estimates from the individual studies were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird. The protocol for this meta-analysis is registered with PROSPERO, No. CRD42018115676. RESULTS Fourteen observational studies with 6786 kidney transplant recipients were enrolled. No significant association was found between PPI exposure and the risk of biopsy-proven acute rejection at ≥ 1 year [pooled odds ratio (OR), 1.25;95% confidence interval (CI), 0.82-1.91, I2 = 55%], graft loss at 1 year (pooled OR = 1.30, 95%CI: 0.75-2.24, I2 = 0%) or 1-year mortality (pooled OR = 1.53, 95%CI: 0.90-2.58, I2 = 34%). However, PPI exposure was significantly associated with hypomagnesemia (pooled OR = 1.56, 95%CI: 1.19-2.05, I2 = 27%). Funnel plots and Egger regression asymmetry test were performed and showed no publication bias. CONCLUSION PPI use was not associated with significant risks of higher acute rejection, graft loss, or 1-year mortality. However, the risk of hypomagnesemia was significantly increased with PPI use. Thus, future studies are needed to assess the impact of PPIs on long-term outcomes.