Calcific Uremic Arteriolopathy on Multimodal Combination Therapy: Still Unmet Goal

Background. Calcific uremic arteriolopathy (CUA) or calciphylaxis though generally noted for its high mortality, recent case reports have shown promising results using single agent therapies. However, it is not clear whether combination therapeutic agents will improve course of the disease. Objective. To determine clinical outcome in subjects with CUA on multimodal treatment. Methods. All patients with end-stage renal failure (ESRF) at The Townsville Hospital, Australia, from April 1, 2006, to March 31, 2011, with diagnosis of CUA were retrospectively studied. Results. Six subjects with CUA (4 females and 2 males) were on various combination therapeutic agents comprising sodium thiosulphate, hyperbaric oxygen, prednisolone, cinacalcet, and parathyroidectomy in addition to intensified haemodialysis, specialist local wound care, and antibiotics. The wounds failed to heal in 3 patients while 5 of the 6 subjects died; cause of death being sepsis in 3 and myocardial infarction in 2. Conclusion. Prognosis of CUA remains poor in spite of multimodal combination therapy. Further prospective studies on a larger population are needed to verify our findings

Extreme hypertriglyceridemia managed with intravenous insulin with or without nil per oral: is there a difference?

Extreme hypertriglyceridemia defined as serum triglyceride (TG) level >50 mmol/l (4425 mg/dl) can lead to acute pancreatitis (1). Rapid lowering of plasma TG is necessary in order to prevent such life threatening complications. However, there is no established guideline on the acute/immediate management of severe hypertriglyceridemia in clinical practice (2). The aim of the study was to review acute management and clinical course of patients with extremely high serum TG at a regional hospital. Ten cases of extreme hypertriglyceridemia admitted at the Australia's Townsville Hospital between January 2010 and October 2013 were retrospectively reviewed. Age range: 24-55 years. Nine out of the 10 subjects were patients with type 2 diabetes, 3 of them were newly diagnosed. Mean haemoglobin A1C was 12% (108 mmol/mol) and mean random blood glucose at presentation was 324 mg/dl (range: 184-533). Five patients presented with acute pancreatitis. Mean TG at presentation was 100.5 mmol/l (8894 mg/dl). Plasma TG levels decreased by about 80% in the first 24 hours in those patients who were managed with nil per oral (NPO) and intravenous (IV) insulin infusion (n=4) and by about 40% in those treated with IV insulin infusion alone without NPO (n=4). Furthermore, mean daily serum TG was lower in subjects on insulin + NPO compared to patients on insulin alone 9.5 vs 33.8 mmol/l (841 vs 2991 mg/dl), p=0.0002; CI: 13.0-38.3. The clinical course was uncomplicated in all except one patient who subsequently developed a pancreatic pseudocyst. Thus, poorly controlled type 2 diabetes is a common trigger for extreme hypertriglyceridemia. Combination of NPO and IV insulin is an effective, simple and safe treatment strategy in immediate management of severe hypertriglyceridemia. Further prospective studies on a larger population are needed to confirm our findings

High rates of lower limb amputation in patients with diabetes end stage renal failure on hemodialysis: is there a causal factor?

Hemodialysis has recently been identified as a risk factor for lower limb amputations (1,2). In spite of this no study has been published that analyses the magnitude and risk factors for amputation amongst hemodialysis patients in rural and remote communities and Indigenous Australian residents of the Tropical Northern region where diabetes and kidney disease are quite common (3). The objectives of this study were to document trends in prevalence and identify risk factors of non-traumatic lower limb amputations in diabetes subjects treated with hemodialysis in the region. 155 current haemodialysis patients attending the Townsville Dialysis Centre were included in the study. Odds ratio and χ2 tests were performed to identify variables most strongly associated with amputation. We identified a 13.6% prevalence of lower limb amputation in 155 subjects on hemodialysis at our centre. The major risk factors of amputations in the cohort were history of ulceration (RR 24.74 [95%CI 6.02-101.76] p<0.0001) and the presence of diabetes (RR 23.19 [95%CI 1.43-375.49] p=0.027). Other variables tested but fell short of statistical significance included: Indigenous background, smoking history, gender and type of ulceration. Thus, patients with end stage renal failure on hemodialysis who have a past history of ulceration and have diabetes mellitus are at higher risk of having lower limb amputation. Primary prevention of diabetes in the sub-population may help in reducing the limb loss. In-depth analysis of the data will be presented at the conference

Macrosomia in non-gestational diabetes pregnancy: glucose tolerance test characteristics and feto-maternal complications in tropical Asia Pacific Australia

Objective: To look into the glucose tolerance test characteristics and determine non-gestational diabetes pregnant subjects. \ud \ud Methods: From 2006 to 2009 all non-gestational diabetes mellitus (non-GDM) pregnant women who delivered macrosomia at the North Australia's Townsville Hospital were retrospectively reviewed by extracting data from clinical record. Glucose tolerance tests results were analysed in the light of an earlier diagnosis of non-GDM.\ud \ud Results: Ninety-one non-GDM mothers with macrosomia were studied and compared with 41 normoglycemic subjects without macrosomia. Of the subjects with non-GDM macrosomia 45 (49.4%) had normal 50g glucose challenge test (GCT) without further testing, another 8 (8.8%) had abnormal GCT but normal 75g oral glucose tolerance test (OGTT). 4 (4.4%) subjects had normal GCT and OGTT. Interestingly 14 out of 16 (87.5%) subjects who were tested with OGTT owing to past history of macrosomia had normal results but delivered macrosomic Only 12 subjects had both GCT and OGTT, the rest of the cohort had either of the 2 tests. Subjects with non-GDM macrosomia had higher frequency of neonatal hypoglycaemia 34% as compared to 10% in non-macrosomic babies p = 0.003. Other feto-maternal complications were similar in both groups. \ud \ud Conclusion: No significant pattern of glucose tolerance characteristics was identified in non-GDM mothers with macrosomic babies. In spite of being normoglycemic significant neonatal hypoglycaemia was recorded in non-GDM macrosomic babies. Further prospective studies on a larger population are needed to verify our findings

Forest Plot.

<p>Forest Plot displaying the Fore Foot Peak Plantar Pressure (MPP) between PPDFU group (cases) and DPN group (control). Overall effect is represented by the coloured diagonal. Six studies are included in total.</p

Meta analyses results.

<p>Legend: Random effects model meta-analyses. Effect size is standardised difference of mean values calculated as (DPN – PPDFU). Hence a negative result implies smaller values for DPN.</p>a<p>Rich et al. (2000) excluded because of issues with unit of analysis;</p>b<p>Studies included Bacarin, Sauseng and Stess;</p>c<p>Analysis of studies with 100% active ulcer group [active ulcer only] (Cavanagh et al Sauseng et al and Brash et al);</p>d<p>All studies (n = 8) including Cavanagh and Boulton with SD estimated from linear regression;</p>d2<p>Excluding Cavanagh and Boulton with SD estimated from linear regression;</p>e<p>Stess et al (1997) excluded due to high level of heterogeneity and inclusion of amputees;</p>f1<p>Rich et al and Stess et al excluded due to reasons given above;</p>f2<p>Rich et al and Stess et al excluded due to reasons given above;</p>g<p>Analysis with history of ulcers only [excluding active ulceration] (Bacarin et al, Boulton et al and Rich et al).</p

Search Results.

<p>Search results indicating total number of identified records (2730) and the number of articles remaining after duplicate removal (894) and the number of records excluded (827) and the number of full text articles assessed for eligibility according to the inclusion and exclusion criteria listed. This resulted in eight observational studies which were included in the meta-analysis.</p

Forest Plot.

<p>Forest Plot displaying the Overall Pressure Time Integral (PTI) between the PPDFU group(cases) and the DPN group(control). Overall effect is represented by the coloured diagonal. Three studies are included in total.</p