User login
Q) Does anemia in CKD patients affect their A1C? Is A1C accurate in CKD patients?
Tight glycemic control is imperative for patients with chronic kidney disease (CKD), but the management of diabetes in CKD can be complex due to factors including anemia and changes in glucose and insulin homeostasis.
A1C is directly proportionate to the ambient blood glucose concentration and in the general diabetic population has proven to be a reliable marker.1 However, it may not be valid in patients with diabetes and CKD. Reduced red blood cell (RBC) lifespan, rapid hemolysis, and iron deficiency may lead to falsely decreased results.2 Decreased RBC survival results from an increase in hemoglobin turnover, which decreases glycemic exposure time.1 This process then lowers the amount of nonenzymatic glucose binding to hemoglobin.1 Folate deficiency caused by impaired intestinal absorption in CKD also affects RBC survival.3 Falsely increased results may be related to carbamylation of the hemoglobin and acidosis, both of which are influenced by uremia.2
Special considerations should be made for dialysis patients with diabetes. In hemodialysis patients, A1C may be falsely decreased due to blood loss, RBC transfusion, and erythropoietin therapy.3 Observational studies have shown that erythropoietin therapy is associated with lower A1C due to the increased number of immature RBCs that have a decreased glycemic exposure time.1 In peritoneal dialysis patients, A1C may increase after the start of therapy as a result of dialysate absorption.3
Research suggests that glycated albumin (GA) provides a short-term index of glycemic control (typically two to three weeks) and is not influenced by albumin concentration, RBC lifespan, or erythropoietin administration.1 A clear consensus on optimal levels of GA has not been established, but GA may be a more reliable marker of glycemic control in patients with diabetes and CKD. Further research is needed to establish a target GA level that predicts the best prognosis for patients with both conditions.1
A1C is the most reliable marker at this time, but special considerations should be made for the patient with CKD. Rather than focus on a single measurement, clinicians need to consider the patient’s symptoms and results from all labwork, along with A1C, to best evaluate glycemic control.4 Further research is needed in patients with diabetes and CKD to explore other reliable markers to help maintain tight glycemic control.
Continued on next page >>
Q) One of my patients developed severe leg cramps while taking statins. I felt it was questionable rhabdomyolysis and stopped the medication; the leg pain went away. Is there a way to know if the rhabdomyolysis is progressive?
Rhabdomyolysis is a serious condition caused by the breakdown of muscle tissue that leads to the release of myoglobin into the bloodstream. This condition can lead to severe kidney failure and death.
Previously, there has been no easy method to predict progressive rhabdomyolysis. But researchers from Brigham and Women’s Hospital recently developed the Rhabdomyolysis Risk Calculator, a prediction score that can help determine whether a patient with rhabdomyolysis is at risk for severe kidney failure or death.
The researchers conducted a retrospective cohort study of 2,371 patients admitted between 2000 and 2011 and examined variables that may be associated with kidney failure and death.5 They identified independent predictors for these outcomes, including age; gender; initial levels of phosphate, calcium, creatinine, carbon dioxide, and creatine kinase; and etiology of rhabdomyolysis (myositis, exercise, statin use, or seizure).5
This tool can assist providers in developing a patient-specific treatment plan. However, further research is needed to validate the current variables, verify the risk prediction score in other populations, and examine its ability to guide individualized treatment plans.
The Rhabdomyolysis Risk Calculator is available at www.brighamandwomens.org/research/rhabdo/default.aspx
Kristy Washinger, MSN, CRNP
Nephrology Associates of Central PA
Camp Hill, PA
REFERENCES
1. Vos FE, Schollum JB, Walker RJ. Glycated albumin is the preferred marker for assessing glycaemic control in advanced chronic kidney disease. Nephrol Dial Transplant Plus. 2011; 4(6):368-375.
2. National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Guideline 2: management of hyperglycemia and general diabetes care in chronic kidney disease. www.kidney.org/professionals/kdoqi/guideline_diabetes/guide2.htm. Accessed April 15, 2014.
3. Sharif A, Baboolal K. Diagnostic application of the A1c assay in renal disease. J Am Soc Nephrol. 2010;21(3):383-385.
4. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.
5. McMahon GM, Zeng X, Walker SS. A risk prediction score for kidney failure or mortality in rhabdomyolysis. JAMA Intern Med. 2013;173(19):1821-1828.
| Clinician Reviews in partnership with |
 |
Renal Consult is edited by Jane S. Davis, CRNP, DNP, a member of the Clinician Reviews editorial board, who is a nurse practitioner in the Division of Nephrology at the University of Alabama at Birmingham and is the communications chairperson for the National Kidney Foundation’s Council of Advanced Practitioners (NKF-CAP); and Kim Zuber, PA-C, MSPS, DFAAPA, who is a physician assistant with Metropolitan Nephrology in Alexandria, Virginia, and Clinton, Maryland; she is also past chair of the NKF-CAP. This month’s responses were authored by Kristy Washinger, MSN, CRNP, who practices at Nephrology Associates of Central PA in Camp Hill, Pennsylvania.
| Clinician Reviews in partnership with |
|
Renal Consult is edited by Jane S. Davis, CRNP, DNP, a member of the Clinician Reviews editorial board, who is a nurse practitioner in the Division of Nephrology at the University of Alabama at Birmingham and is the communications chairperson for the National Kidney Foundation’s Council of Advanced Practitioners (NKF-CAP); and Kim Zuber, PA-C, MSPS, DFAAPA, who is a physician assistant with Metropolitan Nephrology in Alexandria, Virginia, and Clinton, Maryland; she is also past chair of the NKF-CAP. This month’s responses were authored by Kristy Washinger, MSN, CRNP, who practices at Nephrology Associates of Central PA in Camp Hill, Pennsylvania.
| Clinician Reviews in partnership with |
|
Renal Consult is edited by Jane S. Davis, CRNP, DNP, a member of the Clinician Reviews editorial board, who is a nurse practitioner in the Division of Nephrology at the University of Alabama at Birmingham and is the communications chairperson for the National Kidney Foundation’s Council of Advanced Practitioners (NKF-CAP); and Kim Zuber, PA-C, MSPS, DFAAPA, who is a physician assistant with Metropolitan Nephrology in Alexandria, Virginia, and Clinton, Maryland; she is also past chair of the NKF-CAP. This month’s responses were authored by Kristy Washinger, MSN, CRNP, who practices at Nephrology Associates of Central PA in Camp Hill, Pennsylvania.
Q) Does anemia in CKD patients affect their A1C? Is A1C accurate in CKD patients?
Tight glycemic control is imperative for patients with chronic kidney disease (CKD), but the management of diabetes in CKD can be complex due to factors including anemia and changes in glucose and insulin homeostasis.
A1C is directly proportionate to the ambient blood glucose concentration and in the general diabetic population has proven to be a reliable marker.1 However, it may not be valid in patients with diabetes and CKD. Reduced red blood cell (RBC) lifespan, rapid hemolysis, and iron deficiency may lead to falsely decreased results.2 Decreased RBC survival results from an increase in hemoglobin turnover, which decreases glycemic exposure time.1 This process then lowers the amount of nonenzymatic glucose binding to hemoglobin.1 Folate deficiency caused by impaired intestinal absorption in CKD also affects RBC survival.3 Falsely increased results may be related to carbamylation of the hemoglobin and acidosis, both of which are influenced by uremia.2
Special considerations should be made for dialysis patients with diabetes. In hemodialysis patients, A1C may be falsely decreased due to blood loss, RBC transfusion, and erythropoietin therapy.3 Observational studies have shown that erythropoietin therapy is associated with lower A1C due to the increased number of immature RBCs that have a decreased glycemic exposure time.1 In peritoneal dialysis patients, A1C may increase after the start of therapy as a result of dialysate absorption.3
Research suggests that glycated albumin (GA) provides a short-term index of glycemic control (typically two to three weeks) and is not influenced by albumin concentration, RBC lifespan, or erythropoietin administration.1 A clear consensus on optimal levels of GA has not been established, but GA may be a more reliable marker of glycemic control in patients with diabetes and CKD. Further research is needed to establish a target GA level that predicts the best prognosis for patients with both conditions.1
A1C is the most reliable marker at this time, but special considerations should be made for the patient with CKD. Rather than focus on a single measurement, clinicians need to consider the patient’s symptoms and results from all labwork, along with A1C, to best evaluate glycemic control.4 Further research is needed in patients with diabetes and CKD to explore other reliable markers to help maintain tight glycemic control.
Continued on next page >>
Q) One of my patients developed severe leg cramps while taking statins. I felt it was questionable rhabdomyolysis and stopped the medication; the leg pain went away. Is there a way to know if the rhabdomyolysis is progressive?
Rhabdomyolysis is a serious condition caused by the breakdown of muscle tissue that leads to the release of myoglobin into the bloodstream. This condition can lead to severe kidney failure and death.
Previously, there has been no easy method to predict progressive rhabdomyolysis. But researchers from Brigham and Women’s Hospital recently developed the Rhabdomyolysis Risk Calculator, a prediction score that can help determine whether a patient with rhabdomyolysis is at risk for severe kidney failure or death.
The researchers conducted a retrospective cohort study of 2,371 patients admitted between 2000 and 2011 and examined variables that may be associated with kidney failure and death.5 They identified independent predictors for these outcomes, including age; gender; initial levels of phosphate, calcium, creatinine, carbon dioxide, and creatine kinase; and etiology of rhabdomyolysis (myositis, exercise, statin use, or seizure).5
This tool can assist providers in developing a patient-specific treatment plan. However, further research is needed to validate the current variables, verify the risk prediction score in other populations, and examine its ability to guide individualized treatment plans.
The Rhabdomyolysis Risk Calculator is available at www.brighamandwomens.org/research/rhabdo/default.aspx
Kristy Washinger, MSN, CRNP
Nephrology Associates of Central PA
Camp Hill, PA
REFERENCES
1. Vos FE, Schollum JB, Walker RJ. Glycated albumin is the preferred marker for assessing glycaemic control in advanced chronic kidney disease. Nephrol Dial Transplant Plus. 2011; 4(6):368-375.
2. National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Guideline 2: management of hyperglycemia and general diabetes care in chronic kidney disease. www.kidney.org/professionals/kdoqi/guideline_diabetes/guide2.htm. Accessed April 15, 2014.
3. Sharif A, Baboolal K. Diagnostic application of the A1c assay in renal disease. J Am Soc Nephrol. 2010;21(3):383-385.
4. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.
5. McMahon GM, Zeng X, Walker SS. A risk prediction score for kidney failure or mortality in rhabdomyolysis. JAMA Intern Med. 2013;173(19):1821-1828.
Q) Does anemia in CKD patients affect their A1C? Is A1C accurate in CKD patients?
Tight glycemic control is imperative for patients with chronic kidney disease (CKD), but the management of diabetes in CKD can be complex due to factors including anemia and changes in glucose and insulin homeostasis.
A1C is directly proportionate to the ambient blood glucose concentration and in the general diabetic population has proven to be a reliable marker.1 However, it may not be valid in patients with diabetes and CKD. Reduced red blood cell (RBC) lifespan, rapid hemolysis, and iron deficiency may lead to falsely decreased results.2 Decreased RBC survival results from an increase in hemoglobin turnover, which decreases glycemic exposure time.1 This process then lowers the amount of nonenzymatic glucose binding to hemoglobin.1 Folate deficiency caused by impaired intestinal absorption in CKD also affects RBC survival.3 Falsely increased results may be related to carbamylation of the hemoglobin and acidosis, both of which are influenced by uremia.2
Special considerations should be made for dialysis patients with diabetes. In hemodialysis patients, A1C may be falsely decreased due to blood loss, RBC transfusion, and erythropoietin therapy.3 Observational studies have shown that erythropoietin therapy is associated with lower A1C due to the increased number of immature RBCs that have a decreased glycemic exposure time.1 In peritoneal dialysis patients, A1C may increase after the start of therapy as a result of dialysate absorption.3
Research suggests that glycated albumin (GA) provides a short-term index of glycemic control (typically two to three weeks) and is not influenced by albumin concentration, RBC lifespan, or erythropoietin administration.1 A clear consensus on optimal levels of GA has not been established, but GA may be a more reliable marker of glycemic control in patients with diabetes and CKD. Further research is needed to establish a target GA level that predicts the best prognosis for patients with both conditions.1
A1C is the most reliable marker at this time, but special considerations should be made for the patient with CKD. Rather than focus on a single measurement, clinicians need to consider the patient’s symptoms and results from all labwork, along with A1C, to best evaluate glycemic control.4 Further research is needed in patients with diabetes and CKD to explore other reliable markers to help maintain tight glycemic control.
Continued on next page >>
Q) One of my patients developed severe leg cramps while taking statins. I felt it was questionable rhabdomyolysis and stopped the medication; the leg pain went away. Is there a way to know if the rhabdomyolysis is progressive?
Rhabdomyolysis is a serious condition caused by the breakdown of muscle tissue that leads to the release of myoglobin into the bloodstream. This condition can lead to severe kidney failure and death.
Previously, there has been no easy method to predict progressive rhabdomyolysis. But researchers from Brigham and Women’s Hospital recently developed the Rhabdomyolysis Risk Calculator, a prediction score that can help determine whether a patient with rhabdomyolysis is at risk for severe kidney failure or death.
The researchers conducted a retrospective cohort study of 2,371 patients admitted between 2000 and 2011 and examined variables that may be associated with kidney failure and death.5 They identified independent predictors for these outcomes, including age; gender; initial levels of phosphate, calcium, creatinine, carbon dioxide, and creatine kinase; and etiology of rhabdomyolysis (myositis, exercise, statin use, or seizure).5
This tool can assist providers in developing a patient-specific treatment plan. However, further research is needed to validate the current variables, verify the risk prediction score in other populations, and examine its ability to guide individualized treatment plans.
The Rhabdomyolysis Risk Calculator is available at www.brighamandwomens.org/research/rhabdo/default.aspx
Kristy Washinger, MSN, CRNP
Nephrology Associates of Central PA
Camp Hill, PA
REFERENCES
1. Vos FE, Schollum JB, Walker RJ. Glycated albumin is the preferred marker for assessing glycaemic control in advanced chronic kidney disease. Nephrol Dial Transplant Plus. 2011; 4(6):368-375.
2. National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Guideline 2: management of hyperglycemia and general diabetes care in chronic kidney disease. www.kidney.org/professionals/kdoqi/guideline_diabetes/guide2.htm. Accessed April 15, 2014.
3. Sharif A, Baboolal K. Diagnostic application of the A1c assay in renal disease. J Am Soc Nephrol. 2010;21(3):383-385.
4. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.
5. McMahon GM, Zeng X, Walker SS. A risk prediction score for kidney failure or mortality in rhabdomyolysis. JAMA Intern Med. 2013;173(19):1821-1828.