Hypoglycemia and glycemic control in patients treated with dialysis

项目摘要/摘要 低血糖和高血糖是终末期肾病患者常见的病态问题。 用透析治疗。合并糖尿病和不合并糖尿病的透析患者经常发生严重低血糖 由于肾脏糖异生减少，蛋白质能量浪费，迟钝的反调节反应，以及 减少药物清除，并可能因事故、心律失常和 心血管事件。然而，低血糖的准确率(包括亚临床发作)， 低血糖的危险因素以及低血糖与临床结果的相关性在 透析人群。相反，糖尿病治疗不当导致的高血糖可能会加剧疼痛。 周围神经病变、威胁视力的视网膜病变和感染，但标准的血糖测量方法 因为已知在透析患者中血红蛋白A1c是不可靠的，导致诊断和治疗 虚无主义。这项研究项目的目标是全面定义透析患者的血糖。 现代连续血糖监测(CGM)技术，告知临床护理需求，并建立 干预研究基金会。CGM为血糖评估和治疗提供了一种新的范式 这可以提供新的科学见解，并可能改变血糖控制的临床方法。 然而，目前还没有大规模的外部有效研究来了解该病的发生率或严重性。 CGM可检测到的异常，确定哪些患者可能从CGM的使用中受益最大，或检查 在这一人群中，CGM指标是否与临床相关结果相关。我们提出了一个预期的 西北肾中心800名接受透析治疗的患者的社区队列研究--一项非针对 在大西雅图大都市区提供大部分透析护理的盈利组织。这个 队列研究的基础是为期10天的CGM，在基线上使用尖端技术进行 技术参与式研究方法将提高登记、外部效度和临床 关联性。通过这个队列，我们的目标是(1)确定低血糖的发生率和严重程度及其临床 糖尿病和非糖尿病透析患者的危险因素；(2)明确糖尿病患者的分布和临床相关性 糖尿病透析患者血糖时间及相关CGM指标的变化； 低血糖和时间范围内与透析患者相关的临床结果的相关性。结果 可能会为CGM的实施提供机会以改善临床护理，并将定义适当的 临床试验的人群、干预措施、结果和能力假设。

PROJECT SUMMARY/ABSTRACT Hypoglycemia and hyperglycemia are common and morbid problems for end stage kidney disease patients treated with dialysis. Severe hypoglycemia occurs frequently among dialysis patients with and without diabetes due to reduced kidney gluconeogenesis, protein-energy wasting, a blunted counter-regulatory response, and reduced medication clearance and may cause substantial morbidity due to accidents, arrhythmias, and cardiovascular events. However, accurate rates of hypoglycemia (including subclinical episodes), hypoglycemia risk factors, and associations of hypoglycemia with clinical outcomes are not known in the dialysis population. Conversely, hyperglycemia due to inadequately treated diabetes may promote painful peripheral neuropathy, vision-threatening retinopathy, and infections, but standard measures of glycemia such as hemoglobin A1c are known to be unreliable among dialysis patients, leading to diagnostic and therapeutic nihilism. The goal of this research project is to comprehensively define glycemia in dialysis patients using modern continuous glucose monitoring (CGM) technology, informing needs for clinical care and building a foundation for intervention studies. CGM offers a new paradigm for glycemia assessment and management that can provide new scientific insights and potentially change the clinical approach to glycemic management. However, there has been no large, externally valid study to understand the incidence or severity of abnormalities detectable by CGM, identify which patients may benefit most from use of CGM, or examine whether CGM metrics are related to clinically relevant outcomes in this population. We propose a prospective community-based cohort study of 800 patients treated with dialysis at Northwest Kidney Centers, a not-for- profit organization that provides the majority of dialysis care in the greater Seattle metropolitan area. The foundation of the cohort study will be a 10-day period of CGM, performed at baseline using cutting-edge technology. A participatory approach to research will enhance enrollment, external validity, and clinical relevance. With this cohort, we aim to (1) determine the incidence and severity of hypoglycemia and its clinical risk factors among dialysis patients with and without diabetes; (2) define the distribution and clinical correlates of glucose time in range and related CGM metrics among dialysis patients with diabetes; and (3) test associations of hypoglycemia and time in range with clinical outcomes relevant to dialysis patients. Results may suggest opportunities for CGM implementation to improve clinical care and will define appropriate populations, interventions, outcomes, and power assumptions for clinical trials.