Centrum diabetologie

Prague, Czech Republic

Centrum diabetologie

Prague, Czech Republic
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Brunova J.,Centrum Diabetologie | Kratochvilova S.,Centrum Diabetologie | Stipankova J.,KIinika Nefrologie
Osteologicky Bulletin | Year: 2016

Introduction: Osteoporosis and osteopenia are some of the long-term complications in patients after successful organ transplantation. The role in the pathogenesis, which is complex and multifactorial, is played by bone loss in advanced organ failure and, in the posttransplantation period, mainly by immunosuppressive therapy including steroids, secondary hyperparathyroidism and vitamin D deficiency. Apart from the administration of calcium and vitamin D, osteoporosis is mainly treated with bisphosphonates. Their use, however, is limited by the presence of impaired renal function which is relatively common in patients after organ transplantation. In such cases, osteoporosis may be treated with denosumab, a monoclonal antibody against receptor activator of nuclear factor kappa B ligand (RANKL). However, there is not much experience with the administration of denosumab in transplanted patients. Patients and methods: The study followed 46 patients after organ transplantation (27 females and 19 males; a mean age of 56.2 years) who were treated for osteoporosis with denosumab. The organs transplanted were both the kidney and pancreas in 13 patients, the liver in 15 patients, the kidney in 16 patients and the heart in 2 patients. The mean time from transplantation was 8.6 years. Osteoporosis was diagnosed by densitometry using the Lunar Prodigy system according to the WHO criteria. Results: Osteoporosis of the lumbar spine was diagnosed in 35/46 patients (76 %), osteoporosis of the hip in 22/46 patients (48 %) and osteoporosis of the distal radius in 25/46 patients (54 %). Denosumab therapy increased the BMD of the lumbar spine in all patients. The BMD of the hip and forearm increased in 42/46 (91 %) and 28/46 (61 %) patients, respectively. Following the therapy, the BMD of the lumbar spine increased in 35/35 osteoporotic patients (100 %), with a mean BMD increase of 10.9 %. The BMD of the hip increased in 22/22 patients (100 %), with a mean BMD increase of 9 %; the BMD of the forearm increased in 17/25 patients (68 %), a mean increase of 4.5 %. The rates of osteoporosis decreased from 76 % to 26 % for osteoporosis of the lumbar spine, from 48 % to 28 % for osteoporosis of the hip and from 54 % to 41 % for osteoporosis of the forearm. T-scores of the lumbar spine increased significantly both in the entire sample (p < 0.0001) and in patients with osteoporosis of the lumbar spine (p <0.0001). Similarly, T-scores of the hip increased significantly in both osteoporotic patients (p = 0.0019) and the entire sample (p < 0.001). There were no significant differences in the BMD of the forearm prior to and after the therapy. Conclusion: The administration of denosumab to patients after transplantation of solid organs significantly increased BMD and was well tolerated. Thus, denosumab may be used to treat osteoporosis in patients contraindicated for bisphosphonates due to impaired renal function, intolerance or failure of therapy.

Dubsky M.,Centrum diabetologie | Jirkovska A.,Centrum diabetologie | Bem R.,Centrum diabetologie | Sixta B.,Klinika transplantacni chirurgie | And 4 more authors.
Prakticky Lekar | Year: 2010

Diabetic foot disease is one of the most common and most severe complications of diabetes. Aetiology of chronic ulcers is multifactorial and adequate therapy is often very difficult. Acellular porcine dermis could be used to treat chronic wounds with no signs of osteomyelitis and without critical ischaemia. The main advantages of acellular porcine dermis are its ability to be stored for long periods in dried form and its availability. In accordance with the results of our pilot study performed on 14 patients, the use of acellular porcine dermis in therapy of superficial non-infected ulcers was more efficient than with xenografts and is an appropriate alternative to modern bioengineered skin substitutes. We did not observe any serious adverse effects of this treatment.

Bem R.,Centrum diabetologie | Jirkovska A.,Centrum diabetologie
Diabetologie Metabolismus Endokrinologie Vyziva | Year: 2011

Charcot neuropathic osteoarthropathy is a chronic and progressive disease of bone and joints caused by diabetic neuropathy. Diabetes mellitus is the main cause of the peripheral neuropathy. In acute stage, the foot is warm, swollen, and tender and can be markedly erythematous. The acute reaction is often misdiagnosed and many patients present late with established deformity. The diagnosis is based on four-phase bone scan and MRI. The diagnosis by X-ray is late, often in advanced stage of the disease complications (dislocation, fractures). Treatment has traditionally involved the use of various methods to avoid weight bearing, especially in the acute phase. Recent work has begun to suggest that calcitonin and bisphosphonates might be able to arrest the acute process. In the chronic phase, treatment involves a multidisciplinary approach aimed at providing appropriate footwear to reduce plantar pressures and avoid foot ulceration.

Cardiovascular (CV) complications are the most common cause of death in patients with diabetes. Management of hyperglycemia significantly reduces the risk of development and progression of microvascular complications of diabetes whatever the stage of the disease and irrespective of the therapeutic modality used. The importance of management of hyperglycemia in terms of CV risk reduction continues to be a matter of debate. In epidemiological studies hyperglycemia, in particular postprandial hyperglycemia, has been clearly established as an independent risk factor for CV mortality and morbidity. Interventional studies published over the last two years have shown the need for an individualized approach to patients. A strategy shown to have a significantly beneficial effect on CV risk reduction is tight diabetes control, particularly in patients in primary CV prevention early after they have been diagnosed to have diabetes; in these cases, a role is played by what is called "metabolic memory". By contrast, excessively aggressive treatment of hyperglycemia in individuals with advanced diabetes-related complications and already overt CV disease will increase the risk for CV death, presumably due to development of hypoglycemic episodes. A number of comprehensive measures are currently available in the prevention and treatment of CV disease in patients with diabetes. In addition to management of hyperglycemia, these measures include management of other modifiable risk factors such as treatment of hypertension, dyslipidemia and, possibly, treatment of obesity, and antiplatelet therapy. Patients with hyperglycemia have their therapeutic goals "tailored" to meet their specific needs. Target HbA1c levels in individuals at low CV risk are below 4.5%. The levels are less strict (HbA1c below 6%) in those in secondary prevention, with patient safety (absence of hypoglycemia) being the most important consideration. Preference is given to gradual improvement of diabetes control. The drug of first choice in patients with type 2 diabetes is metformin (started immediately after the diagnosis has been established) in combination with lifestyle measures. If monotherapy fails to provide adequate control, other oral hypoglycemic agents, incretins or insulin can be added. Given the uncertainty regarding the appropriateness of use of hypoglycemic agents in terms of long-term prognosis, the procedure is fairly liberal. The method of choice in patients with type 1 diabetes is an intensified insulin regimen. Patient education and regular screening of potential complications of diabetes make an integral part of comprehensive management.

Hypertension is twice as common in diabetic patients as in people without diabetes and is one of the main causes of their high cardiovascular risk. In type 2 diabetes mellitus most cases of hypertension are primary (essential), often with a predominant systolic component. Because of potential peripheral arterial changes, the diagnosis of elevated blood pressure in diabetic patients should be always based on arm measurements which are now generally performed with automated oscillometric instruments. Current criteria for defining hypertension and initiation of therapy are identical to the ones used in the non-diabetic population, i.e. ≥ 140/90 mm Hg. Blood pressure reduction in diabetic patients is a very effective intervention with regard to the lowering of risk of vascular, renal and other complications. Lower target blood pressure levels for diabetic patients are currently not supported by convincing evidence from prospective trials and thus blood pressure treatment should aim at blood pressure values recommended in other patients with hypertension (< 140/90 mm Hg). More intensive blood pressure lowering (to < 130/80 mm Hg) should be pursued in patients with signs of subclinical organ damage, especially microalbuminuria or proteinuria. Treatment should be preferentially initiated by inhibitors of the renin-angiotensin-aldosterone system (RAS) accompanied by non-pharmacological measures; calcium channel blockers and/or diuretics provide convenient additional choices for combination therapy.

The treatment of patients with type 2 diabetes is typically accompanied by hypoglycemia, if insulin or derivatives of sulfonylurea are used within the treatment. Apart from the fact that hypoglycemias are the major obstacle to achieving the desirable compensation of diabetes, hypoglycemia also has a number of serious clinical consequences. A long term serious hypoglycemia may lead to a sudden death, heart attack or irreversible brain damage. Clinically significant are also the light or asymptomatic hypoglycemias which in a considerably negative way affect the patient's quality of life. The use of modern technologies in continuous monitoring of glycemias has shown that the occurrence of asymptomatic hypoglycemias is much higher than we anticipated and that they largely involve nocturnal hypoglycemia. Hypoglycemia is associated with an increased level of depression, anxiety, dissatisfaction with the treatment and with a greater number of physician office visits. Nocturnal hypoglycemia has a negative impact on the quality of sleep, it may impair cognitive functions and performance efficiency next day. The prevention of hypoglycemia is therefore one of the basic goals of diabetes treatment and the low risk of hypoglycemia is among the main requirements that we place on the newly developed antidiabetic drugs. The negligible risk of hypoglycemia, which is comparable to placebo both in monotherapy and in most combinations with the antidiabetic drugs available today, is evidenced by the data from the studies undertaken with empagliflozin. It shows that the low risk of hypoglycemia is one of the benefits of gliflozins, the new group of medications with a unique mechanism of effect which has quite recently appeared on our market.

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