Normally one would not associate Dental, Diabetes, and Dialysis in the same sentence or thought process. However, it is an uncontested fact that Diabetes and the need for Dialysis are closely associated with over 40% of dialysis patients also diabetic. Up to now, I had never heard or read any association between the latter two Ds and Dental. I know that often diabetic patients have dental challenges, but the study I’m about to present notes a causality going the other direction, Dental Problems -> Diabetes and further -> Dialysis.
Writing in the July 9 2023 issue of SciTechDaily, the University At Buffalo wrote an article titled “The Surprising Connection Between Chewing and Type 2 Diabetes.” The article is linked here:
With the following Prompt, I asked my AI to condense the article for this blog into 400 words or fewer entries in laymen’s terms. The Prompt and result follow. My closing comments are at the end. The lead graphic is from Bing Illustrator.
Summarize the following article into a 400-word or less entry at laymen’s level for a blog that concentrates on peritoneal dialysis:
ChatGPT:
Mehmet A. Eskan, a researcher from the University at Buffalo, suggests medical professionals treating Type 2 diabetes (T2D) patients should pay attention to their patient’s dental health. Eskan’s recent study, published in PLOS ONE, found a significant link between chewing functionality and blood sugar levels in T2D patients. Essentially, those who could chew well had much lower blood sugar levels than those who couldn’t.
Eskan and his team analyzed data from 94 T2D patients at a clinic in Istanbul, Turkey. They divided the patients into two groups based on their ability to chew – those with a good “occlusal function” (the ability to chew food effectively), and those who couldn’t chew well due to missing or improperly placed teeth. The results were striking: the group with good occlusal function had an average blood sugar level of 7.48, while those who couldn’t chew well had an average blood sugar level almost 27% higher, at 9.42.
Chewing, or mastication, kickstarts the digestion process by stimulating saliva production. It also helps our bodies absorb fiber and other essential nutrients from food, which are important for controlling blood sugar levels. Moreover, chewing well can promote feelings of fullness, helping to prevent overeating – a major risk factor for T2D.
Eskan’s research comes amid growing recognition of the role oral health plays in managing diabetes. In one case, a patient’s blood sugar level dropped dramatically after dental implants and restoration improved their ability to chew. However, the study also showed that factors like Body Mass Index (BMI), sex, smoking status, medications, or infections did not significantly affect the participants’ blood sugar levels.
High blood sugar levels can have serious health consequences, with a 1% increase linked to a 40% rise in the risk of heart disease among diabetic patients. Eskan hopes his research will spur further studies to understand the cause-and-effect relationship between dental health and blood sugar levels better.
So, the next time you sit down for a meal, remember: chewing your food well isn’t just good manners – it could be critical for your health, especially if you’re living with Type 2 diabetes.
My wife often laments that she spends hours cooking a nice meal for us, and given my military background where you are taught to inhale food on the run in uncertain circumstances, it is often gone in five minutes. As a couple, we are working on slowing our food intake down in keeping with the findings of this article.
Writing in the May 31, 2023 issue of News Medical Life Sciences, Lily Ramsey LLM wrote an article titled ‘A simple tweak to first meal of the day may benefit people with Type 2 diabetes.” Since about 44% of those of us on dialysis also have been blessed with Type 2 diabetes, such a finding is of interest to us also. A link to the article is here. A summary of the article is below.
A study led by UBC Okanagan researchers suggests that people with Type 2 diabetes (T2D) can better control their blood sugar levels by modifying their breakfast to be low in carbs and high in protein and fats.
This single meal modification was found to help control blood sugar levels throughout the day, potentially limiting hyperglycemic swings.
The 12-week study involved 121 participants divided into two groups, one consuming a low-carb, high-protein, high-fat breakfast and the other consuming a traditional, high-carb, low-fat breakfast.
While there were no significant differences in weight, body mass index, or waist circumference between the groups, the low-carb group saw reduced blood sugar levels, and some participants could reduce their glucose-lowering medication.
Additionally, participants with a low-carb breakfast reported lower calorie and carbohydrate intake at lunch and for the rest of the day, suggesting that a low-carb breakfast could impact overall daily eating habits.
Attribution: Bing Illustrator for the lead graph, ChatGPT4 for summarizing the article, Grammarly for cleaning up after me, and me for the idea, concept, and any mistakes.
A couple of days ago I related my long journey to being currently on dialysis. I 100% attribute this requirement to my earlier ailment, diabetes. One aspect I did not relate to is that my grandmother on my mother’s side of the family was diabetic, my mother was diabetic, and our two sons were/are diabetic. This is somewhat moot “proof” that it can be inherited and runs in families. It does not, however in any aspect, remove the burden of where we are, a diabetic on dialysis. This association got me thinking about the importance of really really recognizing the strong tie between being diabetic and its impact on the future statistical probability of needing/requiring Dialysis.Then, I turned to my silent partner in crime, my faithful AI assistant openai.com running gpt-4 with the following prompt, and the subsequent result is included below.
First, a couple of comments. I firmly believe I stayed on Metformin too long, seriously impacting my kidneys. At no time was there any appearance of coordination and/or teamwork or communication between doctors involved in my treatment? I’m sorry to state that to this day it is obvious that such teamwork is lacking. Doctors live in silos from which they rarely seem to leave. Over time my doctors hammered my Hypertension without explaining in any detail the ramifications and/or if/then/else of not keeping it within bounds, which seemed to be ever-changing over time. As soon as an individual’s eGFR passes the 60 wicket regardless of what’s going on with hypertension and A1c, a team should take over and hold the patient by the hand to preclude to the extent possible the need for Dialysis. You draw your own conclusions from the essay below.
GPT-4 Prompt: From a statistical perspective, what is the relationship between diabetes and the subsequent need to go on dialysis? Use citations and include references in at least a 2000-word essay written at a freshman college level.
Introduction
Diabetes is a global health concern that affects millions of people. It is a group of metabolic disorders characterized by high blood sugar levels over an extended period. Type 1 and type 2 diabetes are the most common forms, with type 2 diabetes accounting for about 90% of cases. Diabetes can cause various complications, including kidney disease, cardiovascular disease, and neuropathy. One severe complication is diabetic nephropathy, which may lead to end-stage renal disease (ESRD) and dialysis needs. This essay explores the statistical relationship between diabetes and subsequent dialysis needs by examining relevant literature and studies.
Diabetes and kidney disease: the pathophysiology
Diabetic nephropathy, a leading cause of kidney disease, develops in about 40% of individuals with diabetes (Gheith et al., 2016). High blood sugar levels cause damage to the blood vessels in the kidneys, impairing their ability to filter waste and excess fluids. Over time, this damage accumulates, leading to kidney disease and, eventually, kidney failure.
Kidney disease can be categorized into five stages based on the glomerular filtration rate (GFR), a measure of kidney function. Stage 1 represents the least severe stage, while stage 5, or ESRD, is the most severe, often necessitating dialysis or a kidney transplant. Diabetes increases the risk of developing kidney disease and progressing to ESRD (Afkarian et al., 2013).
Prevalence of diabetes and kidney disease
The prevalence of diabetes has been increasing worldwide, with the International Diabetes Federation (IDF) estimating that 537 million adults will have diabetes in 2021 (IDF Diabetes Atlas, 2021). The number is projected to reach 643 million by 2030 (IDF Diabetes Atlas, 2021). The global prevalence of diabetic nephropathy was estimated at 6.9% in 2020 (Thomas et al., 2020).
Kidney disease is a significant public health concern, affecting more than 850 million people worldwide (Liyanage et al., 2015). Among individuals with ESRD, diabetes is the leading cause, accounting for 44% of cases in the United States (USRDS, 2020). In Europe, diabetes is responsible for 25% of ESRD cases, with variations between countries (ERA-EDTA, 2019).
Diabetes and the Risk of Dialysis
Diabetic nephropathy progresses more rapidly in individuals with poor glycemic control, high blood pressure, and genetic predisposition (Tuttle et al., 2014). Studies have reported that the risk of developing ESRD in individuals with diabetes is 12-25 times higher than in those without diabetes (Afkarian et al., 2013; de Boer et al., 2011).
A study by Afkarian et al. (2013) investigated the risk of ESRD in a cohort of 10,483 individuals with type 1 diabetes and 9,697 individuals with type 2 diabetes. The cumulative incidence of ESRD at 20 years was 3.3% for type 1 diabetes and 1.7% for type 2 diabetes. The study also found that the risk of ESRD increased with the duration of diabetes and higher levels of baseline glycated hemoglobin (A1C), a marker of long-term blood sugar control.
Another study by de Boer et al. (2011) assessed the risk of ESRD in 1,746 individuals with type 1 diabetes and 4,507 individuals with type 2 diabetes. The cumulative incidence of ESRD at 20 years was 2.2% for type 1 diabetes and 1.8% for type 2 diabetes. The study demonstrated that higher baseline A1C levels and longer diabetes duration were associated with increased risks of ESRD, emphasizing the importance of proper blood sugar management.
Factors influencing the need for dialysis in diabetic patients
Several factors can increase the likelihood of diabetic patients requiring dialysis. These factors include:
a. Glycemic control: Maintaining optimal blood sugar levels is critical in delaying the progression of diabetic nephropathy and reducing the risk of ESRD (Ismail-Beigi et al., 2010). Improved glycemic control has been shown to reduce the risk of microvascular complications, including kidney disease, in both type 1 and type 2 diabetes (DCCT/EDIC Study Research Group, 2005; ADVANCE Collaborative Group, 2008).
b. Blood pressure control: High blood pressure is a significant risk factor for the progression of diabetic nephropathy (Molitch et al., 2015). Strict blood pressure control, particularly with medications such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), can slow kidney disease progression and reduce the risk of ESRD in diabetic patients (Lewis et al., 1993; Brenner et al., 2001).
c. Albuminuria: Elevated albumin levels in the urine (albuminuria) are an early sign of kidney damage in diabetic patients. Reducing albuminuria through blood sugar and blood pressure control can delay the progression of kidney disease (Wanner et al., 2016).
d. Lifestyle factors: Adopting a healthy lifestyle, including regular exercise, a balanced diet, and maintaining a healthy weight, can help control blood sugar levels and reduce the risk of kidney disease in diabetic patients (ADA, 2021).
Strategies to reduce the need for dialysis in diabetic patients
Efforts to minimize the risk of dialysis in diabetic patients include:
a. Early detection and monitoring: Regular screening for kidney disease in diabetic patients can facilitate early intervention and slow the progression of kidney disease (ADA, 2021).
b. Integrated care: A multidisciplinary approach that involves primary care providers, endocrinologists, nephrologists, and other healthcare professionals can optimize diabetes management and reduce the risk of complications (ADA, 2021).
c. Patient education: Empowering patients with knowledge about diabetes management, self-monitoring of blood sugar, and healthy lifestyle choices can improve treatment adherence and reduce the risk of kidney disease (Funnell et al., 2010).
Conclusion
Diabetes is a significant risk factor for kidney disease and the subsequent need for dialysis. The relationship between diabetes and dialysis is influenced by glycemic control, blood pressure management, and albuminuria. Early detection, proper management of diabetes, and lifestyle modifications can reduce the risk of kidney disease progression and the need for dialysis in diabetic patients. Continued research and public health initiatives aimed at preventing diabetes, optimizing diabetes management, and raising awareness about kidney disease are essential in addressing this global health challenge.
References
ADA. (2021). Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Suppl. 1), S1-S232.
ADVANCE Collaborative Group. (2008). Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. New England Journal of Medicine, 358(24), 2560-2572.
Afkarian, M., Sachs, M. C., Kestenbaum, B., Hirsch, I. B., Tuttle, K. R., Himmelfarb, J., & de Boer, I. H. (2013). Kidney disease and increased mortality risk in type 2 diabetes. Journal of the American Society of Nephrology, 24(2), 302-308.
Brenner, B. M., Cooper, M. E., de Zeeuw, D., Keane, W. F., Mitch, W. E., Parving, H. H., … & Shahinfar, S. (2001). Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. New England Journal of Medicine, 345(12), 861-869.
DCCT/EDIC Study Research Group. (2005). Sustained effect of intensive treatment of type 1 diabetes mellitus on the development and progression of diabetic nephropathy: the Epidemiology of Diabetes Interventions and Complications (EDIC) study. Journal of the American Medical Association, 290(16), 2159-2167.
de Boer, I. H., Rue, T. C., Hall, Y. N., Heagerty, P. J., Weiss, N. S., & Himmelfarb, J. (2011). Temporal trends in the prevalence of diabetic kidney disease in the United States. Journal of the American Medical Association, 305(24), 2532-2539.
Funnell, M. M., Brown, T. L., Childs, B. P., Haas, L. B., Hosey, G. M., Jensen, B., … & Weiss, M. A. (2010). National Standards for Diabetes Self-Management Education. Diabetes Care, 33(Suppl. 1), S89-S96.
Gheith, O., Farouk, N., Nampoory, N., Halim, M. A., & Al-Otaibi, T. (2016). Diabetic kidney disease: worldwide difference of prevalence and risk factors. Journal of Nephropharmacology, 5(1), 49-56.
Ismail-Beigi, F., Craven, T., Banerji, M. A., Basile, J., Calles, J., Cohen, R. M., … & ACCORD Trial Group. (2010). Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. The Lancet, 376(9739), 419-430.
Lewis, E. J., Hunsicker, L. G., Bain, R. P., & Rohde, R. D. (1993). The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. New England Journal of Medicine, 329(20), 1456-1462.
Liyanage, T., Ninomiya, T., Jha, V., Neal, B., Patrice, H. M., Okpechi, I., … & Perkovic, V. (2015). Worldwide access to treatment for end-stage kidney disease: a systematic review. The Lancet, 5(9981), 1975-1982.
Molitch, M. E., Adler, A. I., Flyvbjerg, A., Nelson, R. G., So, W. Y., Wanner, C., … & Wheeler, D. C. (2015). Diabetic kidney disease: a clinical update from Kidney Disease: Improving Global Outcomes. Kidney International, 87(1), 20-30.
Thomas, M. C., Brownlee, M., Susztak, K., Sharma, K., Jandeleit-Dahm, K. A., Zoungas, S., … & Cooper, M. E. (2020). Diabetic kidney disease. Nature Reviews Disease Primers, 6(1), 1-28.
Tuttle, K. R., Bakris, G. L., Bilous, R. W., Chiang, J. L., de Boer, I. H., Goldstein-Fuchs, J., … & Molitch, M. E. (2014). Diabetic kidney disease: a report from an ADA Consensus Conference. Diabetes Care, 37(10), 2864-2883.
USRDS. (2020). United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD.
Wanner, C., Inzucchi, S. E., Lachin, J. M., Fitchett, D., von Eynatten, M., Mattheus, M., … & EMPA-REG OUTCOME Investigators. (2016). Empagliflozin and progression of kidney disease in type 2 diabetes. New England Journal of Medicine, 375(4), 323-334.
A strong case has been made in a preponderance of reviewed medical journals that diabetes is the primary and number one predictor of a future requirement to go on dialysis. See stats in the table below from CDC here: The extreme need for close diabetic control does not end once a person goes on dialysis; if anything, because PD at a minimum requires dumping a sugar solution into one’s stomach, it becomes even more critical.
For adults with diagnosed diabetes:
69% had high blood pressure, and 44% had high cholesterol.
39% had chronic kidney disease, and 12% reported having vision impairment or blindness.
Diabetes was highest among Black and Hispanic/Latino adults, in both men and women.
This blog is not about the how-to of diabetic control, but about one of the new tools just hitting the market to ascertain the degree of control, that is, how is my “blood sugar/glucose doing?”
Coming out of China is a new class of wearable devices in the form of a wristwatch at a very reasonable price called smart watches, or bio watches. They are generally available from Temu.com/App, Aliexpress.com, etc. for about $40.00. I have purchased two from Temu.com via their App for $39.62. See the Graphic below for all they are purported to be able to measure from here: The watches are based on the GR5515 chip and are Model E400 from Vanssa in China. Scroll down this link for more info on all the watch purports to do:
E400 Functions
I have been using the watch’s many functions in parallel with my go-to standard blood pressure, O2, temperature, and glucose (I use the Libre 3 CGM) as comparisons. I find some of the readings to be right on, and others to be somewhat consistent. It should be pointed out that the documentation that comes with the device explicitly states they are NOT to be used for medical purposes – yet I might add. As the video describes below, they are great for trends. I have found the E400 watch to be a great addition to a bag of tools for the diabetic/person on dialysis used in conjunction with the associated H Band App. Please watch the video embedded below for an independent review of the E400.
My next blog will discuss using the Libre 3 CGM for diabetic control while on dialysis.
Diabetes is a serious health condition that affects millions of people worldwide. For those with diabetes, managing the disease can be a complex and challenging task. For those with diabetes and end-stage renal disease (ESRD), dialysis can be an essential part of their care. In this blog, we’ll discuss the connection between diabetes and dialysis, and what patients need to know to stay safe and healthy.
Diabetes can cause a number of complications that can lead to the need for dialysis, including hypertension, heart disease, and nephropathy. (I have all three, having gone through a triple bypass in 2015.) Nephropathy, or kidney disease, is a major complication of diabetes and can cause ESRD. When ESRD occurs, dialysis is necessary to keep the patient alive.
I was first diagnosed as a diabetic in the early nineties via a glucose tolerance test while on active duty in the Navy. I was first diagnosed with the real possibility of Chronic Kidney Failure in the early 2000 timeframe. My diabetic condition progressed from control with diet and exercise to oral meds to insulin plus oral meds until the present day. Same with ESRD only doctors just stated “we’ll watch it.” What they meant was it was going to happen and we’ll just watch it happen. For me, diabetes and dialysis have been a fact of life, that is sooner or later…….
There are two types of dialysis that may be used for those with diabetes: hemodialysis and peritoneal dialysis. The general populace is often confused by this distinction, thinking only that one goes to a dialysis center three times a week for a couple of hours. Hemodialysis involves using a dialysis machine to filter the blood outside of the body. I underwent hemo as it is called for about six weeks while I was getting set up and moving through the queue for peritoneal dialysis aka PD. It is miserable and time-consuming, and a cold experience wipes you out, and I wouldn’t wish it on anybody including my worse enemies (if I had any which I don’t.)
“Although the ancient Egyptians were the first to describe the peritoneal cavity in approximately 3000 BC, the concept of peritoneal dialysis is relatively new. In the late 19th century, Wegner, a German investigator, was the first to use peritoneal solutions in animals.” From here: The solution used is called dextrose dialysate, or dextrose, or more formally dialysate.
What I use is a 1.5% or 2.5% Dextrose solution of Hydrous Dextrose, Sodium Chloride, Sodium Lactate, Calcium Chloride, Magnesium Chloride, and water. 8000 mL or 8 liters of this fluid is pumped into my Peritoneal cavity via a catheter in my stomach 2 liters at a time. When filled it remains there for two hours (dwell) and then is pumped back out (drain.) This takes place four times every night, seven days a week. This is all controlled by the Liberty Cycler apparatus.
Ideally, the drain takes place at 100ml per minute, or 20 minutes for the entire individual drain process. If you add up four dwell periods of two hours each, and four drains at a minimum of 20 minutes each (this rarely happens in this short a timeframe), you end up with eight hours of dwell, and 80 minutes or one hour and 20 minutes of the drain, for a total time on dialysis ideally of nine hours and 20 minutes. This NEVER NEVER happens. With me, it is more like 10 hours and thirty minutes every night. Add to this setup and tear-down times and you can see that PD requires lots of time to accomplish.
Dialysis is not a walk in the park, but short of a kidney transplant, there are no other solutions currently available. I did read that research into using printed kidneys is currently underway. Sign me up. In a follow-up blog, I intend to discuss in more depth the diabetic side of the diabetic dialysis balance.
