In most Western countries, diabetic nephropathy (DN) has become the single most common condition found in patients with end-stage renal disease (ESRD). This is to some extent due to better survival of diabetic patients with renal failure, but mostly due to the dramatic increase in the prevalence of type 2 diabetes. The majority of type 2 diabetic patients with renal failure suffer from nodular glomerulosclerosis (Kimmelstiel-Wilson); but ischemic nephropathy, irreversible acute renal failure (mostly acute on chronic) and diabetes co-existing with primary renal diseases are common as well. Classical DN evolves in a sequence of stages. After a period of glomerular hyperfiltration, increased urinary albumin excretion [microalbuminuria (MA)] i.e. 30-300 mg/day or 20 - 200 microg/minute indicates the onset of overt DN. Risk factors for development of DN are positive family history, hyperglycemia in the mother during pregnancy, high blood pressure, obesity and insulin resistance. Poor glycemic control (HbAlc) and elevated systolic blood pressure (> 135 mm Hg) interact in enhancing the risk of DN. Proteinuria and smoking are major promoters of progression. The risk of onset of microalbuminuria can be reduced by lowering of blood pressure and specifically by blockade of the renin angiotensin system (RAS). In patients with established DN, the target systolic blood pressure should be <130 mm Hg and RAS blockade is obligatory. Treating all cardiovascular risk factors is a high priority. Antihypertensive management is rendered difficult by extreme volume sensitivity, pronounced activation of the RAS and autonomic neuropathy. Cardiac events are excessively frequent, glycemic control becomes difficult and autonomic diabetic neuropathy with gastroparesis and diabetic foot are additional problems. Hemodialysis or continuous ambulatory peritoneal dialysis should be started relatively early. In the absence of contraindications, transplantation (renal transplantation, combined kidney/pancreas transplantation or pancreas after kidney transplantation) is the treatment of choice.
Diabetes mellitus is the leading single cause for renal replacement therapy. Its development and progression, however, can be ameliorated by adequate therapy. The present article represents the recommendations of the Austrian Diabetes Association for the prevention and treatment of diabetic nephropathy.
Gestational diabetes (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy and is associated with increased feto-maternal morbidity as well as long-term complications in mothers and offspring. GDM is diagnosed by an oral glucose tolerance test (OGTT) or fasting glucose concentrations in the diabetic range. In case of a high risk for GDM/type 2 diabetes (history of GDM or prediabetes [impaired fasting glucose or impaired glucose tolerance]; malformation, stillbirth, successive abortions or birth-weight > 4500 g in previous pregnancies) performance of the OGTT (120 min; 75 g glucose) is recommended already in the first trimester and--if normal--the OGTT should be repeated in the second/third trimester. In case of clinical symptoms of diabetes (glucosuria, macrosomia) the test has to be performed immediately. All other women should undergo a diagnostic test between 24 and 28 gestational weeks. If fasting plasma glucose exceeds 95 mg/dl, 1 h 180 mg/dl and 2 hrs 155 mg/dl after glucose loading (OGTT) the woman is classified as GDM (one pathological value is sufficient). In this case a strict metabolic control is mandatory. All women should receive nutritional counseling and be instructed in blood glucose self-monitoring. If blood glucose levels cannot be maintained in the normal range (fasting < 95 mg/dl and 1 h after meals < 130 mg/dl) insulin therapy should be initiated. Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. After delivery all women with GDM have to be reevaluated as to their glucose tolerance by a 75 g OGTT (WHO criteria).
The prevalence of diabetes is increasing in westernized countries. In addition, about half of all patients suffering from diabetes are not diagnosed. The current article represents the recommendations of the Austrian Diabetes Association for the screening and prevention of type 2 diabetes, based on currently available evidence.
These are the guidelines for diagnosis and treatment of diabetic neuropathy. This diabetic late complication comprises a number of mono- and polyneuropathies, plexopathies, radiculopathies and autonomic neuropathy. The position statement summarizes characteristic clinical symptoms and techniques for diagnostic assessment of diabetic neuropathy. Recommendations for the therapeutic management of diabetic neuropathy, especially for the control of pain in sensorimotoric neuropathy, are provided.
Probiotics are living microorganisms that upon ingestion exert health benefits. The impact of probiotics on gut flora represents a new and interesting therapeutic approach in a number of diseases of the gastrointestinal tract. According to actual publications and guidelines of medical societies, the clinical relevance of probiotics can be described as follows: (a) In the case of ulcerative colitis, available data demonstrate benefits of probiotic therapy. (b) The available data regarding pouchitis are limited, but the therapeutic effect seems to be excellent. (c) In the case of Crohn's disease, the role of probiotics is not clearly defined, thus the results of new trials have to be awaited before probiotic therapy is recommended. (d) Further indications such as antibiotic-associated diarrhea, acute pancreatitis or irritable bowel syndrome have been reported recently. The results of these clinical trials have been encouraging, but they often included only a small number of patients and therefore a clear-cut assessment seems difficult at the moment.
Diabetes mellitus is the leading single cause for renal replacement therapy. Its development and progression, however, can be ameliorated by adequate therapy. The present article represents the recommendations of the Austrian Diabetes Association for the prevention and treatment of diabetic nephropathy.
Diabetes mellitus causes diabetic retinopathy and maculopathy, optical nerve neuropathy, cataract and defects of the eye muscles. The incidence of these defects correlates with duration and quality of the metabolic control. The recommendations of the Austrian Diabetes Association for the diagnosis, the therapeutic measures and requirements for adequate follow-up depending on the stages of the different forms of diabetic eye diseases are summarized.
These are the guidelines for diagnosis and treatment of diabetic neuropathy. This diabetic late complication comprises a number of mono- and polyneuropathies, plexopathies, radiculopathies and autonomic neuropathy. The position statement summarizes characteristic clinical symptoms and techniques for diagnostic assessment of diabetic neuropathy. Recommendations for the therapeutic management of diabetic neuropathy, especially for the control of pain in sensorimotoric neuropathy, are provided.
These are the guidelines for diagnosis and treatment of diabetic neuropathy. This diabetic late complication comprises a number of mono- and polyneuropathies, plexopathies, radiculopathies and autonomic neuropathy. The position statement summarizes characteristic clinical symptoms and techniques for diagnostic assessment of diabetic neuropathy. Recommendations for the therapeutic management of diabetic neuropathy, especially for the control of pain in sensorimotoric neuropathy, are provided.
BACKGROUND Cardiovascular risk factors are a significant burden in end-stage renal disease patients under hemodialysis and are the leading cause of death among these patients. The influence of parathyroid hormone (PTH) on myocardial function as a toxin of uremia is under more attention and evaluation because of growing evidence showing that the effects of PTH on cardiac function may be the most serious consequence of secondary hyperparathyroidism in renal failure. In this study we determined role of excess PTH in the development of left ventricular (LV) hypertrophy as well as LV ejection fraction in patients with end-stage renal disease under regular hemodialysis. METHODS This study is cross-sectional that was done on patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis treatment. For patients, Calcium, Phosphorus, Alkaline phosphatase and Intact PTH (iPTH) were measured. Hypertensive patients were stratified into stages one to three. Echocardiographies for LV hypertrophy and ejection fraction (%) were done and patients stratified into normal, mild, moderate and severe LV hypertrophy. RESULTS The total patients were 73 (F=28 M=45), consisting of 58 non diabetic hemodialysis patients (F=22 M=36), and 15 diabetic hemodialysis patients (F=6 M=9). The mean age was 46.5+/-16 years. The time on hemodialysis was 21.5+/-23.5 months. The LV ejection fraction (EF%) were 51+/-8 percent. 'iPTH' of patients was 309+/-349 pg/ml. 'iPTH' of diabetic and nondiabetic groups was 234+/-265 pg/ml and 329+/-368 pg/ml respectively. Serum alkaline phosphatase was 413+/-348 IU/L. Serum alkaline phosphatase of diabetic and nondiabetic groups were 295+/-179 IU/L and 443+/-375 IU/L respectively. Serum albumin was 4+/-0.75 g/dl. Serum albumin of diabetic and nondiabetic groups was 3.6+/-0.7 g/dl and 4.2+/-0.7 g/dl respectively. Significant inverse correlation of serum ALP with percent of LV ejection fraction and marginal positive correlation of serum ALP with LVH and also marginal correlation of serum iPTH with LVH were seen. Also significant inverse correlation between serum iPTH with percent of LV ejection fraction in non diabetic heart patients was observed. CONCLUSIONS Adverse effects of secondary hyperparathyroidism on LV function and structure in this study show the role of excess PTH in the development of left ventricular (LV) hypertrophy as well as low LV ejection fraction in patients with end-stage renal disease under hemodialysis which needs more attention to control of secondary hyperparathyroidism to reduce the risk of cardiovascular morbidity and mortality in dialysis patients.
Diabetes education, nutritional advice, exercise recommendations and training for smoking cessation comprise the mainstay of diabetes treatment before starting drug therapy. Prevention as well as treatment of diabetes mellitus is positively influenced by life-style modification. In addition cardiovascular risk factors can be reduced by such measures. The article gives in brief recommendations leading towards life-style modification based on current evidence.
Magnesium is a Cofactor in all enzymes transfering phosphate. It is therefore necessary for the energymetabolism and for many synthesis, i.e. DNA and RNA.Mg is one of the most widespread elements of the earthcrust and is found in many nutritients. Nevertheless the daily intake in the western countries is often under the recommended level, due to the western life stile. Regular alcohol intake lessens the resorption and regular sport enhances the excretion via the sweat. Especially in elderly people this can lead to a lack of Magnesium. This may promote muscular cramps and weakness, cardiac arrhythmias, hypertension or bronchial hyperreactivity.It seems to be reasonable to recommend liberally a oral supplementation with magnesium.
Gestational diabetes (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy and is associated with increased feto-maternal morbidity as well as long-term complications in mothers and offspring. GDM is diagnosed by an oral glucose tolerance test (OGTT) or fasting glucose concentrations in the diabetic range. In case of a high risk for GDM/type 2 diabetes (history of GDM or prediabetes [impaired fasting glucose or impaired glucose tolerance]; malformation, stillbirth, successive abortions or birth weight > 4500 g in previous pregnancies) performance of the OGTT (120 min; 75 g glucose) is recommended already in the first trimester and - if normal - the OGTT should be repeated in the second/third trimester. In case of clinical symptoms of diabetes (glucosuria, macrosomia) the test has to be performed immediately. All other women should undergo a diagnostic test between 24 and 28 gestational weeks. If fasting plasma glucose exceeds 95 mg/dl, 1 h 180 mg/dl and 2 hirs 155 mg/dl after glucose loading (OGTT) the woman is classified as GDM (one pathological value is sufficient). In this case a strict metabolic control is mandatory. All women should receive nutritional counseling and be instructed in blood glucose self-monitoring. If blood glucose levels cannot be maintained in the normal range (fasting < 95 mg/dl and 1 h after meals < 130 mg/dl) insulin therapy should be initiated. Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. After delivery all women with GDM have to be reevaluated as to their glucose tolerance by a 75 g OGTT (WHO criteria).
These are the guidelines for preventive care, diagnosis and treatment of diabetic foot syndrome. Diabetic neuropathy, peripheral vascular disease, bone deformity and altered biomechanics are foot-related risk conditions. The position statement is focused on screening methods and recommendations for clinical care for diabetics, who currently have no foot ulcers. A decision pathway is offered with respect to diagnosis and management of diabetic patients at increased risk or who manifest injuries.
The increase in cancer incidence with increasing age is becoming more obvious and more important as the average age of population increases. Currently over 50% of all cancers occur in people who are 65 and older. The clinical behaviour of common malignant diseases may change with age because of intrinsic variation of the neoplastic cells and the ability of the tumor host to support neoplastic growth. Therapeutic decisions should be based on an estimation of patient's life expectancy, functional status, comorbidity, polypharmacy, socioeconomic conditions, nutrition and the presence of geriatric syndromes. This review should give some answers to the many existing questions about cancer in the elderly.
Implementation of regular gerontologic activities of the National Center for Gerontology of the Zagreb Institute of Public Health is carried out through the following areas: 1. Follows, studies, evaluates, supervises, reports and plans projection of the future health needs and functional disabilities of the elderly for institutional and noninstitutional health care in the city of Zagreb and counties of Croatia. 2. Offers professional and methodological help, coordinates, supervises and executes instruction and education for managers of health protection of the elderly and follow up of health needs of geriatric insurers. 3. Actively participates, suggests, evaluates, reports on specific qualities of implementation of total and individual Programs of health measures and procedures in health protection of the elderly. as well as in implementation of the Program of basic preventive health measures of primary, secondary and tertiary prevention for the elderly defined through professional and methodological Basic coverage of application of preventive measures for aimed vulnerable groups of the elderly ; 4. Actively participates and performs scientific-research and publicist gerontological activities. Application of the regular gerontologic activity of the Center for Gerontology in Croatia enables application and evaluation of the Program of health measures and procedures in health care of the elderly with evaluated application of the Program of primary, secondary and tertiary health prevention for the elderly, defined nomenclature, standards and algorithms of health procedures for geriatric patients with adequate network of geriatric health care and rational geriatric health expenditures. Within four areas of regular gerontological activities scientific research the Ministry of Science and Technology conducts project “ Register of health needs of the elderly for institutional care” in the area of biomedical sciences. The aim of this Program is to form the Register of health needs of the elderly for institutional care according to counties in Croatia. It will be the basis for adequate solving of the problems in preventive health care of old sick people and their needs for institutional as well as outinstitutional care.
Elderly people, the increasing population group of public health significance in Croatia, are at the highest risk of health– related disorders and decreased functional ability including cardiovascular and cerebrovascular diseases, diabetes mellitus, osteoporosis, impaired immunity, and impaired cognitive function. Based on the follow up, identification, study, evaluation and report as well as planning of projections of future health needs and functional abilities of the elderly of Croatia, counties of Croatia and the city of application, development, promotion and evaluation of implementation of the Program of health measures and procedures in health protection of the elderly is possible. It also includes Programs of follow up, study and evaluation of health needs and functional ability of psychogeriatric patients so as to ensure effective, adequate and rational psychogeriatric protection of the elderly from mental and behavioural disorders and diseases with regard to growing figures of Alzheimer diseases among older people. Those Programs are carried out by individual gerontologic approach based on professional and methodological instrument – Evidence list No 2.2. of the follow up of individual psychogeriatric patient according to the levels of offered health service by general practice, homes for the aged and disabled people, centers for care and rehabilitation of the elderly, geriatric institutions, psychogeriatric departments and Gerontologic centers in the local communities where elderly live and create. The aim of this Evidence list is to determine and monitor specific health needs and demands of older psychogeriatric patients. Evidential list for following the health requirements of psychogeriatric patients is an important part of the recently introduced Register of health needs of the elderly for institutional care and Subregister for Alzheimer’ s Disease and is created by implementation of professional methodology and the results of European and Croatian gerontological research. It will be the basis for adequate solving of the problems in preventive health care of older people, in the field of mental diseases, and their needs for institutional as well as outinstitutional care.
Croatian population is aging progressively and according to its demographic structure of aging it has all the characteristics of European western countries what classifies it in the fourth group of European countries with very old population according to the UN classification. According to 2001 census in Croatia the share of people over 65 years of age is 15.62% from total population (N=4437460) with age-sex differentiation (males 12.41% and females 18.61%) what is rather dramatic. Public health gerontological analysis in Croatia points to the fact that in the course of last several decades the rate of morbidity and mortality from cardiovascular diseases is increasing what causes an increase in the number of functionally disabled older people from 65 years of age to 74. According to the present-day understanding based on a large number of gerontological and epidemiological researches, healthy regular diet of the elderly rich in nutrients and fibers, which can also meet the reduced energy needs of older people, contribute to the prevention and decrease of a great number of chronic diseases, preserving health and functional capacity of the elderly, increasing their quality of life and in this way increasing health of the entire population. There are evident health benefits of Mediterranean diet because this kind of diet can contribute to the prevention of cardiovascular diseases with the possibility of changing genetic predisposition, hypertension, diabetes mellitus, obesity, dental decay and certain cancers. What is more, gerontological researches have indicated that the traditional Mediterranean diet is associated with significant reduction in overall mortality of elderly population in developed non– Mediterranean countries. Mediterranean diet should be applied to special programs made for vulnerable population groups (children and older people) so as to ensure active and healthy ageing of the population. There is also need for continual education of population but special attention should be given to the education of experts in the field of healthy diet. Gerontological and public health indicators undoubtedly suggest that the combination of beneficial Mediterranean diet and physical activity can ensure active, healthy ageing of both Croatian and European elderly population.
Magnesium is a Cofactor in all enzymes transfering phosphate. It is therefore necessary for the energymetabolism and for many synthesis, i.e. DNA and RNA. Mg is one of the most widespread elements of the earthcrust and is found in many nutritients. Nevertheless the daily intake in the western countries is often under the recommended level, due to the western life stile. Regular alcohol intake lessens the resorption and regular sport enhances the excretion via the sweat. Especially in elderly people this can lead to a lack of Magnesium. This may promote muscular cramps and weakness, cardiac arrhythmias, hypertension or bronchial hyperreactivity. It seems to be reasonable to recommend liberally a oral supplementation with magnesium.
