10 PRACTICAL DIABETES Vol. 38 No. 1 Copyright © 2021 John Wiley & Sons A 84-year-old woman with type 2 diabetes for 13 years became generally unwell; long-term control of her diabetes, hypertension and dyslipidaemia was poor. Investigations revealed a chest infection and her creatinine had risen from 111 to 429μmol/L over seven days (Table 1). Plasma osmolality, and urine ketone levels were normal. She had taken a stable dose of perindopril for several years and was not taking any other nephrotoxic drugs. She had not been obviously hypotensive or hypovolaemic; renal ultrasound was normal. She had a previous history of breast cancer and deep vein thrombosis. She had recently been dyspnoeic with clear chest X-ray but raised D-dimer (1241ng/ml); computed tomography pulmonary angiogram (CTPA) was performed three days before admission with prior eGFR 46ml/min/1.73m2 and creatinine level 111μmol/L. She fulfilled the criteria for contrast induced acute kidney injury (CI-AKI), i.e. an increase in serum creatinine of 25% or 26.5μmol/L, a temporal relationship to the contrast agent (generally two to three days), and other causes of renal impairment excluded.1,2 Risk factors for CI-AKI2,3 are: age; female gender; diabetes mellitus; hypertension; renal impairment; heart failure; myeloma; albuminuria; anaemia; hypovolaemia; nephrotoxic drugs; hypoalbuminaemia; higher glucose level; and higher LDL level. The patient had several risk factors: age, gender, diabetes, hypertension, renal impairment, hyperglycaemia, raised LDL level, and ACE inhibitor use. Characteristics of the contrast (intra-arterial, non-ionic, hyperosmolar or larger volumes) also increase the risk of CI-AKI,1–3 but modern weight-based contrast dosing minimises this. Some risk factors can be modified, some cannot. Lower baseline renal function increases the risk of CI-AKI. An eGFR of 45ml/min/1.73m2 was often taken as a cut off for using intravenous contrast.1 In elderly patients, the Cockcroft Gault formula may be closer to the glomerular filtration rate than the formulae used by the laboratories4 but this patient’s baseline Cockcroft Gault eGFR was identical: 46ml/ min/1.73m2. Different guidelines give different eGFR thresholds from 30 to 60ml/min/1.73m2 for developing CI-AKI.5 Risk stratification models, often derived from cardiology patients with intra-arterial contrast and cardiac disease (both CI-AKI risk factors), may be inappropriate for other patients.6 To avoid CI-AKI, one can consider other imaging modalities, hold potentially nephrotoxic drugs 24 hours before contrast, preload with intravenous normal saline and use safest contrast.2,3 Systematic community control of glucose, cholesterol and blood pressure might have helped this patient; there was no time to achieve this as an inpatient since pulmonary emboli on CTPA can disappear within 48 hours. Treatment is avoidance, general support, and hydration; dialysis removes contrast,7 but is rarely required. The management of metformin with contrast is controversial. The Royal College of Radiologists3 cites a lack of valid evidence regarding metformin-associated lactic acidosis due to contrast, but suggests that if the eGFR is under 60, the clinician and radiologist should liaise regarding temporary metformin cessation. Other guidance8 suggests holding the metformin if eGFR is under 30 and restarting it if eGFR is unchanged, which contrasts to the metformin Summary of Product Characteristics9 that advises avoiding metformin at this eGFR and halting metformin in conditions that might alter renal function. In conclusion, contrast enhanced scans provide much useful information, but one must be aware of the hazards and their risk factors; liaison with the radiology department is invaluable.

Background: Home intravenous (IV) antibiotic treatment of cystic fibrosis (CF) acute pulmonary exacerbations (PExs) has become a widespread occurrence, preferred by most patients over hospital treatment. Better quality of life (QoL) has been quoted as one of the main reasons why patients favour home treatment over hospital care. Patients & Methods: This was a prospective study, which analyzed 181 PExs needing treatment with IV antibiotics in 58 adult CF patients (32 male). FEV1, FVC and QoL scores using Quittner’s CF Questionnaire-Revised (CFQ-R) were recorded at the start (day 1) and end (day 14) of treatment. PExs were classified according to the site where the majority of treatment (>80%) had been delivered (at home or in hospital). Results: Baseline day 1 FEV1 and FVC values were similar in the 2 groups, but after 14 days of IV treatment significantly greater improvement was observed in the hospital treatment group. Baseline total QoL scores were higher in the home treatment group (mean QoL (SEM) 711.8 (20.5) in the home group and 595.4 (35.8) in the hospital group, P=0.003). However, after 14 days of treatment, changes in the total QoL scores were higher in the hospital group (mean QoL (SEM) 49.8 (17.5) in the home group and 140.9 (16.8) in the hospital group, P=0.001). Consequently, on day 14 values of QoL were similar in the 2 groups (mean QoL (SEM) 742.4 (21.5) in the home group and 747.1 (33.4) in the hospital group). Conclusions: QoL demonstrated a significantly greater improvement in the hospital group. On day 14 QoL for the hospital group was similar to that of the home group despite possible disadvantages imposed by the confinement in hospital.

Background: Adult cystic fibrosis (CF) patients often suffer repeated acute pulmonary exacerbations (PExs). As CF is a relatively uncommon disease, previously published studies in the literature have included more than one exacerbation per patient in their data set and considered individual exacerbations of the same patient as separate entities. The validity of this approach has not yet been examined. Materials & Methods: This was a prospective study. Adult CF patients were included if they experienced 3 PExs treated with intravenous antibiotics in one year. Features of PExs included in the analysis were: CF symptom score, spirometry, oxygen saturation, heart rate, body mass index, C-reactive protein, and the time until the next exacerbation. For each parameter, comparisons were made by plotting differences against average using Bland and Altman method. The number of points where differences fell within and outside the 2 standard error of the mean (SEM) from equality were identified. Results: A total of 93 PExs in 31 patients (15 females) were analysed. Percentage of data that fell outside SEM ranged between 20% for BMI to 80% for the time until the next exacerbation. Minimal clinically important differences were also found in at least 40% of pairs of PExs for symptom score, CRP and spirometry measurements. Conclusions: Features of successive PExs differed in the same individual. The findings of this study lends support to considering acute CF pulmonary exacerbations to be separate entities in selected research projects.

Fatigue is a debilitating symptom in patients with cystic fibrosis (CF). Although fatigue is commonly reported in these patients, an effective treatment for this symptom has not been found. The factors associated with fatigue in CF have not been investigated. We conducted a prospective, case-control study in adult patients with CF. All the patients were chronically infected with Pseudomonas aeruginosa and were enrolled in the study during disease stability. A gender and age-matched control group was also recruited. Subjective assessment included three questionnaires: the Chalder fatigue questionnaire, St Mary's Hospital sleep questionnaire (SQ), and the scaled general health and Hillier questionnaire (GHQ). For patients with CF, spirometry, body mass index (BMI), haemoglobin level, C-reactive protein, and the burden of pulmonary exacerbations (PExs) were assessed. The control group completed all the three questionnaires, and their BMI was measured. A total of 78 participants were enrolled in the study (44 patients with CF and 34 control). Female patients with CF received antibiotics for more days than male patients with CF. The fatigue score did not differ between female and male participants in either the patients with CF or the control group; however, the fatigue score was greater for both the sexes in the patients with CF compared with the control group: p = 0.038 for female and p = 0.048 for male. The scores for the SQ and the GHQ did not differ between the two study groups. The fatigue score correlated with the total score for SQ (p < 0.0001) in patients with CF, but not in control participants. In patients with CF and the individuals in the control group, a close correlation was found between the fatigue score and the GHQ domain-specific scores and with the total score; p < 0.0001 for patients with CF and p = 0.001 for control. No correlations were found between the fatigue score and any of the objective parameters studied.

BACKGROUND There is currently no simple scoring system to evaluate change in symptoms during a pulmonary exacerbation (PEx) in adult cystic fibrosis (CF) patients. PATIENTS AND METHODS We evaluated 265 episodes in 58 adult CF patients. A simple symptom score was administered at the start and the end of each PEx. The score evaluated four symptoms: cough, sputum, breathlessness and fatigue. Each symptom was scored from one (mild symptoms) to four (severe symptoms). The total symptom score was the summation of all the four symptoms. The total symptom score was compared with CF Respiratory Questionnaire (CFRQ) and with spirometry. RESULTS There was significant internal correlation between scores for each pair of symptoms. The total symptom score correlated with the functional activity score and the respiratory score domains and with the summary score for CFRQ. The total symptom score correlated with spirometry values. Symptom score improved after 2-week treatment with intravenous (IV) antibiotics in 88.3%, remained unchanged in 7.3% and worsened in 4.4% of all episodes. Changes in symptom score after IV treatment correlated with changes of all main spirometry measurements. CONCLUSION This new symptom score is simple and sensitive to change over a short period. It correlates with established quality-of-life questionnaires and with spirometry. The changes of symptom score over a short period correlate with changes in spirometry. This score can be used as an added tool to assess the outcome of CF PExs.

BACKGROUND Magnetic resonance imaging (MRI) has been shown to be a useful tool to evaluate the volume of the pancreas. There is currently no information about the size of the spleen in cystic fibrosis (CF) patients. PATIENTS AND METHODS We investigated 51 adult volunteers: 28 pancreatic insufficient CF patients [13 with CF-related diabetes (CFRD) and 15 non-diabetic] and 23 male non-CF patients [12 with type 1 diabetes mellitus (T1DM) and 11 healthy control subjects]. Patients with known liver cirrhosis or portal hypertension were excluded. The size of the spleen was measured in all subjects by an investigator unaware of patients' clinical status. For comparison of spleen size in the four study groups only male CF patients were included. For CF patients, spleen size was compared with forced expiratory volume in 1 s (FEV(1)), body mass index (BMI), total number of days of intravenous (IV) antibiotic treatment for pulmonary exacerbations in year previous to study, levels of circulating white blood cells, glycosylated haemoglobin A1c (HbA1c), and exocrine function of the pancreas, as assessed by daily requirement of oral lipase. RESULTS Amongst the four study groups, spleen size was greatest in the male non-diabetic CF patients (P = 0.01). For CF patients, spleen size was greater in male compared to female patients (P = 0.012). For patients with CFRD, there was an inverse correlation between the spleen size and HbA1c (r = -0.59, P = 0.04) and the daily intake of supplementary lipase (r = -0.63, P = 0.02). The size of the spleen in patients with CFRD, but not in CF patients without CFRD, inversely correlated with the days of IV antibiotic treatment received in the year previous to the study (r = -0.67, P = 0.012). There was no correlation between spleen size and BMI, FEV1 and white blood cell counts in any group. CONCLUSION On MRI, the spleen size was greatest in male non-diabetic CF patients in comparison with other groups. The size of the spleen in CFRD patients was smaller when diabetes was poorly controlled, when exocrine pancreatic function was greatly impaired and in those with greater need for IV antibiotics in the year prior to the study.

We investigated differences in the volume of the pancreas in cystic fibrosis (CF) patients with and without diabetes using MRI to study the natural history of CF-related diabetes (CFRD). We investigated 29 pancreas-insufficient adult CF patients, 13 with CFRD and 16 without diabetes. Patients with CFRD were receiving insulin therapy at the time of study. None of the non-diabetic CF patients had evidence of impaired glucose tolerance. Pancreas volume was estimated by MRI scans using T₁ weighted fat-suppression sequences and assessed by an examiner who was unaware of the patients' diabetes status. Pancreas volume of CF patients was measured and subsequently compared with that of non-CF age-matched Type 1 diabetes (T1DM) patients and healthy controls previously investigated. The two CF groups were matched for age and gender. There were no differences in spirometry values, body mass index or pancreatic exocrine function. The pancreas was visible by MRI in only 3 of 13 (23.1%) patients with CFRD and in 5 of 16 (31.3%) patients without diabetes (p-value = 0.7). In total, the pancreas was not detected by MRI as an anatomical entity in 21 of 29 (72.4%) CF patients, irrespective of their diabetes status. When comparing the four study groups, the pancreas was significantly smaller in CF patients than in T1DM patients and healthy controls.