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Diabetic polyneuropathy (DPN) is an independent risk factor for cardiovascular disease in diabetes [1,2]. Meta-analyses indicate that DPN approximately doubles cardiovascular event risk compared to patients without DPN [2], and severe DPN further increases risk [1].
This descriptive study shows a 44-year-old single male, on maintenance hemodialysis for over 15 years, had repeated short-term hospitalizations for alcohol-related acute pancreatitis [3]. His left second toe discoloration led to diagnosis of type 2 diabetes, obesity, and diabetic foot gangrene. In July 2015, he underwent photocoagulation for proliferative diabetic retinopathy [3]. For diabetes, he had been taking saxagliptin 5 mg once daily and repaglinide 0.25 mg three times daily. After acute pancreatitis, these were discontinued and replaced with GLP-1 receptor agonist dulaglutide 0.75 mg weekly subcutaneously. During the December 2015 hospitalization, labs revealed PG 6.493 mmol/L, GA 18.6%, amylase 157 IU/L, lipase 81 IU/L, TG 44 mg/dL, LDL-C 75 mg/dL, γ-GTP 255 IU/L, LDH 161 IU/L, AST 13 IU/L, ALT 10 IU/L, TP 6.8 g/dL, Alb 3.7 g/dL, Cr 4.92 mg/dL, and eGFR 11.5 mL/min/1.73 m² [3].
He met essential criteria for DPN, showing subjective symptoms and bilateral absence of Achilles tendon reflexes [1]. In June 2017, he underwent evaluation by the spine orthopedic service. Neurological exam revealed absent DTR at L2-4 and ATR at S1-2, suggesting peripheral neuropathy. Nerve conduction studies were attempted but meaningful waveforms could not be obtained due to interference from dialysis equipment, highlighting challenges of electrophysiological studies in hemodialysis patients [4].
To assess diabetes-related distress, the PAID questionnaire was administered in December 2017. The total PAID score was 29/100, with highest distress (3/5) in “I feel that I am not in control of my diabetes” and “I feel overwhelmed by the demands of living with diabetes.” Among remaining items, 13 of 20 scored 1/5 (“not a problem”) and 5 scored 2/5.
This case demonstrates the use of the PAID questionnaire to evaluate psychosocial burden in a hemodialysis patient with DPN. Given the difficulty of nerve conduction studies [4], simplified diagnostic criteria [1] offer a practical alternative. Clinicians should address both neuropathic severity and diabetes-related distress to optimize care and potentially reduce cardiovascular risk [1,2].
References: [1] Nakamura. Peripheral Nerve 2012;21:110-1. [2] Liu. PLoS ONE 2019;14(2):e0212574. [3] Koga. INCRETIN 2015; Vancouver, Canada. [4] Stosovic. Nephrol Dial Transplant 2008;23:3327-33. [5] Sempere-Bigorra. J Pers Med 2021;11:230.
