Approximately 200 patients with diabetes annually develop end-stage kidney disease due to progression of diabetic kidney disease in Nara, Japan. We performed a survey to assess the current status of diabetic kidney disease in Nara. We recruited 38,766 patients with diabetes (mean age, 68±13 years; male, 57 %) from August 2013 to July 2014 in 171 institutions. The mean HbA1c was 6.7 % in total, but the proportion of HbA1c ≥8.0 % was higher among young patients than among older ones. To assess the renal function, the estimated glomerular filtration rate was evaluated in 92 % of patients; however, the urinary albumin was measured only in 29 % of patients. The features of medical care in each institution might affect the measurement of urinary albumin. The prevalence of diabetic nephropathy was 35 %, and that of chronic kidney disease was 45 %. Based on these results, we are implementing new measures in Nara to improve the quality of diabetes care and prevent the development and progression of diabetic kidney disease.

A 48-year-old man was under insulin treatment for diabetes that had been diagnosed 8 years prior, but his treatment had been interrupted, and his glycemic control was poor. He was found to have disturbance of consciousness by his family and was taken to the emergency ward. After being transported to our medical center, he was diagnosed with diabetic ketoacidosis (DKA) based on the results of a blood test. His level of consciousness was E1V1M1 on the Glasgow Coma Scale. We noted significant brain edema on computed tomography and brain hypoperfusion on magnetic resonance imaging. We performed systemic control with fluid replacement and continuous insulin injection, and we administered glycerol for brain edema in parallel with treatment for complicated pneumonia using antimicrobial agents. His brain edema improved but eventually led to a vegetative state. Brain edema before treatment in hyperglycemic emergent adult patients, including those with DKA or hyperglycemic hyperosmolar syndrome (HHS), is extremely rarely reported, so we feel that this case is valuable and have thus duly reported it.

The patient was a 38-year-old man diagnosed with HIV infection at age 31 who had started highly active anti-retroviral therapy (HAART). Before therapy, his blood glucose had been normal. After 78 months of HAART, the patient visited our hospital complaining of general malaise. A blood analysis revealed a blood glucose level of 643 mg/dL, HbA1c of 9.8 % and urine ketone of 1+. Therefore, the patient was hospitalized. He was positive for GAD antibodies and showed increased blood ketone bodies and decreased insulin secretion, thus leading to a diagnosis of type 1 diabetes mellitus. The patient also had a high fT4 and low TSH level and was positive for TRAb. Therefore, concurrent Graves' disease was diagnosed. To evaluate the association between HAART and autoimmune disease, titers of GAD antibody and TRAb were measured using banked serum. The patient became positive for GAD antibody and TRAb with improvement in the immune function after HAART. The patient was considered to have developed type 1 diabetes mellitus and Graves' disease associated with immune reconstitution syndrome. It may be important to consider the possibility of type 1 diabetes mellitus when rapid blood glucose worsening is observed during HAART.

A 60-year-old man with no medical history of diabetes experienced mouth dryness for 9 days, for which he drank high volumes of non-alcoholic beverages. Subsequently, he presented with nocturia and polydipsia. Laboratory data indicated HbA1c 12.5 %, blood glucose 396 mg/dL, CPR 3.00 ng/mL, and GAD antibody<0.3 IU/mL; based on these findings, he was diagnosed with type 2 diabetes mellitus. After starting pharmacotherapy, the laboratory findings improved as follows: fasting blood glucose 127 mg/dL, CPR 2.55 ng/mL, and increased insulin secretion. He did not have diabetic microangiopathy. His ABI was reduced (right: 0.54; left: 0.58). Volume-rendered, multidetector row computed tomography indicated chronic total occlusion of the aorta from the renal artery and both common iliac arteries; thus, Leriche syndrome was diagnosed. Renal artery ultrasonography revealed a severely stenotic lesion in the right renal artery. Coronary angiography revealed significant stenosis, for which Y artificial blood vessel replacement surgery was performed, while pharmacological management was continued. Postoperatively, the ABI improved to 1.05 on the right side and 1.07 on the left. Patients with diabetes should be screened not only for microangiopathy but also for macroangiopathy.

The patient was a 43-year-old woman. She developed minimal change nephrotic syndrome at 41 years of age, and was being managed with oral prednisolone as an outpatient of our hospital. She developed malaise 7 days prior to admission, and thirst and polyuria occurred from 3 days prior to admission. On the day of admission, she began vomiting and visited our hospital. At that time, her blood glucose level was 399 mg/dL, a urinary ketone body test was positive, her blood level of ketone bodies was increased, and an arterial blood gas analysis showed metabolic acidosis. She was therefore diagnosed with diabetic ketoacidosis and was admitted to our hospital. Investigations performed after admission revealed the following findings: HbA1c, 6.9 %; urinary C-peptide, <3.2 μg/day; and fasting blood C-peptide, 0.08 ng/mL. Accordingly, she was diagnosed with fulminant type 1 diabetes. Good glycemic control was achieved by the administration of insulin (28 units/day). The association of minimal change nephrotic syndrome with fulminant type 1 diabetes has rarely been reported. We believe that our patient could be important for investigating the pathogenic mechanisms of these two diseases.

Diabetic patients have a high risk of developing infectious disease, and they poorly respond to infections once they occur. Severe infectious diseases, such as urinary infection, leg gangrene and lower respiratory tract infection, occasionally develop in diabetic patients. Odontogenic maxillofacial infection is also a major infectious disease complicating diabetes mellitus. Periodontal disease and other odontogenic infections induce massive odontogenic maxillofacial abscess. We herein report three untreated diabetic patients who rapidly developed maxillofacial abscesses from odontogenic infections. They received antibiotics with appropriate glucose control, and their condition promptly improved. Hyperglycemia has a serious effect on odontogenic maxillofacial infection. Glycemic control is therefore essential for the prevention of odontogenic infection.