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Minerva Urologica e Nefrologica 2004 September;56(3):289-303


language: English

Diabetes mellitus and dialysis

Stein G. 1, Fünfstück R. 2, Schiel R. 3

1 Department of Internal Medicine III Friedrich-Schiller-University, Jena, Germany 2 Department of Internal Medicine I Sophien- and Hufeland-Klinikum Weimar, Germany 3 Department of Diabetes and Metabolic Diseases Inselklinik Heringsdorf Seebad Heringsdorf, Germany


Diabetes mel­lit­us is in­creas­ing, and in ­some coun­tries is the sin­gle ­most im­por­tant ­cause, for end-­stage re­nal dis­ease. In gen­er­al, pri­mar­i­ly eld­er­ly pa­tients on re­nal re­place­ment ther­a­py, are not on­ly af­fect­ed by di­a­betes-re­lat­ed ­long-­term com­pli­ca­tions, but al­so fre­quent­ly ­with a ­wide ­range of co-mor­bid­ities. Apart ­from car­diac com­pli­ca­tions, the pa­tients are sub­ject to a ­wide ­range of vas­cu­lar (i.e. pe­riph­er­al vas­cu­lar dis­ease, ­stroke) and in­fec­tious com­pli­ca­tions. In the ­past this has ­been re­flect­ed by a rel­a­tive­ly ­poor sur­vi­val ­rate on di­al­y­sis, and min­i­mized chanc­es to ob­tain re­nal trans­plan­ta­tion. Today, sev­er­al re­nal re­place­ment strat­e­gies are avail­able, in­clud­ing the ­main 3: he­mod­i­al­y­sis, per­i­to­neal di­al­y­sis or kid­ney trans­plan­ta­tion. For pa­tients ­with di­a­betes mel­lit­us, he­mod­i­al­y­sis is the ­most com­mon­ly ­used ther­a­py. Each di­al­y­sis ­unit ­should ­achieve an op­ti­mal di­al­y­sis ad­e­qua­cy rep­re­sent­ed by a sin­gle ­pool Kt/V of at ­least 1.2. The ­most im­por­tant in­de­pen­dent pre­dic­tor of pa­tient sur­vi­val ­with he­mod­i­al­y­sis treat­ment is age. Other fac­tors re­lat­ed to com­pli­ca­tions are ­left ven­tric­u­lar hy­per­tro­phy, ar­te­ri­al hy­per­ten­sion, hy­per­vo­lae­mia and chron­ic ane­mia. Moreover, me­di­al ar­te­ri­al cal­cifi­ca­tion, mal­nu­tri­tion, gas­troin­tes­ti­nal dis­or­ders and di­al­y­sis ­against low po­tas­sium di­a­ly­sate are re­lat­ed to in­creased mor­bid­ity and mor­tal­ity as ­well. An in­te­gral ­part of treat­ment is the avail­abil­ity of ­good vas­cu­lar ac­cess. The sur­vi­val ­rates of fis­tu­las ­show a near­ly two­fold high­er ­rate of fail­ure for syn­thet­ic ­grafts com­pared ­with ar­ter­i­ov­e­nous fis­tu­las. The ­role of per­i­to­neal di­al­y­sis in re­nal re­place­ment ther­a­py in pa­tients ­with di­a­bet­ic neph­rop­a­thy is ­well es­tab­lished and ­used ­world-­wide. Most pa­tients ­with re­sid­u­al re­nal func­tion ­start ­with con­tin­u­ous am­bu­la­to­ry per­i­to­neal di­al­y­sis (­CAPD), but au­to­mat­ed per­i­to­neal di­al­y­sis can al­so be ­used. An un­re­solved prob­lem as­so­ciat­ed ­with ­CAPD is the glu­cose ab­sorp­tion and ca­lor­ic in­take. The op­ti­mum ad­just­ment of ­blood glu­cose val­ues is ­made ­more dif­fi­cult. Death ­rates of di­a­bet­ic pa­tients on per­i­to­neal di­al­y­sis re­main high­er ­than in non-di­a­bet­ics. The chang­es in per­i­to­neal mem­brane thick­ness and vas­cu­lar al­ter­a­tions in re­la­tion­ship to the du­ra­tion of di­al­y­sis are ­caused main­ly by glu­cose and glu­cose deg­ra­da­tion prod­ucts, ­such as ad­vanced gly­ca­tion end­pro­duct (AGEs). Therefore, new per­i­to­neal di­al­y­sis so­lu­tions are need­ed to re­duce the com­pli­ca­tions and to de­lay a ­long-­time func­tion of the per­i­to­neal mem­brane. Peritonitis re­mains ­still the ma­jor ­cause of dis­con­tin­u­a­tion of di­al­y­sis but ­there is no in­creased ­risk in di­a­bet­ic pa­tients.
Nevertheless, an in­te­gra­tive ­care of end-­stage re­nal dis­ease pa­tients ­with di­a­bet­ic neph­rop­a­thy ­should be of­fered to the pa­tient, start­ing on per­i­to­neal di­al­y­sis and ­switch to he­mod­i­al­y­sis if prob­lems ­arise. During the ­whole ­time pa­tients ­should be ­kept on the re­nal trans­plan­ta­tion wait­ing ­list.

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