Dialysis in diabetic nephropathy

INTRODUCTION

Although the development and progression of diabetic nephropathy may be retarded by normalization of the blood pressure (preferably with an angiotensin converting enzyme inhibitor) and strict control of the plasma glucose concentration, many patients still progress to end-stage renal disease [1-3]. Important determinants of progression include the severity of histologic disease and the absolute amount of proteinuria [4].

Diabetes is the most common cause of new patients requiring renal replacement therapy, accounting for approximately 45 percent of cases in the United States [5,6]. Although less frequent in other countries, 34 and 30 percent of incident dialysis patients have diabetes in Germany and Australia, respectively [7]. An increasing incidence has also been noted in non-German European countries, as reported from data from 10 registries in Europe [8]. However, the incidence appears to have stabilized in Denmark, which may be due to the widespread implementation of intensive renoprotective measures [9].

In the United States and Puerto Rico, although the total number of total number of patients who develop end-stage renal disease due to diabetes continues to increase, the risk of developing end-stage renal disease appears to be decreasing among patients who have diabetes [6]. Although the reasons for the decline in risk are not known, improved glycemic and blood pressure control and the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may play a role [2,6,10].

PATIENT SURVIVAL

Patient survival in diabetics on maintenance dialysis is lower than that seen in nondiabetics with end-stage renal failure due to chronic glomerular disease or hypertension [5,11,12]. As noted in the 2009 USRDS database, only approximately 30 percent of patients with diabetes survived five years after initiation of hemodialysis [13]. Survival also varies inversely with age, being best in young patients with good blood pressure control and no clinically evident cardiac disease [5,14].

However, these survival data may be overly optimistic as it is based upon information from the United States Renal Data system, a data base that excludes patients who have died within the first 90 days of the initiation of dialysis. When such individuals are included in mortality studies, the survival rate of diabetics requiring dialysis remains poor, even in dialysis centers located in countries with relatively high survival rates. As an example, among 84 consecutive patients with type 2 diabetes requiring dialysis in a center in France, 27 (32 percent) died at a mean follow-up of 211 days [15].