Dialysis in diabetic nephropathy
- Lionel U Mailloux, MD, FACP
Lionel U Mailloux, MD, FACP
- Clinical Professor of Medicine
- Hofstra Northwell School of Medicine
- Section Editors
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- David M Nathan, MD
David M Nathan, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Diabetes Mellitus
- Professor of Medicine
- Harvard Medical School
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 (ESRD) [1-3]. Important determinants of progression include the severity of histologic disease and the absolute amount of proteinuria .
Although the overall number of incident ESRD patients is still increasing slowly, now almost up to 120,000 new patients in 2013, the distribution of causes is shifting slightly. Based on data in the United States Renal Data System (USRDS) Annual Report for 2015, with data through 2013, the rate of new ESRD cases with diabetes listed as the primary cause plateaued in 2001 and has declined in most subsequent years, with the lowest rate in 2012 and 2013 approximately 152/million/year population .
Diabetes is the most common cause of new patients requiring renal replacement therapy, accounting for approximately 45 percent of cases in the United States (figure 1) [6,7]. Although the rate of 157 patients per million population for diabetes remains the highest of the renal diagnoses, it has decreased by 4.2 percent in 2011 incident patients . Although less frequent in other countries, 34 and 30 percent of incident dialysis patients have diabetes in Germany and Australia, respectively . An increasing incidence has also been noted in non-German European countries, as reported from data from 10 registries in Europe . However, the incidence appears to have stabilized in Denmark, which may be due to the widespread implementation of intensive renoprotective measures .
In the United States and Puerto Rico, although the total number of patients who develop ESRD due to diabetes continues to increase, the risk of developing ESRD appears to be decreasing among patients who have diabetes . 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 [2,7,12].
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 [6,13,14]. According to the 2015 United States Renal Data System (USRDS), the adjusted survival based on primary diagnosis was 92.9 and 78.3 percent at 3 and 12 months, respectively, for diabetic patients on dialysis (table 1) . This is slightly improved over prior survival data [8,15]. Survival also varies inversely with age, being best in young patients with good blood pressure control and no clinically evident cardiac disease [6,16].
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