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When Kidneys Fail in Diabetes: Therapy Options
Eli A. Friedman, M.D.
 
Diabetes is a complicated and chronic disease that eventually destroys the kidneys. This so-called end-stage renal disease (ESRD) leaves the patient with difficult treatment choices. Though some patients, understandably, withdraw from ESRD therapy,(1) because the therapy so interferes with their quality of life, others, who are healthier and have a strong social support system, are able to attain satisfactory life quality.(2) Indeed, survival of diabetic ESRD patients - whether treated with a kidney transplant or by peritoneal dialysis or hemodialysis - has improved progressively over the past decade (Fig. 1).

Figure 1.
Figure 1
Whether treated by dialysis (combined peritoneal and hemodialysis) or a kidney transplant, survival of diabetic ESRD patients has improved continuously over the past decade. A continuing rise in absolute number and proportion of total diabetic ESRD patients is shown in the statistics provided by the United States Renal Data System 1998 Report.


Despite this progress, diabetes remains the leading cause of ESRD in all industrialized (well-fed) nations. Adequate comprehensive medical care is only infrequently given to individuals with diabetic kidney disease. Whether assessed in Europe or the US, the usual level of support for diabetic patients with symptomatic kidney disease is incomplete and often unsatisfactory.(3)(4)(5)(6)

Hemo- vs. Peritoneal Dialysis
For the large majority - over 80% - of diabetic persons who develop ESRD in the US, Europe or Japan, maintenance hemodialysis, where the patient is hooked to a machine that removes nitrogen waste products, urea and uric acid, from the blood, is the only kidney replacement regimen that will be employed. In the other technique, peritoneal dialysis, the waste products are removed during a fluid exchange in the abdominal cavity. Although enthusiasts for peritoneal dialysis for diabetic ESRD patients previously claimed survival superior to that attained by hemodialysis, careful analyses do not support such advantage.

For maintenance hemodialyis to work, a permanent and durable access to the patient's circulatory system (arteries and veins) must first be established. The most reliable variety of vascular access - an internal, surgically-made connection (arteriovenous fistula) in the wrist - is often more difficult in a diabetic than in a nondiabetic person because arteries are likely to be calcified or arteriosclerotic, that is, degraded by fatty deposits on the walls of the arteries. Many diabetic ESRD patients will need, as a result, synthetic (Dacron) prosthetic vascular grafts.

A typical hemodialysis regimen consists of three weekly treatments lasting four to five hours each. Anemia is one of the side-effects but it responds to new genetically-engineered drugs like erythropoietin which stimulates red blood cell production. Another side-effect, metabolic bone disease, caused by the loss of bone minerals, is minimized by treatment with synthetic vitamin D. Motivated patients trained to perform self-hemodialysis at home gain the longest survival and best rehabilitation afforded by any dialytic therapy for diabetic ESRD.7

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(1) Comment has been made

D.Mtz
How long could a diabetic live under these treatments?
Posted Wed, Mar. 3, 2010 at 8:28 pm EST



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