Attaining long-term survival when treating diabetic patients with ESRD by hemodialysis

Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD). The United States Renal Data System's report indicates that survival of diabetic patients has improved but continues to be reduced compared with that of nondiabetic patients. Several ways to decrease morbidity and mortality in diabetic patients are discussed: (1) Instructions and treatment in the predialysis period markedly influence compliance of patients, and this plays a determinant role in development and progression of diabetic complications before and during maintenance hemodialysis. (2) After the start of hemodialysis therapy, insulin therapy must be adjusted and respect impaired glucose use and prolongation of insulin half-life. (3) By avoiding of puncture of veins prospectively used for arteriovenous fistulae and timely installation of the fistulae, native arteriovenous fistulae can be achieved in more than 70% of diabetic patients. (4) Hypertension, left ventricular hypertrophy, and cardiovascular problems commonly found in diabetic patients require optimal removal of fluid overload. This is difficult to achieve in the presence of accelerated arteriosclerosis and autonomic polyneuropathy in diabetic patients and requires long and smooth dialysis procedures. (5) Infected necroses caused by diabetic polyneuropathy and peripheral vascular disease require appropriate therapy by experienced nephrologists and surgeons.