Choice of renal replacement therapy in patients with diabetic end stage renal disease

Diabetic nephropathy is becoming the leading cause of end-stage renal disease (ESRD) worldwide. Although the prognosis of patients with diabetes and ESRD receiving Renal Replacement Therapy (RRT) has improved greatly, the presence of pre-existing cardiovascular disease means that the survival and medical rehabilitation of diabetics continue to be inferior to that of non-diabetics. RRT should be initiated earlier in patients with diabetes than in non-diabetics and the main choices of modalities are: 1) haemodialysis (HD), 2) Peritoneal dialysis (PD), 3) Kidney transplantation alone (KTA) or 4) simultaneous kidney and pancreas transplantation (SPKT). The most common modality of RRT utilised in the diabetic patient remains HD but this method is associated with many clinical problems, in particular the managment of vascular access and frequent intradialytic hypotension. There is accumulating evidence demonstrating that both survival and medical rehabilitation of patients with diabetes and ESRD is superior after renal transplantation with or without pancreas transplantation.