Diabetes: changing the fate of diabetics in the dialysis unit

The prevalence of diabetes mellitus (DM) is very high worldwide. According to the World Health Organization in 2000 the worldwide prevalence of DM was 171,000,000. Diabetic nephropathy is a major vascular complication of DM. If DM is not treated early and adequately, many diabetic patients may reach end-stage renal disease (ESRD) secondary to advanced irreversible diabetic nephropathy. In many countries diabetic nephropathy has become the single most frequent cause of prevalent ESRD patients undergoing maintenance hemodialysis (MHD). In the early era of renal replacement therapy (RRT) by means of intermittent hemodialysis the prognosis of diabetic patients undergoing MHD was extremely poor and disappointing. While the prognosis of patients suffering from diabetic ESRD and maintained by chronic intermittent dialysis has greatly improved, the rehabilitation rate and survival of these patients continue to be worse than those of non-diabetic patients. A preexisting severely compromised cardiovascular condition, vascular access problems, diabetic foot disease, interdialytic weight gain, and intradialytic hypotension explain most of the less favorable outcome. Despite improved techniques and more aggressive medical therapy in recent years, a review of the fate of diabetics in dialysis units since 1972 reveals that these patients have had significant morbidity and mortality. We still have a long way to go in order to achieve more ideal outcomes for our patients. Most of the diabetic ESRD patients are still maintained by MHD, but they can choose other modalities of RRT such as chronic ambulatory peritoneal dialysis (CAPD), kidney and kidney plus pancreas transplantation. The results of different studies and national registries on the mortality and morbidity of ESRD patients being maintained on different modalities of dialysis are conflicting. It can be concluded that the two modalities of dialysis (CAPD and MHD) are almost comparable in terms of survival. The recent suggestions for nocturnal daily hemodialysis, short daily hemodialysis, and an integrative care approach for the management of diabetics with ESRD provides better promise for these patients.