Diabetic nephropathy: natural course, survivorship and therapy

Diabetes mellitus is a disease with major social and economic consequences. End-stage renal disease (ESRD) due to diabetes occurs in as many as 30% of patients with juvenile diabetes, providing a large percentage (up to 33%) of all patients in need of therapy for ESRD. We have reviewed the natural course of the nephropathy in type I diabetes mellitus and the results of dialysis and transplantation therapy with particular regard to survival and morbidity. Comparisons of the survival of diabetic patients among peritoneal dialysis, hemodialysis, and transplantation are complicated by the lack of sufficient data for peritoneal dialysis and by the bias introduced by patient/treatment selection methods. Presently, it appears that transplantation with a living related donor graft offers the best survival for both graft and patient, with a definite reduction of morbidity associated with the complications of diabetes. Cadaveric transplantation is approximately the equivalent of hemodialysis in patient survival at 1 year and also appears to offer a somewhat diminished morbidity. Peritoneal dialysis data are sparse and skewed by patient selection. However, there is some emerging evidence that therapy with this modality may be associated with a delay in progression of retinopathy, when compared with hemodialysis.