Hemodialysis in the diabetic patient with end-stage renal disease

Diabetes mellitus is now the most common cause of end-stage renal disease (ESRD) in the U.S., and the percentage of ESRD patients with diabetes is increasing yearly. One-year survival in such patients is poorer than in those with other etiologies of ESRD but has improved from 64% to 74% over the past decade. However, overall 5-year survival on dialysis is still less than 20% in this population. It is controversial whether hemodialysis or peritoneal dialysis (CAPD, CCPD) is the best choice. Advantages of hemodialysis include its ready availability and convenience for patients, who are frequently incapacitated by blindness, cerebrovascular disease, and/or amputations. However, patients may tolerate dialytic ultrafiltration poorly due to autonomic neuropathy. Maintenance of vascular access is difficult, which may contribute to inadequate dialysis in some patients. Cardiovascular disease remains the most common cause of death. Management of coronary artery disease is difficult because of the high prevalence of silent ischemia. Control of blood pressure is of paramount importance in preventing cardiovascular complications. Improved survival in diabetics who were dialyzed in a more intensive than usual fashion has been reported recently. In addition, much of the difference in survival rates between diabetics and nondiabetics can be accounted for by the poorer nutritional status in the former group. Thus attention to the dose of dialysis administered and assurance of adequate nutrition should result in improved survival of the diabetic patient on hemodialysis.