Management choices in diabetic end-stage renal disease

A functioning kidney transplant provides the uraemic diabetic patient a greater survival with greater rehabilitation than does either CAPD or maintenance haemodialysis. There are no reports, however, of prospective controlled studies of dialysis versus kidney transplantation in diabetic patients whose therapy was assigned randomly. For the minority ( < 10%) of diabetic ESRD patients who have insulin-dependent diabetes mellitus (IDDM), serious consideration should be devoted to performance of a combined pancreas and kidney transplant to cure diabetes. No matter which ESRD therapy has been elected, optimal rehabilitation in diabetic ESRD patients requires that effort be devoted to recognition and management of co-morbid conditions. Uraemia therapy, whether CAPD, haemodialysis or a kidney transplant should be individualized to the patient's specific medical and family circumstances. Attention to control of hypertension and hyperlipidaemia may slow the course of macrovascular disease, particularly of the coronary arteries, which threatens long-term survival of diabetic kidney recipients. Pretransplant cardiac evaluation is mandatory to identify and correct silent coronary artery disease that may be severe and life threatening. Survival is continuously improving in treating ESRD in diabetes by dialytic therapy, renal transplantation, and in IDDM, by combined pancreas and kidney transplantation. This inexorable progress in therapy reflects multiple small advances in understanding of the pathogenesis of extrarenal micro- and macrovasculopathy in an inexorable disease, coupled with safer immunosuppression.