Dialysis in patients with diabetic nephropathy: CAPD versus hemodialysis

Diabetic nephropathy has emerged as a major cause of ESRD over the past decade, being the most prevalent cause of ESRD requiring dialysis in North America (United States and Canada) and the second highest in the incidence rate in Europe, Japan, Korea, Australia, and New Zealand. A greater proportion of older patients and of patients with diabetic nephropathy and other comorbid conditions has been treated with CAPD. Despite the preferential use of CAPD to treat a high-risk group of patients, the overall and/or selection-adjusted mortality was similar between HD and CAPD groups. Among diabetic patients, selection-adjusted mortality was similar between HD and CAPD or lower in CAPD than in HD, the difference being greatest among younger patients and significant through the age of 52, or higher in CAPD than in HD with higher risk of death for older diabetics (age > or = 50 years), but with similar risk among younger diabetics (age < 50 years). Technique survival was also variably reported as similar between HD and CAPD, lower, or higher with CAPD compared to HD. Diabetic CAPD patients had more hospital admissions and more days in the hospital and higher withdrawal rates from dialysis compared to diabetic HD patients. These disparate results of patient and technique survival between HD and CAPD in diabetic patients may have resulted from patient selection criteria with different comorbid conditions on entrance to dialysis, quantity of dialysis, and other unrecognized factors. Prospective randomized studies are needed to assign a cause-and-effect relationship between the choice of dialysis modality and patient and technique survival among patients with diabetes mellitus as well as with all other diagnostic categories.