Diabetic Patients Requiring

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The course from the onset of diabetes to the clinically evident nephropathy (proteinuria) and then to ESRD lasts 15-25 yr and occurs in approximately one-third of both type 1 and 2 diabetic patients, who then require RRT—dialysis or kidney transplantation.

Regardless of the clinical stage, the management of a diabetic patient is relatively difficult and more complicated than that of age- and gender-matched nondiabetic patients. The toll of comorbid conditions, such as cardiovascular disease, limb amputations, and especially blindness limit, or pre-empt successful therapy and rehabilitation.

In recent years, the frequency of DN has continuously increased, and since 1990 has become the fastest growing cause of chronic kidney disease (CKD) and the leading cause of ESRD worldwide, especially in the industrialized countries (1). Thus, during the last three decades among ESRD patients, the percentage of diabetic patients with ESRD admitted for RRT has dramatically increased in all racial groups, which is a reflection of the growing incidence of diabetes in the general population. DN is now responsible for 44% of all new patients who require RRT in United States, whereas the incident counts and adjusted rates of new patients starting RRT whose ESRD was due to diabetes increased from 2530 (12.5 per million population [pmp]) in 1980 to 42,665 (146.6 pmp) in 2002, respectively (1) (Fig. 1); the adjusted incidence rate for US patients with diabetes is now 148 pmp (42,813 patients). As a result of the increase in new ESRD patients between 1990 and 2001, the adjusted prevalence rate pmp increased considerably to 491 (142,963 patients, 119,338 on dialysis [83.5%], and 23,625 with a kidney transplant [16.5%]) (1) (Fig. 2).

The increasing prevalence of DN is due primarily to the greater number of patients with type 2 diabetes. By the end of 2000, it was evident that at least 95% of newly diagnosed people with diabetes had type 2 diabetes, reflecting the increase in the number of people suffering from obesity, which is associated with diabetes (thrifty gene hypothesis) (2). Many of these newly diagnosed diabetic patients will progress to ESRD, despite strict control of blood pressure and plasma glucose, which might retard the progression of DN but does not arrest it. Conversely, among those with type 1 diabetes, improved glycemic and blood pressure control may actually arrest the progression and even reverse microalbumin-uria, leading to decrease in the incidence of ESRD (3).

December 31 point prevalent ESRD patients. Rates adjusted tor age, gender and race

Counts

December 31 point prevalent ESRD patients. Rates adjusted tor age, gender and race

Counts

Fig. 2. The prevalent counts and adjusted rates by primary diagnosis between 1980 and 2002 according to USRDS data (1).

Similarly to United States, increases in the diabetic ESRD population have been observed in most European countries in which, between 1991 and 2000, the crude incidence of RRT for diabetic ESRD patients increased from 14.8 pmp (type 1 diabetes 26.9 pmp, type 2 diabetes 7.1 pmp) to 26.9% pmp (type 1 diabetes 9 pmp, type 2 diabetes 17.9 pmp), respectively, whereas the corresponding changes in prevalence values were 51.5 pmp (type 1 diabetes 35.8 pmp, type 2 diabetes 15.7 pmp) to 94.8 pmp (type 1 diabetes 50.3 pmp, type 2 diabetes 44.5 pmp) (4). During that time, the average annual change in age- and gender-adjusted incidence rates of RRT for type 2 diabetics varied from 6.5% in Sweden to 20.6% in French-speaking Belgium.

Taking into account the growth of the overall diabetic population, and the aging of the population, it is projected that by 2006 the number of new ESRD patients with diabetes as their primary cause of ESRD will equal the number of patients with all other primary diagnoses and by 2030 there will be 1.3 million diabetics and 945,000 nondiabetics under ESRD treatment—a total of more than 2.2 million patients in the United States (1). Almost half of these patients will be 65 or older and half will be non-Caucasians.

The most important aspect in prevention of CKD in diabetic patients is starting intervention early (i.e., during or even before the stage of microalbuminuria), long before the patient reaches the stage of advanced renal failure. This early intervention is quite imperative, as in all developed countries most diabetic patients are referred late and emergency HD is necessary in approx 30% of diabetic patients referred to renal units. Once the glomerular filtration rate (GFR) of a diabetic patient has reached 30 mL/min, a nephrologist should become the primary care physician. Because of their advanced age and the presence of major comorbidity, dialysis is the standard therapy for type 2 diabetics, whereas kidney or combined kidney-pancreas transplantation represent the standard therapy for type 1 diabetic patients.

In this chapter, we will review the literature and our experience concerning the management of patients with ESRD owing to DN by dialysis.

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