Renal replacement therapy (RRT) and pancreas transplantation
The incidence rates for commencement of RRT in patients with diabetes are 159/million population in the USA and 24/ million population in the UK. Proportionally, these represent 44% and 22% of total incident patients starting RRT per year. There are similar differences in rates between northern (lower) and central (higher) European countries but the precise reasons are not clear.
Most patients with diabetes are managed on hemodialysis – approximately 80% of all dialyzed patients with diabetes in the UK. Kidney transplantation rates tend to be lower in patients with diabetes compared to patients without diabetes in ESRD, perhaps as a result of greater co-morbidities. In the UK in 2007, 14.6% of all new transplants were in patients with diabetes (compared to a relative incidence of 22% of diabetic ESRD); only 7.7% of all established transplants in the UK at the end of 2006 were in people with diabetic nephropathy.
However, survival appears best for kidney transplant recipients compared to those remaining on dialysis, but is improving year on year for all modalities of RRT. In the UK 1-year survival for those aged < 65 years on dialysis was 86.2% for patients with diabetes and 93.1% for patients without diabetes respectively. For those aged > 65 years the survival was 78.4% and 79.7% respectively. Six-month mortality hazard was < 20% and relatively stable over 8 years for those with diabetes < 55 years of age on dialysis but there were higher rates, close to 35% and rising, for those over 65 years of age. In the US, 5-year survival for patients with diabetes on hemodialysis or peritoneal dialysis is < 30%.
As patients approach ESRD, planning for RRT becomes a priority. Patients do much less well if they present in acute on chronic renal failure. All patients with CKD stage 4 (eGFR < 30 mL/min/1.73 m2) should be referred for assessment. Other indications are shown in Box 16.2.
The role of whole-organ pancreas transplantation is controversial. There are no data suggesting that simultaneous pancreas and kidney transplantation (SPK) improves outcome in terms of survival compared to kidney transplant alone. However, quality of life, particularly for patients with hypoglycemic unawareness, is much improved. Survival rates are much better with modern immunosuppressant regimens, with reported rates of 67% at 10 years for SPK compared to 65% for living donor kidney transplants alone. In the UK, the number of SPK procedures rose from 102 in 2005 to 197 in 2007 (worldwide, the figures were approximately 1000 for both years). However, the operative procedure and acute complication rate is much greater than for kidney transplants alone and pancreas transplantation should only be carried out in specialist centers.
Is it diabetic nephropathy?
Because type 2 diabetes is a common condition, patients will also present with non-diabetes related kidney disease. However, it is likely that < 10% with type 2 diabetes and albuminuria have a non-diabetic cause and few of these will have a specifically treatable disease. Interestingly, those with atypical or non-diabetic pathologies tend to have a slower rate of decline in GFR compared to patients with typical glomerulosclerosis.
In the presence of retinopathy and albuminuria > 300 mg/day, it is highly likely that patients have diabetic kidney disease; in the absence of retinopathy and in the presence of microalbuminuria then non-diabetic kidney disease becomes more likely. If patients have signs of systemic disease, rapidly increasing proteinuria or deteriorating renal function, or urinalysis suggesting microscopic hematuria, then they should be referred for specialist review and a non-diabetic cause of their nephropathy should be considered.
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Rudy Bilous MD, FRCP, Professor of Clinical Medicine, Newcastle University, Honorary Consultant Endocrinologist, South Tees Foundation Trust, Middlesbrough, UK
Richard Donnelly MD, PHD, FRCP, FRACP, Head, School of Graduate Entry Medicine and Health, University of Nottingham, Honorary Consultant Physician, Derby Hospitals NHS Foundation Trust, Derby, UK
A John Wiley & Sons, Ltd., Publication
This edition first published 2010, © 2010 by Rudy Bilous and Richard Donnelly. Previous editions: 1992, 1999, 2004
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