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Practical Diabetes Care, 3rd Ed., Excerpt #16: Diabetic Renal Disease Part 5 of 5

David Levy, MD, FRCP

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Renal replacement therapy

The decision to start dialysis is often difficult. The clinical decision is based on many factors, including the presence of uremic symptoms and weight loss, and biochemical measurements including serum creatinine (e.g. serum creatinine 700–800 μmol/L(small mu), eGFR < 12–14 mL/min, falling albumin, hyperkalemia). For hemodialysis patients, vascular access is usually undertaken when eGFR is about 25 mL/min. Distal vascular calcification often prevents use of the radial artery, and an elbow fistula is often required. Everyone must be made aware of the value of the antecubital fossa vessels, and venous cannulation should be avoided at this site in a pre-dialysis patient.

Until recently peritoneal dialysis was preferred, especially in people with diabetes, as it carried improved medium-term survival and preservation of residual renal function compared with hemodialysis. The emergence of the serious complication of encapsulating peritoneal sclerosis has tempered enthusiasm for the technique of late, and there has been a consistent decline in the use of peritoneal dialysis over the past 10 years….

Renal transplantation is now routine for ESRD patients with diabetes, a transformation over the past 20 years. However, survival is still not as high as in non-diabetic transplant patients. The results of live donor transplantation are consistently better than with deceased donor kidneys. Worse glucose control after transplantation is associated with poorer patient (but not graft) survival, but studies are retrospective and as in other areas hyperglycemia may be a marker of less measurable but more important factors.

Pancreas, kidney–pancreas and islet transplantation
Renal transplantation is appropriate for both type 1 and type 2 patients, but in type 1 patients always consider whether pancreatic or islet transplantation might also be beneficial, especially in patients with recurrent severe hypoglycemia, uncontrolled hyperglycemia despite intensification of insulin treatment, and early potentially reversible microvascular complications (Box 8.2). Pancreas-alone transplants are less often given because of the relatively high rate of graft failure. Simultaneous pancreas–kidney transplants now comprise up to 20% of procedures, as kidney graft survival is at least as high as in kidney-alone transplants, and patient survival higher, probably due to the normoglycemia achieved after pancreas transplant. Pancreas-after-kidney procedures are also highly successful, whether performed early or late. Long-term restoration of normoglycemia, defined as non-diabetic HbA1c below 5% (31 mmol/mol) with normal acute insulin response, is now achievable.

Microvascular complications, except for autonomic neuropathy, begin to stabilize and improve within a few years, and intermediate measures of cardiovascular risk, for example CIMT, also improve. Despite the formidable surgery, and the need for lifelong immunosuppression, improvement in quality of life in many cases is dramatic.

Islet transplantation
Interest in islet transplantation increased after Shapiro and colleagues in Edmonton reported success in 2000 using a novel islet isolation technique, intraportal delivery of islets, and steroid-free immunosuppression with daclizumab, tacrolimus and sirolimus. Around 550 islet transplantations were performed between 2000 and 2006. In an international collaborative study using the Edmonton technique (2006), which permitted up to three islet infusions per patient, nearly half of recipients were insulin independent after a year, about one-quarter had partial graft function (usually requiring some insulin treatment) and the remaining one-quarter had complete graft loss. However, even partial graft function protects against severe hypoglycemia, one of the major indications for islet transplantation. Further refinements are likely to improve outcome and side-effects, the latter still common even with the slimmed-down immunosuppression regimen [22].

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References:

  1. Burrows NR, Li Y, Geiss LS. Incidence of treatment for end-stage renal disease among individuals with diabetes in the U.S. continues to decline. Diabetes Care 2010;33:73–7. PMID: 20040673.
  2. Adler AI, Stevens RJ, Manley SE, Bilous RW, Cull CA, Holman RR. Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney Int 2003;63:225–32. PMID: 12472787.
  3. Pham TT, Sim JJ, Kujubu DA, Liu IL, Kumar VA. Prevalence of nondiabetic renal disease in diabetic patients. Am J Nephrol 2007;27:322–8. PMID: 17495429.
  4. Romão JE, Haiashi AR, Elias RM et al. Positive acute-phase inflammatory markers in different stages of chronic kidney disease. Am J Nephrol 2006;26: 59–66. PMID: 16508248.
  5. Houlihan CA, Tsalamandris C, Akdeniz A, Jerums G. Albumin to creatinine ratio: a screening test with limitations. Am J Kidney Dis 2002;39:1183–9. PMID: 12046029.
  6. Stoycheff N, Stevens LA, Schmid CH et al. Nephrotic syndrome in diabetic kidney disease: an evaluation and update of the definition. Am J Kidney Dis 2009;54:840–9. PMID: 19556043.
  7. Fonseca V, Thomas M, Katrak A, Sweny P, Moorhead JF. Can urinary thyroid hormone loss cause hypothyroidism? Lancet 1991;338:475–6. PMID: 1678446.
  8. Bilous R, Chaturvedi N, Sjølie AK et al. Effect of candesartan on microalbuminuria and albumin excretion rate in diabetes: three randomized trials. Ann Intern Med 2009;151:11–20. PMID: 19451554.
  9. Ruggenenti P, Fassi A, Ilieva AP et al. Preventing microalbuminuria in type 2 diabetes. Bergamo Nephrologic Diabetes Complications Trial (BENEDICT) investigators. N Engl J Med 2004;351:1941–51. PMID: 15516697.
  10. Perkins BA, Ficociello LH, Silva KH, Finkelstein DM, Warram JH, Krolewski AS. Regression of microalbuminuria in type 1 diabetes. N Engl J Med 2003;348:2285–93. PMID: 12788992.
  11. Gæde P, Lund-Andersen H, Parving HH, Pederson O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358:580–91. PMID: 18256393.
  12. House AA, Eliasziw M, Cattran DC et al. Effect of B-vitamin therapy on progression of diabetic nephropathy: a randomized controlled trial. JAMA 2010;303:1603–9. PMID: 20424250.
  13. The ASTRAL Investigators. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med 2009;361:1953–62. PMID: 19907042.
  14. Schjoedt KJ, Astrup AS, Persson F et al. Optimal dose of lisinopril for renoprotection in type 1 diabetic patients with diabetic nephropathy: a randomised crossover trial. Diabetologia 2009;52:46–9. PMID: 18974967.
  15. Parving HH, Persson F, Lewis JB, Lewis EJ, Hollenberg NK. Aliskiren combined with losartan in type 2 diabetes and nephropathy. AVOID Study Investigators. N Engl J Med 2008;358:2433–46. PMID: 18525041.
  16. Drechsler C, Krane V, Ritz E, März W, Wanner C. Glycemic control and cardiovascular events in diabetic hemodialysis patients. Circulation 2009;120:2421–8. PMID: 19948978.
  17. Agarwal R. Blood pressure and mortality among hemodialysis patients. Hypertension 2010;55:762–8. PMID: 20083728.
  18. Colhoun HM, Betteridge DJ, Durrington PN et al. Effects of atorvastatin on kidney outcomes and cardiovascular disease in patients with diabetes: an analysis from the Collaborative Atorvastatin Diabetes Study (CARDS). Am J Kidney Dis 2009;54:810–19. PMID: 19540640.
  19. Gal-Moscovici A, Sprague SM. Bone health in chronic kidney disease–mineral and bone disease. Adv Chronic Kidney Dis 2007;14:27–36. PMID: 17200041.
  20. New JP, Aung T, Baker PG et al. The high prevalence of unrecognized anaemia in patients with diabetes and chronic kidney disease: a population-based study. Diabetic Med 2008;25:564–9. PMID: 18445169.
  21. Agarwal R, Rizkala AR, Bastani B, Kaskas MO, Leehey DJ, Besarab A. A randomized controlled trial of oral versus intravenous iron in chronic kidney disease. Am J Nephrol 2006;26:445–54. PMID 17035697.
  22. Shapiro AMJ, Ricordi C, Hering BJ et al. International trial of the Edmonton protocol for islet transplantation. N Engl J Med 2006;355:1318–30. PMID: 17005949.

 

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David Levy, MD, FRCP, Consultant Physician, Gillian Hanson Centre, Whipps Cross University Hospital; Honorary Senior Lecturer
Queen Mary University of London London, UK

This edition first published 2011, © 2011 by David Levy. 1st edition 1998 (Greenwich Medical Media/Cambridge University Press) 2nd edition 2006 (Altman Publications)