David Levy, MD, FRCP
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.
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 .
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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)