Diabetic Nephropathy: Management of the end-stage patient

Abstract

Diabetic nephropathy is currently the leading cause of new patients requiring dialysis in the United States. Management of the diabetic patient with ESRD is complicated by the frequent coexistence of complications affecting other organ systems, including retinopathy, cardiovascular disease, peripheral neuropathy, or autonomic neuropathy, manifested as gastroparesis, diarrhea or obstipation, cystopathy, or orthostatic hypotension. Associated clinical syndromes must be followed and treated, if possible, while preparing the patient to receive renal replacement therapy. Both the clinical condition and the psychosocial environment are key factors in choice of ESRD therapy for an individual patient. Rehabilitation data are best for patients who undergo kidney transplantation, but these data are confounded by the fact that the healthiest patients are referred for this treatment modality. Living, related kidney transplant is the preferred initial choice for the diabetic patient with kidney disease. At most centers, both in the United States and abroad, the cadaveric transplant is the second choice for uremia therapy. At the appropriate institution, the patient with type I diabetes may also be considered for a simultaneous cadaveric pancreas transplant. While awaiting cadaveric transplantation, or if contraindication to transplantation is present (chronic infection, recent malignancy, or severe cardiac disease), diabetic patients with severe impairment of the glomerular filtration rate (less than 10-15 ml/min) are referred for vascular access placement and/or insertion of a peritoneal catheter. The decision regarding the choice of CAPD vs. hemodialysis must be made on an individual basis. Rehabilitation and survival data for these therapies are similar, although technique survival rates for CAPD decline dramatically as time progresses because of infectious complications. In-center hemodialysis has the worst survival and rehabilitation profile, but the sickest, most debilitated patients with the highest number of comorbid conditions tend to be referred for that therapeutic modality. Most studies of rehabilitation were performed before use of recombinant human erythropoietin, and comparison between ESRD treatment modalities will have to be reevaluated now that the drug is routinely used.

The Protective Effects of α-Lipoic Acid on Kidneys in Type 2 Diabetic Goto-Kakisaki Rats via Reducing Oxidative Stress

“…Diabetic nephropathy is a severe, chronic complication of type 2 diabetes mellitus, and it is the main cause of end-stage renal failure in diabetic patients [1]. Hyperglycemia results in an increased production of reactive oxygen species (ROS) which leads to renal dysfunction [2].…”

Therapeutic use of continuous subcutaneous infusion of recombinant human erythropoietin in malnourished predialysis anemic patients with diabetic nephropathy

“…Chronic renal failure (CRF) is accompanied by anemia in which serum EPO levels are low relative to blood hemoglobin (Hb) concentrations (2)(3)(4). CRF patients with diabetic nephropathy are often malnourished and accompanied by a number of metabolic abnormalities, water retention and diabetic vascular complications (5).…”

Preocupante incremento de la diabetes como causa de insuficiencia renal terminal: Evaluación del tratamiento sustitutivo

“…Este peor pronóstico, aparece en todas las modalidades de TSFR: HD (10,20); DPCA (21,22) y trasplante renal (9,10). Los pacientes diabéticos no sólo tienen una mortalidad mayor sino que además, su morbilidad es muy alta.…”