Renal Replacement Therapy in Patients with Diabetic Nephropathy, 1980–1985

Abstract

Diabetic nephropathy, a rarely listed cause of end-stage renal failure (ESRF) among patients starting renal replacement therapy (RRT) in the early seventies, has progressively gained in importance and become one of the major reasons for the continuous growth of the patient population on RRT in most European countries. Amongst new patients commencing RRT in 1985, the acceptance rate varied between 3 and 12 per million population for type I diabetes mellitus and between one and four per million population for type II diabetes mellitus. Nordic countries, particularly Sweden and Finland, had the highest acceptance rate of young patients with type I diabetes mellitus whose median ages were 38-42 years. In most central and southern European countries the median age of patients with type I diabetes mellitus varied between 50 and 58 years. The high number of young patients with type I diabetes mellitus and ESRF in Nordic countries point to a different natural history of this disease. It cannot be excluded, however, that the higher median age in other countries might result from doctors mistakenly diagnosing type I disease in patients with type II disease who need insulin treatment. Patients with type II diabetes mellitus had a similar age distribution at start of RRT throughout Europe and their median ages clustered around 60 years in most countries. The contribution of haemodialysis, peritoneal dialysis and renal transplantation was analysed for diabetic compared to non-diabetic ESRF. Despite large geographical differences in the proportional use of methods of treatment, a general trend to apply CAPD more frequently in diabetic as compared to non-diabetic patients was observed, and this was true for countries with both predominant haemodialysis and predominant transplant programmes. Transplantation without prior dialysis was performed in 17% of Swedish and 30% of Norwegian patients with type I diabetes mellitus. In order to better explain the mortality of patients with diabetic ESRF, the proportional distribution of causes of death was analysed. Myocardial ischaemia and infarction was confirmed to be the leading cause of death in patients with diabetes mellitus on RRT. The coronary death rate was estimated to be 10 times greater in young patients with type I diabetes mellitus as compared to their non-diabetic counterparts. Other cardiovascular as well as infectious causes were recorded in a similar proportion of deaths in diabetics as in non-diabetics. Cancer deaths, however, appeared to be definitely less frequent in patients on RRT due to diabetic nephropathy.

Epidemiology, development and treatment of end-stage renal failure in Type 2 (non-insulin-dependent) diabetic patients in Europe

“…Partly for these reasons, access to RRT for patients with end-stage renal failure due to diabetes has in the past been restricted, particularly in those countries with limitations on resources for provision of RRT [2]. The advent of peritoneal dialysis more than 10 years ago, and increasing use of renal transplantation, combined with a less restricted view of the potential for treatment of patients with diabetic nephropathy has led to a great increase in the acceptance for RRT, from less than 2 % of treated patients 20 years ago [3] to more than 10 % in the mid 1980s [4].…”

“…In the United States, for example, nearly one-third of patients with end-stage renal failure have diabetic ne-* On behalf of the European Dialysis and Transplant Association Registry phropathy and the annual incidence of end-stage renal failure in diabetic patients alone is over 40 per million population [5], compared with 3.6 per million in Europe in 1985 [4]. It is unclear to what extent this difference is due to a greater underlying prevalence of diabetic nephropathy in the United States, or to a more liberal treatment pattern, compared with that in Europe.…”

“…It is unclear to what extent this difference is due to a greater underlying prevalence of diabetic nephropathy in the United States, or to a more liberal treatment pattern, compared with that in Europe. There have also been wide geographic variations reported within Europe in the number of diabetic patients commencing RRT [4] and relatively little is known about the relative rates of acceptance and mode of treatment in patients with Type 2 (non-insulin-dependent) diabetes mellitus compared with those with Type 1 (insulin-dependent) diabetes. Type 2 diabetic patients are older than those with Type 1 diabetes, implying that liberalisation of acceptance of diabetic patients in Europe for RRT may have preferentially increased the number of Type 2 diabetic patients undergoing dialysis or transplantation.…”

Renal Transplantation in Diabetic Patients with or Without Simultaneous Pancreatic Transplantation 1986: Data from the EDTA Registry

“…Details of sex and age distribution suggest that the two groups are not entirely comparable. For unknown reasons, females appeared to be accepted for combined transplantation at the slightly higher proportion of 47% as compared to the 42% female prevalence with diabetic nephropathy (44% for type I diabetes mellitus) among patients accepted for renal replacement therapy in 1983-1985 [6]. Similarly, and in contrast to recipients of combined grafts, male patients with diabetic nephropathy were selected preferentially for kidney transplantation alone, as shown by the sex ratio of 66% males versus 34% females.…”

Increasing Incidence of Diabetic Nephropathy in Spain

“…The prevalence of diabetes in the dialysis popula tion, as reported by the EDTA Registry [1,2], seems to be lower if compared to the report of the United States Renal Data Sys tem (USRDS) [3], Although the EDTA Re gistry recently documented an increasing in cidence and prevalence of end-stage renal failure from diabetic nephropathy, some epi demiological studies suggest that this recent higher incidence may be surpassed by the reality [4], Furthermore, current registries provide information only on the number of diabetic patients with end-stage renal fail ure: more detailed information on the inci dence of diabetic nephropathy with incipient renal failure is currently not available.…”