Perit Dial Int
29(Supplement_2):
132-134
2009
© 2009 International Society for Peritoneal Dialysis
Part 3: Clinical Experiences |
OPTIMAL USE OF PERITONEAL DIALYSIS IN PATIENTS WITH DIABETES
Sung Hee Chung1,
Hyunjin Noh2,
Hunjoo Ha3 and
Hi Bahl Lee4
Kidney Center,1 Soon Chun Hyang University
Hospital; Hyonam Kidney Laboratory,2 Soon Chun Hyang
University; Ewha Womans University College of
Pharmacy,3 Seoul; and Kim's Clinic and Dialysis
Unit,4 Miryang, Korea
Correspondence to: H.B. Lee, Soon Chun Hyang University College of Medicine,
Kim's Clinic and Dialysis Unit, 721-4 Naeedong, Miryang 627-803 Korea.
bahllee{at}naver.com
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ABSTRACT
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The survival of patients with end-stage renal disease (ESRD) resulting
from diabetes continues to improve, but the survival rate among diabetic ESRD
patients remains the lowest among all primary diagnoses probably because of
the higher prevalence of cardiovascular comorbidity associated with diabetes.
Diabetes, age, and comorbidity all significantly modify the effect of
treatment modality on patient survival.
As compared with hemodialysis (HD), peritoneal dialysis (PD) offers an
equal or lower risk of death across all subgroups during the first 1–2
years of dialysis. The association of PD with better outcomes than are seen
with HD is probably a result of a lower prevalence of infections and
congestive heart failure and better preservation of residual renal function
(RRF) in PD patients.
Use of angiotensin converting-enzyme inhibitor (ACEI) or angiotensin II
receptor blocker (ARB) helps to preserve RRF in ESRD patients and to maintain
peritoneal membrane integrity longer in PD patients. Antioxidants can also
support preservation of peritoneal membrane function.
Peritoneal dialysis should be the initial modality of dialysis in all
ESRD patients. Older patients (age 
45 years) with diabetes and patients
without diabetes may switch to HD or receive a kidney graft in 1–2
years' time; younger patients (age < 45 years) with diabetes may stay on PD
longer. Use of ACEI and ARB or antioxidants can help to maintain peritoneal
membrane function longer.
KEY WORDS: Congestive heart failure; diabetes mellitus; end-stage renal disease; infection; peritoneal membrane; residual renal function.
Diabetes remains the leading cause of end-stage renal disease (ESRD) in
many countries. The survival of ESRD patients with diabetes continues to
improve, but the survival rate in this subgroup remains the lowest primarily
because of a higher prevalence of cardiovascular comorbidity
(1).
As compared with hemodialysis (HD), peritoneal dialysis (PD) offers equal
or better patient survival across all subgroups of patients needing dialysis
(2) during the first 2 years
(3). This observation may be
attributable to a lower prevalence of infections and congestive heart failure
(CHF) and better preserved residual renal function (RRF) in PD patients
(1,4–6).
Mortality studies comparing PD and HD show that diabetes, age, and comorbidity
all significantly modify the effect of treatment modality on patient survival
(2).
In this review, we discuss the selection of dialysis modality, the factors
affecting RRF in ESRD patients, and the potential means for maintaining
peritoneal membrane integrity in PD patients as strategies for improving
clinical outcomes in diabetic ESRD patients.
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SELECTION OF DIALYSIS MODALITY
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The U.S. Renal Data System 2007 annual data report showed that interval
mortality rates adjusted for age, sex, race, and primary diagnosis were
consistently down across all modalities and lengths of therapy, with the
exception of year 1 mortality in the HD population in the United States
(1). Even with more detailed
adjustments for severity of disease, the year 1 death rate for HD patients
showed little change since 1999, but death rates for PD patients declined over
the same period.
Very high rates of catheter use for initial HD and a high prevalence of
infections and CHF in HD patients may negatively affect year 1 mortality in HD
patients (1). In 2005, 81% of
incident HD patients used a catheter at their first outpatient dialysis
(1). This factor may be
important in the growing rate of infectious hospitalization and in the lack of
improvement in year 1 mortality in these patients. Patients with pre-ESRD
nephrology care were 46% less likely to use a catheter than were their
counterparts not receiving specialist care. Patients with CHF were 56% more
likely to use a catheter than were those without the diagnosis
(1). Admissions for vascular
access infections in HD patients appeared to be stabilizing, and admissions of
PD patients for peritonitis continued to fall. In 2005, admissions for
bacteremia or septicemia rose in HD patients to 102 admissions per 1000
patient–years, which was 1.5 times the rate in PD patients and 2.4 times
the rate in the transplant population
(1). Admissions for pneumonia
were 1.9–2.2 times more frequent in HD patients than in PD or transplant
patients (1).
In all populations, CHF is a powerful independent predictor of mortality.
The cumulative probability of CHF was 55.9% in the incident HD population at 2
years as compared with 40.8% in the incident PD population
(1).
Vonesh et al. (2)
reviewed nine mortality studies comparing PD and HD and summarized the key
results:
- Among younger patients without and with diabetes in the United States,
Canada, and Denmark, PD is associated with survival equivalent to or better
than that for HD.
- The relative risk (RR) of death for PD as compared with HD varies with time
on therapy: PD has an equal or lower mortality rate during the first 1–2
years; thereafter, results vary by subgroup.
- In the United States, HD is associated with better survival among diabetic
patients over age 45; in Canada and Denmark, no such difference is
observed.
- The RR for death varies according to the type of analysis—as-treated
compared with intent-to-treat.
- In the United States, there appears to be a temporal trend of improved
outcomes associated with PD that exceeds the trend associated with HD.
- Diabetes, age, and comorbidity all significantly modify the effect of
treatment modality on patient survival.
It is apparent from these observations that PD should be the initial
modality of dialysis for all ESRD patients. Older patients with diabetes and
patients without diabetes may switch modality to HD or undergo kidney
transplantation in 1–2 years' time; younger patients with diabetes may
stay on PD longer.
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FACTORS AFFECTING RRF IN ESRD PATIENTS
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Peritoneal dialysis preserves RRF better than HD does. In ESRD, RRF is
clinically important because it contributes to adequacy of dialysis, quality
of life, and mortality. Moist et al.
(4) showed that the risk of RRF
loss was 65% lower in PD patients than in HD patients. History of diabetes,
CHF, and time to follow-up were predictors of RRF loss. Use of angiotensin
converting-enzyme inhibitors (ACEIs) and of calcium channel blockers (CCBs)
was independently associated with decreased risk of RRF loss. Jansen et
al. (5) demonstrated that,
after adjustment for baseline glomerular filtration rate (GFR), age, primary
diagnosis, comorbidity, blood pressure, use of antihypertensive drugs, and
change of treatment, PD patients had a significantly higher time-averaged
residual GFR at the end of 1 year of dialysis than HD patients did. Suzuki
et al. (6) showed that
patients using valsartan, an angiotensin II (AngII) receptor blocker (ARB),
maintained a renal creatinine clearance during the first 2 years of dialysis
that was significantly higher than that in patients not using ARB.
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STRATEGIES FOR PRESERVATION OF PERITONEAL MEMBRANE INTEGRITY DURING PD
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Earlier, our group (7) had
demonstrated that human peritoneal mesothelial cells (HPMCs) constitutively
express renin–angiotensin system, that AngII produced by HPMCs mediates
high glucose–induced upregulation of transforming growth factor β1
(TGFβ1) and fibronectin expression, and that AngII-induced TGFβ1 and
fibronectin expression in HPMCs is mediated by nicotinamide adenine
dinucleotide phosphate oxidase-dependent reactive oxygen species (ROS). These
data suggest that locally-produced AngII and ROS in the peritoneum may be
potential therapeutic targets in peritoneal fibrosis during long-term PD.
In a subsequent study, our group
(8) showed that rats treated
intraperitoneally with commercial PD solution containing 3.86% glucose for 12
weeks had significantly lower drain volume, higher dialysate-to-plasma
(D4/P4) creatinine, and increased membrane thickness.
Omental TGFβ1, vascular endothelial growth factor (VEGF), collagen I, and
lipid oxide levels, and dialysate VEGF and AngII concentrations were
significantly increased in rats treated with PD solution as compared with
control animals. The intraperitoneal antioxidant N-acetylcysteine and
the ARB losartan prevented all of these changes, suggesting that antioxidants
and ARB may allow for better preservation of the functional and structural
integrity of the peritoneal membrane during long-term PD. Duman et
al. (9) had earlier
demonstrated that an ACEI, enalapril, administered intraperitoneally, improved
ultrafiltration capacity and decreased peritoneal thickening.
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CONCLUSIONS
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Evidence suggests that PD should be the initial modality of dialysis in all
ESRD patients. Older patients with diabetes and patients without diabetes may
switch modality to HD or undergo kidney transplantation in 1–2 years
after PD start; younger patients with diabetes may stay on PD longer. Early
referral of patients with chronic kidney disease to nephrologists may reduce
early morbidity and mortality in ESRD patients. Peritoneal dialysis preserves
RRF better than HD does, and the use of ACEI, ARB, or CCB may further help to
slow the decline of RRF in PD patients. Less-frequent use of high glucose PD
solution and use of non-glucose PD solutions, ACEI, ARB, and antioxidants may
help preserve peritoneal membrane function.
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ACKNOWLEDGMENTS
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The work presented here was supported in part by Korea Research Foundation
grant no. E 00014.
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REFERENCES
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ABSTRACT
SELECTION OF DIALYSIS MODALITY
