PD and the Diabetic Patient

Diabetes is the most common cause of end stage renal disease in The United States, accounting for approximately half of all incident dialysis patients1. The vast majority of these patients dialyze using thrice weekly hemodialysis, while only 4.5% use peritoneal dialysis (PD) for renal replacement therapy1. The diabetic patient with ESRD presents many therapeutic challenges, some of which are particularly applicable when PD is selected as the mode of renal replacement therapy (RRT). Though diabetes per se is not a contraindication for PD, the low utilization of PD in diabetics may be due to several perceived therapeutic challenges, including with fluid management, metabolic control (e.g., dyslipidemia, blood sugar) and peritoneal membrane transport characteristics2-8. Despite peritoneal satisfactory ultrafiltration, diabetic patients may have difficulty mobilizing fluid from the interstitial compartment due to low oncotic pressure, since a significant number have proteinuria at the time of initiation of dialysis. Survival data have been inconsistent in this population, with observational studies showing both higher and lower mortality in diabetics using PD, depending on age, gender, and other factors9-12.

Peritoneal Membrane Transport in Diabetic Patients

Peritoneal membrane transport is an important consideration when using PD and plays a role in achieving adequate ultrafiltration (UF). Among diabetic patients, Serlie et al. reported lower transcapillary ultrafiltration (TCUF) compared with non-diabetics, matched for age, sex and duration of continuous ambulatory peritoneal dialysis (CAPD), shortly after initiation of PD6. However, no significant difference was observed one year later. These results suggest that long-term exposure to high glucose concentrations in diabetics prior to CAPD may cause changes in the capillary wall aquaporins, similar to those observed after prolonged exposure to high glucose concentration in non-diabetics. These findings may explain the published discrepancies on the presence or absence of increased peritoneal permeability among diabetic patients13-17. It is possible that differences were observed when diabetics were compared to non-diabetics early in the course of the disease, but not after many years of therapy when both groups could have had abnormally high permeability.

Abnormally high leakage of albumin across capillary walls is also characteristic of diabetic microvascular disease. This increase in capillary permeability is not confined to the renal or retinal capillaries and has been documented in the peritoneal capillaries as well6. Shostak and Gotloib have demonstrated increased permeability in the peritoneal capillaries of diabetic rats, and Krediet et al. have made similar observations in humans18,19. This may be due to a reduction in the fixed negative charges of the capillary basement membrane.

High peritoneal transport inversely correlates with serum albumin concentration (SAC)20, which is a powerful marker of mortality21,22. Nakamoto et al. have confirmed that high peritoneal membrane transport and protein permeability are more common among diabetic patients undergoing PD23. Similarly, Cueto-Manzano, et al. have reported that diabetes mellitus (DM) is significantly more frequent among high transporters and is less frequently associated with low transport24. In their univariate analysis, high peritoneal transport rate, DM, low serum creatinine, low albumin and older age significantly predicted mortality. However, in the multivariate analysis, only DM, low serum creatinine and high peritoneal transport rate were shown as mortality risk factors. Among non-diabetics, high transport did not affect survival. The most important risk factor was DM rather than high peritoneal transport. No difference in peritoneal transport was observed between type I and type II diabetic patients matched for gender, duration of PD and clinical characteristics24.

Despite these issues, many clinicians favor PD in diabetics due to lower infection rates, fewer episodes of hypotension, and the possibility of better residual renal function preservation25.


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