Potential Benefits and Disadvantages of PD in the Treatment of Diabetic Patient

Diabetes mellitus is the fastest growing cause of end-stage renal disease (ESRD) worldwide. In the United States, between 1980 and 2001, the percentage of new patients starting renal replacement therapies whose ESRD was caused by diabetes increased from 14.7% to 44.6%; since 2001 the percentage has stabilized around 44%1. This article reviews the potential benefits and disadvantages of peritoneal dialysis (PD) for the treatment of ESRD in patients with diabetes.

Peritoneal dialysis provides daily renal replacement therapy with ultrafiltration without the need for anticoagulants. Continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) offer many potential benefits to the diabetic ESRD patient [see Definition of CAPD and CCPD], both clinically and socially2. Fluid and electrolyte changes with CAPD and CCPD are slow and sustained, allowing a more hemodynamically stable course of treatment with fewer episodes of hypotension and greater blood pressure control compared to hemodialysis (HD) treatments. Kuriyama reports fewer episodes of arrhythmia, fewer episodes of progressive retinopathy and blood borne diseases3. To date, multiple studies have proposed improved preservation of residual renal function in CAPD vs. HD patients [see Predictors of RRF loss], which contributes to  better volume control and continued clearance2,4,5. In PD and HD, residual renal function is also a predictor of reduced mortality6.. With PD, there is no need for vascular access, reducing the risk of peripheral and/or coronary steal syndromes, central or peripheral venous stenosis, and bloodstream infections. In addition, PD provides numerous life-style advantages to the diabetic patient, inclusive of but not limited to a flexible diet, therapy at home, a sense of greater independence, and reduced transportation needs2,3.

Peritonitis is a common concern for all PD patients. PD patients with diabetes were considered to be at a higher risk of developing peritonitis due the presence of glucose in the dialysate and subsequent absorption7,8,9. More recently however, studies report that diabetes was not associated with an increased risk of peritonitis in patients on PD1,2,10.

Nutrition may also be an issue in diabetic PD patients. Diabetes affects capillaries in various organs (e.g., retina, glomerulus) and in diabetic PD patients, there is increased permeability of the peritoneal capillaries and perfusion of the peritoneum, which may result in increased amino acid and protein losses and low serum albumin concentrations (marker for malnutrition). Studies have reported that significantly greater amounts of protein can be lost via the peritoneum in diabetics compared to non-diabetics and may lead to recalcitrant malnutrition9,11,12. There is limited data to support the effects of PD on diabetic gastroparesis. However, intraperitoneal fluid can increase abdominal pressure which could, in turn, decrease tone of the lower esophageal sphincter and worsen gastroparesis13,14.

A small percentage of diabetics could develop significant obesity related to glucose absorption9. The glycemic control in the diabetic PD patient may also be problematic2,7,8. However, management can be optimized by the physician with pharmacological interventions, monitoring of dietary intake and use of newer non-dextrose based PD solution for optimum ultrafiltration instead of using PD fluid with a higher dextrose concentration.

References:

  1. U.S. Renal Data System. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases; 2013.
  2. Misra M, Khanna R. Peritoneal Dialysis in Diabetic End-Stage Renal Disease. In: Khanna R, Krediet RT, eds.Textbook of Peritoneal Dialysis. 3rd ed. New York: Springer Science+Business Media; 2009:781-801.
  3. Kuriyama S. Peritoneal dialysis in patients with diabetes: are the benefits greater than the disadvantages? Perit Dial Int. 2007;27 Suppl 2:S190-5. www.ncbi.nlm.nih.gov/pubmed/17556303
  4. Cancarini GC, Brunori G, Camerini C, Brasa S, Manili L, Maiorca R. Renal function recovery and maintenance of residual diuresis in CAPD and hemodialysis. Perit Dial Int. 1986;6(2):77-79.
  5. Misra M, Vonesh E, Van Stone JC, Moore HL, Prowant B, Nolph KD. Effect of cause and time of dropout on the residual GFR: a comparative analysis of the decline of GFR on dialysis. Kidney Int. 2001;59(2):754-63. www.ncbi.nlm.nih.gov/pubmed/11168959
  6. Bargman JM, Thorpe KE, Churchill DN. Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol. 2001;12(10):2158-62. www.ncbi.nlm.nih.gov/pubmed/11562415
  7. Chow KM, Szeto CC, Kwan BCH, Pang WF, Ma T, Leung CB, Law MC, Li PK-T. Randomized controlled study of icodextrin on the treatment of peritoneal dialysis patients during acute peritonitis. Nephrol Dial Transplant. 2014;29(7):1438-43. www.ncbi.nlm.nih.gov/pubmed/24578470
  8. Lee HB, Chung SH, Chu WS, Kim JK, Ha H. Peritoneal dialysis in diabetic patients. Am J Kidney Dis. 2001;38(4 Suppl 1):S200-3. www.ncbi.nlm.nih.gov/pubmed/11576955
  9. Fortes PC, Mendes JG, Sesiuk K, Marcondes LB, Aita CAM, Riella MC, Pecoits-Filho R. Glycemic and lipidic profile in diabetic patients undergoing dialysis. Arq Bras Endocrinol Metabol. 2010;54(9):793-800. www.ncbi.nlm.nih.gov/pubmed/21340171
  10. Pulliam J, Li N-C, Maddux F, Hakim R, Finkelstein FO, Lacson E. First-Year Outcomes of Incident Peritoneal Dialysis Patients in the United States. Am J Kidney Dis. 2014. www.ncbi.nlm.nih.gov/pubmed/24927898
  11. Coronel F, Cigarrán S, Herrero JA, Delgado J, Ramos F, Gomis A. Peritoneal protein losses in diabetic patients starting peritoneal dialysis: is there a relationship with diabetic vascular lesions? Adv Perit Dial. 2009;25:115-8. www.ncbi.nlm.nih.gov/pubmed/19886331
  12. Park S-W, Seo J-J, Bae H-S, Kim J-Y, Kim C-D, Park S-H, Kim Y-L. Difficulty in improving malnutrition and low-grade inflammation in diabetic patients on peritoneal dialysis. Ther Apher Dial. 2008;12(6):475-83. www.ncbi.nlm.nih.gov/pubmed/19140846
  13. Cotovio P, Rocha A, Rodrigues A. Peritoneal dialysis in diabetics: there is room for more. Int J Nephrol. 2011;2011:914849. www.ncbi.nlm.nih.gov/pubmed/22013524
  14. Passadakis PS, Oreopoulos DG. Diabetic patients on peritoneal dialysis. Semin Dial. 2010;23(2):191-7. www.ncbi.nlm.nih.gov/pubmed/20525108

 P/N 101806-01 Rev A 12/2014