Specific issues of dialysed diabetics in outpatient practice

Česká verzia

Authors: S. Dusilová Sulková
Authors place of work: Nefrologické oddělení Kliniky gerontologické a metabolické Lékařské fakulty UK a FN Hradec Králové, přednosta prof. MUDr. Luboš Sobotka, CSc., a Subkatedra nefrologie II. interní kliniky Lékařské fakulty UK a FN Hradec Králové, přednosta prof. MUDr. Jaros
Published in the journal: Vnitř Lék 2008; 54(5): 519-522
Category:

Předneseno na 9. celostátním diabetologickém symposiu „Diabetes a urogenitální systém“ ve dnech 1.-2. června 2007 v Novém Adalbertinu v Hradci Králové

Summary

Approximately 40% of patients on dialysis have diabetes mellitus (DM). The basic characteristic of those patients are numerous associated organ complications, especially heart and artery diseases. These and other associated complications in dialysed diabetic patients have a modified pathogenetic and clinical picture and contribute to their poorer prognosis. Anaemia, immunodeficiency as well as malnutrition are manifested earlier and in a more significant manner. Dialysis therapy has the same rules for diabetic and non-diabetic patients. Tolerance to ultrafiltration is lower and haemodynamic instability is easier to provoke in diabetics than in non-diabetic patients. The use of a dialysis solution is beneficial from the point of view of glucose concentration balance. Insulin doses are lower as a result of extended insulin half-time. There is also a degree of insulin resistance, but it can be managed to a great extent by adequate dialysis. There are no fixed guidelines for insulin dosing; the doses roughly amount to half of the doses in patients with normal renal function. The assessment of diabetes compensation is based on glycated haemoglobin, and glycated albumin is also recommended in certain cases. Deciding on the therapy (oral antidiabetic drugs vs. insulin therapy or a combination of both) is based on diabetic care standards; cooperation between the diabetologist and the dialysis doctor is desirable. Customized, specifically designed and targeted intervention in diabetic patients may slow down the progression of diabetic vascular changes, improve diabetes compensation and the patients’ quality of life.

Key words:
diabetes mellitus – dialysis program – ultrafiltration – insulin – glycated haemoglobin – glycated albumin – diabetic nephropathy

Zdroje

1. Jones CJ, Krolewski AS, Rogus J et al. Epidemic of end-stage renal disease in people with diabetes in the United States population: do we know the cause? Kidney Int 2005; 67: 1684-1691.

2. Akmal M. Hemodialysis in diabetic patients. Am J Kidney Dis 2001; 38(Suppl 1): S195-S199.

3. Mehotra R, Budoff M, Hokanson JE et al. Progression of coronary artery calcification in diabetics with and without chronic kidney disease. Kidney Int 2005; 68: 1258-1266.

4. Seghal AR. How can the poor outcomes for diabetic dialysis patients be improved? Semin Dial 2004; 17: 186-187.

5. Galassi A, Spiegel DM, Bellasi A et al. Accelerated vascular calcification and relative hypoparathyreoidism in incident hemodialysis diabetic patients receiving calcium binders. Nephrol Dial Transplant 2006; 21: 3215-3222.

6. Mak RHK. Impact of end-stage renal disease and dialysis on glycemic control. Semin Dial 2000; 13: 4-8.

7. Cano N et al. Malnutrition in hemodialysis diabetic patients. Evaluation and prognostic influence. Kidney Int 2002; 62: 593-601.

8. Thomas MC, MacIsaac RJ, Tsamalandris C et al. The burden of anaemia in type 2 diabetes and the role of nephropathy: a cross-sectional audit. Nephrol Dial Transplant 2004; 19: 1792-1797.

9. Mohanram A, Zhang Z, Shahinfar S et al. Anemia and end-stage renal disease in patients with type 2 diabetes and nephropathy. Kidney Int 2004; 66: 1131-1138.

10. Snyder RW, Berns JS. Use of insulin and oral hypoglycemic medications in patients with diabetes mellitus and advanced kidney disease. Semin Dial 2004; 17: 365-370.

11. Inaba M, Okuno S, Kumeda Y et al. Glycated albumin is better glycemic indicator than glycated hemoglobin values in hemodialysis patients with diabetes: effect of anemia and erythropoietin injection. J Am Soc Nephrol 2007; 18: 896-903.

12. Robitaille R et al. Altered laboratory findings associated with end-stage renal disease. Semin Dial 2006; 19: 373-380.

13. Flauto RP, Leon JB, Sehnal AR. The provision and outcomes of diabetic care of hemodialysis patients. Am J Kidney Dis 2003; 41: 125-131.

14. Frimat L, Loos-Ayav C, Panescu V et al. Early referral to a nephrologist is associated with Berger outcomes in type 2 diabetes patients with end-stage renal disease. Diabetes Metab 2005; 30: 67-74.

15. Schwenger V, Zeier M, Ritz E. How can be poor outcomes for diabetic dialysis patients be improved? Semin Dial 2004; 17: 186-187.

16. McMurray SD. The challenges of diabetes care in the dialysis unit. Semin Dial 2003; 16: 197-198.

17. McMurray SD, Johnson G, Davis C et al. Diabetes education and care management significantly improve patients outcomes in the dialysis unit. Am J Kidney Dis 2002; 40: 566-575.