Abysmal prognosis of patients with type 2 diabetes entering dialysis

Introduction. The importance of noninsulin-dependent diabetes mellitus (typ e II diabetes) as a leading cause of end-stage renal disease is now widely recognized. The purpose of this study was to assess life-prognosis and its predictors in a cohort of patients newly entering dialysis. Material and methods. Eighty-four consecutive type II diabetes patients (40 % of all patients) starting dialysis between 01/01/95 and 31/12/96 were stu died retrospectively, focusing on clinical data at inception and life-progn osis after a mean follow-up of 211 days. Patients were divided into three g roups, according to onset of renal failure: acute 11% (9/84), chronic 61% ( 51/84) and acutely aggravated chronic renal failure 28% (25/84). Results. Patients (mean age 67 years) had longstanding diabetes (mean durat ion similar to 15 years), heavy proteinuria (similar to 3g/24h) and diabeti c retinopathy (67%). The average creatinine clearance (Cockcroft's formula) was 13 ml/min. Cardiovascular diseases were highly prevalent at the start of dialysis: history of myocardial infarction (26%), angina (36%) and acute left ventricular dysfunction (67%). More than 80% of the patients underwen t the first session dialysis under emergency conditions, a situation in par t related to late referral to the nephrology division (63% for chronic pati ents). A great majority of the patients were overhydrated when starting dia lysis, as evidenced by the average weight loss of 6 kg, during the first mo nth of dialysis, required to reach dry weight. Nearly 64% of the patients p resented high blood pressure (> 140/90 mmHg) when starting dialysis despite antihypertensive therapy (mean: 2.3 drugs). The outcome of this type II di abetes population was dramatic: 32% (27/84) died after a mean follow-up of 211 days, mostly from cardiovascular diseases. The rate of recovery of rena l function was low in both the acute and the acutely aggravated renal failu re group (30% and 24%, respectively). Of note, iatrogenic nephrotoxic agent s accounted for renal function impairment in nearly 30% of patients. Conclusion. Our observational study illustrates the high burden of cardiova scular diseases contrasting with sub-optimal cardiovascular therapeutic int erventions in type II diabetes patients entering dialysis. Factors aggravat ing renal failure were mainly iatrogenic, and therefore largely avoidable. Late referral generally implied a poor clinical condition at the start of d ialysis.