Hemodialysis in diabetic patients

Diabetic nephropathy is a leading cause of end-stage renal disease, and its prevalence and incidence vary greatly from country to country, being highe st in the United States and Japan. In the United States, diabetic nephropat hy accounts for approximately 40% of patients beginning renal replacement t herapy. Type 2 diabetes is the largest and fastest-growing single disease t hat requires dialytic therapy. Most patients succumb to cardiovascular caus es, including coronary artery disease and myocardial infarction, sudden dea th, cardiac failure, and stroke. The survival from cardiovascular complicat ions is relatively better in East Asian countries and to a lesser extent in Mediterranean countries compared with countries that traditionally have hi gher cardiovascular death rates. Peripheral vascular disease and sepals con tribute to increased morbidity and mortality. Amputation of limbs secondary to peripheral vascular disease in particular has adverse effects on rehabi litation. Asymptomatic hypoglycemia may develop in hemodialysis patients. S uch hypoglycemia is not associated with a hormonal balance but is postulate d to be due to blunted hormonal response to hypoglycemia. Diabetic muscle i nfarction is another rare complication attributable to diabetic microangiop athy; magnetic resonance imaging may help in the diagnosis. Risk factors fo r increased mortality include advanced age, poor glycemic control before st arting dialysis, smoking, left ventricular hypertrophy, hypoalbuminemia, an d neuropathy, in particular, autonomic dysfunction. In addition to adequate dialysis, it is advisable to achieve tight blood pressure control (at leas t < 140/90 mm Hg and preferably much lower), better blood glucose control ( hemoglobin A(1c) <7%), correction of nutritional status, and appropriate fo ot care. (C) 2001 by the National Kidney Foundation, Inc.