Renal replacement therapy for diabetic end-stage renal disease. Experienceof a Tunisian hospital centre

Objective: To determine the epidemiological and clinical characteristics of 299 uremic diabetics at the initiation of renal replacement therapy (RRT) and to evaluate their morbidity and the factors influencing their mortality during the dialysis period. Patients and methods; All patients starting RRT for diabetic end-stage rena l disease (ESRD) at Charles Nicolle Hospital of Tunis during a period of se ven years (1990-1996) constituted the study population. During the follow-u p period ended on December 31, 2000, all morbid events, hospitalizations an d deaths were recorded. Multivariate analysis according to the Cox proporti onal hazards model was performed to identify the predictors of mortality. Results: There were 238 type 2 (79.6%) and 61 type 1 diabetics (20.4%) repr esenting 20.3% of all patients accepted for RRT. The mean age at the onset of RRT was 53.16 +/- 12.43 years (range: 23 to 80 years). A poor glycemic c ontrol was observed in 46.7% of type 2 diabetics and in 67.3% of type 1 dia betics (p = 0.0055). A third of patients started RRT in emergency condition s and 91% required a temporary vascular access. At the time of onset of RRT , 86.7% of patients were hypertensive and 52.1% had a nephrotic syndrome. B lindness was observed in 22.9% of type 1 diabetics and in 7.5% of type 2 di abetics (p = 0.0014). During the follow-up period, 217 patients died repres enting a rate of 22% patient-years, 26.7% of these deaths occurred during t he first 3 months of RRT and 53% were attributed to infectious or cardiovas cular complications. Actuarial survival rates were 68.4%, 59.6% and 45.3% a t 1, 2 and 4 years, respectively. Age, co-morbidities and conditions of ons et of RRT were independently correlated with survival time. Conclusion: Diabetes is a frequent cause of ESRD in Tunisia, the delayed re ferral to a nephrologist and coexistence of serious co-morbidities at the i nitiation of RRT resulted in a high rate of early death. Greater efforts sh ould be made in our country in view of improving the quality of medical car e of uremic diabetics before and during RRT.