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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">RELEVANCE OF <span class="elsevierStyleItalic">DIABETES MELLITUS</span> IN NEPHROLOGY</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Diabetes mellitus</span> &#40;<span class="elsevierStyleItalic">DM</span>&#41; is the most important disease related to renal replacement therapy &#40;RRT&#41;&#44; due to its prevalence and clinical&#44; economic and social impact&#46; It is estimated that 0&#46;3&#37; of the general population suffer from type 1 <span class="elsevierStyleItalic">DM</span> and 7&#37; from <span class="elsevierStyleItalic">DM</span> type 2&#46;<span class="elsevierStyleSup">1</span> The prevalence of <span class="elsevierStyleItalic">DM</span> is dependent on the diagnostic criteria used and varies throughout the world&#44; but the increase in the incidence of type 2 <span class="elsevierStyleItalic">DM</span> is estimated between 3 and 5&#37; annually&#46;<span class="elsevierStyleSup">1</span> This is due largely to poor health habits&#59; therefore&#44; its growth is even higher in developing countries&#46; Progression to chronic kidney disease &#40;CKD&#41; in stage 5D increases due to a more prolonged exposure to hyperglycaemia&#44; its association with high blood pressure &#40;HTN&#41;&#44; obesity&#44; sedentary lifestyle and other risk factors&#44; and its lower mortality&#44; which leads to patients undergoing RRT&#46; Therefore&#44; the term &#34;epidemic of the 21st century&#34; is no exaggeration&#46;</p><p class="elsevierStylePara">It is estimated that the overall cost of treating patients with type 2 diabetes with target organ damage is at least &#8364;2&#44;136 per year and may exceed &#8364;54&#44;000 per year for patients on haemodialysis &#40;HD&#41;&#46; Finally&#44; <span class="elsevierStyleItalic">DM</span> is a cardiovascular &#40;CV&#41; risk factor and a source of clinical complications&#44; hospital admissions&#44; poor quality of life and loss of years in full health and at work&#46; This disease has a significant impact&#46;</p><p class="elsevierStylePara">Data from monitoring more than 5&#44;000 patients in the UKPDS study allowed us to establish the clinical course of nephropathy in type 2 <span class="elsevierStyleItalic">diabetes mellitus&#46;</span><span class="elsevierStyleSup">2</span> Statistically&#44; it takes 19 years to develop the disease&#44; 11 years to go from microalbuminuria to macroalbuminuria and a decline in renal function starts 10 years later&#46; However&#44; patients who were included in the UKPDS with a Cr greater than 2mg&#47;dl were undergoing RRT in just 2&#189; years&#44; which is the patient profile faced regularly&#46; The objective of intervention in <span class="elsevierStyleItalic">DM</span> is clearly in the initial stages&#44; focusing on renoprotection and cardioprotection&#44; reducing CV events and the need for RRT&#46; In fact&#44; there is now evidence that intervention and close monitoring of patients with type 1 diabetes reduces the need for RRT in these patients&#46; A Finnish study of 20&#44;000 patients treated between 1965 and 1999&#44; had incidence rates of only 2&#46;2&#37; at 20 years in patients on dialysis&#44; with a decreasing trend in the later stages&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Nevertheless&#44; the challenge of treating <span class="elsevierStyleItalic">DM</span> patients on dialysis is an ongoing one &#40;and daily for some&#41;&#46; Articles like the one presented in this issue by the group from the Hospital Universitario San Carlos&#44; Madrid&#44; gives a historical perspective on the treatment of diabetic patients on peritoneal dialysis &#40;PD<span class="elsevierStyleSup">4</span>&#41;&#46;</p><p class="elsevierStylePara">There are not many PD programmes of 25 years&#44; as in this study&#46; The most relevant result is the description of a worse outcome for patients with <span class="elsevierStyleItalic">DM</span> and the quantification of this risk in our area&#46;<span class="elsevierStyleSup">4</span> Patients with <span class="elsevierStyleItalic">DM</span> in this study have higher rates of mortality&#44; transfer to HD&#44; hospital admissions&#44; non-peritoneal infections and peritonitis&#44; in line with previous published studies&#46;<span class="elsevierStyleSup">5</span> For example&#44; in the study of the <span class="elsevierStyleItalic">Grupo Centro de Di&#225;lisis Peritoneal&#44;</span><span class="elsevierStyleItalic">GCDP</span> &#40;Peritoneal Dialysis Group Centre&#41;&#44; the probability of survival at 2 years was 86&#46;7&#37; in patients without <span class="elsevierStyleItalic">DM</span> and 75&#46;2&#37; in patients with type 2 <span class="elsevierStyleItalic">DM&#46;</span><span class="elsevierStyleSup">6</span> In the study published in this issue&#44; however&#44; two different historical PD periods were compared&#46; The most recent &#40;post-1992&#41; had double-bag systems&#44; the first glucose-free solutions and the widespread use of automated systems&#44; as well as erythropoietin&#46; In this second phase&#44; the rate of peritonitis was reduced accordingly and global outcome indicators improved&#44; although the risk of death attributable to <span class="elsevierStyleItalic">DM</span> was not significantly reduced&#46;</p><p class="elsevierStylePara">The first stage of the article referred back to the 1980s &#40;pre-1992&#41;&#44; when some groups raised concerns about the appropriateness of including patients with <span class="elsevierStyleItalic">DM</span> in dialysis programmes due to its high morbidity and mortality&#46; This period &#40;pre-1992&#41; has some striking data reflecting a negative selection of patients for PD&#44; which was not specifically outlined in the article&#46; For example&#44; the prevalence of diabetic patients on PD was 55&#37; compared to the average reported by the register of 18&#37; on HD&#44; or 20&#37; recorded by the <span class="elsevierStyleItalic">GCDP</span> between 2003 and 2009&#46;<span class="elsevierStyleSup">5</span> In addition&#44; they reported a high percentage of patients with blindness and other comorbidities&#44; which limited the number of patients stopping the therapy to undergo transplant surgery to only 5&#46;8&#37; in the total follow-up of patients with type 2 <span class="elsevierStyleItalic">DM</span>&#46; The low HD transfer rate could be due to the previous technique being maintained well or because patients were not able to change from one technique to another&#46; In other words&#44; it would be patients indicated for PD rather than those choosing PD&#44; which is a risk factor in itself&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">Against this backdrop&#44; the new RRT 3&#46;0 model offers an integrated approach for dialysis techniques and transplantation with a fluid exchange between them&#44; as each reaches a plateau in a particular patient&#46;<span class="elsevierStyleSup">8</span> This model is becoming a reality in many Spanish hospitals&#46;</p><p class="elsevierStylePara">The study published by Coronel et al&#46; also serves as a reference for comparison for other groups starting PD&#46; In general&#44; these PD programmes are not large&#46; For example&#44; the Community of Madrid has an average size of around 25 patients&#44; with a high turnover&#44; fluctuations in the number and difficulties with growth&#46; Therefore&#44; retrospective studies of this type have been used so far as a reference to reflect the reality of PD in our area and time&#44; highlighting differences with studies in other health systems and other countries&#46; The collaboration between institutions is necessary to begin to have benchmarks for comparison with recent larger multicentre data&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">DM</span> is the most important risk factor for PD patients and this poor prognosis is related to the CV pathology of patients entering PD&#44; as indicated by other studies&#46;<span class="elsevierStyleSup">6</span> The study by Coronel et al&#46; shows an overall risk of death from <span class="elsevierStyleItalic">DM</span> of 1&#46;96 compared to non-<span class="elsevierStyleItalic">DM</span> patients on PD&#46; Although they did not have their own data on the evolution of <span class="elsevierStyleItalic">DM</span> patients on HD&#44; as it was not the objective of the study&#44; the comparison between techniques is inevitable&#46; External references show a similar picture on the evolution of <span class="elsevierStyleItalic">DM</span> patients on HD&#46; According to the 2009 USRDS report&#44; only 30&#37; of <span class="elsevierStyleItalic">DM</span> patients survive 5 years after starting HD&#44; and these data would be even worse if the early mortality of patients who did not reach 3 months in HD were included &#40;excluded from that register<span class="elsevierStyleSup">10</span>&#41;&#46;</p><p class="elsevierStylePara">The paper reports that half of the deaths were associated with CV events&#46; The morbidity of <span class="elsevierStyleItalic">DM</span> is associated with predialysis CV damage&#44; the concomitance of other risk factors &#40;dyslipidaemia&#44; HTN&#44; etc&#46;&#41; and tissue deposition of advanced glycation end products &#40;AGE&#41;&#46; AGEs that accumulate in CKD have a direct effect on the vascular wall&#44; promoting accelerated atherosclerosis and protein-calorie malnutrition&#46; In fact&#44; in some series&#44; the risk attributable to <span class="elsevierStyleItalic">DM</span> greatly diminishes if corrected for the presence of previous cardiovascular events and albumin levels&#46;<span class="elsevierStyleSup">11</span> For example&#44; the data presented by the <span class="elsevierStyleItalic">GCDP</span> indicate that the risk of death in type 2 diabetes patients is 2&#46;5 times that of non-<span class="elsevierStyleItalic">DM</span> after correction for age&#46; The association between type 2 diabetes and previous cardiovascular events excludes the variable type 2 <span class="elsevierStyleItalic">DM</span> due to trying to put it in the same model <span class="elsevierStyleItalic">DM</span> and CV event prior to PD&#46;<span class="elsevierStyleSup">6&#44;7</span></p><p class="elsevierStylePara">The comparison of survival between HD and PD remains controversial&#44; especially because the information comes from records and observational studies or from post-hoc analyses&#46; Such questions cannot be resolved with a clinical trial design&#44; so the information must come from observational studies with a prospective design and sufficient sample size and control of covariates and confounding factors&#46; A recent comprehensive review in our journal concluded that both techniques were similar&#44; with a slight advantage for PD in the first 2-3 years of evolution and HD later&#46; In the specific case of patients with <span class="elsevierStyleItalic">DM</span>&#44; younger people seem to have better outcomes with PD and the elderly with HD&#46;<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara">A recent retrospective study goes beyond the multivariate analysis using the propensity score to reduce the selection bias of either technique&#46;<span class="elsevierStyleSup">13</span> This study gives an advantage to patients on PD&#44; particularly in the initial period&#44; with a probability of survival of 85&#46;5&#37; compared with 80&#46;7&#37; in HD&#44; and 71&#46;1&#37; versus 68&#37; in HD after 2 years &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#44; the trend continues without reaching significance in the third year&#46; Overall&#44; the risk of death favours PD by 8&#37; in the ITT analysis&#46; However&#44; in the stratified analysis for diabetic patients&#44; this benefit was only seen in the first year&#46; The authors conclude that PD may be a good initial RRT technique&#46; This advantage of PD in the early stages may be related to the better preservation of residual renal function and worse outcomes after a while&#44; with the failure to control the volume or metabolic factors&#46;</p><p class="elsevierStylePara">In short&#44; PD as a technique appears to be at least as good as HD for RRT patients&#44; therefore patient choice must be considered in the decision-making process in most cases&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">WHAT ARE THE THEORETICAL ADVANTAGES AND DISADVANTAGES OF PERITONEAL DIALYSIS FOR <span class="elsevierStyleItalic">DIABETES MELLITUS</span> PATIENTS&#63;</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">PD has a number of theoretical advantages for patients with <span class="elsevierStyleItalic">DM</span>&#44; such as better haemodynamic tolerance&#44; maintenance of residual renal function&#44; vascular capital preservation and use of peritoneal insulin for improved glycaemic control &#40;currently not used&#41;&#46; HD currently has a less stable electrolyte profile associated with a greater incidence of arrhythmias&#44; the high-flow prosthetic fistulas lead to a haemodynamic overload which&#44; along with hypertension&#44; promote the development of left ventricular hypertrophy &#40;LVH&#41;&#46; These factors are behind the episodes of sudden death in HD&#46; On the other hand&#44; patients with <span class="elsevierStyleItalic">DM</span> have specific risks with this technique&#44; primarily metabolic&#46; Diabetic gastroparesis worsens in PD and promotes anorexia and secondary malnutrition&#46; Glucose overload increases insulin resistance and makes it difficult to control the lipid profile&#46;</p><p class="elsevierStylePara">Diabetic patients have a thicker&#44; poorly vascularised peritoneal membrane even before starting PD&#44; as demonstrated in peritoneal biopsies obtained after inserting the catheter&#46;<span class="elsevierStyleSup">14</span> This may influence the poorer outcome in peritoneal permeability in the medium term&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">INTEGRATION VIA THE RRT 3&#46;0 MODEL FOR <span class="elsevierStyleItalic">DIABETES MELLITUS</span> PATIENTS</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">We can summarise that PD seems to be a good starting technique for RRT with <span class="elsevierStyleItalic">DM</span> patients and has a certain advantage in the first 2 years&#46; The current concept considers RRT as an integrated service of PD&#44; HD and transplant &#40;TX<span class="elsevierStyleSup">15</span>&#41;&#46; There is no evidence to guide our <span class="elsevierStyleItalic">DM</span> patients towards one particular technique or another&#44; and key factors such as comorbidity&#44; social situation and&#44; above all&#44; patient preference should be a starting point for RRT&#46;</p><p class="elsevierStylePara">In fact&#44; the model proposed by some groups suggests the use of PD initially&#44; and early TX&#44; while keeping HD for those patients where PD fails&#46;<span class="elsevierStyleSup">16</span> Early TX is the best alternative for patients with <span class="elsevierStyleItalic">DM</span> whose comorbidity does not prevent it&#46; The American record has a survival rate for <span class="elsevierStyleItalic">DM</span> undergoing TX of 67&#37;-77&#37; at 5 years&#46;<span class="elsevierStyleSup">10</span> Although still lower than that of non-<span class="elsevierStyleItalic">DM</span>&#44; it is a significant improvement on the 30&#37; survival at 5 years for <span class="elsevierStyleItalic">DM</span> patients treated with HD or PD&#46; It may be that recovering renal function promotes the elimination of AGEs from <span class="elsevierStyleItalic">DM</span> and other uremic mediators that favour accelerated atherosclerosis and are agents of direct vascular injury&#46; In addition&#44; TX is associated with a better quality of life and rehabilitation&#44; personally and at work&#46; Therefore&#44; TX should be offered to all diabetic patients in RRT without absolute contraindication and as early as possible&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">FUTURE MANAGEMENT OF <span class="elsevierStyleItalic">DIABETES MELLITUS</span> IN RENAL REPLACEMENT THERAPY</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Another worth noting part of the study presented in this issue is that the prognosis of patients with type 2 diabetes does not improve in the second stage &#40;post-1992&#41;&#46; Despite technical advances in the treatment&#58; double bag&#44; cyclers&#44; use of erythropoietic agents and the new drugs at our disposal for controlling blood pressure&#44; dyslipidaemia&#44; glycaemia and mineral vascular disease&#44; the mortality is unchanged&#46; It is true that hospital admission rate and annual stay in the most recent period are reduced&#44; but we do not know if it is as a result of a better prognosis or overall improvement in hospital ambulatory processes and reduced stays&#46; Although the authors have not given a detailed analysis of comorbidity between both stages&#44; non-<span class="elsevierStyleItalic">DM</span> and <span class="elsevierStyleItalic">DM</span> type 1 patients who began PD after 1992 have improved their prognosis&#46;</p><p class="elsevierStylePara">Many misleading factors may interfere with an analysis like this&#44; because other studies have reported an overall improvement in results over the years&#46; For example&#44; in the US registry&#44; the mortality of diabetic patients on HD and PD was reduced from 27&#46;4&#37; in 1980 to 18&#46;6&#37; in 2007 and <span class="elsevierStyleItalic">DM</span> survival after PD improved by 21&#46;8&#37; in the last half of the 1990s&#46;<span class="elsevierStyleSup">10</span> Other studies in the same country showed a lower peritoneal technique failure rate when comparing the 2002-2003 period with the 1996-1997 period&#46;<span class="elsevierStyleSup">17</span> Although we have no data published by the Spanish registry for patients with <span class="elsevierStyleItalic">DM</span>&#44; global annual mortality improved from 12&#37; in PD in 2002 to 7&#46;8&#37; per annum 5 years later&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">The treatment of <span class="elsevierStyleItalic">DM</span> patients on PD requires dedication and integrated monitoring to reduce cardiovascular risk on all fronts&#46; Diet&#44; exercise and weight control are crucial&#44; as well as control of fluid intake&#44; which reduces the use of hypertonic solutions&#46; A new indication for glucose-free solutions was discovered with icodextrin or amino acids as agents to reduce glucose intake for patients&#46; In addition&#44; the importance of preserving RRF makes all the kidney protecting measures in the pre-dialysis stage continue to have an effect&#46; We have no evidence that glycaemic control&#44; the use of RAAS blockers or other measures reduce the mortality of our patients&#46; We sincerely think it is difficult to implement a randomised trial with mortality targets to test these intervention measures at present&#44; but there is a whole pathophysiological substrate and partial evidence indicating that the hope of maintaining FRR and improving survival of <span class="elsevierStyleItalic">DM</span> on PD is on the right path&#46;<span class="elsevierStyleSup">19</span></p><p class="elsevierStylePara">Until recently&#44; it was accepted that diabetic patients should start dialysis early&#44; even earlier than non-<span class="elsevierStyleItalic">DM</span> patients&#46; However&#44; the IDEAL study released this year&#44; which is a randomised clinical trial of 828 patients followed over three and a half years&#44; shows no benefit in starting scheduled RRT at a clearance between 10 and 14m&#47;min compared to doing so at 7ml&#47;min&#46;<span class="elsevierStyleSup">20</span> It must be made clear that the study allowed patients with symptoms or without complications to start RRT&#46; In fact&#44; 76&#37; of patients assigned to a late start did so before reaching 7ml&#47;min renal function&#46; Finally&#44; there was only 6 months difference between the start of RRT in the two groups&#46; The survey is not specifically dedicated to patients with <span class="elsevierStyleItalic">DM</span> or PD&#44; but provides evidence for inclusion in RRT after a patient&#39;s complete clinical assessment and against early initiation strategy based solely on figures&#46; In any case&#44; PD has the added advantage of allowing a gradual start relying on and caring for RRF&#46; Recently&#44; it was seen that patients with preserved RRF have less vascular calcification and that this factor could be involved in the protection of that residual diuresis&#46;<span class="elsevierStyleSup">21</span></p><p class="elsevierStylePara">The future of PD for patients with <span class="elsevierStyleItalic">DM</span> is via peritoneal membrane protection&#44; minimising glucose load&#44; using new&#44; more biocompatible solutions&#44; preventing peritoneal infections and developing specific treatments to prevent peritoneal fibrosis&#46;</p><p class="elsevierStylePara">While we await the results of early intervention on cardiac and renal damage in our patients&#44; we must strive to improve the prognosis of diabetic patients reaching RRT&#46; PD appears to be a better starting technique than HD for those patients who choose it&#44; due to its lower mortality in the first 2-3 years&#44; greater independence and improved efficiency&#44; because of its lower cost&#46; At that time&#44; we should be able to provide the patient with TX&#46; If this is not possible&#44; integrated control must be maintained according to Table 1 with RRF protected&#46; Once PD is insufficient to maintain the patient&#39;s situation&#44; we must offer the transfer to HD within an integrated model&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Key points</span></p><p class="elsevierStylePara">1&#46; <span class="elsevierStyleItalic">DM</span> determines a poor prognosis in any dialysis technique mainly at the expense of added CV damage&#46;</p><p class="elsevierStylePara">2&#46; The future is early detection and intervention with kidney protection measures&#46;</p><p class="elsevierStylePara">3&#46; PD results have improved in recent years&#46;</p><p class="elsevierStylePara">4&#46; PD is a good starting technique for RRT in <span class="elsevierStyleItalic">DM</span> patients&#46; Transplant is the technique of choice and should be performed as early as possible&#46;</p><p class="elsevierStylePara">5&#46; The RRT integrated model is the only technique recommended that maintains free choice and is economically sustainable&#46;</p><p class="elsevierStylePara"><a href="10682&#95;108&#95;11418&#95;en&#95;w477710641710682&#95;18107&#95;9995&#95;es&#95;10682&#95;340&#95;9995&#95;es&#95;fig&#95;1&#95;portoles&#95;en&#46;ppt" class="elsevierStyleCrossRefs">10682&#95;108&#95;11418&#95;en&#95;w477710641710682&#95;18107&#95;9995&#95;es&#95;10682&#95;340&#95;9995&#95;es&#95;fig&#95;1&#95;portoles&#95;en&#46;ppt</a></p><p class="elsevierStylePara">Table 1&#46; Measures to improve long-term outcomes in diabetic patients on peritoneal dialysis</p>"
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The treatment of diabetic patients on peritoneal dialysis remains a challenge 25 years later
El tratamiento de pacientes diabéticos en diálisis peritoneal sigue siendo un reto 25 años después
J.. Portolésa
a Servicio de Nefrología, Hospital Universitario Fundación Alcorcón (REDinREN Carlos III. Red 06/0016), Alcorcón, Madrid,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">RELEVANCE OF <span class="elsevierStyleItalic">DIABETES MELLITUS</span> IN NEPHROLOGY</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Diabetes mellitus</span> &#40;<span class="elsevierStyleItalic">DM</span>&#41; is the most important disease related to renal replacement therapy &#40;RRT&#41;&#44; due to its prevalence and clinical&#44; economic and social impact&#46; It is estimated that 0&#46;3&#37; of the general population suffer from type 1 <span class="elsevierStyleItalic">DM</span> and 7&#37; from <span class="elsevierStyleItalic">DM</span> type 2&#46;<span class="elsevierStyleSup">1</span> The prevalence of <span class="elsevierStyleItalic">DM</span> is dependent on the diagnostic criteria used and varies throughout the world&#44; but the increase in the incidence of type 2 <span class="elsevierStyleItalic">DM</span> is estimated between 3 and 5&#37; annually&#46;<span class="elsevierStyleSup">1</span> This is due largely to poor health habits&#59; therefore&#44; its growth is even higher in developing countries&#46; Progression to chronic kidney disease &#40;CKD&#41; in stage 5D increases due to a more prolonged exposure to hyperglycaemia&#44; its association with high blood pressure &#40;HTN&#41;&#44; obesity&#44; sedentary lifestyle and other risk factors&#44; and its lower mortality&#44; which leads to patients undergoing RRT&#46; Therefore&#44; the term &#34;epidemic of the 21st century&#34; is no exaggeration&#46;</p><p class="elsevierStylePara">It is estimated that the overall cost of treating patients with type 2 diabetes with target organ damage is at least &#8364;2&#44;136 per year and may exceed &#8364;54&#44;000 per year for patients on haemodialysis &#40;HD&#41;&#46; Finally&#44; <span class="elsevierStyleItalic">DM</span> is a cardiovascular &#40;CV&#41; risk factor and a source of clinical complications&#44; hospital admissions&#44; poor quality of life and loss of years in full health and at work&#46; This disease has a significant impact&#46;</p><p class="elsevierStylePara">Data from monitoring more than 5&#44;000 patients in the UKPDS study allowed us to establish the clinical course of nephropathy in type 2 <span class="elsevierStyleItalic">diabetes mellitus&#46;</span><span class="elsevierStyleSup">2</span> Statistically&#44; it takes 19 years to develop the disease&#44; 11 years to go from microalbuminuria to macroalbuminuria and a decline in renal function starts 10 years later&#46; However&#44; patients who were included in the UKPDS with a Cr greater than 2mg&#47;dl were undergoing RRT in just 2&#189; years&#44; which is the patient profile faced regularly&#46; The objective of intervention in <span class="elsevierStyleItalic">DM</span> is clearly in the initial stages&#44; focusing on renoprotection and cardioprotection&#44; reducing CV events and the need for RRT&#46; In fact&#44; there is now evidence that intervention and close monitoring of patients with type 1 diabetes reduces the need for RRT in these patients&#46; A Finnish study of 20&#44;000 patients treated between 1965 and 1999&#44; had incidence rates of only 2&#46;2&#37; at 20 years in patients on dialysis&#44; with a decreasing trend in the later stages&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Nevertheless&#44; the challenge of treating <span class="elsevierStyleItalic">DM</span> patients on dialysis is an ongoing one &#40;and daily for some&#41;&#46; Articles like the one presented in this issue by the group from the Hospital Universitario San Carlos&#44; Madrid&#44; gives a historical perspective on the treatment of diabetic patients on peritoneal dialysis &#40;PD<span class="elsevierStyleSup">4</span>&#41;&#46;</p><p class="elsevierStylePara">There are not many PD programmes of 25 years&#44; as in this study&#46; The most relevant result is the description of a worse outcome for patients with <span class="elsevierStyleItalic">DM</span> and the quantification of this risk in our area&#46;<span class="elsevierStyleSup">4</span> Patients with <span class="elsevierStyleItalic">DM</span> in this study have higher rates of mortality&#44; transfer to HD&#44; hospital admissions&#44; non-peritoneal infections and peritonitis&#44; in line with previous published studies&#46;<span class="elsevierStyleSup">5</span> For example&#44; in the study of the <span class="elsevierStyleItalic">Grupo Centro de Di&#225;lisis Peritoneal&#44;</span><span class="elsevierStyleItalic">GCDP</span> &#40;Peritoneal Dialysis Group Centre&#41;&#44; the probability of survival at 2 years was 86&#46;7&#37; in patients without <span class="elsevierStyleItalic">DM</span> and 75&#46;2&#37; in patients with type 2 <span class="elsevierStyleItalic">DM&#46;</span><span class="elsevierStyleSup">6</span> In the study published in this issue&#44; however&#44; two different historical PD periods were compared&#46; The most recent &#40;post-1992&#41; had double-bag systems&#44; the first glucose-free solutions and the widespread use of automated systems&#44; as well as erythropoietin&#46; In this second phase&#44; the rate of peritonitis was reduced accordingly and global outcome indicators improved&#44; although the risk of death attributable to <span class="elsevierStyleItalic">DM</span> was not significantly reduced&#46;</p><p class="elsevierStylePara">The first stage of the article referred back to the 1980s &#40;pre-1992&#41;&#44; when some groups raised concerns about the appropriateness of including patients with <span class="elsevierStyleItalic">DM</span> in dialysis programmes due to its high morbidity and mortality&#46; This period &#40;pre-1992&#41; has some striking data reflecting a negative selection of patients for PD&#44; which was not specifically outlined in the article&#46; For example&#44; the prevalence of diabetic patients on PD was 55&#37; compared to the average reported by the register of 18&#37; on HD&#44; or 20&#37; recorded by the <span class="elsevierStyleItalic">GCDP</span> between 2003 and 2009&#46;<span class="elsevierStyleSup">5</span> In addition&#44; they reported a high percentage of patients with blindness and other comorbidities&#44; which limited the number of patients stopping the therapy to undergo transplant surgery to only 5&#46;8&#37; in the total follow-up of patients with type 2 <span class="elsevierStyleItalic">DM</span>&#46; The low HD transfer rate could be due to the previous technique being maintained well or because patients were not able to change from one technique to another&#46; In other words&#44; it would be patients indicated for PD rather than those choosing PD&#44; which is a risk factor in itself&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">Against this backdrop&#44; the new RRT 3&#46;0 model offers an integrated approach for dialysis techniques and transplantation with a fluid exchange between them&#44; as each reaches a plateau in a particular patient&#46;<span class="elsevierStyleSup">8</span> This model is becoming a reality in many Spanish hospitals&#46;</p><p class="elsevierStylePara">The study published by Coronel et al&#46; also serves as a reference for comparison for other groups starting PD&#46; In general&#44; these PD programmes are not large&#46; For example&#44; the Community of Madrid has an average size of around 25 patients&#44; with a high turnover&#44; fluctuations in the number and difficulties with growth&#46; Therefore&#44; retrospective studies of this type have been used so far as a reference to reflect the reality of PD in our area and time&#44; highlighting differences with studies in other health systems and other countries&#46; The collaboration between institutions is necessary to begin to have benchmarks for comparison with recent larger multicentre data&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">DM</span> is the most important risk factor for PD patients and this poor prognosis is related to the CV pathology of patients entering PD&#44; as indicated by other studies&#46;<span class="elsevierStyleSup">6</span> The study by Coronel et al&#46; shows an overall risk of death from <span class="elsevierStyleItalic">DM</span> of 1&#46;96 compared to non-<span class="elsevierStyleItalic">DM</span> patients on PD&#46; Although they did not have their own data on the evolution of <span class="elsevierStyleItalic">DM</span> patients on HD&#44; as it was not the objective of the study&#44; the comparison between techniques is inevitable&#46; External references show a similar picture on the evolution of <span class="elsevierStyleItalic">DM</span> patients on HD&#46; According to the 2009 USRDS report&#44; only 30&#37; of <span class="elsevierStyleItalic">DM</span> patients survive 5 years after starting HD&#44; and these data would be even worse if the early mortality of patients who did not reach 3 months in HD were included &#40;excluded from that register<span class="elsevierStyleSup">10</span>&#41;&#46;</p><p class="elsevierStylePara">The paper reports that half of the deaths were associated with CV events&#46; The morbidity of <span class="elsevierStyleItalic">DM</span> is associated with predialysis CV damage&#44; the concomitance of other risk factors &#40;dyslipidaemia&#44; HTN&#44; etc&#46;&#41; and tissue deposition of advanced glycation end products &#40;AGE&#41;&#46; AGEs that accumulate in CKD have a direct effect on the vascular wall&#44; promoting accelerated atherosclerosis and protein-calorie malnutrition&#46; In fact&#44; in some series&#44; the risk attributable to <span class="elsevierStyleItalic">DM</span> greatly diminishes if corrected for the presence of previous cardiovascular events and albumin levels&#46;<span class="elsevierStyleSup">11</span> For example&#44; the data presented by the <span class="elsevierStyleItalic">GCDP</span> indicate that the risk of death in type 2 diabetes patients is 2&#46;5 times that of non-<span class="elsevierStyleItalic">DM</span> after correction for age&#46; The association between type 2 diabetes and previous cardiovascular events excludes the variable type 2 <span class="elsevierStyleItalic">DM</span> due to trying to put it in the same model <span class="elsevierStyleItalic">DM</span> and CV event prior to PD&#46;<span class="elsevierStyleSup">6&#44;7</span></p><p class="elsevierStylePara">The comparison of survival between HD and PD remains controversial&#44; especially because the information comes from records and observational studies or from post-hoc analyses&#46; Such questions cannot be resolved with a clinical trial design&#44; so the information must come from observational studies with a prospective design and sufficient sample size and control of covariates and confounding factors&#46; A recent comprehensive review in our journal concluded that both techniques were similar&#44; with a slight advantage for PD in the first 2-3 years of evolution and HD later&#46; In the specific case of patients with <span class="elsevierStyleItalic">DM</span>&#44; younger people seem to have better outcomes with PD and the elderly with HD&#46;<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara">A recent retrospective study goes beyond the multivariate analysis using the propensity score to reduce the selection bias of either technique&#46;<span class="elsevierStyleSup">13</span> This study gives an advantage to patients on PD&#44; particularly in the initial period&#44; with a probability of survival of 85&#46;5&#37; compared with 80&#46;7&#37; in HD&#44; and 71&#46;1&#37; versus 68&#37; in HD after 2 years &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#44; the trend continues without reaching significance in the third year&#46; Overall&#44; the risk of death favours PD by 8&#37; in the ITT analysis&#46; However&#44; in the stratified analysis for diabetic patients&#44; this benefit was only seen in the first year&#46; The authors conclude that PD may be a good initial RRT technique&#46; This advantage of PD in the early stages may be related to the better preservation of residual renal function and worse outcomes after a while&#44; with the failure to control the volume or metabolic factors&#46;</p><p class="elsevierStylePara">In short&#44; PD as a technique appears to be at least as good as HD for RRT patients&#44; therefore patient choice must be considered in the decision-making process in most cases&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">WHAT ARE THE THEORETICAL ADVANTAGES AND DISADVANTAGES OF PERITONEAL DIALYSIS FOR <span class="elsevierStyleItalic">DIABETES MELLITUS</span> PATIENTS&#63;</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">PD has a number of theoretical advantages for patients with <span class="elsevierStyleItalic">DM</span>&#44; such as better haemodynamic tolerance&#44; maintenance of residual renal function&#44; vascular capital preservation and use of peritoneal insulin for improved glycaemic control &#40;currently not used&#41;&#46; HD currently has a less stable electrolyte profile associated with a greater incidence of arrhythmias&#44; the high-flow prosthetic fistulas lead to a haemodynamic overload which&#44; along with hypertension&#44; promote the development of left ventricular hypertrophy &#40;LVH&#41;&#46; These factors are behind the episodes of sudden death in HD&#46; On the other hand&#44; patients with <span class="elsevierStyleItalic">DM</span> have specific risks with this technique&#44; primarily metabolic&#46; Diabetic gastroparesis worsens in PD and promotes anorexia and secondary malnutrition&#46; Glucose overload increases insulin resistance and makes it difficult to control the lipid profile&#46;</p><p class="elsevierStylePara">Diabetic patients have a thicker&#44; poorly vascularised peritoneal membrane even before starting PD&#44; as demonstrated in peritoneal biopsies obtained after inserting the catheter&#46;<span class="elsevierStyleSup">14</span> This may influence the poorer outcome in peritoneal permeability in the medium term&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">INTEGRATION VIA THE RRT 3&#46;0 MODEL FOR <span class="elsevierStyleItalic">DIABETES MELLITUS</span> PATIENTS</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">We can summarise that PD seems to be a good starting technique for RRT with <span class="elsevierStyleItalic">DM</span> patients and has a certain advantage in the first 2 years&#46; The current concept considers RRT as an integrated service of PD&#44; HD and transplant &#40;TX<span class="elsevierStyleSup">15</span>&#41;&#46; There is no evidence to guide our <span class="elsevierStyleItalic">DM</span> patients towards one particular technique or another&#44; and key factors such as comorbidity&#44; social situation and&#44; above all&#44; patient preference should be a starting point for RRT&#46;</p><p class="elsevierStylePara">In fact&#44; the model proposed by some groups suggests the use of PD initially&#44; and early TX&#44; while keeping HD for those patients where PD fails&#46;<span class="elsevierStyleSup">16</span> Early TX is the best alternative for patients with <span class="elsevierStyleItalic">DM</span> whose comorbidity does not prevent it&#46; The American record has a survival rate for <span class="elsevierStyleItalic">DM</span> undergoing TX of 67&#37;-77&#37; at 5 years&#46;<span class="elsevierStyleSup">10</span> Although still lower than that of non-<span class="elsevierStyleItalic">DM</span>&#44; it is a significant improvement on the 30&#37; survival at 5 years for <span class="elsevierStyleItalic">DM</span> patients treated with HD or PD&#46; It may be that recovering renal function promotes the elimination of AGEs from <span class="elsevierStyleItalic">DM</span> and other uremic mediators that favour accelerated atherosclerosis and are agents of direct vascular injury&#46; In addition&#44; TX is associated with a better quality of life and rehabilitation&#44; personally and at work&#46; Therefore&#44; TX should be offered to all diabetic patients in RRT without absolute contraindication and as early as possible&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">FUTURE MANAGEMENT OF <span class="elsevierStyleItalic">DIABETES MELLITUS</span> IN RENAL REPLACEMENT THERAPY</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Another worth noting part of the study presented in this issue is that the prognosis of patients with type 2 diabetes does not improve in the second stage &#40;post-1992&#41;&#46; Despite technical advances in the treatment&#58; double bag&#44; cyclers&#44; use of erythropoietic agents and the new drugs at our disposal for controlling blood pressure&#44; dyslipidaemia&#44; glycaemia and mineral vascular disease&#44; the mortality is unchanged&#46; It is true that hospital admission rate and annual stay in the most recent period are reduced&#44; but we do not know if it is as a result of a better prognosis or overall improvement in hospital ambulatory processes and reduced stays&#46; Although the authors have not given a detailed analysis of comorbidity between both stages&#44; non-<span class="elsevierStyleItalic">DM</span> and <span class="elsevierStyleItalic">DM</span> type 1 patients who began PD after 1992 have improved their prognosis&#46;</p><p class="elsevierStylePara">Many misleading factors may interfere with an analysis like this&#44; because other studies have reported an overall improvement in results over the years&#46; For example&#44; in the US registry&#44; the mortality of diabetic patients on HD and PD was reduced from 27&#46;4&#37; in 1980 to 18&#46;6&#37; in 2007 and <span class="elsevierStyleItalic">DM</span> survival after PD improved by 21&#46;8&#37; in the last half of the 1990s&#46;<span class="elsevierStyleSup">10</span> Other studies in the same country showed a lower peritoneal technique failure rate when comparing the 2002-2003 period with the 1996-1997 period&#46;<span class="elsevierStyleSup">17</span> Although we have no data published by the Spanish registry for patients with <span class="elsevierStyleItalic">DM</span>&#44; global annual mortality improved from 12&#37; in PD in 2002 to 7&#46;8&#37; per annum 5 years later&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">The treatment of <span class="elsevierStyleItalic">DM</span> patients on PD requires dedication and integrated monitoring to reduce cardiovascular risk on all fronts&#46; Diet&#44; exercise and weight control are crucial&#44; as well as control of fluid intake&#44; which reduces the use of hypertonic solutions&#46; A new indication for glucose-free solutions was discovered with icodextrin or amino acids as agents to reduce glucose intake for patients&#46; In addition&#44; the importance of preserving RRF makes all the kidney protecting measures in the pre-dialysis stage continue to have an effect&#46; We have no evidence that glycaemic control&#44; the use of RAAS blockers or other measures reduce the mortality of our patients&#46; We sincerely think it is difficult to implement a randomised trial with mortality targets to test these intervention measures at present&#44; but there is a whole pathophysiological substrate and partial evidence indicating that the hope of maintaining FRR and improving survival of <span class="elsevierStyleItalic">DM</span> on PD is on the right path&#46;<span class="elsevierStyleSup">19</span></p><p class="elsevierStylePara">Until recently&#44; it was accepted that diabetic patients should start dialysis early&#44; even earlier than non-<span class="elsevierStyleItalic">DM</span> patients&#46; However&#44; the IDEAL study released this year&#44; which is a randomised clinical trial of 828 patients followed over three and a half years&#44; shows no benefit in starting scheduled RRT at a clearance between 10 and 14m&#47;min compared to doing so at 7ml&#47;min&#46;<span class="elsevierStyleSup">20</span> It must be made clear that the study allowed patients with symptoms or without complications to start RRT&#46; In fact&#44; 76&#37; of patients assigned to a late start did so before reaching 7ml&#47;min renal function&#46; Finally&#44; there was only 6 months difference between the start of RRT in the two groups&#46; The survey is not specifically dedicated to patients with <span class="elsevierStyleItalic">DM</span> or PD&#44; but provides evidence for inclusion in RRT after a patient&#39;s complete clinical assessment and against early initiation strategy based solely on figures&#46; In any case&#44; PD has the added advantage of allowing a gradual start relying on and caring for RRF&#46; Recently&#44; it was seen that patients with preserved RRF have less vascular calcification and that this factor could be involved in the protection of that residual diuresis&#46;<span class="elsevierStyleSup">21</span></p><p class="elsevierStylePara">The future of PD for patients with <span class="elsevierStyleItalic">DM</span> is via peritoneal membrane protection&#44; minimising glucose load&#44; using new&#44; more biocompatible solutions&#44; preventing peritoneal infections and developing specific treatments to prevent peritoneal fibrosis&#46;</p><p class="elsevierStylePara">While we await the results of early intervention on cardiac and renal damage in our patients&#44; we must strive to improve the prognosis of diabetic patients reaching RRT&#46; PD appears to be a better starting technique than HD for those patients who choose it&#44; due to its lower mortality in the first 2-3 years&#44; greater independence and improved efficiency&#44; because of its lower cost&#46; At that time&#44; we should be able to provide the patient with TX&#46; If this is not possible&#44; integrated control must be maintained according to Table 1 with RRF protected&#46; Once PD is insufficient to maintain the patient&#39;s situation&#44; we must offer the transfer to HD within an integrated model&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Key points</span></p><p class="elsevierStylePara">1&#46; <span class="elsevierStyleItalic">DM</span> determines a poor prognosis in any dialysis technique mainly at the expense of added CV damage&#46;</p><p class="elsevierStylePara">2&#46; The future is early detection and intervention with kidney protection measures&#46;</p><p class="elsevierStylePara">3&#46; PD results have improved in recent years&#46;</p><p class="elsevierStylePara">4&#46; PD is a good starting technique for RRT in <span class="elsevierStyleItalic">DM</span> patients&#46; Transplant is the technique of choice and should be performed as early as possible&#46;</p><p class="elsevierStylePara">5&#46; The RRT integrated model is the only technique recommended that maintains free choice and is economically sustainable&#46;</p><p class="elsevierStylePara"><a href="10682&#95;108&#95;11418&#95;en&#95;w477710641710682&#95;18107&#95;9995&#95;es&#95;10682&#95;340&#95;9995&#95;es&#95;fig&#95;1&#95;portoles&#95;en&#46;ppt" class="elsevierStyleCrossRefs">10682&#95;108&#95;11418&#95;en&#95;w477710641710682&#95;18107&#95;9995&#95;es&#95;10682&#95;340&#95;9995&#95;es&#95;fig&#95;1&#95;portoles&#95;en&#46;ppt</a></p><p class="elsevierStylePara">Table 1&#46; Measures to improve long-term outcomes in diabetic patients on peritoneal dialysis</p>"
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