Diabetic Patients and Peritoneal Dialysis

Abstract

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The prevalence of diabetes mellitus (DM) among patients requiring renal replacement therapy (RRT) has been on the rise worldwide, with DM now being the primary cause of end-stage renal disease (ESRD) in roughly one-third of RRT initiations. Although renal transplantation is the optimal treatment for ESRD, its limited availability has led to in-center hemodialysis (HD) being widely used as the default RRT modality in many countries. However, peritoneal dialysis (PD) may offer a superior option for diabetic patients due to its slower ultrafiltration rate, which can help mitigate the dialysis-induced hypotension and coronary ischemia that are associated with extracorporeal circulation during HD. Despite these advantages, unfounded concerns about technique failure and increased complication rates have discouraged some clinicians from recommending PD as a first-line RRT for diabetic patients.

We conducted a retrospective study comparing the incidence of complications and technique survival rates between diabetic and non-diabetic patients undergoing PD at a dialysis unit in Morocco. Our findings reveal that, diabetic patients undergoing PD experienced no significant difference in technique survival or incidence of complications compared to their non-diabetics. Nevertheless, only a small proportion (17.5%) of patients in our PD unit was diabetic, suggesting a need to improve access to PD for diabetic patients with ESRD.

Introduction

The number of patients with diabetes mellitus (DM) who require renal replacement therapy (RRT) has increased globally. DM is now the leading cause of end-stage renal disease (ESRD), accounting for about one-third of all patients initiating RRT worldwide. ESRD poses a significant public health challenge and requires substantial resources, in terms of both finances and human capital[1]. In Morocco, diabetes accounts for 32.8% of all cases of renal failure[2]. While renal transplantation is the preferred treatment for ESRD, limited access has resulted in dialysis, mainly in-center hemodialysis (HD), being used in most countries[1]. However, Hong Kong, the Jalisco region of Mexico, and Guatemala have implemented peritoneal dialysis (PD) as the first-line treatment, with 71%, 61%, and 57% of ESRD patients receiving PD, respectively. The global rise in the number of ESRD patients is making it increasingly challenging for low- and middle-income countries to provide adequate dialysis access[3].

Peritoneal dialysis presents numerous benefits in comparison to hemodialysis and is therefore an appealing alternative. PD offers slow and sustained ultrafiltration, which is particularly beneficial for patients with multiple cardiovascular comorbidities, such as those with diabetes[4]. It reduces the risks associated with rapid ultrafiltration during HD, such as intradialytic hypotension, myocardial ischemia, and cardiac arrhythmias. PD also helps preserve residual renal function (RRF), which is especially important for diabetic patients. Moist et al.[5]found that PD patients had a 65% lower RRF loss than HD patients. Other benefits of PD include greater patient autonomy, reduced incidence of diabetic retinopathy flare-ups, lower doses of erythropoietin-stimulating agents to achieve hemoglobin goals, and a lower risk of contracting certain transmissible diseases, such as hepatitis C[6]. Despite these advantages, and the equivalent survival rates of PD and HD[7], patients with diabetes are typically referred to HD, regardless of medical evidence or patient preference.

The aim of this study was to analyze our PD unit’s experience with peritoneal dialysis treatment for diabetics and compare the incidence of complications and the technique survival rates to those of non-diabetic patients.

Methods

We conducted a retrospective study that included all incident adult patients starting peritoneal dialysis at our dialysis unit in the Department of Nephrology at Hassan II University Hospital of Fez from January 2018 to December 2022.

This region, also called the Fez-Meknes region, is one of the 12 new regions of Morocco established by the 2015 territorial division. It covers an area of over 40,000 Km² and has a population of over 4.2 million people[8]. This region has seen a rapid increase in the number of hemodialysis units. In 2021, there were 51 hemodialysis centers; however, there was only one peritoneal dialysis center, located at our university hospital.

To identify diabetic patients, we used the diagnostic criteria of fasting blood glucose levels of ≥ 1.26 g/L or blood glucose levels of ≥ 2.00 g/L two hours after a glucose load[9].

Blood glucose levels were closely monitored and managed through a combination of dietary adjustments and sub-cutaneous insulin therapy, as indicated.

Peritoneal dialysis catheter insertion was performed by a nephrologist using mini-laparotomy under local or loco-regional anesthesia. A two-week observation period preceded dialysis initiation.

Peritoneal dialysis prescriptions for diabetic patients were individualized based on factors such as residual renal function, adequacy of dialysis, and fluid balance.

Dialysis was initiated for diabetic patients with the Continuous Ambulatory Peritoneal Dialysis (DPCA) method, utilizing Dianeal 1.36% solution. This method involved three exchanges daily, with an empty abdomen at night to facilitate adequate drainage and fluid balance. As patients progressed, a transition to Dialysis Prescription Automated Peritoneal Dialysis (DPA) was proposed. Under the DPA regimen, all eligible patients were transitioned to using a cycler. The DPA protocol entailed utilizing the Dianeal 1.36% solution for nightly dialysis sessions lasting 8-9 hours, allowing for four to five cycles. No Icodextrin or other non-glucose dialysat was used, due to their unavailability. The use of Dianeal 2.27% was limited to short periods to optimize fluid balance.

Our patients attended regular follow-up appointments with a multidisciplinary team comprising nephrologists, endocrinologists, dietitians, and diabetes educators. This collaborative approach ensured comprehensive oversight of each patient’s medical condition and allowed for timely adjustments to their treatment plans as needed.

We collected the data from the patients’ medical records, which were then processed using Microsoft Excel.

The statistical analysis employed in this study involved a comparison between diabetic and non-diabetic patients, with a specific focus on the incidence of complications and the technique survival rate. To achieve this, a combination of Kaplan-Meier survival analysis and the Cox proportional hazards model was utilized.

The Kaplan-Meier survival analysis was utilized to estimate and compare the technique survival rates of diabetic and non-diabetic patients. The log-rank test associated with the Kaplan-Meier analysis was applied to assess the statistical significance of differences observed between the two groups.

In addition, both bivariate and multivariate analyses using the Cox proportional hazards model were employed to perform a more refined assessment of the impact of diabetes technique survival while accounting for potential confounding factors. Covariates such as age, gender, and Charlson Comorbidity Index were considered in the model to adjust for their potential influence.

Results

The study included 80 patients who underwent PD, with a mean age of 47 +/-17 years and a sex ratio of 1.1 M/F. The main etiologies of ESRD were hypertension, glomerular nephropathies, diabetes, and polycystic

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