[Pre-occupying increase in diabetes as cause for terminal kidney failure. Evaluation of treatment strategies].

OBJECTIVE

To study the incidence, prevalence, treatment modalities and prognosis of diabetic patients on renal replacement therapy.

MATERIAL

We studied all end-stage renal failure (ESRF) diabetic patients on renal replacement therapy in "Area Sanitaria 1" in Madrid from 1978 to 1998.

RESULTS

Diabetes mellitus has become the leading cause of ESRF in our health area of Madrid, 30% of all causes of ESRF. Incidence of diabetics beginning RRT was 33.3 per million population (pmp) in 1998, while in 1993-94 diabetes was 15% and 21 pmp, respectively, table 1. The proportion of diabetics on RRT has increased from 7.4% 1986 to 12.7% 1998. The prevalence of diabetics on RRT in 1998 was 135 pmp, with an overall prevalence of 1054 pmp. At the mean time, the proportion between incident diabetics type 2/diabetics on RRT has increased from 15% in 1987-88, to 54% in 1993-94 and to 81% in 1997-98, consequently, mean age of diabetic patients at beginning RRT has increased from 47 years before 1988, 58 in 1989-90, 61 in 1993-94, 62 in 1995-96 and 63 in 1997-98 (Table I). We studied 182 diabetics admitted for renal replacement therapy, 106 males and 76 females, 105 were diabetics type 1 and 77 type 2. Their mean age at RRT beginning was 57.12 years (SD). Hemodialysis (HD) was the first modality of treatment for 128 (70%) diabetics and CAPD for 54. Seventy out of 128 patients on HD were dialyzed in the Hospital Unit, 40% on AFB (acetate free biofiltration) and 58 in two Satellite Units, that means a higher proportion of diabetics on CAPD and on HD in Hospital Unit. Diabetics allocated to CAPD were 5 years, as mean, younger than patients allocated to HD (p < 0.01) and the proportion of diabetes type 1 was higher in CAPD (72%) than in HD (51%), p 0.05. During the mean follow-up period (51.45 months) 79 patients changed their treatment modality and 45 of them received a kidney allogral. Relative risk of drop-out was higher in CAPD technique when compared to HD. Clinical complications were frequently observed: ocular (77%), cardiovascular (Myocardial infarction 1.7%), acute cerebrovascular disease (21%) and distal angiopathy (35%), 10% amputee. At December of 1998, 89 patients were dead. Cardiovascular and cerebrovascular diseases (29%) and Infections (27%) were the two most frequent causes of death. Unknown-origin deaths represent 19% of all deaths. The overall survival (Kaplan Meier) was 92%, 80%, 72%, 61% and 54% at 1, 2, 3, 4 and 5 years, respectively (57 patients completed last period). Survival was better on HD than on CAPD, but without statistical significance, although the significant difference in age and in proportion of diabetes type 2 between both groups. Data analysis estimated by Cox proportional hazards regression shows that younger age and ki,r transplantation had a positive independent effect on survival, whik clinical distal angiopathy had important negative effect on survival.

CONCLUSIONS

Diabetes mellitus has become the leading case of ESRF in our health area of Madrid. Young age and kidney transplantation had a positive independent effect on survival, while clinical distal angiopathy had important negative effect.