Treatment of the uremic diabetic.

Improved patient survival and rehabilitation have been continuously reported over the last decade for diabetics in irreversible kidney failure. There have, however, been no controlled prospective trials of the relative merits of CAPD, maintenance hemodialysis, or kidney transplantation in the uremic diabetic. As a generalization, younger, more rehabilitatable diabetics have been offered a kidney transplant, while older, often sicker diabetics have been relegated to CAPD, leaving most diabetics in the subset managed by maintenance hemodialysis. Treatment preference has reasonably been based on a team's experience and available facilities. Furthermore, nonuniform criteria for patient selection, and timing of the onset of uremia therapy, preclude direct comparisons between series of treated diabetics. While survival of diabetics treated with maintenance hemodialysis or peritoneal dialysis has improved substantially in recent years, survival and rehabilitation after kidney transplantation are superior to other forms of uremia therapy. Cumulative data suggest that a treated uremic diabetic patient has a 50% chance of living 3 years on hemodialysis, a 50% chance of surviving 5 years if he receives a well functioning cadaveric kidney transplant, and an even longer anticipated survival of 50% for 7.5 years if transplanted with a well-functioning living-related kidney. Even better results may be attainable with kidneys from HLA-identical siblings, particularly when transplanted early and employing cyclosporine rather than azathioprine, thereby allowing reduction of steroid dosage to minimal levels. Kidney transplantation, when judiciously undertaken by a team skilled in overall diabetic management, is the treatment of choice for the uremic diabetic. Dialytic therapy, however, has appreciable value, not only as an alternative in patients in whom transplantation is contraindicated, or for whom a kidney is not available, but as life-sustaining therapy while awaiting surgical intervention. No matter how treated, diabetic nephropathy need no longer be viewed as a disease of desperation. Unfortunately, proffering a substitute for the diabetic patient's own renal function does not, in and of itself, diminish progression of preexisting multisystem micro- and macrovascular disease. Implantation of a functioning kidney transplant in a failing diabetic with the renal-retinal syndrome provides a firm base upon which, with careful attention to regulation of blood glucose, reduction of hypertensive blood pressure, and provision of emotional support, a new, tenuous life may be built.