[Continuous ambulatory peritoneal dialysis in diabetic patients].

Diabetes mellitus has become one of the most prevalent causes of renal disease, and approximately 30% of all insulin-dependent diabetic patients die of renal failure. Renal transplantation is generally the preferred treatment for diabetic patients with end-stage renal disease because it leads to a better quality of life than any other form of dialysis. Because fluid retention, electrolyte and acid-base disturbances are present in diabetics at a higher glomerular filtration rate than in non-diabetics, dialysis is initiated when the creatinine clearance is 10-20 ml/min, levels slightly higher than the recommended 5 ml/min for non-diabetics. Since 1978 continuous ambulatory peritoneal dialysis (CAPD) has become the preferred mode of therapy for diabetics. This method of dialysis offers several medical advantages: slow and sustained ultrafiltration, stable cardiovascular status, easier control of hypertension, preservation of residual renal function for a period longer than haemodialysis, steady state biochemical parameters. An additional advantage is a good, tight control of blood sugar achieved by intraperitoneal administration of insulin, which eliminates the need for multiple subcutaneous insulin injections. Intraperitoneally administered insulin closely mimics physiological events, though this route usually requires higher daily insulin doses. Heparinisation and access-related complications, which are the major cause of morbidity while on haemodialysis, are avoided. The social advantages include the possibility of home dialysis, long distance travel, uninterrupted job-related activity. Peritonitis remains the main complication of CAPD in diabetics. The pathogenesis, spectrum of organisms and treatment of peritonitis in diabetics do not differ from those seen in non-diabetics. The technique of catheter insertion, postoperative catheter care and common catheter complications are similar in diabetics to that in nondiabetic patients. Nutritional problems during CAPD may be aggravated by the loss of proteins, amino-acids, polypeptides and vitamins in the dialysate. They are especially important in those diabetics who are wasted and malnourished because of poor food intake, vomiting, and intercurrent illnesses. Foot problems are very important in diabetics on CAPD, and a multidisciplinary approach is absolutely crucial. The major contributory factors in the development of foot ulceration are neuropathy, peripheral vascular disease and abnormal stress. With proper selection of patients, diabetics can survive for a long period of time on CAPD. The morbidity and mortality observed during this therapy are primarily related to associated risk factors such as cardiovascular disease, atherosclerotic complications and infections. Certain features of CAPD make it a suitable therapy for diabetics.