Peritoneal dialysis in patients with diabetic nephropathy

Since the introduction of peritoneal dialysis (PD) into clinical nephrology at the end of the 1970s, many improvements have led to acceptance of this method as renal replacement therapy equivalent to hemodialysis. It is unclear whether the diabetic patient is the ideal candidate for PD and if this procedure should be the preferred method of treatment of renal failure in these patients, especially when kidney transplantation cannot be performed. PD may provide several advantages for diabetic patients with end-stage renal failure; for example, better hemodynamic stability is achieved during peritoneal ultrafiltration and vascular access surgery becomes unnecessary. On the other hand, the continuous glucose absorption may lead to increased insulin requirements, obesity and hyperlipidemia. Furthermore, peritoneal protein loss may aggravate malnutrition, which is frequently present in these patients. However, for a differentiated assessment of outcome in PD, the individual history (diabetes type 1 or type 2) and accompanying comorbidity of diabetic patients have to be considered. Nowadays nephrologists have to be aware of the concept of individualized therapy, which is integrated into an overall plan and takes into account the different conditions of diabetic patients and their treatment options. By improving removal of sodium and water, as well as improving quality of metabolic control, new dialysis solutions (icodextrin, neutral-pH solutions) and automated PD could have a positive impact on outcome in diabetic patients. In contrast, from retrospective studies on PD there is evidence of higher long-term mortality rates in elderly women with diabetes and in patients with cardiac insufficiency than in those on hemodialysis. Further research is necessary in order to optimize individualized therapy for diabetic patients with end-stage renal disease in the future.