1. Incidence of end-stage renal disease (ESRD) due to diabetic nephropathy (DN)
DN occurs in 40% of patients with diabetes mellitus (DM) across the United States; 40%-50% of ESRD patients have DN as the primary cause, which is the first. This is followed by hypertension and then nephritis. The prevalence of diabetes mellitus in China is 9.7%, and the prevalence of diabetic nephropathy in Chinese community patients with type 2 diabetes mellitus from 2009 to 2013 is 10%-40%; diabetic nephropathy accounts for 16.4% of ESRD in China, and chronic nephritis still ranks first. The proportion of diabetes mellitus among the patients with abdominal dialysis in Guangzhou Zhongshan First Hospital was 56.84%. The data of Beijing China-Japan Friendship Hospital shows that diabetic nephropathy is the first cause of ESRD in its population over 60 years old.
2. DN-ESRD replacement therapy: Early or Late?
2.1 Timing of dialysis.
Absolute indications: uremic pericarditis or plagiocele; uremic encephalopathy; severe metabolic acidosis; severe hyperkalemia; refractory volume overload. Empirical recognition: small and medium molecular solute levels are associated with complications and survival and require dialysis for clearance; malnutrition is associated with long-term patient prognosis and improving the patient’s nutritional status may improve long-term survival; diabetic patients should start dialysis treatment early to obtain a good prognosis; when renal function declines to a certain level, such as an estimated glomerular filtration rate (eGFR) of 15 ml/min・1.73 m2, dialysis should be Consider starting dialysis; it is dangerous to start dialysis when eGFR drops below 6 ml/min ・1.73m2.
2.2 Should DN-ESRD patients receive renal replacement therapy earlier?
Reasons: often with severe complications of other systems, including: cardiovascular comorbidity: major cause of death; peripheral vascular disease: amputation rate 25%; peripheral and autonomic neuropathy; gastroparesis and diabetic gastrointestinal disease: 50% symptomatic; retinopathy: 97% associated, blindness 25-30%.
2.3 Reality
According to data from the 2014 US National Kidney Disease Registry:Since 1996, there has been a trend towards earlier dialysis for patients with kidney disease in the US. There is a similar trend in the UK. So what is the situation in China? A survey by Liu Li et al. on the eGFR of dialysis patients in Beijing over the years found that the number of dialysis patients with eGFR 5-9.9 ml/min.1.73 m2 was gradually increasing, and there was also a trend of early dialysis.
Nevertheless, is there a theoretical basis for early dialysis?The results of an RCT published in the New England Journal in 2010 showed that there was no significant difference in the risk coefficient for all-cause mortality between patients on early dialysis DN and those on late dialysis, nor was there a significant difference in the number of all-cause deaths.
2.4 Guideline recommendations
Therefore, the European Renal Best Practice (ERBP) guidelines state that the timing of starting dialysis treatment in patients with stage 5 CKD with diabetes is similar to that of patients without diabetes (1A). 2014 Expert Consensus on Diabetic Nephropathy in China also states that patients with diabetic nephropathy with GFR below 15 ml/min.1.73 m2 can choose renal replacement therapy, including hemodialysis, peritoneal dialysis and renal transplantation, when conditions allow. It does not state that patients with diabetic nephropathy should advance dialysis.
Instead, the 2012 KDIGO guidelines state that the timing of renal replacement therapy is: it is recommended to start dialysis when the following manifestations occur: one or more signs and symptoms due to renal failure (acid-base imbalance, electrolyte disturbance, skin pruritus, plasmapheresis); uncontrollable hypertension or volume load; progressive deterioration of nutritional status that is difficult to correct by diet; cognitive impairment; occurring mostly in GFR 5.0 ml/ min/1.73m2 (2B).
2.5 Timing of referral.
Timely referral will allow more time to determine the modality of renal replacement therapy, establish dialysis access earlier, and improve the prognosis of dialysis patients. The British Society of Nephrology recommends referral to nephrology for blood creatinine above 150umol/L. American Diabetes Association: diabetic patients with GFR <30ml/min should be promptly referred to a nephrologist.
3. Choice of dialysis modality for DN-ESRD: HD or PD?
3.1 PD was previously considered to be preferred for DN patients for the following reasons.
3.1.1 Comparison of DN-ESRD alternative treatment methods.
Previously, it was considered that peritoneal dialysis does not require machine dependence, treatment time can be flexibly scheduled; fluid exchange can be performed anywhere, easy to travel, no anticoagulation or puncture required; easy to learn; independence, smooth life autonomy process, protection of residual renal function, etc.
3.1.2 Barriers affecting the choice of HD in patients with DM
DN is more complicated to make arteriovenous endovascular fistula due to arteriosclerosis; arteriovenous endovascular fistula is not easy to mature, often takes three months; fistula survival time is short in diabetic patients. Vascular calcification makes arterial flow insufficient.
3.2 Reality
Renal replacement modality for ESRD patients in the United States: the number of hemodialysis patients in the United States has been significantly higher than the number of peritoneal dialysis patients since the 1980s to the present. The basic distribution of PD patients in Asia: most countries and regions are currently dominated by hemodialysis. In Hong Kong, PD is still the main renal replacement modality. epidemiological information of dialysis patients in China in 2014: mainland China: about 326,000 dialysis patients in 2014, accounting for 20% of global ESRD. Among them, 280,000 were HD and 46,000 were PD. And in terms of treatment costs: statistics from the United States in 2009 showed that the annual cost of peritoneal dialysis exceeded the cost of hemodialysis.
According to the National Health Development Research Center of China, the annual cost of medical care for domestic ESRD patients is about 90,000-100,000 RMB; the annual cost of PD is about 93,520 RMB, while HD is about 103,416 RMB. It is suggested that peritoneal dialysis has more cost advantage.
3.3 Comparative survival options for different dialysis modalities.
Twenty-five papers were analyzed in a 2015 meta-analysis, and most of the results showed that PD survival was superior to HD in the initial phase after dialysis initiation, a process that lasted approximately 6 months-3 years. This advantage gradually disappears as time increases. The results of only one of the RCTs showed that the 5-year survival of DN-ESRD patients with preferred PD was significantly better than that of HD patients, but the sample size of this study was too small, with 38 cases in both groups.
However, the literature included in this meta-analysis had many shortcomings: all but one was an RCT study, which was observational; the included studies did not include only DN patients; the length of follow-up varied (from 1 to 8 years); the statistical methods were inconsistent; none of the literature provided data on quality of life, patient satisfaction, major and minor comorbidities, hospitalization, deterioration of residual renal function, glycemic control, and other data. Therefore, the reliability is not strong. According to Yu Xueqing et al. reported that the treatment of ESRD with PD has a good survival rate, with a 5-year survival rate of 36%. The survival rate of hemodialysis patients in China is 20%-70% on the mainland.
3.4 Analysis of the occurrence of cardiovascular disease in different dialysis modalities in China.
Academician Hou Fanfan initiated a national multicenter study that enrolled 2,388 individuals (1775 HD, 613 PD), including 512 DN (129 PD; 383 HD). CONCLUSION: Cardiovascular morbidity is more prevalent in chronic PD dialysis patients than in MHD for older dialysis patients and long-term dialysis patients.
3.5 Based on a large meta-analysis of the literature and many clinical studies, the ERBP clinical practice guideline concludes that: with the availability of various renal replacement therapy modalities, patients receive unbiased information and the choice of therapy is recommended according to the patient’s condition and wishes.