We studied the long-term outcome of 268 patients suffering from diabetic end-stage renal disease (DM-ESRD) treated with long-term haemodialysis between 1978 and 1991, with special emphasis on visual acuity as well as the heterogeneity of DM-ESRD. The 50% patient survival on haemodialysis was 60 months. Visual disturbances were found in 73.1% (392/536) of eyes at the start of haemodialysis. Chronological assessment of visual acuity demonstrated the stabilization of visual acuity and 87.1% (364/418) of eyes were stable, 4.8% (20/418) were improved, and 8.1% (34/418) were aggravated in the long term respectively. The change of visual acuity was frequently seen in the short term, and rapid shifts of body fluid to correct overhydration induced abrupt changes of glycaemic control as well as retraction of macular oedema. Hence it might be one of the factors affecting rapid change of visual acuity in the short term. Meanwhile, long-term deterioration of visual acuity resulted from either hypertension unresponsive to medical treatment or poor glycaemic control. Some DM-ESRD patients had only background retinopathy at the start of haemodialysis and these were likely to have the nephrosclerotic glomerular lesion. They were old, not nephrotic and had a mild degree of diabetes during the predialysis stage. Thus, DM-ESRD patients seem to have some heterogeneity in their clinical characteristics, and old DM-ESRD patients with only background retinopathy have the appearance of diabetic macroangiopathy rather than microangiopathy.

Directional atherectomy (DA) was developed as a new therapeutic modality for coronary artery disease. For the past 3 years, we have applied DA intervention to vascular access failure with either poor blood flow rate or high venous pressure. DA intervention was performed on 27 lesions of 16 hemodialyzed patients. A reduction of stenosis to less than 20% of that before treatment was judged a technical success, and the rate of technical success was 84%. All patients showed adequate blood flow rates after DA intervention, indicating initial success. Although restenotic events occurred frequently, repeated DA interventions could be performed successfully. The patency rate at 1 month after DA intervention was 100%, at 3 months 93%, at 6 months 92% and at 12 months 75%. The short-term patency rate of DA was more satisfactory than the results of percutaneous transluminal angioplasty as reported by several investigators. Regarding the site of stenosis, restenotic events were relatively fewer in the lesions occurring at the native vein compared to those at graft-venous anastomotic sites. Eccentric-type stenosis was also associated with fewer restenotic events than circumferential-type stenosis. These results suggest that eccentric-type stenosis at the native vein is the most suitable lesion for the application of DA intervention in terms of long-term patency. As no severe complications occurred after DA intervention, this would appear to be a useful therapeutic modality for the correction of vascular access failure.

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