Aggressive Ophthalmological Management in Diabetic End-Stage Renal Disease: A Study of 31 Consecutively Referred Patients

Abstract

We prospectively followed the course of eye disease in patients with diabetic end-stage nephropathy from the time of initial referral by the renal unit. A total of 31 patients (62 eyes) – 9 of whom had functioning renal transplants and 22 of whom were on maintenance dialysis – were consecutively evaluated for 6-24 months (mean follow-up of 18 months). Visual acuity and diabetic retinopathy stabilized or improved in all 18 eyes of the transplant patients and in 41 of 44 (93%) eyes of the dialysis patients. When first evaluated, economically useful vision (20/200 or better) was present in 11 of 18 (61 %) eyes in the transplant group and in 25 of 44 (57%) eyes in the dialysis group. At the most recent evaluation, economically useful vision was present in 13 of 18 eyes (72%) in the transplant group versus 28 of 44 eyes (64%) in the dialysis group. Ambulatory vision (counting fingers or better) was present in 15 of 18 eyes (83%) in the transplant group versus 37 of 44 eyes (84%) in the dialysis group.

Vitreous hemorrhage in diabetes patients with proliferative diabetic retinopathy undergoing hemodialysis

“…For patients with diabetic kidney disease undergoing hemodialysis, vitreous hemorrhage seems to be a hemodialysis‐induced hemorrhagic complication, because hemodialysis requires systemic anticoagulation therapy. However, to the best of our knowledge, just two studies on vitreous hemorrhages in patients undergoing hemodialysis have been published. In the first prospective uncontrolled study, Berman et al.…”

“…In the first prospective uncontrolled study, Berman et al. reported that a comparison of diabetic eyes in the dialysis (hemodialysis and peritoneal dialysis) and transplant groups showed that two (5%) of the 44 eyes in the dialysis group and none (0%) of the 18 eyes in the transplant group required vitrectomy for vitreous hemorrhage; the difference did not reach statistical significance. In the second case series study, Hayashi et al.…”

“…Vitreous hemorrhage is a major cause of unexpected and severe visual deterioration in diabetes patients with proliferative diabetic retinopathy (PDR). Diabetes patients with PDR are also likely to have end‐stage kidney disease requiring renal replacement therapy, because retinopathy and nephropathy usually progress in parallel as a result of long‐term diabetic microvasculopathy. For this reason, many nephrologists might be concerned that starting hemodialysis in diabetes patients with PDR could be associated with an increased risk of subsequent vitreous hemorrhage, as routine hemodialysis requires systemic anticoagulation using unfractionated heparin.…”

“…For this reason, many nephrologists might be concerned that starting hemodialysis in diabetes patients with PDR could be associated with an increased risk of subsequent vitreous hemorrhage, as routine hemodialysis requires systemic anticoagulation using unfractionated heparin. However, somewhat surprisingly, numerous studies have reported that the severity of retinopathy, visual acuity and macular edema in diabetic eyes stabilized or even improved after initiation of hemodialysis, although the precise mechanisms are still being debated. If hemodialysis per se has stabilizing effects on PDR that lead to vitreous hemorrhage, hemodialysis might be associated with a decreased risk of vitreous hemorrhage.…”

Dialytic Therapy for the Diabetic ESRD Patient

“…We routinely collaborate with an ophthalmologist skilled in retinal disorders. By this tack, laser and/or vitreous surgery can be integrated as a component of comprehensive management (56). Similarly, we consult--even in asymptomatic patients-a cardiologist familiar with uremia in diabetic patients.…”