Predialysis Care in Diabetic Patients: The Missing Link?

Abstract

Management of type 2 diabetic nephropathy (DMN) was once considered the sole responsibility of endocrinologists. In the early years, patients who suffered from DMN either died prematurely due to cardiovascular complications, or from concurrent advanced diabetesrelated end-organ damage. As a result of the high morbidity and mortality and the poor quality of life, these patients were less likely to be advised dialysis treatment when they reached end-stage renal disease (ESRD).With the advancement in management of cardiovascular diseases and the knowledge on the importance of metabolic control, better survival of diabetic patients is achieved. Many diabetic patients develop ESRD during the course of their disease. Diabetic nephropathy has become the fastest growing segment of ESRD worldwide. As more diabetic patients are recruited into the dialysis program, the nephrologists are left with the challenge to deal with multiple comorbidity and physical dysfunction associated with diabetes mellitus, in addition to treatment of the uremic state. Despite rigorous effort in the management of cardiovascular complications and advances in dialysis therapy, and to the frustration of the healthcare workers, diabetic patients still fare poorly in terms of survival and quality of life (1-3). The burden being imposed on the healthcare system is also enormous (4). Predialysis management in diabetic patients with chronic renal insufficiency (CRI)While endocrinologists tend to focus on the management of early diabetes mellitus and the prevention of diabetes-related complications, nephrologists tend to focus mainly on the dialysis aspect of therapy. The "predialysis period", the "no-man's land", is considered to be merely a period for "dialysis planning". In reality, the progression of CRI to ESRD is a continuum of disease and the pre-dialysis period is actually a very critical period that deserves more proper attention if the outcome of dialysis is to be improved. Unfortunately, the importance of pre-dialysis care of diabetic patients is often, if not always, neglected and habitually inadequate (5). This is further aggravated by the problems of late referrals and diagnosis. Multiple comorbidity conditions of diabetic patients are often blamed as the reason for their unfavorable outcome despite optimization of the dialysis therapy. In fact, many of these complications are seen early before the commencement of any dialysis treatment. As a matter of fact, the pre-dialytic period is the most vulnerable period for the development of malnutrition, left ventricular hypertrophy (LVH), uncontrolled blood pressure, hypo-or hyperglycemia, acidosis and calcium/phosphate disturbances. Abundant data now suggest that baseline parameters at the onset of dialysis do bear a prognostic role in the outcome of dialysis therapy (5-7). This situation is especially true in the diabetic populations since such patients are prone to comorbidity conditions. The latter, once developed, usually run a relentless course.The artificial segregation of patients from a...