Preocupante incremento de la diabetes como causa de insuficiencia renal terminal: Evaluación del tratamiento sustitutivo

Objective: To study the incidence, prevalence, treatment modalities and prognosis of diabetic patients on renal replacement therapy. Material: We studied all end-stage renal failure (ESRF) diabetic patients on renal replacement therapy in "Area Sanitaria 1" in Madrid from 1978 to 1998. Results: Diabetes mellitus has become the leading cause of ESRF in our health area of Madrid, 30% of all causes of ESRF. Incidence of diabe tics beginning RRT was 33,3 per million population (pmp) in 1998, while in 1993-94 diabetes was 15 % and 21 pmp, respectively, table 1. The propor tion of diabetics on RRT has increased from 7,4 % 1986 to 12,7 % 1998. The prevalence of diabetics on RRT in 1998 was 135 pmp, with an overall prevalence of 1054 pmp. At the mean time, the proportion between incident diabetics type 2/ diabetics on RRT has increased from 15 % in 1987-88, to 54 % in 1993-94 and to 81% in 1997-98, consequently, mean age of diabe tic patients at beginning RRT has increased from 47 years before 1988, 58 in 1989-90, 61 in 1993-94, 62 in 1995-96 and 63 in 1997-98 (Table I). We studied 182 diabetics admitted for renal replacement therapy, 106 males and 76 females, 105 were diabetics type 1 and 77 type 2. Their mean age at RRT beginning was 57 12 years (SD). Hemodialysis (HD) was the first modality of treatment for 128 (70%) diabetics and CAPD for 54. Seventy out of 128 patients on HD were dialyzed in the Hospital Unit, 40% on AFB (acetate free biofiltration) and 58 in two Satellite Units, that means a higher proportion of diabetics on CAPD and on HD in Hospital Unit. Diabetics allocated to CAPD were 5 years, as mean, younger than patients allocated to HD (p<0.01) and the proportion of diabetes type 1 was higher in CAPD (72%) than in HD (51%), p0,05. During the mean follow-up period (51 45 months) 79 patients changed their treatment modality and 45 of them received a kidney allogra[. Relative risk of drop-out was higher in CAPD technique when compared to HD. Clinical complications were frequently observed: ocular (77%), cardiovascular (Myocardial infarction 1 7%), acute cerebrovascular disease (21%) and distal angiopathy (35%), 10% amputee. At December of 1998, 89 patients were dead. Cardiovascular and cerebrovascular diseases (29%) and Infections (27%) were the two most frequent causes of death. Uknown-origin deaths represent 19% of all deaths. The overall survival (Kaplan Meier) was 92%, 80%, 72%, 61% and 54% at 1, 2, 3, 4 and 5 years, respectively (57 patients completed last period). Survival was better on HD than on CAPD, but without statistical significance, although the significant difference in age and in proportion of diabetes type 2 between both groups. Data analysis estimated by Cox proportional hazards regression showd that younger age and ki,r transplantation had a positive independent effect on survival, whik clinical distal angiopathy had important negative effect on survival. Conclusions: Diabetes mellitus has become the leading case of ESRF in our health area of Madrid. Young age and kidney transplantation had a positive independent effect on survival, while clinical distal angiopathy had important negative effect.