This document discusses peritoneal dialysis (PD) in diabetic patients. It notes that about one third of new dialysis patients have diabetes as their primary diagnosis. PD has several potential advantages for diabetics including no need for vascular access, better preservation of renal function, and lifestyle benefits. However, concerns with PD in diabetics include higher peritonitis rates and differences in peritoneal membrane characteristics that may impact transport. Maintaining good glycemic control, preserving residual renal function, and intensive patient education are important factors for successful PD treatment in diabetics.

1. PD In Diabetic Patients
Dr. Osama El-ShahatDr. Osama El-Shahat
Consultant Nephrologist
Head of Nephrology Department
New Mansoura General Hospital
(international(
)Egypt(

2. AgendaAgenda
 Introduction
 PD in diabetic Patients :
 PD membrane
 PD Fluids
 Education
 Potential advantages
 Concerns
 Insulin requirements in PDInsulin requirements in PD
 Conclusion

3. Diabetes mellitus: factsfacts
 By the year 2030 366 million people (4,4% vs. 2,8% now)
 Caused by genetic, environmental factors, chronic
subclinical inflammation
 Enhanced cardiovascular morbidity and mortality:
especially in females
About one third of the new patientsAbout one third of the new patients
receiving dialysis treatmentreceiving dialysis treatment

4. Diabetes as the primary diagnosis ofDiabetes as the primary diagnosis of
incident renal replacement treatmentincident renal replacement treatment
patients in 2000patients in 2000

5. PrinciplesPrinciples ofof PDPD
 Dialysis fluid is introduced to the
peritoneal cavity through a catheter
placed in the lower part of the
abdomen.
 peritoneum serves as the dialysis
membrane. The peritoneal cavity can
often hold more then 3 litres, but in
clinical practice only 1.5 – 2.5L of fluid
are used.
 Solutes are transported across the
membrane by diffusion.
 Fluid is removed by ultrafiltration
driven by an osmotic pressure gradient.

6. PD fluidsPD fluids
Glucose :
Glucose was the only osmotic agent available
until 1990.
It is not directly toxic, effective and
inexpensive available in con. 1.36% 1.5% 2.2%
3.86 and 4.25% with high glucose concentration
is used for effective UF

7. Sitter T.PDI 2005; 25;415-25Sitter T.PDI 2005; 25;415-25
Diabetes mellitus and PDDiabetes mellitus and PD::

8. PhysionealPhysioneal
↓↓ Infusion painInfusion pain
↓↓ PeritonitisPeritonitis
↑↑ Glycemic controlGlycemic control
↑↑ AppetiteAppetite
↑↑ Patient acceptancePatient acceptance
NoNo ↓↓ UFUF
PhysionealPhysioneal
↓↓ Infusion painInfusion pain
↓↓ PeritonitisPeritonitis
↑↑ Glycemic controlGlycemic control
↑↑ AppetiteAppetite
↑↑ Patient acceptancePatient acceptance
NoNo ↓↓ UFUF
IcodextrinIcodextrin
↓↓ Glucose loadGlucose load
↑↑ Glycemic controlGlycemic control
↑↑ UF, control of fluid statusUF, control of fluid status
↓↓ DyslipidemiaDyslipidemia
↑↑ Quality of lifeQuality of life
↑↑ Time on PDTime on PD
IcodextrinIcodextrin
↓↓ Glucose loadGlucose load
↑↑ Glycemic controlGlycemic control
↑↑ UF, control of fluid statusUF, control of fluid status
↓↓ DyslipidemiaDyslipidemia
↑↑ Quality of lifeQuality of life
↑↑ Time on PDTime on PD
Pecoits-Filho, et al. Kidney Int. 2003;64(suppl 88):S100-S104.
Vardhan, et al. Kidney Int. 2003;64(suppl 88):S114-S123.
NutrinealNutrineal
↓↓ Glucose loadGlucose load
↑↑ Glycemic controlGlycemic control
↑↑ Protein intake, nutritional statusProtein intake, nutritional status
NutrinealNutrineal
↓↓ Glucose loadGlucose load
↑↑ Glycemic controlGlycemic control
↑↑ Protein intake, nutritional statusProtein intake, nutritional status
NNewew PDPD solutionssolutions

9. IcodextrinIcodextrin andand fluid statusfluid status

11. Diabetes mellitus and PeritonealDiabetes mellitus and Peritoneal
Dialysis:Dialysis: potential advantagespotential advantages
 No need for vascular access
 No need for systemic anticoagulation
 Continuous therapy
 Gradual ultra filtration
 Better preservation of renal function
 Fewer episodes of hypotension
 Better control of anemia
 Lifestyle advantages
 More liberal diet

12. Diabetes and peritoneal dialysis:
What about RRF?

13. Diabetes and peritoneal dialysis:
What about RRF?

14. ARB’s and PD and RRF

16. PD in diabetics: concerns
About Differences in peritoneal membrane
structure?
 Higher peritonitis rates?
About morbidity and mortality

17. Physiology of Peritoneal Transport
Peritoneal blood folw
50-100ml/min.
blood
water
ultrafiltration
Urea,Cr
Electrolyte
diffusion
Abd. carvity
Diffusion is depend on dialysate
not depend on peritoneal blood flow

18. Diabetes and peritoneal
membranemembrane characteristicscharacteristics

20. PDC- parameters
diabeticsdiabetics vsvs nonnon diabeticsdiabetics
 Diabetic patients probably
 have a larger vascular surface area,
potentially related to neo-angiogenesis
 have a more leaky membrane,
 probably due to interstitial damage
 Diabetic patients probably
 have a larger vascular surface area,
potentially related to neo-angiogenesis
 have a more leaky membrane,
 probably due to interstitial damage
Nakamoto *multiplied by 10 et al, AJKD, 2002Nakamoto *multiplied by 10 et al, AJKD, 2002

22. DiabetesDiabetes andand peritonitis riskperitonitis risk

23. Diabetes mellitus and PD:Diabetes mellitus and PD:
determinants of survival: the role of inflammationdeterminants of survival: the role of inflammation????

25. ConclusionsConclusions
Peritoneal dialysis seems to be associated with 48% lower mortality than
hemodialysis over the first 2 years of dialysis therapy independent of
modality switches or differential transplantation rates.
Clin J Am Soc Nephrol 8: 619–628, 2013Clin J Am Soc Nephrol 8: 619–628, 2013..

29. Quellhorst et al, JASN 2002Quellhorst et al, JASN 2002
Insulin therapy in ESRDInsulin therapy in ESRD

31. Impact of education on diabetic
compliance
Intensive counseling of diabetic patients
on PD :
 Importance of salt restriction
 Importance of glucose monitoring
 Deleterious effect of high glucose solutions
Quan and Wang T. et al, PDI 2006Quan and Wang T. et al, PDI 2006

32. Impact of education on diabetic
compliance
After 1 year:
Compliance to salt restriction increased from
19.5 to 76.2 %
Only 3/31 used 2.5% and 1/31 used 4.25%
Fluid status improved as measured by bio-
impedance measurement
Quan and Wang T. et al, PDI 2006Quan and Wang T. et al, PDI 2006

33. SAGE-Hindawi Access to Research International Journal of Nephrology Volume
2011, Article ID 914849, 10 pages doi:10.4061/2011/914849

34. SAGE-Hindawi Access to Research International Journal of Nephrology Volume
2011, Article ID 914849, 10 pages doi:10.4061/2011/914849

35. Conclusion
 No doubt that diabetes is an evil disease, with negative
impact on outcome of ESRD patients
 PD in an integrated care approach is a suitable
alternative for diabetics
 Attention to
 preservation of RRF
 Blood Sugar control
 Use of ARABs
 Low –GDP mandatory
 Patient education and training

37. Do glucose free solutions leadDo glucose free solutions lead
toto better glycemia controlbetter glycemia control??

38. Daily insulin requirements for diabetic
patients on peritoneal dialysis