Dialysis and Diabetes

Diabetic dialysis patients is increasing. Of dialysis patients is about 1 / 3-1 / 4 has been the origin of Diabetes Mellitus. This ratio is expected to gradually increase. It is therefore necessary to have a special approach to diabetic patients on dialysis.

Kidney disease in diabetic hyperfiltration and microalbuminuria (30-300 mg / day) begin with. Gradually increase in proteinuria and glomerular filtration rate to be seen by the reduction of azotemia and had to end stage renal disease. This time varies according to the type of diabetes.

Insulin-dependent (Type I) consists of end-stage renal failure in patients with diabetes are between 15-30 years time. Non-insulin dependent (Type II) diabetes in this period is between 1-20 years.


10-20 ml / min creatinine clearance. When should start dialysis. (Serum creatinine 3-5mg / dl, as is the lower)
If symptoms begin uremia [anemia, pruritus, nausea, vomiting, loss of appetite, weakness, such as the ammonia smell the breath]
If fluid overload [edema in the feet (swelling) arcides (fluid accumulation in the abdominal membrane) such as pulmonary edema]
If serum creatinine 5-8mg / dL

Note: Early Diabetes patients received dialysis for long life, eye, heart, is shown to prevent foot complications. Studies diabetic retinopathy (eye to the patient blindness.) Showed accelerated 1-2 years before starting dialysis.


The choice of treatment the patient's age, level of education, place of residence, family and social structure, patient comfort, associated diseases (such as heart sick. And blindness) are selected considering.

Transplantation transplantation seems especially relatives live a better treatment option. Hemodialysis and peritoneal dialysis are also other treatment options.

Contraindications Renal Transplantation in Diabetic Patients:

- Age> 65 years
- Extremity gangrene if
- If you have severe coronary artery disease
- Peripheral nörapat or peripheral vascular disease due to inactivity If

kidney transplant is performed.


To receive hemodialysis patients with heart - should attempt to create a place of vessels by vascular surgery. Patients because it is often difficult to create the risk of atherosclerosis in the arteries. The truth of the patient's creatinine clearance 20-30 ml / min decreased the creation of this before entering hemodialysis. Before this operation should be looking at the condition of the vessel with Doppler ultrasound, large-scale, healthy arteries veins should be preferred. Created from the patient's own vein arterio-venous fistula (AVF) is more healthy. With the Brekiosefelik or basilic vein transposition AVF AVF has been observed that longer life of the elbow fistula. 4-6 weeks after fistula operation it is necessary to time the arrival of the vessel. If arteriovenous graft native AVF can not be made (artificial blood vessel) is the second option. Forward large vessels in patients with vascular problems (such as the subclavian vein or jugular vein) can be placed in permanent hemodialysis catheters. (Contraindication or peritoneal dialysis in these patients should be preferred.)

Diabetic patients must be selected to use the dialysate bicarbonate. 5.5 mmol / L glucose-containing dialysis prevent an occurrence time of hypoglycemia.

Dry weight is the case at the end of dialysis in diabetic patients should always be accessible. So be patient much liquid left over. But diabetic patients with atherosclerosis and edemeyip tolerate excessive fluid shooting hypotension due to autonomic neuropathy can develop and cramps. Not to exceed 2 kg between the two dialysis fluid intake is necessary for it and make long and slow dialysis. Such as hemodialysis 3 times a week for 8 hours. Or frequent dialysis (5 times a week) or are on dialysis every night method to solve this problem.

Complications that occur during dialysis

Hypotension: hypotension, nausea and vomiting in dialysis in diabetic hemodialysis patients would more often than other patients. This deterioration of peripheral vascular resistance can be either from cardiac causes, hypoalbuminemia, malnutrition, anemia, pre-dialysis may be due to antihypertensive Unusable. Are made to avoid:

- High sodium dialysate sodium and linear models
- Low-speed ultrafiltration
- Intermittent ultrafiltration
- Use of hypertonic albumin
- Hematocrit is above 30%
- Admission to the morning antihypertensive
- To not eat in Dialysis
- Leg exercises
- Dialysate to reduce the heat (especially near the end of dialysis)
- Some drugs, such as the use of midodrine and fludrocortisone (not Turkey)
- On-line hemofiltration
- Acetate-free biofiltration

Hypertension: 50% of diabetic patients undergoing dialysis use of antihypertensive medication. Reninangioten you have hypertension during dialysis may be due to excess fluid shooting from the system activation. Dialysis angiotensin- coverting enzyme inhibitors are used. Beta blockers are recommended for use in diabetic patients. Because disturb glucose control even overshadow the symptoms of hypoglycaemia. But positive cardiac effects were observed. Calcium antagonists, alpha blockers, antihypertensives such as hypertension medication may be the second option.

Arrhythmia, coronary ischemia: Excess liquid extraction, due to hypotension in patients with heart rhythm disorders, coronary ischemia, angina pectoris olabilir.o2 inhalation, oral or supkut or IV nitroglycerin used. Anti-arrhythmic used by the arrhythmia. Diabetics, especially when the arrhythmia Hypokalemia should be more inclined to pay attention to it.

metabolic Control

Blood sugar control is good HbA c <7.5 which patients live longer. For the prevention of this disease in addition to cardiovascular patients should be under the control of cholesterol, triglyceride levels as well.

Dialysis in patients with type 2 (non-insulin dependent) diabetes; Type 1 (insulin dependent) is more than 2 levels of patients with diabetes. After 64 years of this three-fold increase. Type 2 patients age, obesity, increased risk with reduced physical activity. These patients primarily diet, weight loss, exercise should be recommended. Approximately half of the use of oral glucose-lowering drugs. Increase the use of insulin ilerdikc years. Uremic patients with Type 2 insulin is usually recommended. However, oral medications are used more widely.

Type 2 disease in diabetes and insulin resistance creates inappropriate insulin secretion response. Uremia suppresses insulin secretion. Therefore, treatment may need less sugar lowering type2 diabetic uremic patients. (If using insulin dose may be reduced, if using oral medication may need to cut.)

Properties of the oral hypoglycemic agents;
Class Example Mechanisms Hypoglycemia Risk Kidney gray. Clearing Dialysis Use
Sülfanilür increases the secretion of insulin to glyburide glipizide dose Must have Yes Setting Variables
Thiozolidinediones Troglitazor to (Avandia) reduces the Peripheral Insulin Resistance Rare Yes Adjusting the dose is not necessary (Hepatic Toxicity Attention) Unknown
Biguonid with metformin (Glikofaj) reduces hepatic glucose production Least Not applicable Unknown
Acarbose İnhibitür of alpha glucosidase (Glikobay) Gastro Intestinal Absorption of carbohydrates reduces Use caution None Unknown


Vitreo-retinopathy and vision loss prolifeatif hemorrhage, retinal detaç financing, macular edema, glaucoma, cataract, may be due to corneal disease. Good control of blood pressure, the development of hemodialysis techniques, ophthalmologists often reduced the development of blindness examination. Panretinal laser photocoagulation and vitreo bleeding vitrectomy are in treatment.

Peripheral vascular disease

Year 5-25% of diabetic dialysis patients' happens in the lower extremity amputation. To avoid; daily washing and drying, nail, finger between care, tightening the shoes and socks to wear, it is necessary to go in the regular podiatrist. If you found a lesion due to ischemia should be referred immediately vascular surgeon, vascular bypass surgery may be able to prevent amputation. Treatment of diabetic foot wounds is urgently needed. Necessary growth factors in wound debridement therapy should be used. Amputation rate in diabetic CAPD patients, transplantation, hemodialysis treatment is no different.

Peripheral Neuropathy

Sensorimotor and / or diabetic autonomic neuropathy seen in hemodialysis patients. Uremic diabetics may suffer from paraplegia and guadropleji. In patients with nausea, vomiting, and diarrhea may also gastroparesis. Diabetic neuropathic symptoms may be reduced by renal transplantation and CAPD. Good glucose control is below the 7.5% hbaıc can correct these findings.

Neurontin complained of severe burning and pain in diabetic neuropathy (Gobepent's) and Tegretol (carbamazepine) as prescribed. This should make the drug dose adjustment.


Adynamic bone disease is more common renal osteodstrof findings in these patients. Storing aluminum in bone may be due to the aluminum-containing phosphate binders. After starting hemodialysis could break the bones within 2 years. Should be avoided in diabetic aluminum phosphate binder. Bone pain or fractures in diabetic patients before and after infusion of desferrioxamine should be examined by looking at aluminum levels.

MALNUTRITION (malnutrition)

Is common in diabetic hemodialysis patients. 25-30 kcal / kg / day should be given to the diet. It should be 50% protein while kabonhidrat and 1.3 - 1.5 / kg / day should be. Dialysate fluid is 200 mg / dl glucose should contain. Metoclopramide given for gastroparesis. Loperamide is also given antibiotics and diabetic diarrhea. Paretenal amino acid solutions can be used in patients with eating disorders. Blood albumin level of 3.5 g / dl must be on.

Diabetic Kidney Patient in Cardiovascular Diseases (CVD)

The prevalence of coronary heart disease in diabetic dialysis patients is 46.4%, the prevalence of non-diabetic patients (32.2%) is higher. More frequent atrial and ventricular arrhythmias in these patients, heart block, asystole, and cardiogenic shock, pulmonary congestion is observed. Some physicians are reluctant than beta-blockers in diabetic patients. However, the beneficial effects of coronary ischemia and arrhythmia were seen in the direction. To avoid the risk of cardiac troponin T test can benefit from dialysis.

CVD preventive maneuvers:

early Dialysis
ACE inhibitors or blockers angiotensinresept
Kept low blood pressure
The aspirin? Plavix?
Prevention of fluid overload (low salt intake, diuretics)
Statins (LDL cholesterol 100 mg / dl eclipse)
Trimetazidine (Vastarel) use (based on personal experience)

If you need PTCA (Percutaneous transüminal coroner angioplasty) or bypass surgery can be done. Both methods 2 year survival rate is approximately the same. But at the time of hospital mortality after bypass surgery is a bit more. Which is reduced with the new technique.


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