Review: The epidemic of diabetic renal disease — the practical challenges for renal replacement programmes

Abstract

Diabetic patients represent the largest group requiring renal replacement therapy in the developed nations, although take-on rates in the UK still lag behind other countries. As a group, diabetic patients present specific challenges to those providing renal replacement, including disproportionate late referral and under-recognition of renal insufficiency, multiple co-morbidity, and issues relating to choice of dialysis modality and when dialysis should be started. This review explores these issues and argues that it is by concentrating on the pre-dialysis phase of care that clinicians are most likely to achieve a more favourable clinical outcome. In addition to the benefits of good blood pressure and diabetic control, time is needed to inform and educate the patient prior to dialysis, and to evaluate co-morbidity if transplantation is to be considered. To achieve this, patients require nephrological supervision in the context of a well-resourced, multidisciplinary pre-dialysis programme, commencing a minimum of one year before starting renal replacement therapy.