Renal replacement therapy for diabetic end-stage renal disease. Experience of a Tunisian Hospital Centre

Objective: To determine the epidemiological and clinical characteristics of 299 uremic diabetics at the initiation of renal replacement therapy (RRT) and to evaluate their morbidity and the factors influencing their mortality during the dialysis period. Patients and methods: All patients starting RRT for diabetic end-stage renal disease (ESRD) at Charles Nicolle Hospital of Tunis during a period of seven years (1990-1996) constituted the study population. During the follow-up period ended on December 31, 2000, all morbid events, hospitalizations and deaths were recorded. Multivariate analysis according to the Cox proportional hazards model was performed to identify the predictors of mortality. Results: There were 238 type 2 (79.6%) and 61 type 1 diabetics (20.4%) representing 20.3% of all patients accepted for RRT. The mean age at the onset of RRT was 53.16 ± 12.43 years (range: 23 to 80 years). A poor glycemic control was observed in 46.7% of type 2 diabetics and in 67.3% of type 1 diabetics (p = 0.0055). A third of patients started RRT in emergency conditions and 91% required a temporary vascular access. At the time of onset of RRT, 86.7% of patients were hypertensive and 52.1% had a nephrotic syndrome. Blindness was observed in 22.9% of type 1 diabetics and in 7.5% of type 2 diabetics (p = 0.0014). During the follow-up period, 217 patients died representing a rate of 22% patient-years, 26.7% of these deaths occurred during the first 3 months of RRT and 53% were attributed to infectious or cardiovascular complications. Actuarial survival rates were 68.4%, 59.6% and 45.3% at 1, 2 and 4 years, respectively. Age, co-morbidities and conditions of onset of RFff were independently correlated with survival time. Conclusion: Diabetes is a frequent cause of ESRD in Tunisia, the delayed referral to a nephrologist and coexistence of serious co-morbidities at the initiation of RRT resulted in a high rate of early death. Greater efforts should be made in our country in view of improving the quality of medical care of uremic diabetics before and during RRT.