Editorial Nephron 23: 2-5 (1979)
Early Dialysis in Diabetic Patients with Chronic Renal Failure Shan! G. Massry, Ehen I. Feinstein and David A. Goldstein1
Many investigators have reported that diabetic nephro pathy develops in patients who have had diabetes mellitus for a prolonged period of time [1-3]. Our own data showed that the duration of diabetes prior to the onset of renal disease is 15.5 ±1.1 and 12.8+0.8 years in the juvenile and adult diabetics, respectively [4], Furthermore, once renal disease is overt, its progression to end-stage renal failure is rapid. The mean duration between the onset of renal disease and the requirement for maintenance dialysis was 2.8 ± 0.4 years in the juvenile group and 3.1 ±0.2 in the adult diabetics [4], Knowles [1] estimated that some 3,200 patients with diabetes mellitus will die of uremia each year in the United States unless their lives are supported by other means. Based on these calculations and a population of 200 million in the USA, there would be 16 new diabetic patients per million per year reaching end-stage renal failure and requir ing chronic dialytic therapy. Since the total number of new patients who may need dialysis treatment to maintain their lives is about 50 per million per year, it is obvious that pa tients with renal failure due to diabetes mellitus form a major segment (30%) of the new patients entering chronic dialysis programs. Indeed, in the dialysis population of Rao et al. [5], 23% are diabetics. Medical projections indi cate that the number of patients in the chronic dialysis pool in the US will stabilize at 60.000 by the year 1984. This may mean that by that year there would be some 20,000 patients with diabetes mellitus treated with some form of dialysis therapy. 1 Dr. Goldstein is a recipient of a Fellowship from the National Institutes of Health, No. 1F 32 AM 05754.
There are two major goals for a successful chronic dia lysis therapy: First, to maintain the life of the patient, and second, to rehabilitate the patient and enhance the quality of his life. Most of the available information indicates that the mortality is higher in the diabetic patients treated with hemodialysis than in the nondiabetic patients. This issue has been reviewed in detail by Rubin and Friedman [6], There is reasonable information on mortality in 490 diabetic pa tients treated with hemodialysis [4.7-16]. The data show that between 20 and 77% of the patients in various reports were alive by the end of 1 year. In most series, however, the 1-year survival rate was below 50%. This is in contrast to a 1-year survival rate of 85-90% in nondiabetic dialysis patients [16]. Analysis of the data in terms of number of deaths per 1,000 dialysis months revealed a range of 25-86 (mean 46 ± 9) deaths/1,000 dialysis months [4], as com pared to 13 deaths/1.000 dialysis months in the nondiabetic patients [16], There is only one report by Ma et al. [12] on 18 diabetic patients where the I-year survival rate was 86%, a value similar to the nondiabetic patients. It is of interest that the group in Minneapolis [15] reported that the 1-year survival rate in diabetics treated with hemodialysis has improved after 1972. The rates were 57.5% before 1972 and 73.5% after 1972. They attributed this improvement to better dialysis care and better control of blood pressure and fluid overload. The reasons for this high mortality among the diabetic patients treated with hemodialysis are increased incidence of myocardial infarction, infection, cerebrovascular acci dent and uremia. Table I details the causes of death in the three large series of diabetic patients treated with dialysis. The high mortality and high incidence of various com
Downloaded by: Boston University 128.197.229.194 - 1/13/2019 10:33:43 AM
Division of Nephrology and Department of Medicine, The University of Southern California School of Medicine, Los Angeles, Calif.
Early Dialysis in Diabetic Patients with Chronic Renal Failure
Table I Cause of death
Cardiac Cerebrovascular Infection Uremia Hyperkalemia Miscellaneous Total deaths
Shapiro et at. [16] 1974
Slifkin et ai. [13] 1976
Goldstein and Massry [4) 1978
n
%
n
%
n
%
13 2 3 5 1 3
48 7 11 18 4 11
15 9 10 6 2 4
33 19 21 13 4 9
23 7 8 8 3 4
43 13 15 15 6 8
27
46
53
retinopathy which then developed with the progression of renal failure. It appears, therefore, that renal failure and its complications such as hypertension, fluid overload, and bleeding tendencies may contribute significantly to the progression of diabetic retinopathy. Indeed, Kjeilstrand et al. [23] reported that the rapid progression of retinopathy in diabetic patients begins during the 1- or 2-year period prior to initiation of dialysis, and hypertension, which may become more severe prior to or during this period, may play an important role in the deterioration of the retino pathy. Watkins et al. [24] also suggested that deterioration in eyesight occurs as diabetes is coupled with renal failure and hypertension and is accompanied by sodium and fluid retention; retinal edema and even detachment can be anti cipated in these patients. Indeed, the preliminary report of Rao et ai. [25] indicates that the adequate control of blood pressure and fluid overload in diabetic dialysis patients improved the stability of vision. Diabetic retinopathy is one of the most disturbing and limiting complications of diabetes mellitus. It markedly restricts the rehabilitation of the patient and interferes seriously with the quality of his life [26], It is critical, there fore, that any overall approach for the management of diabetic nephropathy should take into consideration cer tain therapeutic steps that would improve or prevent the progression of retinopathy. If uremia and its side effects contribute to diabetic retinopathy, early control of uremia and its complication may result in better management of the retinopathy. Early dialysis will lead to early ameliora tion of uremia, control of fluid overload, normalization of blood pressure and reduction in bleeding tendencies. All these may be beneficial and may improve and/or prevent worsening of the retinopathy.
Downloaded by: Boston University 128.197.229.194 - 1/13/2019 10:33:43 AM
plications that lead to the death of the dialysis diabetic patients are most probably related to the fact that the initia tion of dialysis in these patients is late. It is customary that patients enter the dialysis program when their glomerular filtration rate is less than 10 ml/min. However, the applica tion of such a criterion to the diabetic patient may not be appropriate. Goldstein and Massry [4] reported that the most com mon complication observed in the diabetic patients after the onset of renal failure is circulatory congestion; this oc curred in 105 of their 150 patients, and in 86 the congestive episode occurred when serum creatinine was greater than 5.0 mg/100 ml. 37 patients had pleural effusion. Similarly, hypertension developed in 103 of their 150 patients after the onset of renal disease. Since both hypertension and circulatory overload may have severe and deleterious effects on the patients, the control of these complications may have a favorable influence on the longevity and on the incidence of complications. Fluid overload, circulatory congestion and hypertension may be controlled by adequate dialysis. All the 68 patients of Goldstein and Massry [4] who entered chronic hemo dialysis were hypertensive, but 63 became normotensive after adequate dialysis. It is interesting that 25 of these 63 patients had marked hypertension that necessitated at least three drugs for its control prior to the initiation of hemo dialysis. It is apparent, therefore, that if dialysis therapy is initiated earlier in the diabetic patients, such a procedure may permit early control of blood pressure and circulatory congestion and may reduce the period of time during which the patients are exposed to these harmful complications. Hypertension is a well-recognized important risk factor in the genesis of atherosclerosis [17], Its control is most beneficial in the overall approach to the prevention and management of atherosclerotic heart disease [18,19]. It is, therefore, obvious that any procedure, such as early dia lysis, which may easily control hypertension may be critical for improving longevity and reducing cardiac and cerebro vascular complications in the diabetic dialysis patients. Retinopathy is a common complication of diabetes mellitus. Its incidence as reported in the literature has varied between 45 and 83% in patients who had had diabetes for more than 15 years [20,21], Unfortunately, there is not adequate information in these studies on the chronologic relationship between retinopathy and renal disease. Ashton [22] found that retinopathy is always present in patients with diabetic nephropathy. In fact, there is a claim that diabetic glomerulosclerosis does not occur without retino pathy. Our own data [4] showed that as much as 40% of our patients had clear evidence of renal disease without
3
Massry/Feinstein/Goldstcin
Peripheral neuropathy and autonomic nervous system disturbances are common in patients with diabetes mellitus [27]. These abnormalities restrict the patient’s mobility and may cause orthostatic hypotension, gastroparesis and bladder atony [28], However, the uremia of the diabetic nephropathy by itself causes peripheral neuropathy and disturbances of the autonomic nervous system and as such may compound and further complicate diabetic neuro pathy. Since uremic neuropathy occurs late in the course of chronic renal failure and generally responds to adequate dialysis [29], the initiation of early dialysis may prevent the development of uremic neuropathy and may reverse that which is already present. One can then reason that early dialysis may lessen the overall neuropathic complication in the diabetic patients. Vascular disease is common in diabetics [30] and vascu lar calcification is not infrequently seen in patients with long-standing diabetes mellitus. Although the mechanisms of the vascular calcification in diabetics are not [31,32] de lineated, it is possible that uremia contributes to this com plication. At least two reasons have led to this postulate. First, uremia, per se, is known to be associated with wide spread vascular calcification [33] ; and, second, the vascular calcification in diabetics not infrequently develops while renal failure progresses [30]. It is, theoretically, plausible that early control of uremia may be associated with de creased incidence of vascular calcification and their dev astating consequences. At present there are neither prospective nor retrospec tive evaluations of the role of early dialysis on the mortality and morbidity of diabetics with renal failure. It is possible that early dialysis of the diabetic patients who develop chronic renal failure may provide a promise for better sur vival and rehabilitation of these patients and may enhance the quality of their lives.
References 1 Knowles, H .C .: Magnitude of the renal failure problem in diabetic patients. Kidney int. 6: 52-58 (1974). 2 Watkins, P.J.: Blainey, J.D .; Brewer, D.B.; Fitzgenal, M.G.; Malins, J.M .; O'Sullivan, D.J., and Pinto, J.A .: The natural history of diabetic renal disease, a follow-up study of a series of renal biopsies. Q.JI Med. 41: 437-456 (1972). 3 Balodintos, M .C .: Joslin's diabetes mellitus (Lea & Febiger, Phila delphia 1971). 4 Goldstein, D. A. and Massry, S.G.: Diabetic nephropathy: clini cal course and effect of hemodialysis. Nephron 20:286-296 (1978). 5 Rao, T.K .: Hirsch, S.; Avram, M.M., and Friedman, E.A.: Uremia in systemic disease. Clin. Nephrol, (in press, 1978).
6 Rubin, J.E. and Friedman, E. A.: Dialysis and transplantation of diabetics in the United States. Nephron 18: 309-316 (1977). 7 Blagg, C.R.: Visual and vascular problems in dialyzed diabetic patients. Kidney int. 6: 27-32 (1974). 8 Ghavamian, M .; Gulch, C. F.; Kopp, K. F., and Kollf, W. J .: The sad truth about hemodialysis for end-stage diabetic nephropathy. J. Am. med. Ass. 222: 1386-1389(1972). 9 White, N.; Snowden,S. A.: Parsons, V.: Sheldon, J., and Bewich, M .: The management of terminal renal failure in diabetic patients by regular dialysis therapy. Nephron 11: 261-275 (1973). 10 Kassissieh, S.D .; Yen, M.C.: Lazarus, J.M .; Lowrie, E.G.; Goldstein. H. H.: Takacs, F. J.; Hampers. C. L., and Merrill, J. P .: Hemodialysis-related problems in patients with diabetes mellitus. Kidney int. 6: 100-108(1974). 11 Huang, C.; del Greco, F.: Ivanovich, P.; Krumlovsky, F.A.: Roguska, J.: Simon, W. M., and Hano, J .: Maintenance dialysis for diabetic nephropathy with uremia. J.chron.Dis. 28: 365-374 (1975). 12 Ma, K.W .; Masler, D.S.. and Brown, C.D .: Hemodialysis in diabetic patients with chronic renal failure. Ann. intern. Med. 83: 215-217(1975). 13 Slifkin, R. F.; Heff, M.S.; Baez, A .; Gupta, S.; Mattoo, N., and Haimov, M.: Maintenance dialysis in diabetic patients. Proc. Eur. Dialysis Transplantn Ass. 13: 377-386 (1976). 14 Shideman, J. R.; Buselmeier,T.J., and Kjellstrand, C. M.: Hemo dialysis in diabetics. Archs intern. Med. 136: 1126-1130 (1976). 15 Comty, C. M.; Kjellsen, D., and Shapiro, F.L.: A reassessment of the prognosis of diabetic patients treated by chronic hemo dialysis. Trans. Am. Soc.artif. internal Organs 22:404-410 (1976). 16 Shapiro, F. L.: Leonard. A., and Comty, C. M.: Mortality, mor bidity and rehabilitation results in regularly dialyzed patients with diabetes mellitus. Kidney int. 6: 8-15 (1974). 17 Kännel, W .B.: Role of blood pressure in cardiovascular mor bidity and mortality. Prog.cardiovasc. Dis. 17: 5-24 (1974). 18 Veteran's Administration Cooperative Study Group on Anti hypertensive Agents. 1. Effects of treatment on morbidity in hyper tension. J. Am. med. Ass. 202: 1028-1034 (1967). 19 Veteran's Administration Cooperative Study Group on Anti hypertensive Agents. 11. Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressure averaging90through 114mmHg.J.A m .m ed.A ss.2/i: 1143-1152 (1970). 20 Burditt. A. F. : Caird, F.L, and Draper, G .J.: The natural history of diabetic retinopathy. Q.JI Med. 37: 303-317 (1968). 21 Paul, J.T. and Presley, S.J.: Complications of long term diabetes mellitus. Ann. intern. Med. 49: 142-150 (1958). 22 Ashton, N.: Diabetic retinopathy: relationship to glomerulo sclerosis. Br. med.J. /: 1002 (1957). 23 Kjellstrand, C .M .: Simmons, R.L.: Goetz, F.C.: Clien, M.B.; Buselmeier, T.J., and Najarian, J.S.: Mortality and morbidity in diabetic patients accepted for renal transplantation. Proc. Eur. Dialysis Transplantn Ass. 9: 345-358 (1972). 24 Watkins, P.J.: Parsons, V., and Bewick, M.: The prognosis and management of diabetic nephropathy. Clin. Nephrol. 7: 243-249 (1977). 25 Rao, K.V.; Sutherland, D.; Kjellstrand, C.M .; Najarian, J.S., and Shapiro, F. L .: Comparative results between dialysis and transplantation in diabetic patients. Trans. Am.Soc.artif.internal Organs 23: 427-432 (1977).
Downloaded by: Boston University 128.197.229.194 - 1/13/2019 10:33:43 AM
4
5
Early Dialysis in Diabetic Patients with Chronic Renal Failure
32 Larsson, Y.; Lichtenstein, A., and Ploman, K.G.: Degenerative vascular complications in juvenile diabetes mellitus treated with 'free diet’. Diabetes /: 449 (1952). 33 Massry, S.G. and Coburn, J.W. : Clinical aspects of dialysis and uremia (Thomas, Springfield 1975).
Shaul G. Massry, MD. Professor and Chairman, Division of Nephrology, University of Southern California, School of Medicine, 2025 Zonal Avenue, Los Angeles, CA 90033 (USA)
Downloaded by: Boston University 128.197.229.194 - 1/13/2019 10:33:43 AM
26 Comty, C.M .; Leonard, A.. and Shapiro, F.L.: Psychosocial problems in dialyzed diabetic patients. Kidney int. 6: 144-151 (1974). 27 Lock, S .: Joslin's diabetes mellitus (Lea & Febiger, Philadelphia 1971). 28 Ellenberg, M.: Neuropathy in long-standing insulin dependent diabetic patients. Kidney int. 6: 77-84(1974). 29 Raskin, N.H. and Fishman, R.A.: The kidney (Saunders, Phila delphia 1976). 30 Bradley, R .F .: Joslin's diabetes mellitus (Lea & Febiger, Phila delphia 1971). 31 White, P .: Natural course and prognosis of juvenile diabetes. Diabetes 5: 445-450 (1956).
Early Dialysis in Diabetic Patients with Chronic Renal Failure Shan! G. Massry, Ehen I. Feinstein and David A. Goldstein1
Many investigators have reported that diabetic nephro pathy develops in patients who have had diabetes mellitus for a prolonged period of time [1-3]. Our own data showed that the duration of diabetes prior to the onset of renal disease is 15.5 ±1.1 and 12.8+0.8 years in the juvenile and adult diabetics, respectively [4], Furthermore, once renal disease is overt, its progression to end-stage renal failure is rapid. The mean duration between the onset of renal disease and the requirement for maintenance dialysis was 2.8 ± 0.4 years in the juvenile group and 3.1 ±0.2 in the adult diabetics [4], Knowles [1] estimated that some 3,200 patients with diabetes mellitus will die of uremia each year in the United States unless their lives are supported by other means. Based on these calculations and a population of 200 million in the USA, there would be 16 new diabetic patients per million per year reaching end-stage renal failure and requir ing chronic dialytic therapy. Since the total number of new patients who may need dialysis treatment to maintain their lives is about 50 per million per year, it is obvious that pa tients with renal failure due to diabetes mellitus form a major segment (30%) of the new patients entering chronic dialysis programs. Indeed, in the dialysis population of Rao et al. [5], 23% are diabetics. Medical projections indi cate that the number of patients in the chronic dialysis pool in the US will stabilize at 60.000 by the year 1984. This may mean that by that year there would be some 20,000 patients with diabetes mellitus treated with some form of dialysis therapy. 1 Dr. Goldstein is a recipient of a Fellowship from the National Institutes of Health, No. 1F 32 AM 05754.
There are two major goals for a successful chronic dia lysis therapy: First, to maintain the life of the patient, and second, to rehabilitate the patient and enhance the quality of his life. Most of the available information indicates that the mortality is higher in the diabetic patients treated with hemodialysis than in the nondiabetic patients. This issue has been reviewed in detail by Rubin and Friedman [6], There is reasonable information on mortality in 490 diabetic pa tients treated with hemodialysis [4.7-16]. The data show that between 20 and 77% of the patients in various reports were alive by the end of 1 year. In most series, however, the 1-year survival rate was below 50%. This is in contrast to a 1-year survival rate of 85-90% in nondiabetic dialysis patients [16]. Analysis of the data in terms of number of deaths per 1,000 dialysis months revealed a range of 25-86 (mean 46 ± 9) deaths/1,000 dialysis months [4], as com pared to 13 deaths/1.000 dialysis months in the nondiabetic patients [16], There is only one report by Ma et al. [12] on 18 diabetic patients where the I-year survival rate was 86%, a value similar to the nondiabetic patients. It is of interest that the group in Minneapolis [15] reported that the 1-year survival rate in diabetics treated with hemodialysis has improved after 1972. The rates were 57.5% before 1972 and 73.5% after 1972. They attributed this improvement to better dialysis care and better control of blood pressure and fluid overload. The reasons for this high mortality among the diabetic patients treated with hemodialysis are increased incidence of myocardial infarction, infection, cerebrovascular acci dent and uremia. Table I details the causes of death in the three large series of diabetic patients treated with dialysis. The high mortality and high incidence of various com
Downloaded by: Boston University 128.197.229.194 - 1/13/2019 10:33:43 AM
Division of Nephrology and Department of Medicine, The University of Southern California School of Medicine, Los Angeles, Calif.
Early Dialysis in Diabetic Patients with Chronic Renal Failure
Table I Cause of death
Cardiac Cerebrovascular Infection Uremia Hyperkalemia Miscellaneous Total deaths
Shapiro et at. [16] 1974
Slifkin et ai. [13] 1976
Goldstein and Massry [4) 1978
n
%
n
%
n
%
13 2 3 5 1 3
48 7 11 18 4 11
15 9 10 6 2 4
33 19 21 13 4 9
23 7 8 8 3 4
43 13 15 15 6 8
27
46
53
retinopathy which then developed with the progression of renal failure. It appears, therefore, that renal failure and its complications such as hypertension, fluid overload, and bleeding tendencies may contribute significantly to the progression of diabetic retinopathy. Indeed, Kjeilstrand et al. [23] reported that the rapid progression of retinopathy in diabetic patients begins during the 1- or 2-year period prior to initiation of dialysis, and hypertension, which may become more severe prior to or during this period, may play an important role in the deterioration of the retino pathy. Watkins et al. [24] also suggested that deterioration in eyesight occurs as diabetes is coupled with renal failure and hypertension and is accompanied by sodium and fluid retention; retinal edema and even detachment can be anti cipated in these patients. Indeed, the preliminary report of Rao et ai. [25] indicates that the adequate control of blood pressure and fluid overload in diabetic dialysis patients improved the stability of vision. Diabetic retinopathy is one of the most disturbing and limiting complications of diabetes mellitus. It markedly restricts the rehabilitation of the patient and interferes seriously with the quality of his life [26], It is critical, there fore, that any overall approach for the management of diabetic nephropathy should take into consideration cer tain therapeutic steps that would improve or prevent the progression of retinopathy. If uremia and its side effects contribute to diabetic retinopathy, early control of uremia and its complication may result in better management of the retinopathy. Early dialysis will lead to early ameliora tion of uremia, control of fluid overload, normalization of blood pressure and reduction in bleeding tendencies. All these may be beneficial and may improve and/or prevent worsening of the retinopathy.
Downloaded by: Boston University 128.197.229.194 - 1/13/2019 10:33:43 AM
plications that lead to the death of the dialysis diabetic patients are most probably related to the fact that the initia tion of dialysis in these patients is late. It is customary that patients enter the dialysis program when their glomerular filtration rate is less than 10 ml/min. However, the applica tion of such a criterion to the diabetic patient may not be appropriate. Goldstein and Massry [4] reported that the most com mon complication observed in the diabetic patients after the onset of renal failure is circulatory congestion; this oc curred in 105 of their 150 patients, and in 86 the congestive episode occurred when serum creatinine was greater than 5.0 mg/100 ml. 37 patients had pleural effusion. Similarly, hypertension developed in 103 of their 150 patients after the onset of renal disease. Since both hypertension and circulatory overload may have severe and deleterious effects on the patients, the control of these complications may have a favorable influence on the longevity and on the incidence of complications. Fluid overload, circulatory congestion and hypertension may be controlled by adequate dialysis. All the 68 patients of Goldstein and Massry [4] who entered chronic hemo dialysis were hypertensive, but 63 became normotensive after adequate dialysis. It is interesting that 25 of these 63 patients had marked hypertension that necessitated at least three drugs for its control prior to the initiation of hemo dialysis. It is apparent, therefore, that if dialysis therapy is initiated earlier in the diabetic patients, such a procedure may permit early control of blood pressure and circulatory congestion and may reduce the period of time during which the patients are exposed to these harmful complications. Hypertension is a well-recognized important risk factor in the genesis of atherosclerosis [17], Its control is most beneficial in the overall approach to the prevention and management of atherosclerotic heart disease [18,19]. It is, therefore, obvious that any procedure, such as early dia lysis, which may easily control hypertension may be critical for improving longevity and reducing cardiac and cerebro vascular complications in the diabetic dialysis patients. Retinopathy is a common complication of diabetes mellitus. Its incidence as reported in the literature has varied between 45 and 83% in patients who had had diabetes for more than 15 years [20,21], Unfortunately, there is not adequate information in these studies on the chronologic relationship between retinopathy and renal disease. Ashton [22] found that retinopathy is always present in patients with diabetic nephropathy. In fact, there is a claim that diabetic glomerulosclerosis does not occur without retino pathy. Our own data [4] showed that as much as 40% of our patients had clear evidence of renal disease without
3
Massry/Feinstein/Goldstcin
Peripheral neuropathy and autonomic nervous system disturbances are common in patients with diabetes mellitus [27]. These abnormalities restrict the patient’s mobility and may cause orthostatic hypotension, gastroparesis and bladder atony [28], However, the uremia of the diabetic nephropathy by itself causes peripheral neuropathy and disturbances of the autonomic nervous system and as such may compound and further complicate diabetic neuro pathy. Since uremic neuropathy occurs late in the course of chronic renal failure and generally responds to adequate dialysis [29], the initiation of early dialysis may prevent the development of uremic neuropathy and may reverse that which is already present. One can then reason that early dialysis may lessen the overall neuropathic complication in the diabetic patients. Vascular disease is common in diabetics [30] and vascu lar calcification is not infrequently seen in patients with long-standing diabetes mellitus. Although the mechanisms of the vascular calcification in diabetics are not [31,32] de lineated, it is possible that uremia contributes to this com plication. At least two reasons have led to this postulate. First, uremia, per se, is known to be associated with wide spread vascular calcification [33] ; and, second, the vascular calcification in diabetics not infrequently develops while renal failure progresses [30]. It is, theoretically, plausible that early control of uremia may be associated with de creased incidence of vascular calcification and their dev astating consequences. At present there are neither prospective nor retrospec tive evaluations of the role of early dialysis on the mortality and morbidity of diabetics with renal failure. It is possible that early dialysis of the diabetic patients who develop chronic renal failure may provide a promise for better sur vival and rehabilitation of these patients and may enhance the quality of their lives.
References 1 Knowles, H .C .: Magnitude of the renal failure problem in diabetic patients. Kidney int. 6: 52-58 (1974). 2 Watkins, P.J.: Blainey, J.D .; Brewer, D.B.; Fitzgenal, M.G.; Malins, J.M .; O'Sullivan, D.J., and Pinto, J.A .: The natural history of diabetic renal disease, a follow-up study of a series of renal biopsies. Q.JI Med. 41: 437-456 (1972). 3 Balodintos, M .C .: Joslin's diabetes mellitus (Lea & Febiger, Phila delphia 1971). 4 Goldstein, D. A. and Massry, S.G.: Diabetic nephropathy: clini cal course and effect of hemodialysis. Nephron 20:286-296 (1978). 5 Rao, T.K .: Hirsch, S.; Avram, M.M., and Friedman, E.A.: Uremia in systemic disease. Clin. Nephrol, (in press, 1978).
6 Rubin, J.E. and Friedman, E. A.: Dialysis and transplantation of diabetics in the United States. Nephron 18: 309-316 (1977). 7 Blagg, C.R.: Visual and vascular problems in dialyzed diabetic patients. Kidney int. 6: 27-32 (1974). 8 Ghavamian, M .; Gulch, C. F.; Kopp, K. F., and Kollf, W. J .: The sad truth about hemodialysis for end-stage diabetic nephropathy. J. Am. med. Ass. 222: 1386-1389(1972). 9 White, N.; Snowden,S. A.: Parsons, V.: Sheldon, J., and Bewich, M .: The management of terminal renal failure in diabetic patients by regular dialysis therapy. Nephron 11: 261-275 (1973). 10 Kassissieh, S.D .; Yen, M.C.: Lazarus, J.M .; Lowrie, E.G.; Goldstein. H. H.: Takacs, F. J.; Hampers. C. L., and Merrill, J. P .: Hemodialysis-related problems in patients with diabetes mellitus. Kidney int. 6: 100-108(1974). 11 Huang, C.; del Greco, F.: Ivanovich, P.; Krumlovsky, F.A.: Roguska, J.: Simon, W. M., and Hano, J .: Maintenance dialysis for diabetic nephropathy with uremia. J.chron.Dis. 28: 365-374 (1975). 12 Ma, K.W .; Masler, D.S.. and Brown, C.D .: Hemodialysis in diabetic patients with chronic renal failure. Ann. intern. Med. 83: 215-217(1975). 13 Slifkin, R. F.; Heff, M.S.; Baez, A .; Gupta, S.; Mattoo, N., and Haimov, M.: Maintenance dialysis in diabetic patients. Proc. Eur. Dialysis Transplantn Ass. 13: 377-386 (1976). 14 Shideman, J. R.; Buselmeier,T.J., and Kjellstrand, C. M.: Hemo dialysis in diabetics. Archs intern. Med. 136: 1126-1130 (1976). 15 Comty, C. M.; Kjellsen, D., and Shapiro, F.L.: A reassessment of the prognosis of diabetic patients treated by chronic hemo dialysis. Trans. Am. Soc.artif. internal Organs 22:404-410 (1976). 16 Shapiro, F. L.: Leonard. A., and Comty, C. M.: Mortality, mor bidity and rehabilitation results in regularly dialyzed patients with diabetes mellitus. Kidney int. 6: 8-15 (1974). 17 Kännel, W .B.: Role of blood pressure in cardiovascular mor bidity and mortality. Prog.cardiovasc. Dis. 17: 5-24 (1974). 18 Veteran's Administration Cooperative Study Group on Anti hypertensive Agents. 1. Effects of treatment on morbidity in hyper tension. J. Am. med. Ass. 202: 1028-1034 (1967). 19 Veteran's Administration Cooperative Study Group on Anti hypertensive Agents. 11. Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressure averaging90through 114mmHg.J.A m .m ed.A ss.2/i: 1143-1152 (1970). 20 Burditt. A. F. : Caird, F.L, and Draper, G .J.: The natural history of diabetic retinopathy. Q.JI Med. 37: 303-317 (1968). 21 Paul, J.T. and Presley, S.J.: Complications of long term diabetes mellitus. Ann. intern. Med. 49: 142-150 (1958). 22 Ashton, N.: Diabetic retinopathy: relationship to glomerulo sclerosis. Br. med.J. /: 1002 (1957). 23 Kjellstrand, C .M .: Simmons, R.L.: Goetz, F.C.: Clien, M.B.; Buselmeier, T.J., and Najarian, J.S.: Mortality and morbidity in diabetic patients accepted for renal transplantation. Proc. Eur. Dialysis Transplantn Ass. 9: 345-358 (1972). 24 Watkins, P.J.: Parsons, V., and Bewick, M.: The prognosis and management of diabetic nephropathy. Clin. Nephrol. 7: 243-249 (1977). 25 Rao, K.V.; Sutherland, D.; Kjellstrand, C.M .; Najarian, J.S., and Shapiro, F. L .: Comparative results between dialysis and transplantation in diabetic patients. Trans. Am.Soc.artif.internal Organs 23: 427-432 (1977).
Downloaded by: Boston University 128.197.229.194 - 1/13/2019 10:33:43 AM
4
5
Early Dialysis in Diabetic Patients with Chronic Renal Failure
32 Larsson, Y.; Lichtenstein, A., and Ploman, K.G.: Degenerative vascular complications in juvenile diabetes mellitus treated with 'free diet’. Diabetes /: 449 (1952). 33 Massry, S.G. and Coburn, J.W. : Clinical aspects of dialysis and uremia (Thomas, Springfield 1975).
Shaul G. Massry, MD. Professor and Chairman, Division of Nephrology, University of Southern California, School of Medicine, 2025 Zonal Avenue, Los Angeles, CA 90033 (USA)
Downloaded by: Boston University 128.197.229.194 - 1/13/2019 10:33:43 AM
26 Comty, C.M .; Leonard, A.. and Shapiro, F.L.: Psychosocial problems in dialyzed diabetic patients. Kidney int. 6: 144-151 (1974). 27 Lock, S .: Joslin's diabetes mellitus (Lea & Febiger, Philadelphia 1971). 28 Ellenberg, M.: Neuropathy in long-standing insulin dependent diabetic patients. Kidney int. 6: 77-84(1974). 29 Raskin, N.H. and Fishman, R.A.: The kidney (Saunders, Phila delphia 1976). 30 Bradley, R .F .: Joslin's diabetes mellitus (Lea & Febiger, Phila delphia 1971). 31 White, P .: Natural course and prognosis of juvenile diabetes. Diabetes 5: 445-450 (1956).
