INTRODUCTION
According to a report in 2019, 463 million people are suffering from diabetes mellitus, which will rise to 578 million by 2030[1]. The widespread presence of diabetes has led to increased cases of diabetic nephropathy. A study by Jin et al[2] concluded that the most common cause of End-stage renal disease is diabetic nephropathy. A cohort study by Rashid et al[3] comprised 47917 people, and out of this, 6594 (13.8%) people had renal failure with the underlying cause of diabetes mellitus. Renal failure is also known as end-stage renal disease (ESRD). According to Hu et al[4], the widely accepted treatments for ESRD are peritoneal dialysis (PD) and hemodialysis (HD), where kidney transplantation is not available. PD requires a catheter to be inserted into the peritoneal cavity, whereas HD requires an artificial kidney or dialyzer to clear out the toxins from the body. Diabetic ESRD patients on dialysis are more susceptible to developing Cardiovascular risks and complications in comparison to non-diabetic patients. These patients are also vulnerable to developing variations in blood glucose levels, which makes the patient harder to handle. Hu et al[4] describe the best dialysis method according to the patient's need and tolerance.
ASSOCIATION OF DIALYSIS UNDER DIFFERENT PARAMETERS
Hu et al[4] reviewed different studies that include Randomized clinical trials, cohort studies, retrospective Studies, and case-control studies based on different components. Vonesh et al[5] found that the survival rates of patients undergoing PD and HD are similar. Still, the difference lies in the selection of groups according to age and other co-morbidities. A prospective study in Korea compared the survival rate of PD over HD. Choi et al[6] recruited 1060 ESRD patients undergoing PD (30.6%) and HD (69.4%). They concluded that PD has greater survival chances than HD. Some studies show that Patients undergoing HD tend to have a better survival rate than patients undergoing PD. After analyzing multiple research papers by Hu et al[4], concluded that PD is the first preferable choice for diabetic ESKD patients. It is preferred in young patients, has a good prognosis, and has a more appropriate glycemic control, whereas in older patients with uncontrolled blood glucose, PD should be used with more vigilance. Variations in blood glucose levels are crucial components of glucose metabolism disorders. Continuous hyperglycemic states lead to diabetic neuropathy, diabetic nephropathy, and diabetic retinopathy[7]. Persistent exposure to glucose in ESKD patients undergoing PD leads to further deterioration of diabetes. Recent studies also show that elevated glucose harms the peritoneal membrane. Hence, the icodextrin solution improves glycemic control in diabetic ESRD patients[8]. In addition, fluctuations in blood glucose levels are also associated with increased mortality in diabetic ESRD patients receiving PD[9]. A study by Jin et al[10] 2015 analyzed 46 patients undergoing HD. 36 out of these patients had diabetic ESRD, and the remaining 10 only had ESRD without diabetes. These patients were kept under a continuous glucose monitoring system. They found that patients with diabetic ESRD had greater glucose variations on the days of receiving HD vs on days not undergoing HD. Mácsai et al[11] showed that patients receiving PD are more likely to absorb more glucose from peritoneal solutions that may cause disturbances in HbA1c levels. Still, PD is recommended for patients who have unfit glycemic control. Hence, more research is still needed to understand this in more detail. Diabetic patients are immunocompromised, and these patients also require more time to heal. Patients going through PD have greater chances of developing peritonitis, gastrointestinal perforation, and bleeding. Ozener et al[12] conducted a study that included 915 patients undergoing PD. Two hundred seventeen out of 915 had diabetes mellitus, and it concluded that PD patients had greater chances of developing peritonitis. Choi et al[6] also concluded that an infection was the most common cause of mortality among patients receiving PD. According to a study conducted in 2013 by Gupta et al[13] that concluded that infection is the second most likely cause of mortality in patients undergoing HD. They further stated that Vascular access-related infections are distinguishable causes of infection. The risk of Infection is similar in both PD and HD, the type of infection is different though. They further stated that patients with ESKD and diabetes should be preferred for PD as there are chances of its prevention. They also concluded that the type of dialysis should be chosen according to the patient’s needs and situation[4]. Rhee et al[14] 2018 conducted a study that showed ESKD patients receiving HD are more susceptible to sudden cardiac death (SCD). Recent studies also suggested that cardiovascular disease (CVD) is the most common cause of mortality in patients undergoing HD. A recent study in 2024 by Olmaz et al[15] showed that CVD risk is higher in ESKD patients receiving PD[15]. According to Hu et al[4], HD is preferable for patients already susceptible to CVDs. They also concluded that patients with CKD are liable to develop vascular calcification, which promotes further progression of CVD. Residual renal function (RRF) is defined as the capability of native kidneys to eliminate Urea and Creatinine. Keeping RRF within normal limits is crucial for patients undergoing PD and HD. It is quite a tough task to maintain RRF in diabetic ESKD patients because variable glycemic index in diabetic patients leads to an abrupt drop in RRF and hypervolemia. The above results are extracted from a recent retrospective study done in 2024 by Kim et al[16] that analyzed 80 diabetic patients undergoing PD. In addition to this, RRF is a crucial indicator of a patient’s health undergoing PD. According to Hu et al[4], HD leads to a rapid decrease in RRF. Hence, patients should be preferred PD for better outcomes. They describe that ESKD patients on dialysis have very disturbed lifestyles. They further stated that patients undergoing PD and HD have very different impacts on their quality of life. Recently, technology has played a very important role in bringing convenience to patients on dialysis. Due to these changes, patients can resume their social and personal lives even on dialysis. Automated PD (APD) brings the change and has become more efficient than conventional PD. Hu et al[4] further emphasized the benefits of APD, making it a more suitable option for diabetic ESKD patients. HD is one of the most old and traditional dialysis methods, but it also comes with many disadvantages. It causes protein loss, making the patient suffer from malnutrition. Malnutrition is defined as when the body’s needs are not fulfilled, and the person's growth is retarded. ESKD patients undergoing dialysis tend to fall into the category of malnutrition. After reviewing many articles, Hu et al[4] conclude that PD causes malnutrition in younger ESKD patients, whereas HD causes malnutrition in older ESKD patients. They analyzed many articles and concluded that HD patients are more prone to develop bone disease, heart disease, and oral problems. Hu et al[4] prefer to use APD for diabetic ESKD patients for a better quality of life. Further research is still needed. Diabetic ESKD patients undergoing dialysis are under great financial pressure due to hospitalization and medicines. Hu et al[4] suggest that PD is a more profitable option than HD. Therefore, diabetic ESKD patients should be advised to undergo PD as it can relieve financial distress and aid the patients to live a more balanced life. Kim et al[16] showed that Fluid overload could lead to an abrupt decrease in RRF and increase the risk of mortality. Hu et al[4] concluded that HD is the preferable choice for Diabetic ESKD patients as it keeps the Fluid content of the body within normal limits. Although preventive measures should be taken as required. Selecting the most suitable dialysis method for ESKD patients remains controversial. Although Hu et al[4] did an amazing job covering every possible aspect of the topic. As the world grows, new findings and technologies are continuously added to dialysis regimens to improve the patient’s health and life. This topic lies in the fact that every patient is different, and doctors must provide the dialysis method according to the patient's needs. Therefore, while considering which dialysis method should be advised, one should consider all the abovementioned aspects.
CONCLUSION
Diabetic ESKD patients always suffer from multiple problems and complications. This is the reason that why diabetic ESKD patients are difficult to handle. PD and HD both have their own merits and demerits. Selecting the best dialysis method should depend on the patient’s health, economic status, nutritional status, hemodynamics and other co-morbidities to make the patient’s life more convenient. Hence, the dialysis method should be chosen according to the patient’s needs. Awareness and education about the respective dialysis method should be provided to the patient to make him adhere to the method and also understand his condition more profoundly. Still, there is a lack of research on glucose metabolism, RRF, infectious complications, and malnutrition. Further research is still needed to understand these aspects in detail. More work is needed to describe a better approach to mitigate the patient's complications and provide them with customized treatment plans to improve their lives.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Endocrinology and metabolism
Country of origin: Qatar
Peer-review report’s classification
Scientific Quality: Grade B, Grade B
Novelty: Grade A, Grade B
Creativity or Innovation: Grade B, Grade B
Scientific Significance: Grade A, Grade A
P-Reviewer: Salovic B S-Editor: Li L L-Editor: A P-Editor: Xu ZH
