The Best Time to Start Dialysis in Diabetic

You may be wondering that when to start dialysis in diabetes. Also you may have hard time on deciding that. As your doctor’s opinion you might be thinking about doing it now. Or you may think that starting dialysis later. Therefore it’s better to get an proper idea about when to start dialysis.

The dialysis requirement of a diabetic patient depend on various factors. Doctors decide the dialysis requirement mainly by the estimated Glomerular Filtration Rate ( eGFR ). When it’s below 15 ml/min/1.73m2 it’s consider as the best time to start dialysis. However these values are not the sole factors when deciding this. The patient’s general condition and other complications associated with diabetic nephropathy are used to decide this requirement.

Why would a diabetic need dialysis?

Diabetes is a chronic debilitating disease which associated with long term complications. The diabetic nephropathy is one of the main component on those. Scientists have confirmed that most of the chronic kidney disease ( CKD ) cases in the worldwide are contributed by diabetes. Most diabetic patients are present with early features of nephropathy when they initially diagnosed as diabetic. The worst part is there is still a majority of patients who present at later stages of diabetic nephropathy.

Diabetes can worsen the CKD which is already having also. Therefore anytime a patient diagnosed with diabetes it’s better to do eGFR regularly. The rapid progression of the kidney disease caused by diabetes made that most diabetic kidney disease patients ultimately end up in dialysis units.

How to decide the best time for dialysis ?

The need for dialysis is decided mainly by the eGFR value of the patient. eGFR is calculated by the serum creatinine value. eGFR give an quantitative analysis of the kidney function. The lower the value, the less functioning ability of a kidney. According to eGFR value kidney disease is staged in to five main components.

Stage eGFR valueDescription
1more than 90kidney damage with normal kidney function
289 – 60kidney damage with mild loss of kidney function
3a59 – 45mild to moderate loss of kidney function
3b44 – 30moderate to severe loss of kidney function
429 – 15severe loss of kidney function
5less than 15kidney failure
CKD stages according to eGFR values
When to start dialysis?
When to start dialysis?

As the nephrologists advice it is high time to start dialysis when a patient reach to CKD stage 5 which means when a person’s eGFR lost over 15. Dialysis would be haemodialysis or peritoneal dialysis. It depends on the patient’s general condition and preference. Both haemodialysis and peritoneal dialysis have their own pros and cons.

But there are studies performed on deciding whether higher eGFR levels or the lower levels are best to start dialysis. The results showed that there are not much of a differences starting dialysis in higher or lower levels. These studies performed in patients whose eGFR levels higher than 10 and lower than 10. There were 11 clinical trials performed over this and results were differ from each studies.

Therefore scientists decided that even though eGFR value used to determine the time to start dialysis, it can’t be applied for each and every population in all over the world. They identified that the ethnicity of the patient is a factor that determine individual patient’s kidney function.

And also when a person’s kidney become fail, their muscles are breaking down. That’s why CKD patients are having less muscle mass. Because of this muscle breakdown process, there are excess creatinine accumulate in their blood. Therefore it will be difficult to detect true kidney function. And also because of these patients develop fluid overload their kidney tend to filter more urine. So it will detect as high eGFR. So it is also identified as a drawback of using eGFR as a sole factor on deciding time of dialysis.

Another factor that clinicians used to determine is uremic complications. Uremic complications are developed within CKD patients due to excess collection of uremic waste products. Thereby people’s body affected systematically. Uremic pericarditis, uremic encephalopathy, uremic cardiomyopathy, uremic frost are few of these complications.

In addition to that if a patient develop hyperkalaemia resistant to drugs or metabolic acidosis resistant to drugs the dialysis would be the best option for them. Because hyperkalaemia itself is fatal for human body. Excess potassium levels in the blood can be toxic to cardiac muscle cells. It ultimately causes heart attacks. Metabolic acidosis or increasing acidic products in our blood affects systemically to cause multisystem failure. Therefore immediate intervention for both these situations is mandatory. Thereby as a solution for that, clinicians use dialysis.

Anyway the commencement of dialysis in a diabetic patient is same as non diabetic patient. Ultimately it’s all about a clinical judgement.

What is the life expectancy of a diabetic on dialysis?

There is no doubt that lifespan of a dialysis patient is less than to a non dialysis patient. For the past few decades the life expectancy of a dialysis patient gradually reduced. But the data collected from 2008 showed that there is a significant improvement of the survival rate. For a patient with haemodialysis the five years survival rate improves up to 34% and this value is 40% in peritoneal dialysis patient.

However all these values are vary with the individual patient factors. Researches shows that patient who is older than 65 years have a mortality rate twice than a normal person. It also depend on other comorbid conditions like hypertension, heart diseases, strokes. Therefore it’s hard to giving an exact number about patient’s life expectancy.

Is insulin bad for kidneys?

Insulin is not as identified as harmful for kidney even in CKD patients. Because insulin is a hormone which is produced in our pancreas. It is very much important in controlling human metabolism. Insulin helps to store excess glucose in our blood as glycogen in liver and skeletal muscles. Therefore it can be converted in to glucose again in hunger states. Diabetes is a result of lack of insulin production from pancreas and lack of insulin sensitivity of the body cells. So excess glucose accumulates in our blood and that can cause a great harm to our body.

Therefore as a treatment method doctors use insulin externally. For type 1 diabetes insulin is the first line therapy as there is lack of insulin production in these patient’s body. And for type 2 diabetes basically clinicians use anti diabetes drugs like metformin as first line therapy because they only have lack of insulin sensitivity, and lifestyle modifications also. But insulin would be the ultimate solution for them also if they won’t improve with above mentioned treatment methods. Therefore insulin is concerned as the best treatment modality for diabetic patients up to now. And the insulin is a Nobel prize winning innovation as well.

Lack of insulin in a diabetic patient can cause excess accumulation of lipids, slowing growth on young patients and even slowing the puberty also. It all comes as an extra burden. The main danger with lack of insulin in a diabetes is worsening the condition. It can lead to diabetic emergencies like ketoacidosis and hyperosmolar non ketotic state. It would life threatening if we didn’t do proper medical treatment immediately. So there’s no doubt that insulin is one of the best drug in health sector.

Diabetic kidney damage can be reversed
Diabetic kidney damage

Can you reverse diabetic kidney damage ?

Diabetic kidney disease can be reversed, but only if you identified it in early stages. Before patient develop chronic kidney disease there’s a stage called micro albuminuria. In this stage there’s a very little damage to micro tubules in the kidneys. There for albumin, the main plasma protein get filtered from kidneys.

So albumin can be detected on urine samples. But the amounts very less which is 20 to 200 mg/L. This is the earliest marker that your body alarming as your kidneys are about to fail. If we can detect a patient in this micro albuminuria stage it can be reversed without progressing to CKD. Strict lifestyle modifications and drug therapies are used for this. And patients are advised on regular blood sugar monitoring and frequent micro albuminuria testing.

But after patient developed CKD there is no reversal of the condition. Patients kidneys are gradually deteriorating and we only can reduce the rate of progression. And the sad story is once patients reach to CKD state it’s hard to select drug therapies as well. Because most of the drugs are filtered through kidneys. So if the drug we are giving increases work load in failing kidneys, it will fasten the deterioration of the organs.

Therefore it’s very important to detect it early by regular medical follow up. As because it will be less complications for the patient and less burden to the health sector as well. Ultimately it will helps to improve quality of life and the life expectancy of the patient.

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Sapumal Edirisinghe
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