PD and diabetes

Hi Dr. Agar,

At the age of 59, as recently as a few months ago my father was diagnosed with kidney failure and is currently in the verge of deciding what sort of dialysis to start. He is leaning towards PD given that it provides some level of convenience compared to HD. However he has been taking diabetes medicine for about 3-4 years now with mixed results until his doctor put him on insulin about three months ago. Since he begun using insulin his blood sugar level has been normal or close to normal.

Under these conditions, and in the light of the fact that the solution used for PD contains glucose, what are the risks of him going with PD? Is there a solution available for diabetics? How does HD compare to PD in his case?

Thank you!

Dear Brooklyn

There are so many ‘ifs’, buts’, maybes’ and possibilities all rolled up together in that question that, without knowing far more than I could ever know about your father from an internet site, I am really at a loss to answer with any specifics or advice that is likely to be certain re your dad.

That said, there are some overview comments I could make.

Firstly, PD is not contraindicated in diabetics – indeed many believe it should be the first therapy of choice in diabetics and many of our PD patients in my own unit are diabetic. Clearly I do not know your dad, but if PD has been suggested as (1) appropriate and (b) a good choice, then I would suspect there are no unforeseen issues that might prevent him from taking that route.

Firstly, in the earlier days of PD, we used to add insulin to the PD bags … indeed that practice actually gave very nice absorptive control of the blood sugar through insulin absorption during the dwell phase … but there were sterility issues for some patients who, perhaps through either poor sight, inaccurate dexterity or simple carelessness, ended up (more frequently than in the non-diabetic population) with peritonitis. Each injection of insulin … and the amounts we had to use were staggering as only about 1/3rd of the dose was absorbed so the intra-peritoneal doses were (or seemed) huge … was a potential ‘breach’ of sterility and, sadly, on some occasions, more than potential! In many studies, PD patients who used intra-peritoneal insulin tended to have (a) good sugar control but (b) poorer sterile technique. Peritonitis reared its head as a real issue. As a result, intra-PD insulin has largely been replaced by insulin self-given S/C as usual (or given by insulin pump) … and, with the newer and better insulin combinations of levemir/determir combined with regular rapid-acting insulin schedules, sugar control can be stabilised very nicely and excellent sugar control obtained.

There are non-glucose solutions available but they are costly and most would say that they offer little advantage over standard glucose solutions - for the diabetics - if the insulin regimes are individualised and carefully adjusted and maintained. We use solutions like icodextrin for better fluid management and for daytime bag dwells for our almost exclusively APD population of PD patients … yes, see, I am a nocturnal ‘advocate’, whether PD or HD … but we don’t usually or routinely use non-glucose or glucose ‘substitute’ solutions in any way to ‘spare’ the sugar load. We control glucose levels with S/C insulin … just as we do in non-diabetics.

Diabetics can have issues with HD too. Often the blood vessels are not as ‘ideal’ – especially peripheral arterial flows – in diabetic patients and it is true that our fistula surgeons … amazingly good though they are … do have more trouble with fashioning arteriovenous fistulae (AVF) in our diabetics over and above the non-diabetic patients. Further, the diabetic arm often carries the additional surgical hubris of obesity – not always, just often – and fashioned AVF more often than not need a second stage superficialisation procedure to raise the vein to be at an accessible distance under the skin surface for needling. While superficialisation is a very common procedure for all dialysis patients to get optimal needling depths, it is most frequent in our diabetic patients. So … diabetics can have issues with HD too. There are others - too many to deal with here – but this is just commonly the 1st issue we encounter in HD in diabetic patients.

In a word, and back to your question … on the surface and with the very little information I have about your dad, he sounds like he might be ideal for PD. If this is the recommendation, then likely that is true. HD is good, but so is PD. It doesnt have the technique longevity that HD has, but, at least in the 1st 2-3 years, the data shows excellent expectations for good outcomes and he can always transfer if the technique is failing for him further down the track.

Here, the art is in the timing! We do tend to run the failing PD patient too far and too long before accepting that the PD is failing … and this results in poor or failing health which then, in turn, necessitates facility HD care … from which most patents never re-emerge into the home!

If we were smarter to …

(1) offer PD first (maybe more often than we do!) but, then, be …

(2) smarter at ‘picking’ the decline of PD as a viable dialysis option 2, 3, 4 etc years down the track so that …

(3) we could initiate the transition to HOME training for HD while the PD is still working well enough (even though (or because) the 1st signs of technique failure are visible) to sustain the patient through HD training so that …

(4) a seamless transiton to home HD can be made, timed and thought through, such that …

(5) the patient can and does remain at home (with the exception of the training period) and with a seamless and relatively ‘painless’ switch from PD to HD being made by a thoughtful team

… this is (and should be) how PD morphs to HD … each being complimentary to but not competitive with the other

We try to do that … not always with success … but its the thought that counts!

Hope that’s been of some help.