PD decision making


Should I go on PD, since I am diabetic?



Dear brojack

In the past, there were some strongly held views, though not a lot of good evidence, to preferentially recommend PD first for diabetics. Indeed, ‘PD first’ is a mantra still practiced and recommended widely across the globe.

However, both PD and HD are suitable for most diabetics and we now prefer to suggest that the decision re ‘which type of dialysis’ should primarily be made on lifestyle choice, choosing the dialysis option that best fits with ‘what you want to do with’, and ‘how you want to live’ your life.

Have you used the " My Life, My Dialysis Choice’ decision aid that Dori Schatell wrote with me? It may be worth your while starting with this. It can be found at https://mydialysischoice.org/

That said, PD in diabetics is a generally good option … travel is easier, home training is quicker, and there are some other practical advantages … but PD tends to generate a ‘use by’ date in many patients and may fail in the longer term … most services finding a 50% failure rate in the technique at between 3-5 years as the peritoneal membrane ages. In diabetics, this can be a bit quicker, too, as advanced glycation end-products (AGE) are slowly deposited in the membrane, causing the peritoneal membrane to lose the capacity to ultrafilter (ie: remove fluid). As the fluid most commonly used for PD is a glucose-based solution, this can destabilise DM control, too. Weight gain is common in PD, and many diabetics can struggle with this. The glucose solutions can also affect the control of your sugar - though this is usually manageable.

HD is good, too, though access surgery can be more problematic in diabetics with prematurely damaged blood vessels. Weight gain is less of an issue but travel is a little more difficult and training for home HD is slower and more complex. HD is commonly done in centre-based services - though we strongly advocate for home-based HD care.

In the end, we believe that dialysis should - as best as is humanly possible - be dictated by lifestyle choices … which dialysis best suits and fits into the way you choose to live your life, your life commitments, and your life aspirations. Dialysis should be structured to your lifestyle, and NOT the other way round. Wherever possible, your should avoid a dialysis option being imposed for ‘medical reasons’ unless those medical reasons are for a valid contraindication. For instance, some people maybe unsuited to PD due to past extensive abdominal surgery, the presence of un-fixable abdominal herniae, or the presence of an ileostomy or colostomy. Some diabetics may have visual problems that make PD a little more difficult though we have trained many severely vision impaired diabetics to successfully do PD at home. While there is not much that can be considered as a contraindication for HD, vascular access can loom large as a problem in some diabetics.

In the end, use the decision aid and see where it directs you. its a good starting point. Discuss all options with your team - but remember, some teams can be unfamiliar with all the options in home therapies, and may need to be specifically pushed on this.