Abstract
Background
During recent years, the number of patients with end-stage renal disease (ESRD) has been rising worldwide. Especially older patients and those with diabetes contribute to this rise. The aim of the present study was to evaluate whether patients older than 65 years with type 2 diabetes, who started first dialysis, have a higher prevalence of vascular diseases and co-morbidities, show a higher incidence of vascular complications and/or have a higher mortality rate than elderly non-diabetic patients with ESRD.
Patients and methods
In this study, 82 consecutive patients with ESRD, who had either type 2 diabetes or did not have diabetes and who had started chronic hemodialysis (HD) in our dialysis center during the years 1994 to 2002, were included. Patients were included when they were older than 65 years. Patients were divided into two groups: those with diabetes (DM) (n = 47) and those without diabetes (nDM) (n = 35). For both groups the number of co-morbidities as well as the prevalence of vascular diseases and vascular risk-factors at the start of HD was evaluated. In addition, the incidence of vascular complications was registered over a 3-year observation period. In both groups serum(S)-creatinine, blood urea nitrogen (BUN), creatinine clearance, hemoglobin, fasting blood glucose, HbA1c (in diabetic patients), cholesterol, triglycerides and phosphorus were evaluated.
Results
At the start of HD the creatinine clearance was significantly higher in diabetic subjects (nDM 7.1 ± 2.1 vs DM 9.5 ± 4.4 ml/min/1.73 m2; p < 0.005). For S-creatinine the difference was not statistically significant (nDM 8.7 ± 3.3 mg/dl vs DM 7.4 ± 2.4; p = 0.07). Fasting blood glucose was significantly higher in diabetic patients (p < 0.001). BUN, hemoglobin, phosphorus and lipids were not significantly different in both groups. There was no statistically significant difference in systolic or diastolic blood pressure, but a higher amount of antihypertensive drugs were necessary in the DM group for blood pressure control (p < 0.01). In both groups there was a high prevalence of vascular diseases at the start of HD. In the diabetic patients the prevalence of peripheral vascular disease was significantly higher. Furthermore, in the first and second year significantly more vascular complications were observed in the DM group (p < 0.01). Survival was low in both groups. The 3-year survival was 20.0% in non-diabetic and 17.0% in diabetic patients (NS).
Conclusion
Patients older than 65 years with ESRD have a low survival with and without type 2 diabetes. The mortality rate was only slightly higher in the diabetic group and was not statistically significant. The prevalence of vascular diseases and co-morbidities is high in both groups; however, the incidence of cardiovascular complications was significantly higher in our diabetic patients.
Zusammenfassung
Hintergrund
In den letzten Jahren ist die Zahl von Patienten mit terminaler Niereninsuffizienz weltweit stetig gestiegen. Vor allem ältere Patienten und jene mit Diabetes stellen den Hauptzuwachs dar. Ziel der vorliegenden Arbeit war es zu untersuchen, ob Patienten mit Typ 2 Diabetes über 65 Jahre, die eine Hämodialyse benötigen, eine höhere Prävalenz an vaskulären Erkrankungen und Komorbiditäten haben, eine höhere Inzidenz an vaskulären Komplikationen aufweisen und/oder eine höhere Sterblichkeit haben, als jene Patienten ohne Diabetes.
Patienten und Methodik
82 konsekutive Patienten mit Typ 2 Diabetes oder ohne Diabetes über 65 Jahre mit terminaler Niereninsuffizienz, die zwischen 1994 und 2002 an unserem Zentrum hämodialysepflichtig wurden, wurden in die Studie eingeschlossen. Die Patienten wurden in 2 Gruppen geteilt: jene mit Diabetes (DM) (n = 47) und jene ohne Diabetes (nDM) (n = 35). Für beide Gruppen wurden die Zahl der Komorbiditäten sowie die Prävalenz der vaskulären Erkrankungen und Risikofaktoren zum Zeitpunkt des Dialysebeginns erhoben. Weiters wurde die Inzidenz vaskulärer Komplikationen während des ersten Dreijahresintervall untersucht. In beiden Gruppen wurden Serum-(S-)-Kreatinin, BUN, Kreatininclearence, Hämoglobin, Nüchtern-Blutzucker, HbA1c (bei Diabetikern), Cholesterin, Triglyzeride und Phosphor ermittelt.
Ergebnisse
Zum Zeitpunkt des Dialysestarts war die Kreatininclearence bei Diabetikern signifikant höher (nDM 7,1 ± 2,1 vs. DM 9,5 ± 4,4 ml/ min/1,73m2; p<0,005). Für das S-Kreatinin war der Unterschied nicht statistisch signifikant (nDM 8,7 ± 3,3 mg/dl vs. DM 7,4 ± 2,4; p = 0,07). Der Nüchtern- Blutzucker war bei Diabetikern signifikant höher (p < 0,001). BUN, Hämoglobin, Phosphor und die Lipide waren in den beiden Gruppen vergleichbar. Selbiges gilt für systolischen und diastolischen Blutdruck. Es waren aber mehr Antihypertensiva in der Gruppe der Diabetiker notwendig (p < 0,01). In beiden Gruppen fand sich eine hohe Prävalenz an vaskulären Erkrankungen zu Beginn der Dialyse. In der Gruppe der Diabetiker war die Prevalenz der peripheren arteriellen Verschlusskrankheit statistisch signifikant häufiger. Weiters war die Anzahl an vaskulären Komplikationen im ersten und zweiten Jahr nach dem Dialysebeginn bei Diabetikern statistisch signifikant höher (p<0,01). Die Überlebensrate war in beiden Gruppen niedrig. Das 3-Jahres-Überleben lag bei Nicht- Diabetikern bei 20,0% und bei Diabetikern bei 17,0% (NS).
Schlussfolgerung
Patienten über 65 Jahre mit terminaler Niereninsuffizienz haben eine niedrige Überlebensrate. Das gilt sowohl für Patienten mit Typ 2 Diabetes als auch für Patienten ohne Diabetes. Die Sterblichkeitsrate war bei Diabetikern nur gering höher. Die Prävalenz von vaskulären Erkrankungen war in beiden Gruppen hoch. Die Inzidenz kardiovaskulärer Komplikationen während des Untersuchungsintervalls war jedoch bei Diabetikern höher.
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Pieringer, H., Biesenbach, G. Hemodialysis in patients older than 65 years with end-stage renal failure. Z Gerontol Geriat 41, 139–145 (2008). https://doi.org/10.1007/s00391-007-0467-x
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DOI: https://doi.org/10.1007/s00391-007-0467-x