title: Better outcomes of peritoneal dialysis in diabetic patients in spite of risk of loss of autonomy for home dialysis.
abstract: BACKGROUND
  Diabetes mellitus is a leading cause of chronic renal failure, challenging therapy strategies. Patients with diabetes may benefit from peritoneal dialysis (PD) but higher technique failure is feared. Our purpose was to critically evaluate clinical outcomes of this modality in diabetics, in order to find quality improvement strategies in these risk patients.
  
  
  METHODS
  A registry-based study of 432 incident patients, 23% with diabetes, from a university hospital PD program was performed. Traditional methods (Kaplan-Meier, Cox models) and innovative survival analysis, taking competing risks into account, were performed, as well as exploring the trends in cohorts according to the decade of PD start.
  
  
  RESULTS
  In spite of the detrimental effect of diabetes in patient survival compared to non-diabetics (77%, 52% vs 86%, 71%, at 2 and 4 years, respectively; p < 0.0001) the hazard ratio (HR) for death decreased in the more contemporary cohort (0.303, 95% confidence interval (CI) 0.150 - 0.614, p < 0.001). It is noteworthy that diabetes was not associated with lower technique survival: 74%, 51% vs 79%, 57%, at 2 and 4 years, respectively (p = not significant (NS)). On multivariate analysis, diabetes was an independent predictor for mortality, but not for technique failure. The hazard ratio (HR) for technique failure also decreased in the more recent cohort (0.566, 95% CI 0.348 - 0.919, p = 0.021). Among reasons for transfer to hemodialysis, proportion of ultrafiltration failure was similar between groups (26% vs 22%, p = NS), but drop-out due to loss of autonomy occurred more in the group with diabetes (23% vs 5%, p = 0.004), mainly due to ischemic stroke. The hospitalization rate was also higher in diabetic patients (1.39 vs 0.84 episodes per patient-year (E/PY), p = 0.004) but the peritonitis rate was not increased (0.53 vs 0.61 E/PY, p = NS).
  
  
  CONCLUSIONS
  PD was an effective long-term renal replacement therapy in diabetics, without higher rates of technique failure, ultrafiltration failure or peritonitis. Better outcomes were achieved in the contemporary cohort. The menace of autonomy loss due to stroke and higher hospitalization rates enhance the need for assisted PD strategies and better control of comorbidities.
authors.affiliation: Nephrology Department, Centro Hospitalar e Universitário de Coimbra; Nephrology Department, Centro Hospitalar do Porto - Hospital de Santo António and UMIB/ICBAS-University of Porto (UP); UnIFai, ICBAS-UP; PDMA, UP; ISP, UP; and Populations Studies Department, ICBAS-UP Porto, Portugal.
authors.forename: P
authors.initials: P
authors.lastname: Cotovio
authors.affiliation: Nephrology Department, Centro Hospitalar e Universitário de Coimbra; Nephrology Department, Centro Hospitalar do Porto - Hospital de Santo António and UMIB/ICBAS-University of Porto (UP); UnIFai, ICBAS-UP; PDMA, UP; ISP, UP; and Populations Studies Department, ICBAS-UP Porto, Portugal.
authors.forename: A
authors.initials: A
authors.lastname: Rocha
authors.affiliation: Nephrology Department, Centro Hospitalar e Universitário de Coimbra; Nephrology Department, Centro Hospitalar do Porto - Hospital de Santo António and UMIB/ICBAS-University of Porto (UP); UnIFai, ICBAS-UP; PDMA, UP; ISP, UP; and Populations Studies Department, ICBAS-UP Porto, Portugal.
authors.forename: M J
authors.initials: MJ
authors.lastname: Carvalho
authors.affiliation: Nephrology Department, Centro Hospitalar e Universitário de Coimbra; Nephrology Department, Centro Hospitalar do Porto - Hospital de Santo António and UMIB/ICBAS-University of Porto (UP); UnIFai, ICBAS-UP; PDMA, UP; ISP, UP; and Populations Studies Department, ICBAS-UP Porto, Portugal Nephrology Department, Centro Hospitalar e Universitário de Coimbra; Nephrology Department, Centro Hospitalar do Porto - Hospital de Santo António and UMIB/ICBAS-University of Porto (UP); UnIFai, ICBAS-UP; PDMA, UP; ISP, UP; and Populations Studies Department, ICBAS-UP Porto, Portugal Nephrology Department, Centro Hospitalar e Universitário de Coimbra; Nephrology Department, Centro Hospitalar do Porto - Hospital de Santo António and UMIB/ICBAS-University of Porto (UP); UnIFai, ICBAS-UP; PDMA, UP; ISP, UP; and Populations Studies Department, ICBAS-UP Porto, Portugal.
authors.forename: L
authors.initials: L
authors.lastname: Teixeira
authors.affiliation: Nephrology Department, Centro Hospitalar e Universitário de Coimbra; Nephrology Department, Centro Hospitalar do Porto - Hospital de Santo António and UMIB/ICBAS-University of Porto (UP); UnIFai, ICBAS-UP; PDMA, UP; ISP, UP; and Populations Studies Department, ICBAS-UP Porto, Portugal Nephrology Department, Centro Hospitalar e Universitário de Coimbra; Nephrology Department, Centro Hospitalar do Porto - Hospital de Santo António and UMIB/ICBAS-University of Porto (UP); UnIFai, ICBAS-UP; PDMA, UP; ISP, UP; and Populations Studies Department, ICBAS-UP Porto, Portugal.
authors.forename: D
authors.initials: D
authors.lastname: Mendonça
authors.affiliation: Nephrology Department, Centro Hospitalar e Universitário de Coimbra; Nephrology Department, Centro Hospitalar do Porto - Hospital de Santo António and UMIB/ICBAS-University of Porto (UP); UnIFai, ICBAS-UP; PDMA, UP; ISP, UP; and Populations Studies Department, ICBAS-UP Porto, Portugal.
authors.forename: A
authors.initials: A
authors.lastname: Cabrita
authors.affiliation: Nephrology Department, Centro Hospitalar e Universitário de Coimbra; Nephrology Department, Centro Hospitalar do Porto - Hospital de Santo António and UMIB/ICBAS-University of Porto (UP); UnIFai, ICBAS-UP; PDMA, UP; ISP, UP; and Populations Studies Department, ICBAS-UP Porto, Portugal.
authors.forename: A
authors.initials: A
authors.lastname: Rodrigues
mesh_terms: D000328:Adult; D000368:Aged; D002423:Cause of Death; D003928:Diabetic Nephropathies / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006437:Hemodialysis, Home / Q000379:methods* / Q000401:mortality*; D006785:Hospitals, University; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010352:Patient Dropouts / Q000706:statistics & numerical data; D010530:Peritoneal Dialysis / Q000379:methods* / Q000401:mortality*; D026684:Personal Autonomy; D011174:Portugal; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D016896:Treatment Outcome
keywords: Diabetes; outcomes; peritoneal dialysis