Published online Mar 15, 2025. doi: 10.4239/wjd.v16.i3.100592
Revised: December 18, 2024
Accepted: December 27, 2024
Published online: March 15, 2025
Processing time: 153 Days and 19.9 Hours
Diabetes is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) worldwide. While both haemodialysis (HD) and peritoneal dialysis (PD) are commonly used treatment options for ESKD, the choice of dialysis modality in diabetic ESKD patients remains a critical decision influenced by various patient-related, healthcare system, and socio-economic factors. This article examines the factors influencing the selection of dialysis modalities for diabetic patients, with a focus on the challenges and opportunities in low-resource settings. Key considerations include the impact of comorbidities such as peripheral arterial disease and CKD-related mineral bone disorder (MBD), as well as patient preferences, caregiver burden, and the availability of healthcare infrastructure. The article highlights the need for personalized approaches to dialysis selection, considering both clinical outcomes and quality of life. It also emphasizes the potential benefits of home dialysis, including home HD and PD, in improving patient autonomy and long-term survival. The article advocates for better government policies, increased awareness, and improved support systems to enhance the accessibility and efficacy of dialysis treatments, particularly in underserved populations. Further research comparing the outcomes of different dialysis modalities across diverse settings is essential to guide global treatment strategies for diabetic ESKD patients.
Core Tip: The choice of dialysis modality in diabetic patients with end-stage kidney disease should be individualized, considering factors such as comorbidities (e.g., peripheral arterial disease, chronic kidney disease-related mineral bone disorder), patient preferences, healthcare infrastructure, and caregiver support. In low-resource settings, promoting home dialysis options and improving access to peritoneal dialysis can enhance patient outcomes and quality of life. Healthcare policies, education, and better support systems are key to optimizing dialysis choices, particularly for diabetic populations in underserved areas.
- Citation: Prabhahar A, Batta A, Hatwal J, Kumar V, Ramachandran R, Batta A. Optimizing dialysis modalities for diabetic end-stage kidney disease: A focus on personalized care and resource-limited settings. World J Diabetes 2025; 16(3): 100592
- URL: https://www.wjgnet.com/1948-9358/full/v16/i3/100592.htm
- DOI: https://dx.doi.org/10.4239/wjd.v16.i3.100592
Diabetes is the leading cause of chronic kidney disease (CKD) worldwide and in India[1,2]. Approximately 40-50% of individuals with type II diabetes develop CKD[3]. Despite the availability of newer medications aimed at slowing CKD progression, many patients still progress rapidly to end-stage kidney disease (ESKD) and require kidney replacement therapy (KRT). The global annual incidence of ESKD due to diabetes had increased by nearly 3 times between 2000 and 2015[4]. Haemodialysis (HD), peritoneal dialysis (PD), kidney transplantation and comprehensive clinical care are recommended treatment options in ESKD patients with diabetes. Though, kidney transplantation improves the survival compared to remaining on dialysis, the mortality risk after transplant among diabetic individuals is higher compared to non-diabetic individuals[5]. Hence, dialysis is a crucial element in management of ESKD care. There is a lack of consensus regarding the optimal KRT modality (PD vs HD) for the diabetic ESKD population. Globally, 89% of ESKD patients are on HD and 11% on PD, although data specific to the diabetic ESKD population is not available[6,7]. In India, 94% of ESKD patients receive HD, with only 6% on PD[8].
In patients with ESKD due to diabetes, the most crucial factor influencing their health-related quality of life (QOL) is the appropriateness, timing, modality, and setting of RRT. While clinical outcomes tend to be comparable across different KRT modalities, certain modalities may offer advantages for specific clinical factors. For example, patients who are on PD tend to have better graft outcomes after kidney transplant than those who were on HD[9]. As such, the choice of dialysis modality is influenced by patient preferences, taking into account factors such as QOL, personal health objectives, comorbidities, support from family and caregivers, and the healthcare environment. Healthcare economics and regional policies also greatly influence the allocation and accessibility of dialysis modalities within an area[10]. Ideally, dialysis decisions should be made through a joint effort, where patients, their families, and healthcare providers collaborate to assess treatment choices at an appropriate stage of CKD. The authors Hu Hu et al[11] must be congratulated for throwing light on various factors that must be considered before deciding between HD and PD specifically focusing on the diabetic population rather than ESKD in general. Some of the factors mentioned include survival rate, glycemic control, infectious complications, cardiovascular events, residual renal function, patients’ QOL, economic benefits, malnutrition, and fluid overload. However, many other factors need consideration in addition to the above. Factors associated with KRT planning in CKD depends on both patient-related and healthcare system related factors. In the following section, we have elaborated some of these factors, which can impact the choice of KRT modalities in the Indian subcontinent, which houses 1/4th of the world’s diabetic population. We have highlighted that factors such as CKD-related mineral bone disease (CKD-MBD) and peripheral arterial disease (PAD) play a crucial role in determining the choice of dialysis modalities, as they significantly affect vascular health in patients with CKD. All patients who need maintenance KRT should be given an option of initiation of KRT with home dialysis (which includes home HD and PD), which improves the QOL compared to in-center HD[10].
The prevalence of diabetes in India when diagnosed through a combination of HbA1c and oral glucose tolerance test is 21%[12]. The proportion of diabetic individuals who develop ESKD, along with other cardiovascular comorbidities, is growing exponentially in India. Various patient related factors influence the selection of dialysis modalities. Young-onset Type II diabetes is a particularly common risk factor for rapid progression to ESKD, early development of cardiovascular diseases, blindness due to diabetic retinopathy in Indian subjects[13-15]. A study showed that, 20% of the CKD population in India (predominantly diabetic) were at a high or very high-risk of developing an adverse cardiovascular outcome[16]. Poor glycemic control, unawareness of the disease, and lack of access to healthcare are all additional risk factors for progression of the disease and development of complications including infections in India[17,18]. Late referral and inadequate preparation for KRT result in higher mortality[19]. Referral systems to nephrology care also impact the choosing of dialysis modalities as patients with late referral tend to choose HD over PD[20]. In a study of 23601 patients on maintenance in-center HD (37% diabetes), 1/3rd of the patients died within 1 year of follow-up. Many of the deaths in the HD population is attributed to vascular access infections, for which diabetes (hazard ratio for mortality-1.35) and temporary jugular dialysis catheters (hazard ratio for mortality-1.96) are mainly contributory. There is higher dropout rates among Indian patients initiated on HD, because of financial hardships and poor patient-caregiver support systems[21,22]. Also, PD is not available in many of the low-income countries[23]. Despite availability, absence of PD-specific policies, indifferent attitudes from patients and physicians, a lack of structured awareness and training programs, and affordability issues are some of the key factors for underutilization of PD in India[24]. We beg to differ from the view by Hu et al[11], that PD is less costlier compared to HD. The costs of PD are lesser compared to in-center HD only in high income regions and tend to vary across low-income regions depending upon government support systems[25]. Due to the lack of local manufacturing of PD fluids and policies to economically support PD, PD tends to be more expensive in low-income countries. In India, most of the HD center are located in the urban areas, where the prevalence of diabetes is 18.5%[17]. With the rising incidence of diabetes in rural areas, where the prevalence of diabetes is 14.9%[17], promoting PD through government policies can make PD an accessible option for rural population. A health technology assessment in Indonesia found that a PD-first policy is more cost-effective than HD[26]. Similarly, Thailand used a similar approach to negotiate pricing and build sustainable infrastructure, ensuring broader access without compromising outcomes. The International Society of Nephrology framework for setting up dialysis programs in low-resource settings prioritize PD over HD to improve outreach of chronic dialysis programs[27].
Very few studies are available in India that compare survival rates with dialysis modalities among patients with diabetes and ESKD. One study showed that PD was associated with a greater number of quality-adjusted life years lived per person with ESKD compared to HD (3.3 vs 1.6)[28]. PD, though, an excellent KRT modality in diabetic individuals is also associated with complications and higher drop-outs, if the expenses are managed through out-of-pocket expenses[29]. Therefore, it is essential to consider various factors when selecting KRT modalities, including government policies that support different KRT options, socio-economic and political factors, access to KRT modalities, and the training and education of different KRT modalities among caregivers. In addition, comorbidity burden and the preferences of patients and caregivers must be taken into account. All these factors significantly influence QOL and survival in low-resource settings. Large-scale studies in diabetic populations should be conducted to compare KRT outcomes in both high- and low- resource settings to understand the differences between the two modalities.
PAD is more common in the type II diabetes population compared to the general population[30]. The Dialysis Outcomes and Practical Patterns Study (DOPPS) showed that the prevalence of PAD in the HD population is 12%-38% in various groups and is associated with high mortality[31]. Diabetic patients who are on HD are 3.5 times more likely to get PAD than the non-diabetic HD population[31]. Various CKD-related risk factors such as oxidative stress, uremic solutes, and hyperphosphatemia aggravate the PAD risk in addition to the risk factors posed by diabetes. Few studies have suggested that PAD is more common in HD than PD patients[32]. The presence of diabetes and PAD are associated with poor arterio-venous fistula patency rates[33]. Elbow may be the preferred site for creating arterio-venous fistula rather than the wrist (which is usually preferred) in patients with established PAD and diabetes[34]. Moreover, conversion of HD to PD due to vascular access failures are higher in patients with diabetes[35]. It may be wiser to screen ESKD diabetic patients for PAD at baseline and subject those with PAD or risk of developing PAD for PD than HD. Screening during out-patient visits may include measuring ankle-brachial and toe-brachial indices in addition to routine physical examination and questionnaire methods[36]. Symptomatic patients may be subjected to duplex ultrasound, which is the gold standard diagnostic modality for detection of PAD[36]. Thus, screening and treatment with drugs (like statins) may delay the onset and decrease the progression of PAD and also avoid arterio-venous fistula failures. An ongoing multi-center, randomized, double-blind controlled trial (comparing rivaroxaban vs placebo)-Treatment of cardiovascular disease with low dose Rivaroxaban in Advanced Chronic Kidney Disease (TRACK study) is investigating the occurrence of composite cardiovascular outcomes (includes PAD, vascular access thrombosis) in diabetic patients with advanced CKD and ESKD. Subclinical PAD is not a contraindication to HD. But, for those with established PAD like history of amputation, PD maybe the preferred dialysis modality, as HD is associated with poorer survival[37].
CKD-MBD involves biochemical, hormonal, and metabolic disturbances of the calcium-phosphate axis along with extra skeletal calcification. Extra-skeletal calcification leads to vascular stiffening and endothelial dysfunction[38]. CKD-MBD in diabetes is characterized by both high and low bone turnover states[39]. Hyperphosphatemia due to high turnover bone disease can impair the maturation and preservation of patency of AV fistulas[40,41]. An increased phosphate burden causes arterial medial calcification and left ventricular hypertrophy, which together heighten the likelihood of coronary artery disease and PAD[42]. A form of low turnover bone disease known as adynamic bone disease (ABD), is characterized by suppressed activity/resistance to parathyroid hormone seen classically in diabetic CKD patients and patients on PD[38]. In ABD, the buffering capacity of the bones is decreased leading to excessive vascular calcification and is associated with poor overall survival[43]. ABD is more common in PD than HD[44]. Age, duration of maintenance dialysis, usage of calcium-based phosphate binder, hyperglycemia and usage of vitamin K antagonists like warfarin are associated with vascular calcification in CKD.
CKD-MBD screening should start once the patient reaches CKD stage G3a (< 60 mL/min/1.73m2)[42]. Monitoring of calcium, phosphate, alkaline phosphatase levels, 25-hydroxy vitamin D, parathyroid hormone levels and in special cases bone biopsy are recommended to characterize and manage CKD-MBD accordingly[42]. The frequency of testing depends upon the magnitude of abnormalities and progress of kidney disease. Adequate phosphorus control and avoidance of hypercalcemia are essential to prevent vascular calcification[42]. There are no specific guidelines which provide recommendations exist for choosing dialysis modalities in patients with CKD-MBD. Patients with severe vascular calcification due to CKD-MBD maybe advised for PD because of the risk of fistula failures, unless there are complications. Decreasing usage of dextrose-based PD solutions and maintaining parathyroid hormone in therapeutic range (2 to 9 times the upper limit of normal) may prevent onset of ABD in patients opting for PD.
It is important to assess the caregiver burden before and after dialysis therapies. Patients undergoing dialysis often become more fragile and dependent on others for daily activities. This increased need for assistance can place a significant physical and emotional burden on their family caregivers. Caregiver burden is measured through different scales[45]. Some of them include SF-36 (Short Form-36 Health Survey), Zarit Burden Interview, Centre for Epidemiologic Studies Depression Scale) and Beck Depression Inventory[46]. These scales collectively offer a comprehensive evaluation of caregiver burden, addressing both physical and psychological components. The caregiver burden between PD and HD is not much different[46]. There is heterogeneity among the study population and scoring systems used and also, home HD was not analyzed[46].
A cross-sectional study involving 231 PD patients (142 self-care, 89 assisted care) found mostly comparable QOL among caregivers between self-care and assisted PD[47]. Thus, caregiver burden should not be an excuse for not opting assisted PD. HD requires patients to visit dialysis center multiple times a week, reducing caregiver involvement at home but creating logistical challenges like transportation and coordination of care. Caregiver burden is significantly higher after initiation of dialysis. A study on geriatric patients with ESKD found that caregiver burden, assessed using the Geriatric Assessment and the Groningen Frailty Indicator, increased significantly from 23% to 38% in the initial 6 months of dialysis therapy (P = 0.004)[48].
As diabetic patients on dialysis tend to be fragile and older, caregivers’ opinions and burden must be assessed and dialysis options must be chosen. Educational, supportive, family-based and psychological interventions should be utilized to alleviate the caregiver burden[49]. Timely recognition of available support systems, exploring options for assisted dialysis, providing short-term respite care, and offering flexibility in treatment plans are also crucial in reducing caregiver burden. Encouraging home-based dialysis (including home HD) without recognizing caregiver burden may also lead to poor outcomes. Remote monitoring and mobile monitoring teams can some of the psychological components of caregiver burden in home based dialysis.
Home HD is associated with greater patient autonomy and treatment satisfaction compared to the in-center HD[10]. Between the home dialysis modalities (home HD and PD), there is improved patient survival in home HD patients compared to PD after the first year of initiation of dialysis[50,51]. As the QOL is better with home HD compared to in-center HD, treatment intensification is possible. Intensive HD is associated with better blood pressure control, reduction in left ventricular hypertrophy, better phosphate control, lesser dietary restrictions[10]. A recently published Cochrane review showed that Home HD compared to in-center HD is also associated with improved survival, reduced hospitalization rates. It is unclear whether home HD is worth the cost relative to its benefits in the first two years[52].
Fistula cannulations are performed by patients themselves or their family members predominantly. Patients with vascular access issues are continued on tunneled catheters, though the risk of infection remains a concern. It is unclear, whether vascular access problems are increased in home HD compared to in-center HD[52]. But first access related adverse event was higher in patients with frequent dialysis than with conventional 3-sessions per week dialysis[53]. Presence of diabetes is a risk factor for technique failure[54]. Other reasons for technique failure in home HD include adverse events, medical instability, caregiver and patient burnout. Performing home HD also requires a greater motivation among the patients and caregivers.
Setting up home HD is not easy. It requires incorporation of technology to enable dialysis systems, changing the environment to accommodate dialysis systems, establishing patient and caregiver support systems[10]. Remote monitoring applications like continuous glucose monitoring devices, monitoring of vitals and other dialysis parameters can improve home HD outcomes in diabetes patients with comorbidities and alleviate some of the caregiver burden[55]. Hence, in diabetic individuals with motivation, support systems, environment, good vascular access, home HD can be associated with better clinical outcomes.
The selection of an appropriate dialysis modality for diabetic patients with ESKD requires a patient-center, holistic approach that considers clinical factors and healthcare system constraints. In low-resource settings such as India, the decision between HD and PD should be influenced by factors including healthcare access, socioeconomic status, comorbidities (particularly cardiovascular diseases, PAD, and CKD-MBD), as well as government policies. While both modalities offer viable treatment options, PD may offer superior QOL and survival benefits, particularly for patients with specific comorbidities. However, challenges related to cost, access, and policy support hinder its widespread adoption. Promoting PD in rural areas where in-center HD access is limited could significantly improve outcomes. In addition, home HD should be considered in carefully selected patients, as it is associated with better survival and QOL outcomes. There is an urgent need for further research to compare long-term outcomes across various dialysis modalities, particularly in low-resource settings, to guide clinical practice and policy decisions. Future studies should focus on evaluating the impact of government policies, healthcare infrastructure, and socioeconomic factors on dialysis modality selection. Additionally, more comprehensive research on the management of comorbidities such as PAD and CKD-MBD, and their influence on dialysis outcomes, is essential. Strengthening infrastructure and policy initiatives that prioritize PD and home HD, combined with educational programs to support patients and caregivers, could reduce dropout rates and improve survival outcomes. Collaboration between healthcare providers and policymakers, supported by evidence from systematic reviews and meta-analyses, will be critical in shaping better care strategies for diabetic patients with ESKD.
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