Diabetes & PD Management of diabetic patient getting PD-treatment

1. Diabetes & PDManagement of diabetic patient getting PD-treatment Aase Riemann Amsterdam PD-consultant EDTNA/ERCA

2. Dialysis and diabetes • Dialysis and diabetes • extremely difficult • Challenges • daily life • avoid severe complications • Future of patients depending on motivation, willingness and commitment • selfmanagement tools • self-efficacy

3. The mission of the chronically ill • As chronically ill one has to learn to elevate life above the illness • If the patients succeeds in this, life will be worth living Grypdonck, M., 2000

4. Content • HD or PD • Free choice • Key points • Professionals • Conclusion and discussion

5. HD or PD • Discussions which treatment preferable • Results of studies comparing diverge • Results also depending on contribution of non-glucose based PD-solutions • Diabetes is no contradiction for PD

6. Research • Higher mortality diabetes patients on HD • during the first 2 years • also the elderly Fenton, SS et al, 1997 • Higher mortality in PD-patients Collins, AJ et al,1999

7. Research • Higher mortality on PD • elderly diabetes patients first 90 days • after 180 days similar with HD Winkelmayer, WC et al, 2002 • Higher mortality on PD than on HD • diabetes patients > 65 years • lower diabetes patients < 65 years Vonesh, EF et al, 2004

8. Research • Conclusions research with caution • unequal clinical conditions of patients Jay, LX et al 2002 • Diabetes patients on PD • better controlled blood pressure • higher hemoglobin levels • longer residual renal function Masud Iqbal, M et al 2005

9. HD or PD • Insufficient evidence to support preference HD or PD for medical reasons • Daily life, lifestyle, social environment and personality to be considered • Choice made by the well-informed patient • Demand for well-balanced and structured education ERBP Advisory Board, 2010

10. Utilization of home-dialysis • Differences between countries • Asymmetric modality distribution • Relation to non-medical factors - private or public providers • Possibilities for free choice of modality not always present Blake PG, 2010

11. Problems PD and diabetes • Glucose-containing dialyse solutions • hyperglycaemia • obesity • hyperlipidaemia • AccelIerating inflammatory proces • Advanced Glycation End Products, AGEs • changes in the peritoneal membrane

12. Problems PD and diabetes • Fibrosis of membrane • reducing function of membrane • less diffusion • detrimental changes in anuric patients EAPOS trial, Davids EJ et al, 2005 • Ultrafiltration failure • End of PD

13. Use of nonroblems PD and diabetes • Icodextrin 7.5 % • derived glucose polymer Non-glucose based • reducing glucose calorie load • avoiding glucose toxicity • hydrolized to oligosaccharides • reducing level of GDP’s • Once daily • Long-term dwell • avoids excessive accumulation of lactate • reduces significantly insulin requirements

14. Non-glucose PD solutions • Amino acids 1.1%, PH = 6.7 • daily protein intake • once daily • avoids excessive nitrogen load • Bicarbonate-lactate solution • double- chamber dialysate • neutral PH • better preservation of membrane • reduction of pain

15. Early initiation • Daily scheme of patients with or without diabetes • 2 x 1,36/1x amino acid/1 x Icodextrin • APD Icodextrin for the last bag • Less marked changes in longitudinal membrane function EAPOS trial, Davids EJ et al, 2005 • Non-glucose based dialysate solutions • Reduce calorie load • Glucose toxicity • Maintain optimum blood glucose level reducing risk of vascular complications Dasgupta M, 2005

16. Our care

17. Complications PD and diabetes • Vasculair damage • Cardiovasculair death Krediet R, Balafa O, 2010 • Raised ACE level significant risk factor cardivasculair events and death Wong T et al, 2008 • Microangiophatie • Macroangiophatie • coronairy and cerebal • infarct • diabetical foot

18. Complications • Neuropatie • Disturbed sensors, motoric and autonomus nerves • Varied complications • limited joint mobility • decreased mobility • Retinopathie • blindness • Low quality of life

19. Patient education • Focus on the patient • in relation to his individual circumstances • you must reach the patient and his family • Experienced PD and diabetes nurse • Multidisciplinairy team

20. Role of nurses • Grypdonck M, 2002 • As “skilled companion” • To help the patient to change… • To help him accept…. • To help him manage his own illness and life….

21. Subjects • PD • aseptic technique • steps in CAPD or APD • emergency measure in case of contamination • exit site care • troubleshooting and complications • record keeping • ordering supplies

22. Subjects • Diabetes • normoglycaemia • regular controls • tablets and insuline • attention CAPD to APD • less or more insulin • foot-control • eye- control

23. Control of bloodsugars • Technique, different devices • hygiene • what is a normal bloodsugar level? • frequency of control, curves • registration • relation to diet and motion • symptoms of hyper and hypo • use of glycagon

24. Caution with use of lcodextrin • Falsely raised blood glucose measurements • systematic circulation of oligosaccharides • substantial concentrations • missing diagnosis of hypoglycaemia • glucose monitoring kids • investigation for inference

27. Use of Insuline • How does it work • Technique • location at body • time • diet, motion, stress • symptoms of hyper and hypo • hygiene

28. Diabetes

29. Controls • PD and diabetes • Support, housevisits and telecare • lab • weight • bloodpressure • PD-scheme • diet • exit site • location of insertion • feet • eyes • hygiene

30. others

31. Other subjects • Daily life • selfmanagement and self-efficacy • materials and supplies • social life • family • work • hobbies • holiday

32. Disciplines nephrology and diabetes • Multidisciplinairy collaboration • Doctors • family doctor • nephrologist • diabetiologist • dermatologist • surgeon • revalidation department

33. Nurses • District nurse • PD- nurse • Diabetic nurse • Cotrols at least twice a year • Insuline insert locations • feet • eyes • new material

34. Telecare

35. Use telecare • Communication • screens and video communication • Monitoring • devices bloodsugar mesurement, lab, pharmacy • Information • files • Education • websites • Entertainment

36. Chronically • Diseases • short episode in healthy life • treatment and medicin • recovery or death • PD and diabetes • chronical • rest of life • quality of life

37. Key points • Awareness of high glucose concentrated fluids • Non-glucose solution and diabetes • Correct equipment when using Icodextrin • Regular controles • Education and support

38. Discussie en vragen