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End-stage diabetic nephropathy.

Chronic renal failure has become the leading cause of death in juvenile-onset diabetes; it now accounts for half of all deaths' in patients who develop their diabetes before the age of 20. The earliest clinical feature of the disease is symptomless proteinuria, which is sometimes intermittent and separated by weeks or months of negative test results. The mean duration of diabetes before the onset of proteinuria is about 15 years. Once the condition is detected, life expectancy varies considerably: the mean is five years but some patients survive as long as 18 years.2-4 The prognosis for renal function is equally variable, so that mild impairment may persist for some months or even years without further deterioration. Once the decline in function accelerates, however, renal failure usually develops rapidly and inexorably. Most patients die within two years' of developing a persistent blood urea concentration of 10 mmol l. The cause of this rapid terminal deterioration is unknown, but its recognition is important in planning the management of diabetic patients with advancing renal failure. The diabetic with end-stage renal failure faces the same choices as does the non-diabetic uraemic patient: maintenance haemodialysis, maintenance peritoneal dialysis, and renal transplantation. Reports of the results with maintenance dialysis are difficult to compare, but, in general terms, in diabetic patients survival rates for the first, second, and third years are about 610,, 4800, and 3100 respectively, while the corresponding figures in non-diabetics are 930 , 820,1 and 730 -SO that after three years the chances of survival are more than twice as good in non-diabetics.6 For diabetic patients with relatively stable chronic renal failure in whom vascular access is a problem maintenance peritoneal dialysis may be preferable. Preliminary results suggest that survival rates are similar to those obtained with haemodialysis,7 8 and an important benefit may be a halt in the progression of retinopathy.8 9 The difficulties of dialysis and the poor prognosis that it offers have encouraged some diabetic units to recommend early renal transplantation.° 11 Patients accepted for transplantation should undergo surgery quickly, since the mortality rate in diabetics awaiting operation on temporary dialysis is higher than in non-diabetics.'2 Extensive experience with renal transplantation has been gained at the University ofMinnesota, where diabetics have been offered transplants since 1969. For the first three years of the programme most patients underwent