Continuous Ambulatory Peritoneal Dialysis in

Diabetic Patients
The Relationship of Hypertension to Retinopathy
and Cardiovascular Complications
JACQUES ROTTEMBOURG, M O H A M E D R E M A O U N , KALIL M A I G A , P A U L B E L L I O , BELKACEM I S S A D ,

A M A R B O U D J E M A A , AND P I E R R E - Y V E S C O S S E T T E

SUMMARY From August 1978 to December 1983,51 insulin-dependent diabetic patients with end-
stage renal disease were selected for treatment by continuous ambulatory peritoneal dialysis. There
were 27 male and 24 female patients, with a mean age of 52.3 ± 13.5 years. Forty-five patients
dialyzed themselves by continuous ambulatory peritoneal dialysis and six were treated by continuous
cyclic peritoneal dialysis. All patients were treated at home. The cumulative duration of treatment was
65.6 patient-years; 14 patients were dialyzed for at least 24 months. Extrarenal complications were
frequent at start of continuous ambulatory peritoneal dialysis, including hypertension in 48 patients,
proliferative retinopathy in 50, and cardiovascular complications in 30. Age appeared to be the major
risk factor, with success rates at 2 years of 78% in patients under age 50 years and only 50% in patients
over age 50. The main cause of death was vascular and the main cause of transfer to other therapeutic
modalities was abdominal complications or malnutrition or both. Excellent control of blood pressure,
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uremia, and blood glucose levels was obtained on a daily program of four exchanges. Improvement in
visual status was frequently observed, mainly in the young population. In patients with juvenile
diabetes, continuous ambulatory peritoneal dialysis should be part of an integrated program with
transplantation, while in the elderly, the method offers a unique opportunity for them to treat
themselves at home. (Hypertension 7 [Suppl II]: II-125-11-130, 1985)

KEY WORDS • insulin-dependent diabetes • end-stage renal failure

D ATA presented at the last European Dialysis

I and Transplantation Association congress 1
and during a recent international symposium
entirely devoted to prevention and treatment of diabet-
ic nephropathy 2 clearly illustrated that diabetes is the
only growing cause of end-stage renal disease (ESRD)
in all of the industrialized countries. Indeed, a recent
explosion in the acceptance of diabetic patients for
dialysis and transplantation is observed when treat-
ment facilities become available. Despite the very en-
couraging results achieved with transplantation, 3 " 5 the
majority of diabetic patients with ESRD are treated by
dialysis.6"* Continuous ambulatory peritoneal dialysis
(CAPD) has been satisfactory for patients with insulin-
From the Department of Nephrology, H&pital de la Pitie, Paris,
France.
Part of this work was presented at the IX International Congress
of Nephrology, Los Angeles, California, USA, in June 1984.
Address for reprints: Dr. Jacques Rottembourg, Service de N6-
phrologie, Hopital de la Pitie, 83 bd de l'Hdpital, 75651 Paris
Cedex 13, France.
11-125
dependent diabetes (IDD), and very encouraging re-
sults after 2 years have been reported. 9 "" Therefore the
time has come for a critical appraisal of the true advan-
tages and shortcomings of CAPD in this population.
Specific data are given about control of blood pressure,
vision, and cardiovascular status.
Patients and Methods
Patients
Between August 1978 and December 1983, 51 un-
selected patients with IDD were trained in dialysis
methods in an individualized unit of the Department of
Nephrology of the Hopital de la Piti6 in Paris. They
accounted for 30% of the 170 patients trained in CAPD
during the same period and for 60% of the IDD patients
treated by dialysis methods during the same period.
The CAPD technique was the first choice of 46 pa-
tients, and 5 patients were transferred to CAPD from
hemodialysis (HD) because of ocular (one patient),
cardiovascular (three patients), and vascular access
(one patient) problems. Forty-five of the 51 patients
 II-126 DIABETES AND HYPERTENSION
were trained in CAPD and the remaining six were also
treated at home, mainly because of vision problems,
with continuous cyclic peritoneal dialysis (CCPD).
The data of these six patients were included in the
CAPD series. As of December 1983, the cumulative
duration of treatment was 65.6 patient-years, with an
average time per patient of 17.1 ± 11 (SD) months
(range 1-38 months). Fourteen patients were treated at
least 2 years and four patients for 3 years.
At the beginning of treatment there were 27 male
and 24 female patients whose mean age was 52.3 ±
13.5 years. The mean age when diabetes was discov-
ered was 29.2 ± 15.2 years. The mean delay between
discovery of diabetes and start of dialysis was 23 ±
17.6 years. The mean delay between the time that the
serum creatinine level was 200 ± 50 fimol/L and the
start of dialysis was 32.2 ± 12.8 months. Thirty-five
patients had been treated with insulin since the discov-
ery of diabetes and 16 had been treated temporarily
with oral antidiabetic drugs. All patients were treated
with insulin when dialysis was started.
Extrarenal complications at start of CAPD were ex-
tremely severe (Table 1).
Methods
Training for CAPD and CCPD took place in a sepa-
rate unit with a nursing staff especially devoted to this
task. The training period lasted an average of 22 days
(12-32 days). Treatment was conducted through a
double-cuff Tenckhoff catheter (supplied by Quinton
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Instruments, Seattle, WA, USA); we preferred the
curled type.12 The composition of the dialysate and
features of the bag have been described." In most
cases, CAPD was carried out with four exchanges per
day using three 2-liter bags with 1.5% dextrose con-
centration and one 2-liter bag with 4.5% dextrose con-
centration. The CCPD was conducted by the family of
the patient or a trained nurse with a cycler machine
dispensing three to four 2-liter bags overnight while
fluid was left in the peritoneal cavity during the
daytime. 13
Considering the daily peritoneal absorption of about
100 g of dextrose and the daily loss of about 10 g of
protein through the dialysate effluent, the patients
were asked to eat a diet with a carbohydrate content
TABLE 1. Extrarenal Complications in 51 Patients with Insulin-
Dependent Diabetes Before Dialysis Treatment
Type n %
Hypertension (> 160/100) 48* 94
Proliferative retinopathy 50 98
Total blindness 6 12
Previous history of myocardial
infarction 26 41
Angina pectoris 30 59
Peripheral vascular disease 30 59
Clinical peripheral neuropathy 38 75
Previous cerebrovascular accident 5 10
Three patients previously treated by hemodialysis were normo-
tensive at time of CAPD.
SUPPL II HYPERTENSION, VOL 7, No 6, NOV-DEC 1985
ranging between 130 and 150 g/day and a protein con-
tent of about 1.5 g/kg of body weight per day. Water
and salt intake was adjusted according to residual renal
function, clinical state of hydration, and blood pres-
sure values. Furosemide was administered orally with
the aim of preserving residual urinary output.
Patients and their relatives were trained to measure
the blood sugar level with the finger-prick technique
on the Glucometer Ames (Ames Miles Division, Paris,
France). During the initial training, control blood sug-
ar was measured four times per day at each exchange.
At home, only two measurements were performed rou-
tinely by the patients, but every 2 weeks they were
required to take six readings at 0800, 1100, 1400,
1800, 2000, and 2200 hours. Our goal was to obtain a
fasting blood glucose level of less than 10 mmol/L.
During CAPD, insulin was administered exclusively
through the peritoneal route with a special injection
site on the line of the bag. Insulin schedules according
to time and meals are shown in Table 2 for patients
treated by CAPD. Patients treated by CCPD received
subcutaneous injections of regular insulin twice daily
and a mixture of regular and long-acting insulin once
daily.
Results
Survival Rates, Cause of Dropout, Technical
Complications, and Hospitalization
The overall rates of patient survival and technique
success according to age are given in Figure 1. At 2
years the survival rate of all patients was 63%. In 19
patients under age 50 years (mean age 39 ± 8 years)
the technique success rate at 2 years was 78% and in 27
patients over age 50 years it was only 50% (mean age
61.5 ± 8 years).
The dropout rate including deaths and transfers to
other therapeutic modalities increased with age. A to-
tal of 14 patients transferred from hemodialysis for the
following reasons: inability to manage the technique, 5
patients; recurrent peritonitis, 4; sclerosing peritonitis,
2; malnutrition, 1; bowel perforation, 1; and loss of
ultrafiltration, 1. (Three of these patients died during
the 2 months after transfer.) The causes of transfer of
patients to HD were mainly due to abdominal compli-
cations or malnutrition. Five patients were unable to
handle the technique, and as they could not care for
themselves at home, they were transferred in the early
phase of HD. Later causes of transfer were severe
abdominal complications including recurrent peritoni-
tis, sclerosing encapsulating peritonitis, loss of ultra-
filtration, and malnutrition. The 13 deaths were from
the following causes: myocardial infarction, 3 pa-
tients; gangrene and sepsis, 6; cerebrovascular acci-
dent, 1; malnutrition, 1; liver insufficiency, 1; and
bowel perforation, 1. This one abdominal death occur-
ring in a patient treated with CAPD was caused by an
acute abdominal complication related to a perforated
sigmoidal diverticulum.
The overall frequency of peritonitis was 86 epi-
sodes, one every 9.6 patient-months. In 68 patients a
pathogen was isolated: 47 gram-positive, 26 gram-
 AMBULATORY PERITONEAL DIALYSIS IN DIABETIC PATlEmS/Rottembourg et al. 11-127

TABLE 2. Estimation of Daily Insulin Requirement and Carbohydrate Intake from Food and Dialysate in Insulin-
Dependent Diabetic Patients Treated with CAPD
Timing of bag exchange and meals
0700 1200 1600 2000
Components hours hours hours hours Total
Dextrose concentration of the 2-L bag (%) 1.5 1.5 1.5 4.5
Routine dextrose absorption per 2-L bag (g) 25 20 20 60 125
Routine carbohydrate intake per meal (g) 30 70 20 40 160
Regular insulin routinely injected (IU) 18 26 14 30 88

100 1978-1983 FIGURE 1. Rates of actuarial survival and

technique success according to age of 46 pa-
90. tients with IDD treated by continuous peritone-
^ ^
21N al dialysis from August 1978 to December
80. s
1983.
^ ^
70. 2IV
20 - v \ ""-K4 «3
% 60. 16^—

50.

40.
^4°---.,
9 __0 Patient Survival Rate.All cases
30.
Technique Success Rate
20. „. _„ 19 patients under 50 y (m. age 39.1 ±8y)
O - O " p a t * nts over 50 y (m.age 61. 5±8y)

0.5 i 15 2 2.5 3
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Time, years

negative, and 5 fungi; 18 cultures were aseptic, includ-
ing 9 from patients receiving antibiotics for other rea-
sons. Eight peritoneal catheters had to be changed
because of recurrent peritonitis in three cases, tunnel
infection in one, skin exit infection in two, and dis-
lodgment in two.
Duration of hospitalization per patient per year was
23 ± 17 days during the first year of treatment, train-
ing period not included, and 18 ± 8 during the second
year.
Main Clinical Values
Hypertension
At the start, 48 patients were hypertensive. Three
patients previously treated by hemodialysis and trans-
ferred to CAPD because of cardiovascular complica-
tions such as hypotension and cardiac failure were
normotensive. Ninety-three percent received hypoten-
sive drugs, including diuretics, 36 patients; beta
blockers, 25; central sympatholytic agents, 29; vasodi-
lators, 18; and converting enzyme inhibitors, 5. At
start of CAPD, three patients (7%) were normotensive
without any therapy, 17 (37%) were normotensive
with treatment including mostly three to four drugs;
and 26 (56%) were hypertensive despite intensive
treatment.
After 1 year of CAPD treatment, 17 of 31 patients
(55%) were strictly normotensive without drug therapy
(if one excludes diuretics to prevent residual renal
function). Fourteen (45%) took antihypertensive
drugs, but in smaller amounts than previously; of
these, 10 were normotensive and 4 remained hyperten-
sive. After 2 years, 11 patients of 14 (79%) were
normotensive and 3 were treated either with beta
blockers and central sympatholytics or central sym-
patholytics and vasodilators (Table 3).
In eight patients with major autonomous neurologic
disorders, severe postural hypotension was observed
and was augmented when rapid ultrafiltration is in-
duced by using dialysate with a high dextrose concen-
tration. Sodium supplement or albumin infusion may
sometimes be necessary in such instances.
Visual Status
Visual status was assessed at start of treatment and
after at least 6 months of CAPD (range 6-38 months)
in 46 patients. At each ophthalmic visit the best cor-
rected visual acuity for each eye was determined, a
thorough ophthalmic examination was completed, and
retinopathy was documented by multiple-field stereo-
photography (one per year). The visual acuities were
grouped into functional stages: 1) reading visual acu-
ity, 20/10 to 20/50; 2) impaired visual acuity, 20/70 to
20/100; 3) ambulating visual acuity, 20/160 to count-
 11-128 DIABETES AND HYPERTENSION SUPPL II HYPERTENSION, VOL 7, No 6, NOV-DEC 1985

TABLE 3. Evolution of Blood Pressure and Hypotensive Therapy in 46 Patients Treated with CAPD for More Than
One Month
Period (mo) 0-1 6 12 24 36
Patients (n) 46 37 31 14 4
Blood pressure (mm Hg)
Supine systolic 173±42 150 ±30 149 ±30 146 ±32 137±28
Diastolic 96±27 85 ±14 86±17 83 ±16 89±13
Orthostatic systolic 165 ±63 143 ±25 136±22 144±28 138 ±35
Diastolic 9O±35 90±16 82±12 86 ±18 80 ±16
Patients taking antihypertensive
drugs
n 43 19 14 3 1
% 93 51 45 21 25

ing fingers; 4) minimal visual function, hand motions
to light perceptions; and 5) no visual function, no light
perception. All but one patient had proliferative reti-
nopathy, 64% were in stages 1 and 2, and 36% in stage
3. Results on visual function and visual course are
shown in Table 4. Visual acuity measurements in 46
patients showed the following distribution: stage 1, 30
eyes; stage 2, 26 eyes; stage 3, 22 eyes; stage 4, 7 eyes;
stage 5, 5 eyes.
Visual course over the period of study gave the
following results: visual improvement was noted in 14
eyes (mainly in young patients under 50 years old) due
to spontaneous resorption of vitreous hemorrhage,
photocoagulation, and surgical vitrectomy. Deteriora-
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amputations. These were exclusively in the lower
limb, including 5 toes, 5 forefeet, 12 legs at different
levels, and 1 thigh. Diffuse necrotic skin lesions
were observed in four patients. Six patients died after
amputations.
Discussion
During the past 5 years it was well demonstrated that
CAPD could offer patients with insulin- and non-insu-
lin-dependent diabetes with ESRD excellent control of
both uremia and blood glucose levels, and their com-
plications.*"" 14 For these reasons, since 1978 many
institutions have selected CAPD as the preferred mode
of home dialysis for diabetics.' 5 Nevertheless, two ma-

tion of visual function occurred in 17 eyes due to
numerous events (some patients experienced more
than one): recurrent vitreous hemorrhage, 5 eyes; cata-
ract, 6 eyes; macular degeneration, 3 eyes; and anterior
segment neovascularization, 3 eyes.
Cardiovascular Complications
Complications were categorized as cardiac, cerebro-
vascular, and peripheral vascular. Extrarenal compli-
cations, mainly cardiovascular, were noted at the start
of CAPD. During treatment, the condition of most
patients improved, but one died within the first month
of treatment of cerebrovascular accident; 3 died of
myocardial infarction after I, 15, and 27 months of
treatment; and 16 suffered from angina pectoris, main-
ly during the short period of fluid overload.
During observation, 11 patients of 46 required 23
jor drawbacks have limited its extensive use: patients
who are partially or totally blind find the technique
difficult to manage despite intensive training14 and the
dropout rate is high because of the severe and some-
times lethal abdominal complications.16
The most recent data published, including our own
results,8-l0-l7 demonstrate that if one considers not only
patient survival rate but the technique's success rate,
the results obtained with CAPD can compete favorably
with those obtained in a diabetic population of the
same mean age treated not only by hemodialysis and
intermittent peritoneal dialysis6-18-l9 but by transplan-
tation. The only exception is represented by the excel-
lent graft survival rate when using a living related
donor.3"5 The dropout rate, including deaths and trans-
fers, is largely influenced by age, the major risk factor.
In our series, the technique success rate at 2 years with

TABLE 4. Visual Function and Visual Course in 46 Patients Treated with CAPD
Visual function
Baseline Final Visual course
Stage Acuity n % n % Group n %
1 20/10 ±20/50 30 34 38 42 Improved 14 16
2 20/70-20/100 26 29 21 23 Stable 56 60
3 20/160-counting fingers 22 24 16 17 Decreased 17 18
4 Light perception 7 8 11 13 Minimal function 5 6
5 Totally blind 5 5 5 5
Totals 92 100 92 100 Totals 92 100
 AMBULATORY PERITONEAL DIALYSIS IN DIABETIC PATIENJS/Rottembourg et al.
CAPD was 78% for patients under age 50 years and
only 50% for those over age 50. Patients transferred
mainly because of technical problems.
Excellent clinical status with good control of blood
pressure, satisfactory values of major biological varia-
bles, and good nutrition are routinely obtained in many
patients with CAPD on a daily program of four ex-
changes, including only one 2-liter bag with high dex-
trose concentration. Extracellular fluid volume can be
controlled by changing the dialysate formulation, prin-
cipally by increasing the dextrose concentration. In our
experience with the regimen described, daily fluid re-
moval was found to be 1200 ± 230 ml/day and the
sodium balance negative on 80 ± 25 mmol/day.20 Our
results agreed with those of other studies dealing with
diabetics showing a good control of blood pressure by
CAPD.9-10- u - 18 This control seems to be progressive
with time: 7% of patients at start of CAPD, 55% at 1
year, and 79% at 2 years were normotensive without
any medication. Rapid control of hypertension was
also associated with a relatively high frequency of
symptomatic orthostatic hypotension. Despite a pro-
gressive increase in body weight after 1 and 2 years of
treatment, arterial blood pressure had no tendency to
return toward high levels. This increase in body weight
may probably be attributed not only to a gain in lean
body mass but to expanded extracellular volume.
Some of these patients became hypotensive, suggest-
ing sodium depletion and hypovolemia. Further stud-
ies are required to explain this phenomenon: is there a
depletion of pressor substance with a high molecular
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weight? is there any disturbance in the vascular reac-
tivity with CAPD?
Rapid deterioration of visual function is one of the
major threats to diabetic uremic patients who undergo
maintenance hemodialysis therapy.21 Poor control of
hypertension and blood glucose level, and the meta-
bolic disturbances induced by diabetes and uremia,
together with the deleterious effect of heparin are
claimed by these authors as being responsible for the
progression toward blindness often encountered in
these patients. With CAPD the reports improve:
Khanna et al.'° reported improvement in 3 of 19 eyes
and deterioration of 4 of 30 eyes. Good control of
blood pressure and blood glucose levels, no acute
shifts in body weight or osmolality, and no intensive
use of heparin enabled patients to maintain visual acu-
ity at the same level as at the start of CAPD. In addi-
tion, active therapy such as scatter photocoagulation
and surgical vitrectomy can often clearly alter the natu-
ral course of diabetic retinopathy.22-23
Vascular complications remain the main cause of
death among diabetics treated by all forms of renal
replacement therapy including CAPD. In addition to
cardiac disease and cerebrovascular accidents, the se-
verity of some peripheral vascular disease, leading to
gangrene and in some cases death through sepsis,
should be emphasized. Also, CAPD has been consid-
ered as a contributing factor to the acceleration of
peripheral vascular disease.24 In fact, there is a high
rate of amputation, around 20 to 25%, among diabetic
II-129
patients using all forms of dialysis and after transplan-
tation.3- 6 Adequate prevention seems possible through
an early program of foot care.
Excluding diabetic patients from treatment is no
longer acceptable when the therapeutic facilities are
available. Several treatment modalities now offer in-
creasing numbers of diabetic patients with ESRD long-
er survival, decreased morbidity, and better rehabilita-
tion, and at a lower cost for the community, and CAPD
should be one of the therapies available. It is probably
the only dialysis method that diabetics can perform
themselves at home. With acceptable rates of peritoni-
tis and diminution of peritoneal complications, CAPD
could really be the dialysis method of choice. An inte-
grated program CAPD-transplantation could become
the preferred supportive treatment for those with juve-
nile diabetes. Although tedious precautions are re-
quired to avoid peritoneal infection, CAPD offers a
unique opportunity to treat elderly diabetics at home
and ensure the best control of diabetes, uremia, and
hypertension.
Thus while CAPD may be the best treatment selec-
tion for some diabetics, all forms should be available
to give each patient a good first choice.
References
1. Wing AJ, Broyer M, Brunner FP, et al. Combined report on
regular dialysis and transplantation in Europe, 1982. XII Pro-
ceedings of the European Dialysis and Transplantation Associ-
ation. London: Pitman, 1983:5-75
2. Keen H, Legrain M. Prevention and treatment of diabetic
nephropathy. Lancaster, England: MTP Press, 1983
3. Sutherland EDR, Fryd DS, Peters C, Ferguson RM, Najarian
JS. Current status of kidney transplant in uremic diabetics at
the University of Minnesota. In: Friedman EA, L'Esperance
FA, eds. Diabetic renal retinal syndrome. 2nd ed. New York:
Grune & Stratton, 1982:373-383
4. Belzer F, Glass N, Sollinger H, Miller D. Functional survival
of juvenile diabetic patients after renal transplantation. In:
Friedman EA, L'Esperance FA, eds. Diabetic renal retinal
syndrome. 2nd ed. New York: Grune & Stratton, 1982:
385-393
5. Brynger N, Larson O. Ten years' experience of renal trans-
plantation in diabetic patients. In: KQss R, Legrain M, eds.
Se'minairesd'Uro-Ne'phrologie. Paris: Masson, 1982:127-137
6. Shapiro F, Comty C. Hemodialysis in diabetes 1981. Updates.
In: Friedman EA, L'Esperance FA, eds. Diabetic renal retinal
syndrome. 2nd ed. New York: Grune & Stratton, 1982:
309-320
7. Legrain M, Rottembourg J, Gahl GM, Bentchikou A, Strippoli
P. The treatment of renal failure in diabetic patients. The best
buy. In: Keen H, Legrain M, eds. Prevention and treatment of
diabetic retinopathy. Lancaster, England: MTP Press, 1983:
361-376
8. Legrain M, Rottembourg J, Bentchikou A, etal. Dialysis treat-
ment of insulin-dependent diabetic patients: ten years' experi-
ence. Clin Nephrol 1984;21:72-81
9. Amair A, Khanna R, Leibel B, et al. Continuous ambulatory
peritoneal dialysis in diabetics with end-stage renal disease. N
Engl J Med 1982;306:625-630
10. Khanna R, Wu G, Chisholm L, Oreopoulos DG. Further expe-
rience with CAPD in diabetics with end-stage renal disease.
Diabetic Nephropathy 1983;2:8-12
11. Rottembourg J, El Shahat Y, Agrafiotis A, et al. Continuous
ambulatory peritoneal dialysis in insulin-dependent diabetic
patients: 40 months' experience. Kidney Int 1983;23:4O-47
12. Rottembourg J, Jacq D, Vonlanten M, Issad B, El Shahat Y.
 11-130 DIABETES AND HYPERTENSION
Straight or curled TenckhofF peritoneal catheter for continuous
ambulatory peritoneal dialysis. Peritoneal Dialysis Bull 1981;
1:123-125
13. Diaz Busco JA, Walker PJ, Farmer CD, Changler JT, Holt KL,
Cox P. Continuous cyclic peritoneal dialysis Trans Am Soc
Artif Intern Organs 1981 ;27:51-53
14. Flynn CT. The diabetic on CAPD. In: Friedman EA, L'Esper-
ance FA, eds. Diabetic renal and retinal syndrome. I st ed. New
York: Grune & Stratton, 1981:321-336
15. Jacobs C, Brunner F, Brynger H, et aJ. The first five thousand
diabetics treated by dialysis and transplantation in Europe.
Diabetic Nephropathy 1983;2:11-17
16. Rottembourg J, Gahl GM, Poignet JL, et al. Severe abdominal
complications in patients undergoing continuous ambulatory
peritoneal dialysis. Proc Eur Dial Transplant Assoc 1983;
20:236-242
17. Madden MA, Zimmerman S, Simpson D. Continuous ambula-
tory peritoneal dialysis in diabetes mellitus. Am J Nephrol
1982;2:133-139
18. Slingeneyer A, Mion C, Selam JL. Home intermittent (IPD)
and continuous ambulatory peritonea] dialysis (CAPD) as a
Downloaded from http://ahajournals.org by on April 19, 2021
SUPPL II HYPERTENSION, VOL 7, No 6, NOV-DEC 1985
long-term treatment of end-stage renal failure in diabetics. In:
Gahl GM, Kessel M, Nolph KD, eds. Advances in peritoneal
dialysis. Amsterdam: Excerpta Medica, 1981:378-383
19. Kjellstrand C, Whitley K, Comty C, Shapiro F. Dialysis in
patients with diabetes mellitus. Diabetic Nephropathy 1983;
2:5-17
20. Legrain M, Renaux C, Rottembourg J. La dialyse p6riton6ale
continue ambulatoire. Nouv Presse Med 1980;9:3153—3158
21. Shapiro FL, Leonard A, Comty CM. Mortality, morbidity and
rehabilitation results in regularly dialyzed patients with diabe-
tes mellitus. Kidney Int 1974;6:58-64
22. Diabetic Retinopathy Study Research Group. Preliminary re-
port on the effects of photocoagulation therapy. Am J Ophthal-
mol 1976;81:383-391
23. Ramsay RC, Cantrill L, Knolbloch WH, Shapiro FL, Comty
CM, Kjellstrand CM. Visual parameters in diabetic patients on
chronic dialysis. Diabetic Nephropathy 1983;2:3O-38
24. Brown PM, Honston KW, Fenton SSA, Cattran DC. Symp-
tomatic exacerbation of peripheral vascular disease with chron-
ic ambulatory peritoneal dialysis. Clin Nephrol 1981;16:
258-261