**15. Diabetic nephropathy and hemodialysis**

Chronic kidney disease has been related with progression to PDR and DME in type 2 diabetic patients in advanced stages of their microvascular impairment. Systematic assessment of 2135 type 2 diabetic patients for 8 years revealed in 9.2% of new-onset DME identified in fundus photographs that had meaningful relationship with albumin/creatinine ratio below 31 mg/g at baseline, mean follow- serum creatinine levels and estimated glomerular filtration rate 30 and 45 mL/min/1.73 m2 [46]. This longitudinal study clearly emphasizes the importance of screening the DME patients for abnormal renal profile at baseline and throughout the whole follow up. A marked VEGF expression secondary to glomerular injury and elevated levels of serum VEGF in patients with advanced nephropathy could explain the incomplete and unstable response of their macular edema to intravitreal treatment. Introduction to hemodialysis of patients with end-stage renal disease and coexisting DME was associated with significant reduction in the central retinal thickness lasting over the next 12 months, to a level that eliminated the need for intravitreal treatment in 93.2% of the eyes. The fluid resolution was greater in eyes with subretinal detachment compared to spongelike swelling and macrocystic edema. A significant correlation between changes of BCVA and central retinal thickness at 12 months after hemodialysis initiation was found in the patients with good BCVA (over 20/50) but not in the patients with poor BCVA (less than 20/50) [47]. In clinical practice, a sizable group of patients with advanced renal decompensation

**Figure 7.**

*59 years old male, DM for 25 years, renal failure, chronic hemodialysis, CAD, DME, PDR, recurrent anterior uveitis, recurrent iris neovascularization, secondary glaucoma. a, b -Perimacular edema progressing centrally during deterioration of CAD and CABG, VA 20/20, c* − *6 months and 4 intravitreal injections later, VA 20/20, d - OCTA –superficial plexus, capillary dropout, microaneurisms, hyperreflectivefoci and distorted enlarged foveolar avascular zone.*

had notable stabilization of their DME after induction of hemodialysis and needed less intensive management, however they remain at high risk for recurrences of the edema and severe retinal ischemia (**Figure 7**).
