Diabetic nephropathy: an update

Article Abstract:

A potential complication of diabetes mellitus, diabetic nephropathy (kidney disease), affects 30 to 35 percent of all diabetics. Diseased blood vessels in the kidneys prevent the kidneys from functioning normally. The ability of the kidneys to filter the blood then becomes diminished. Symptoms of diabetic nephropathy progress from protein in the urine (proteinuria) to potentially life-threatening end-stage kidney disease requiring kidney dialysis or transplantation. The mechanism causing diabetic nephropathy is poorly understood. The membranes of tiny blood vessels in the kidney filtering structures become thickened. These changes increase the rate at which blood is filtered through the kidneys, the glomerular filtration rate (GFR). Exercise, which increases the excretion of protein in the urine, can be used as a test to determine which diabetic patients are at risk for further diabetic nephropathies. Three theories concerning the development of diabetic nephropathies are proposed. The genetic theory implies a genetic predisposition for blood vessel complications. Studies show a difference in the thickness of blood vessel membranes between diabetic and nondiabetic twins. The metabolic theory implicates high blood sugar or low insulin in causing blood vessel complications. The hemodynamic theory states that changes in the force and flow of blood through vessels causes cell injury. Patients with a genetic predisposition to changes in the blood vessel structures in combination with the effects of high blood sugar can develop complications in the kidneys. Treatment is aimed at sugar control, reducing high blood pressure and restricting protein in the diet. The values of aldose reductase inhibitors (to prevent protein in the urine), antiplatelet therapy (to prevent blood-clotting platelets from aggregating) and control of blood lipids (to reduce atherosclerotic build-up in kidney blood vessels) are being investigated. (Consumer Summary produced by Reliance Medical Information, Inc.)

Kidneys, Blood vessels, Kidney, Chronic kidney failure

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Treatment selection considerations for the hypertensive diabetic patient

Article Abstract:

Hypertension is twice as common among diabetic patients as in the general population. And, since both diabetes and hypertension are independent risk factors for heart disease, the hypertensive diabetic patient faces an increased risk for developing accelerated cardiovascular disease. Roughly half of all diabetics become hypertensive. The treatment of hypertension in diabetic patients is complicated by the fact that many of the drugs routinely prescribed for hypertension have adverse effects on other aspects of diabetes. Perhaps the most important of these are the effects of antihypertensive drugs on the nephropathy (kidney disease) which is common among diabetic patients. Diabetic nephropathy must be taken into account when prescribing treatment for the diabetic patient with high blood pressure. Diuretics may cause life-threatening imbalances of electrolytes and accelerate kidney deterioration by stimulating the renin-angiotensin-aldosterone system. Diuretics alone are therefore likely to be detrimental to the patient with diabetic nephropathy, but may be beneficial when used with other drugs that compensate for the adverse effects. Beta-blockers may also have detrimental effects on diabetics, including the development of hypertensive crises during hypoglycemia (episodes of low blood sugar). When angiotensin-converting-enzyme (ACE) inhibitors are used, signs of kidney deterioration must be watched for; ACE inhibitors will further compromise reduced renal function. In conclusion, the treatment of hypertension has important medical benefits. But among diabetics, hypertension cannot be treated without first taking into account the diabetic complications which might be present, and the chances for adverse effects of antihypertensive drugs. (Consumer Summary produced by Reliance Medical Information, Inc.)

Hypertension, Drug therapy

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Diabetic nephropathy: the internist's role

Article Abstract:

About one third of patients with diabetes mellitus develop diabetic nephropathy, a condition causing the kidneys to malfunction. Although the use of insulin has improved the overall health of diabetics, kidney destruction can be potentially life-threatening. A growing number of patients with end-stage renal (kidney) disease (ESRD) are diabetics. In the January 1990 issue of Archives of Internal Medicine, Camerini-Davalos et al. report on the diagnosis, care and treatment of patients with diabetic nephropathy. Diabetic nephropathy is caused by damage to the small blood vessels in the kidney blood circulation. Although poorly understood, a combination of genetics, chemical factors and the behavior of blood circulation contributes to the development of diabetic nephropathy. Since there is no cure, medical care must be aimed at early detection and prevention of kidney damage. Internists should learn to recognize stages of nephropathy. Early recognition allows physicians and patients to plan for the future and be watchful for experimental therapies. Protein and blood in the urine, a hallmark of poor kidney functioning, should be investigated in all diabetics. Treatment of patients initially diagnosed with overt diabetic nephropathy should include drug therapy to reduce high blood pressure. Physicians should be mindful of toxic effects of blood pressure-lowering (antihypertensive) drugs. Other therapies include administration of antiplatelet drugs, which inhibit blood clotting cells from aggregating, and restricting protein in the diet. In patients with rapidly declining kidney function, early planning for dialysis and kidney transplantation is necessary. Close attention to diabetics at risk for kidney disease is essential. (Consumer Summary produced by Reliance Medical Information, Inc.)

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