The natural history and epidemiology of diabetic nephropathy: implications for prevention and control

Article Abstract:

End-stage renal disease (ESRD, the final phase of kidney disease) among diabetics is the result of diabetic nephropathy, a complication unique to this disorder. ESRD resulting from diabetic nephropathy accounted for 10,025 new cases in 1987. Diabetic nephropathy is indicated by a persistently positive urine test for albumin (albuminuria) when no other kidney disease is present. It appears late in the progression of kidney disease and is often followed immediately by hypertension (high blood pressure) and abnormal kidney function. One way of learning about the disease is to study its earlier stages with kidney biopsies from people with insulin-dependent diabetes mellitus (IDDM); inferences made about non-insulin-dependent diabetes (NIDDM) can then be made. Researchers have identified five stages of diabetic nephropathy among IDDM patients. They are: renal hypertrophy (enlargement) and hyperfunction (increased filtration rate); renal lesions without clinical signs; incipient nephropathy; clinical diabetic nephropathy; and end-stage renal failure. Stage 3, when nephropathy begins to manifest itself, can include amounts of albumin in the urine too small to detect in ordinary clinical assays. Prevention in IDDM victims can aim at preventing further deterioration as well as treating the albuminuria, or by halting the development of nephropathy. Hyperglycemia (increased glucose, or sugar, in the blood) should be prevented from the time of diagnosis onward by aggressive blood monitoring; glucose control seems less effective once albuminuria has become evident. Hypertension should be controlled and protein intake restricted to the level of the recommended daily allowance (0.8 g/kg body weight). Family histories of hypertension of diabetic nephropathy should be noted by clinicians. Patients with IDDM are at higher risk for developing ESRD, but most newly treated cases are NIDDM patients. ESRD rates vary among races within the United States, with higher rates among blacks, Mexican-Americans, and American Indians. The predictive value of screening for very small amounts of albumin in urine for people with NIDDM has not been demonstrated. Since current differences in ESRD frequency could be due to different levels of medical care, preventive measures should be promoted among these groups until equal access to preventive care is assured for all. (Consumer Summary produced by Reliance Medical Information, Inc.)

Care and treatment, Prevention, Complications and side effects, Diabetes, Diabetes mellitus, Diabetic nephropathies

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Understanding Resource Use in Liver Transplantation

Article Abstract:

Doctors need to find ways to reduce the huge cost of liver transplants. The average cost for this operation and the first year of treatment after the operation is about $200,000. Only about 4,000 people received a liver transplant in the US in 1997. Although the treatment is very beneficial, it is hard to justify the cost. Most of this cost is for care received before the operation. This in turn is related to the shortage of donor organs. Efforts are underway to find alternatives, such as organs grown in culture and organs from animals.

Editorial, Ethical aspects, Resource allocation

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Resource Utilization in Liver Transplantation: Effects of Patient Characteristics and Clinical Practice

Article Abstract:

Liver transplants will be more costly in older patients who are critically ill compared to other groups. This was the conclusion of a study of resource use by 711 patients who received a liver transplant. Costs were higher if both donor and recipient were 60 years old or older, if the recipient had alcoholic liver disease, was treated in the intensive care unit or had more than one liver transplant. Costs varied widely among the transplant centers in the study.

Medical care, Medical care utilization

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