Diabetic nephropathy: improving prognosis.
Diabetes is the disorder most often linked with development of end-stage renal disease (ESRD) in the USA, Europe, South America, Japan, India, and Africa. Kidney disease is as likely to develop in long-duration non-insulin dependent diabetes (type 2) as in insulin-dependent diabetes mellitus (type 1). Nephropathy in diabetes, if sub-optimally managed, follows a predictable course starting with microalbuminuria through proteinuria, azotemia and culminating in ESRD. The rate of renal functional decline in diabetic nephropathy is slowed by normalization of hypertensive blood pressure, establishment of euglycemia, and a reduced dietary protein intake. When compared with other causes of ESRD, the diabetic patient sustains greater mortality and morbidity due to associated systemic disorders especially coronary artery and cerebrovascular disease. A functioning kidney transplant provides the uremic diabetic patient better survival with superior rehabilitation than does either continuous ambulatory peritoneal dialysis (CAPD) or maintenance hemodialysis. There are no reports, however, of prospective controlled studies of dialysis versus kidney transplantation in diabetic patients whose therapy was assigned randomly. Survival in treating ESRD of diabetes is continuously improving. This progress reflects multiple small advances in understanding of the pathogenesis of extrarenal micro- and microvasculopathy coupled with safer immunosuppression. Combined pancreas and kidney transplantation has so far been performed for a minority (< 10%) of diabetic ESRD patients and has offered cure of the diabetes and full rehabilitation. No matter which ESRD therapy has been elected, optimal rehabilitation in diabetic ESRD patients requires that effort be devoted to recognition and management of co-morbid conditions.
Friedman
Eli A
EA
Department of Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, USA.