The Medical clinics of North America
-
Med. Clin. North Am. · Jan 2013
ReviewThe pathogenesis and management of hypertension in diabetic kidney disease.
Hypertension commonly coexists with diabetes, and its prevalence is even higher in the presence of diabetic kidney disease. The pathogenesis of hypertension in this population stems from increased extracellular volume and increased vasoconstriction that results from mechanisms that may be attributed to both diabetes and the eventual impairment of renal function. Antihypertensive therapy aimed at reducing blood pressure remains a primary goal in preventing the incidence of diabetic kidney and slowing its progression. ⋯ Using combination RAAS therapy further reduces proteinuria, but the benefits of this strategy compared with the potential risks of hyperkalemia and acute deterioration of renal function are still unknown. Endothelin receptor antagonists also lower proteinuria, but these can be associated with volume overload and edema with no clear long-term benefit on renal function yet identified. Further large clinical trials are needed to better understand how progression to ESRD can be slowed or halted in patients with diabetic kidney disease.
-
The increasing prevalence of diabetes has led to DKD becoming the leading cause of ESRD in many regions. The economic cost of DKD will grow to prohibitive amounts unless strategies to prevent its onset or progression are urgently implemented. In type 1 and type 2 diabetes, the presence of microalbuminuria and macroalbuminuria confers increased risk of developing ESRD and of death. ⋯ Albumin excretion frequently regresses, and GFR can decline without abnormality in albumin excretion. There is emerging evidence that changes in renal function occurring early in the course of diabetes predict future outcomes. The major challenges are to prevent DKD onset, to detect it early, and to improve DKD outcomes globally.
-
Hyperglycemia management in chronic kidney disease (CKD) patients presents difficult challenges, partly due to the complexity involved in treating these patients, and partly due to lack of data supporting benefits of tight glycemic control. While hyperglycemia is central to the pathogenesis and management of diabetes, hypoglycemia and glucose variability also contribute to outcomes. Multiple agents with different mechanisms of action are now available; some can lower glucose levels without the risk of hypoglycemia. This article reviews metabolic changes present in kidney impairment/failure, current views about glycemic goals, and treatment options for the diabetic patient with CKD.
-
Med. Clin. North Am. · Jan 2013
Pancreas transplantation and reversal of diabetic nephropathy lesions.
Pancreas transplantation is the only available treatment that has restored long-term (10 or more years) normoglycemia without the risks of severe hypoglycemia, allowing testing of the reversibility of diabetic nephropathy lesions. The authors studied renal structure before and 5 and 10 years after pancreas transplantation in nonuremic patients with long-term type 1 diabetes, with established diabetic nephropathy lesions at baseline. Diabetic glomerular lesions were not significantly changed at 5 years but were dramatically improved after 10 years, with most patients' glomerular structure returning to normal at the 10-year follow-up. These studies also showed that tubulointerstitial remodeling was also possible.