Kidney Disease

High blood pressure, or hypertension, is a major factor in the development of kidney problems in people with diabetes. Both a family history of hypertension and the presence of hypertension appear to increase chances of developing kidney disease. Hypertension also accelerates the progress of kidney disease where it already exists.

Hypertension usually is defined as blood pressure exceeding 140 millimeters of mercury-systolic and 90 millimeters of mercury-diastolic. Professionals shorten the name of this limit to "140 over 90." The terms systolic and diastolic refer to pressure in the arteries during contraction of the heart (systolic) and between heartbeats (diastolic).

Hypertension can be seen not only as a cause of kidney disease, but also as a result of damage created by the disease. As kidney disease proceeds, physical changes in the kidneys lead to increased blood pressure. Therefore, a dangerous spiral, involving rising blood pressure and factors that raise blood pressure, occurs. Early detection and treatment of even mild hypertension are essential for people with diabetes.

Scientists have made great progress in developing methods that slow the onset and progression of kidney disease in people with diabetes.

Blood Pressure Medicines

Drugs used to lower blood pressure (antihypertensive drugs) can slow the progression of kidney disease significantly. One drug, an angiotensin-converting enzyme (ACE) inhibitor, has proven effective in preventing progression to stages IV and V.1 Calcium channel blockers, another class of antihypertensive drugs, also show promise.

An example of an effective ACE inhibitor is captopril, which the Food and Drug Administration approved for treating kidney disease of Type I diabetes. The benefits of captopril extend beyond its ability to lower blood pressure; it may directly protect the kidney's glomeruli. ACE inhibitors have lowered proteinuria and slowed deterioration even in diabetic patients who did not have high blood pressure.

Some, but not all, calcium channel blockers may be able to decrease proteinuria and damage to kidney tissue. Researchers are investigating whether combinations of calcium channel blockers and ACE inhibitors might be more effective than either treatment used alone. Patients with even mild hypertension or persistent microalbuminuria should consult a physician about the use of antihypertensive medicines.

Low-Protein Diets

A diet containing reduced amounts of protein may benefit people with kidney disease of diabetes. In people with diabetes, excessive consumption of protein may be harmful. Experts recommend that most patients with stage III or stage IV nephropathy consume moderate amounts of protein.

Intensive Management

Antihypertensive drugs and low-protein diets can slow kidney disease when significant nephropathy is present, as in stages III and IV. A third treatment, known as intensive management or glycemic control, has shown great promise for people with IDDM, especially for those with early stages of nephropathy.

Intensive management is a treatment regimen that aims to keep blood glucose levels close to normal. The regimen includes frequently testing blood sugar, administering insulin on the basis of food intake and exercise, following a diet and exercise plan, and frequently consulting a health care team.

A number of studies have pointed to the beneficial effects of intensive management. Two such studies, funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, are the Diabetes Control and Complications Trial (DCCT)2and a trial led by researchers at the University of Minnesota Medical School.3

The DCCT, conducted from 1983 to 1993, involved 1,441 participants who had IDDM. Researchers found a 50-percent decrease in both development and progression of early diabetic kidney disease (stages I and II) in participants who followed an intensive regimen for controlling blood sugar levels. The intensively managed patients had average blood sugar levels of 150 milligrams per deciliter--about 80 milligrams per deciliter lower than the levels observed in the conventionally managed patients.

In the Minnesota Medical School trial, researchers examined kidney tissues of long-term diabetics who received healthy kidney transplants. After 5 years, patients who followed an intensive regimen developed significantly fewer lesions in their glomeruli than did patients not following an intensive regimen. This result, along with findings of the DCCT and studies performed in Scandinavia, suggests that any program resulting in sustained lowering of blood glucose levels will be beneficial to patients in the early stages of diabetic nephropathy.

When people with diabetes reach ESRD, they must undergo either dialysis or a kidney transplant. As recently as the 1970's, medical experts commonly excluded people with diabetes from dialysis and transplantation, in part because the experts felt damage caused by diabetes would offset benefits of the treatments. Today, because of better control of diabetes and improved rates of survival following treatment, doctors do not hesitate to offer dialysis and kidney transplantation to people with diabetes.

Currently, the survival of kidneys transplanted into diabetes patients is about the same as survival of transplants in people without diabetes. Dialysis for people with diabetes also works well in the short run. Even so, people with diabetes who receive transplants or dialysis experience higher morbidity and mortality because of coexisting complications of the diabetes--such as damage to the heart, eyes, and nerves.

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