Diabetic Nephropathy: Natural Course, Survivorship and Therapy

Abstract

Diabetes mellitus is a disease with major social and economic consequences. End-stage renal disease (ESRD) due to diabetes occurs in as many as 30% of patients with juvenile diabetes, providing a large percentage (up to 33%) of all patients in need of therapy for ESRD. We have reviewed the natural course of the nephropathy in type I diabetes mellitus and the results of dialysis and transplantation therapy with particular regard to survival and morbidity. Comparisons of the survival of diabetic patients among peritoneal dialysis, hemodialysis, and transplantation are complicated by the lack of sufficient data for peritoneal dialysis and by the bias introduced by patient/treatment selection methods. Presently, it appears that transplantation with a living related donor graft offers the best survival for both graft and patient, with a definite reduction of morbidity associated with the complications of diabetes. Cadaveric transplantation is approximately the equivalent of hemodialysis in patient survival at 1 year and also appears to offer a somewhat diminished morbidity. Peritoneal dialysis data are sparse and skewed by patient selection. However, there is some emerging evidence that therapy with this modality may be associated with a delay in progression of retinopathy, when compared with hemodialysis.

Prolonged Dietary Protein Restriction in Diabetic Nephropathy

“…This increase in protein excretion negates the effects of increased albumin synthesis, and, usually, it is not possible to obtain an increase in nitrogen balance or observe an increase in the serum albumin concentration. As demon¬ strated after 1 year in the present study and in other studies,20 institution of a low-protein diet in proteinuric patients re¬ duces the urinary excretion of protein. Although albumin synthesis is decreased, the substantial reduction in urinary losses permits attainment of a positive protein balance.19 While a beneficial effect of dietary restriction on protein excretion was observed after 1 year, urinary excretion of protein increased in the second 12-month interval, and the serum concentration of albumin was reduced.…”

Glomerulonephritis in Diabetic Patients and Its Effect on the Prognosis

“…Either an increased incidence of infection or functionalstructural abnormalities of the glomeruli may explain the high incidence of glomerular disease complicating dia betic patients [1,3,14]. Reported types of GN as complica tions in diabetic patients include MGN [1,3,7,16,19,21,[24][25][26], EPGN [10,18,22], MCNS [4,20,23], MPGN [25], dense deposit disease [9], mesangial PGN [12] and rapidly progressive glomerulonephritis (RPGN) [6].…”

Comparison of Type II and Type I Diabetics Treated for End-Stage Renal Disease in a Large Prepaid Health Plan Population

“…Diabetic nephropathy has become the most frequent single cause of end-stage renal disease (ESRD) in the US [1,2], Among all patients treated with maintenance hemo dialysis, diabetic nephropathy is diagnosed in 20-25%, and the incidence is apparently still increasing (3,4], This is of considerable importance for the rational allocation of resources for ESRD therapy, since diabetics generally have more complications and require larger expenditures than other ESRD patients [5,6]. Although a large propor tion of diabetic patients reaching ESRD have type II diabetes [7,8], very little is known about the natural history of the renal disease in adult-onset diabetics.…”