This year, the slogan of World Kidney Day on March 11, 2010 was adopted as “Control your diabetes well, protect your kidneys”. The number of diabetic patients is increasing rapidly in the world and in our country. In addition, patients with chronic kidney disease are increasing rapidly and this increase is unfortunately due to the chronic kidney disease seen in diabetic patients, which we call diabetic nephropathy (DN). On the World Kidney Day, we would like to address this dangerous disease, which, with a rapid course, eventually turns the patients it affects into dialysis patients.
Diabetic nephropathy is a common problem: As of the end of 2008, approximately 55 thousand patients with end-stage renal disease are treated with dialysis and kidney transplantation in Turkey. About 45 thousand of them are on dialysis, but 7-8 thousand of them live with a functional transplant kidney. Every year, about 10%, that is, around 5 thousand new diabetic patients are added to this number. Diabetic patients are in the first place with a rate of 30% among the patients who have just started treatment and those who are still being treated. Perhaps more important than this is the fact that only 12% of the 11 thousand dialysis patients 10 years ago were diabetic. Type I diabetes, which usually starts in childhood and means absolute insulin deficiency, at least 30% develops minimal protein leakage, which we call microalbuminuria, the first sign of diabetic nephropathy 15 years after diagnosis, and just under half of them develop significant protein leakage or established DN. Since the onset of diabetes cannot be determined well in Type 2 diabetes, which starts in adulthood and we see more commonly, it cannot be said how long this rate will be. But this rate is certainly less than in Type 1 diabetes and tends to decrease in recent years, thanks to advances in insulin therapy, treatment of protein leakage, and careful monitoring and control of hypertension. For example, in one study, DN was observed in 32 patients per year in 1000 patients in the 90s, while this rate decreased to 15 in the 2000s. However, when we consider the prevalence of Type 2 diabetes and its rapidly increasing number due to increasing obesity and inactivity, the frightening situation I mentioned above emerges.
Diabetic nephropathy progresses rapidly: In the early period of DN, it manifests itself with a symptom called microalbuminuria, which is detected only by a special method. Then, this situation progresses to a protein leakage of more than 3-5 gm per day, which is detected even with routine urine analysis. Generally, hypertension is added to the table if it has not started before this period. Then, a rapidly developing kidney function loss and finally being a dialysis patient occurs. The most serious problem of these patients is a serious salt and water accumulation and the resulting high blood pressure, accompanied by left heart failure and shortness of breath, which develops with fluid accumulation in the lungs. Therefore, most patients need to be taken to emergency dialysis treatment before their urea and creatinine levels increase too much. Therefore, it has become a rule to prepare for dialysis early in these patients.
Diabetic nephropathy can be prevented: If a person has diabetes, he must first accept this fact and fulfill the requirements of this disease. Unfortunately, the cost is heavy when diabetic control is not performed in patients. Control of blood sugar is the most important measure in the beginning. The key to this is primarily not to gain weight or to lose weight if we are overweight, and to take a moderate diet consisting of flour and sugar foods in 5 meals throughout the day. Oral medications initially, but as the age of diabetes increases, even if sugar control is good, timely insulin therapy will accompany the diet. HbA1C (glucosylated hemoglobin) levels, which is a test showing 3-month sugar control, should be checked every 3 months and should be kept below the 6.5% target. A common mistake we encounter in diabetic patients is monitoring the patient by only looking at their blood sugar. In fact, some of the patients do this work on their own and do not even follow a doctor. However, these patients should be followed closely in terms of hypertension, cardiovascular diseases, capillary changes at the base of the eye, eye retinal diseases that cause blindness with hemorrhages, and peripheral nerve disease, which causes a dangerous process leading to diabetic foot amputation of the leg or arm. A simple urine analysis comes in all five of the tests that need to be done. Better still, for the early diagnosis of protein leakage in the urine, the determination of microalbuminuria and creatinine in the urine together or the total amount of microalbumin in 24 hours is extremely important for the early diagnosis of DN. If microalbuminuria has started, the most important measure is again good control of sugar, it can prevent DN. If overt proteinuria—that is, its detectability in routine urine—appears as the disease progresses, glycemic control will no longer work. Since the formation of DN is closely related to the increase in intrarenal pressure, it is also necessary to administer a blood pressure medication from the ARB or ACEI group in order to reduce the intrarenal pressure, to reduce the existing microalbuminuria or proteinuria, even if there is no high blood pressure.
There are a number of studies showing that the follow-up of patients by a nephrologist, especially at the stage of onset of microalbuminuria, prolongs the survival of the kidneys, if possible. If the blood pressure (blood pressure) of the patients is high, it must be lowered below 130. Ensuring this is extremely important in terms of preventing DN progression. We should underline the importance of eating salt-free, along with medication, in order to control blood pressure. Diabetic patients are essentially salt sensitive and therefore hypertension is more common in diabetics than in nondiabetics. If DN develops and kidney dysfunction also occurs, it becomes even more sensitive to salt. Therefore, if a patient with DN cannot follow a salt-free diet, it is absolutely impossible to lower his blood pressure with medication.
Diabetic patients undergoing dialysis have a worse prognosis: Diabetic patients are faced with a negative prognosis in terms of cardiovascular diseases, even if they do not have kidney failure. When kidney disease is added to this situation, the process of arteriosclerosis accelerates and this makes this course more negative. The life expectancy of diabetic patients on dialysis is one and a half times shorter than non-diabetic dialysis patients.
Diabetic dialysis patients can also have kidney transplant: There is no obstacle for diabetic patients to have kidney transplant. The life expectancy of transplanted patients is better than those undergoing dialysis. A significant portion of chronic kidney failure patients who do not have diabetes before kidney transplant surgery develop diabetes after transplantation due to drugs that have to be used.
Genetic predisposition to diabetes may be fate, but a diabetic patient may have all kinds of negative complications, especially kidney disease. With careful monitoring and treatment of diabetes, preventive measures can cease to be fate.
