Pathophysiology and Prevention of End Stage Renal Disease in Diabetes Mellitus

Abstract

 This study describes the cause and prevention of end stage renal disease (ESRD) in diabetes mellitus (DM). ESRD is defined by a glomerular filtration rate (GFR) of <15ml/min (normal is >60 ml/min). Patients with ESRD are treated with dialysis or kidney transplant. GFR is estimated (eGFR) from serum creatinine levels, taking into account age, gender and race. There are many causes of ESRD but DM is the leading cause. Hypertensive nephropathy, glomerular diseases and cystic disease of the kidneysare other causes of ESRD. In the early stages of diabetes, eGFR is normal or slightly high with slight fluctuations associated with changes in postprandial glucose levels. DM gives rise to proteinuria only in those with persistent and uncontrolled hyperglycemia, especially when not treated with insulin therapy or when insulin therapy is inadequate. More commonly, untreated DM or treatment with oral antidiabetic drugs along with angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) is likely to result in progression of diabetic nephropathy into ESRD. Thus prevention of ESRD is attainable by treating DM with a paradigm of therapy consisting of a combination of long acting and short acting insulin regimens and avoiding the use of ACEI/ARB to treat proteinuria. Hypertension control is attainable without the use of ACEI/ARB drugs. In conclusion, full attention to glycemic control with insulin and less emphasis on proteinuria control is fundamental for the prevention of ESRD in diabetes.