A 22 y.o. patient with diabetic nephropathy says, “I have two kidneys and I’m still young. If I stick to my insulin schedule, I don’t have to worry about kidney damage, right?” Which of the following statements is the best response?
A. “You have little to worry about as long as your kidneys keep making urine.”
B. “You should talk to your doctor because statistics show that you’re being unrealistic.”
C. “You would be correct if your diabetes could be managed with insulin.”
D. “Even with insulin, kidney damage is still a concern.”
Correct Answer: D. “Even with insulin, kidney damage is still a concern.”
Kidney damage is still a concern. Microvascular changes occur in both of the patient’s kidneys as a complication of the diabetes. Diabetic nephropathy is the leading cause of end-stage renal disease. The kidneys continue to produce urine until the end stage. Nephropathy occurs even with insulin management.
Option A: In T2DM, UKPDS (United Kingdom Prospective Diabetes Study) showed that targeting an HbA1C of 7% led to a lower risk of microvascular complications, including nephropathy. However, blood pressure (BP) control also led to a decrease in cardiovascular mortality.
Option B: The benefits of good glycemic control early in the onset of disease carried over even after a long time, despite glycemic control being similar in both groups on longer follow up. This effect is “metabolic memory,” a term coined by DCCT/EDIC investigators.
Option C: Studies in patients with T1DM and overt proteinuria have also shown that ACE inhibitors slow the progress of diabetic nephropathy. The IDNT and RENAAL studies have shown similar benefits in T2DM patients. These studies provide clear evidence of the benefit of RAS-blocking medication on slowing progression of diabetic nephropathy, independent of their effect on BP.
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