Curing Diabetes

Although diabetic nephropathy has no cure, certain interventions can slow its progress. These interventions include closely controlling blood glucose levels, using antihypertensive therapy, restricting protein intake, treating urinary tract infections (UTls), withholding nephrotoxic drugs and dyes, and using dialysis and transplantation.

Glucose Control

Tight blood glucose control-maintaining glucose levels as close to normal as possible without increasing the frequency or severity of hypoglycemic episodes-can help delay the onset and slow the progression of nephropathy. Tight blood glucose control also can reverse microalbuminuria in some patients. However, tight blood glucose control doesn’t affect the course of advanced nephropathy.

Antihypertensive Drug Therapy

Aggressive antihypertensive therapy may slow the progression of diabetic nephropathy. Certain antihypertensive drugs, such as angiotensin­converting enzyme (ACE) inhibitors and calcium channel blockers, may be used to treat hypertension. They also inhibit diabetic nephropathy in hypertensive patients and in normotensive patients with microalbuminuria.

However, ACE inhibitors may cause hyperkalemia and should be used cautiously if your patient has renal failure. Expect to avoid thiazide diuretics and beta-lockers because thiazide diuretics may worsen hyperlipidemia and hyperglycemia, and beta-blockers may mask or alter the symptoms of hypoglycemia.

Protein Restriction

Restricting your patient’s protein intake can reduce the rate of urine albumin excretion and kidney deterioration. The typical dietary protein intake in the United States is 1.2 to 1.4 g/kg/day. The physician may prescribe a diet that limits protein intake to 0.8 g/kg/day or less. For example, if your patient weighs 143 lb (65 kg), she may be limited to 52 grams of protein per day.

Therapy for Urinary Tract Infections

If your patient develops a UTI, her risk of renal dysfunction increases. If she has signs and symptoms of a UTI, such as dysuria (burning on urination), urinary frequency or urgency, or foul­smelling urine, the physician may request a urine sample for culture and sensitivity testing. And if your patient has an infection, the physician will prescribe an antibiotic. Before administering the antibiotic, however, check a current drug reference to determine if the drug is contraindicated or requires cautious use in a patient with a kidney disease, such as nephropathy.

Nephrotoxic Drug and Dye Restrictions

Your patient may be taking nephrotoxic drugs, such as an aminoglycoside or a nonsteroidal anti-inflammatory drug (NSAID). If so, the physician will monitor her kidney function by testing her serum creatinine levels. If your patient has impaired kidney function, the physician may adjust her drug dosage based on her GFR or creatinine clearance or prescribe a less nephrotoxic drug.

Radiographic dyes also are nephrotoxic. If your patient must undergo a test that requires radiographic dye, the physician may prescribe I.V. mannitol to be given 1 hour before the test to induce osmotic diuresis and minimize nephrotoxic effects.

Dialysis and Transplantation

A patient with end-stage renal disease may need hemodialysis or peritoneal dialysis, or she may be a candidate for a kidney transplant. Many patients who undergo hemodialysis develop sclerotic blood vessels from the numerous needle punctures at the dialysis access site. Eventually, they may have no more access sites to continue hemodialysis. These patients may be good candidates for peritoneal dialysis or kidney transplant.A donor kidney for a transplant can be obtained from a living relative, a living unrelated person, or a cadaver. A transplanted kidney has a 75% to 80% chance of functioning for at least 5 years. However, kidney transplants have many drawbacks:

• Donor kidneys are in short supply. Depending on your patient’s blood type and whether she has certain proteins or antibodies, she may never be offered a kidney.
• The risk of organ rejection is high, especially in the first year after the transplant.
• Expensive, long-term therapy with immunosuppressants is needed to help prevent organ rejection.
• Immunosuppression may lead to infection or malignancy .
• Immunosuppression makes tight glucose control more difficult.

Patients who test positive for the human immunodeficiency virus or who have a malignancy aren’t candidates for kidney transplant. Those with psychosis, active infection, severe neuropathies, or inoperable cardiovascular disease may not be approved for the procedure. Transplant complications include thrombosis, infection, anastomotic leaks (usually at the ureters), bleeding, and adverse effects of immunosuppression.

Filed under: Chronic Complications