"Hyperkalemia is a potentially life-threatening metabolic problem caused by inability of the kidneys to excrete potassium, impairment of the mechanisms that move potassium from the circulation into the cells, or a combination of these factors "FN12. The article states that acute episodes of hyperkalemia are commonly triggered by the introduction of a medication affecting potassium, and that illnesses and dehydration can also be factors. The physician must also be aware therefore that a common positive response by patients in these circumstances was to a sodium bicarbonate supplementation.
Another bit of information that might be important to the diagnosing physician would be that "elevated serum aldosterone causes the renal cortical collecting ducts to excrete potassium and retain sodium, further lowering serum potassium" FN13. Potassium levels should be monitored in an ongoing fashion to determine whether they are stable or not. Additional monitoring should take place for hypertension since twenty to sixty percent of diabetics are affected by it.
Antihypertensive agents are used to treat the hypertension and the physician should be aware when prescribing calcium channel blockers or ACE inhibitors, even though most studies have shown that ACE inhibitors do reduce the progression towards microabluminuria. One recent study showed that "a significant reduction in the risk of developing microalbuminuria in patients with diabetes and normoalbuminuria has been demonstrated for ACE inhibitors only" FN14.
This particular study showed that the affects of ACE inhibitors is independent to baseline blood pressure, renal function and type of diabetes, but that the data was no comprehensive enough to say that there other modifiers might not be present. The study concluded that and individual patient data meta-analysis would be required in order to ensure that the stated results were not skewed in any manner. Other studies have also attempted to compare the use of ACE inhibitors or ARBs with placebos. One recent study "found no mortality benefit in patients with diabetic kidney disease" FN15 when comparing their use. However, a different study concluded that "there were too few trials comparing ACE inhibitors with ARB's to draw clear conclusions" FN16.
Pain is an additional factor when considering treatment of diabetic patients who are experiencing kidney failure or diabetic nephropathy. Diabetic patients oftentimes have other medical problems that have contributed to their kidney problems, including diabetic neuropathy, retinopathy, gasteoparesis, kidney and liver diseases.
Diabetics may also experience ulcers (especially on their feet) and have a higher occurrence rate of infections than those patients without diabetes. Recent studies have also shown that many physicians and medical personnel maintain poor attitudes towards those individuals who are experiencing diabetes and that could "contribute to the poor treatment outcomes observed in people with type 2 diabetes" FN17.
The study was conducted in Argentina but additional studies have been recorded in developed countries with similar results. Some of the studies have come to the same conclusion that changing attitudes by educating health care professions could contribute to an improvement in the lives and the quality of care for individuals suffering from diabetes. Educating patients and professionals alike would likely lower the cost of the disease as well.
Knowing the effects and costs of different pharmaceuticals would also be beneficial for both the physician and the patient. Many times diabetics are bombarded with various medicines to not only alleviate the pain they are experiencing but to also help maintain the various illnesses and diseases they are besought with. One favorite pharmaceutical that has helped in the management of pain associated with diabetic neuropathy as well as other diseases is Pregablin (Lyrica). A recent study showed that "pregabalin seems to decrease the presynaptic release of neurotransmitters (e.g., substance P, glutamate) that are involved with pain sensation and transmission" FN18.
After considering the cost, many physicians will be more likely to prescribe Lyrica than they would in prescribing other similar pharmaceuticals. Lyrica is less expensive than both Neurotin and generic gabapentin, two medicines used to control pain in lieu of Lyrica.
If, after all treatments have been implemented, a diabetic patient experiences kidney failure a transplant might be the only remaining viable option for that patient. The bad news on this front is that there are currently about 65,000 individuals with severe kidney disease who are candidates for a transplant and that there is a shortage of good kidneys available for transplant. Only about 16,000 of the 65,000 patients will receive kidneys this year, and most of those will only receive one, instead of two.
There is some good news on this front however. Some scientists have been testing the blood-purifying capacity of kidneys obtained for transplant from people 60 years and older. A recent study has show that "culling the worn-out kidneys - scientists have identified organs likely to last in their new hosts" FN19. The study also attempted to bolster a recipient's odds by 'transplanting the older kidneys in pairs."
This is important news because these measures could expand the number of available kidneys for transplant purposes. The study showed that currently nearly two-thirds of the transplanted kidneys fail within the first decade. With additional kidneys available for this procedure, not only will more individuals be helped, the kidneys will last longer and prolong the patient's life as well.
Doctors in the new study gave transplant candidates two options. The first was to get on a waiting list for a single kidney from a person of unknown age, the second was to receive one or two kidneys from a person age 60 or older. According to the study, there were 62 patients who elected to get the screened kidneys from an older person, and almost all of these patients received a pair. The results after two years of study were that researchers found the patients who had received older kidneys (that had been tested before transplant) only about 6% had kidney failure. "That same percentage failed among untested kidneys obtained from donors under age 60" FN19. The same study found that 23% of untested kidneys from donors age 60 and over failed.
The study advocated transplanting kidneys from brain-dead donors in pairs. The study also showed that transplanting two kidneys into a single recipient might limit the number of organs available to other people in the short-term, the 'kidneys would last longer and reduce the number of transplant recipients returning to the waiting list'.
Overall, it would seem that many of the current treatments for diabetic patients can be fine-tuned in order to facilitate observation in regards to diabetic nephropathy. Maintaining a consistent 'normal ' blood pressure, in-line glucose levels, albumin levels of 7 or above and holding to a regulated pharmaceutical regime would be some of the best, and most consistent methods of ensuring that diabetic patients have the best opportunity to stay healthy while not contracting diabetic nephropathy.
Physicians who are capable and willing to assist their diabetic patients in following the guidelines espoused in this paper will likely see less presenting of all diseases, including nephropathy.
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Gagliardino, J.J.; Gonzalez, C.; Caporale, J.E.; (2007) the diabetes-related attitudes of health care professionals and persons with diabetes in Argentina, Pan American Journal of Public Health,…