Diabetes mellitus and renal replacement therapy in Italy: prevalence, main characteristics and complications

An update of irbesartan and renin-angiotensin system blockade in diabetic nephropathy

Type 2 diabetes is a chief cause of pathologies such as cardiovascular disease, nephropathy and retinopathy, and its prevalence is increasing worldwide. Development of renal disease can be slowed by tight glycaemic control and treatment of associated hypertension with angiotensin-converting enzyme inhibition, as The Diabetes Control and Complications Trial and the UK Prospective Diabetes Study have demonstrated. Recent clinical trials have supported the use of angiotensin II receptor antagonists in the treatment of diabetic nephropathy, resulting in the approval of new therapeutic indications in the US and Europe. The main goal of this review is to demonstrate how results from the Programme for Irbesartan Mortality and Morbidity Evaluation and other recent studies, based on the effects of renin-angiotensin system blockade, can be appropriate in clinical practice, thus displaying benefits of irbesartan therapy at any stage of renal disease in diabetics.

What is the impact of PRIME on real-life diabetic nephropathy?

Type 2 diabetes is increasing globally and is a major cause of conditions such as cardiovascular disease, retinopathy and nephropathy. The Diabetes Control and Complications Trial and the UK Prospective Diabetes Study demonstrated that the progression of renal disease could be slowed by tight glycaemic control and treating any associated hypertension with angiotensin-converting enzyme inhibition. Recent clinical trials have supported the use of angiotensin II receptor antagonists in the treatment of diabetic nephropathy, resulting in the approval of new therapeutic indications in the United States and Europe. The objective of this review is to demonstrate how results from the Program for Irbesartan Mortality and morbidity Evaluation studies apply to clinical practice, and to show how the benefits of irbesartan therapy can be realised at any stage of renal disease in patients with diabetes.

Nephropathy in type 2 diabetes

End-stage renal failure (ESRF) in diabetic patients, mostly type 2, has become the most frequent cause of renal replacement therapy in western Europe. The majority of patients with type 2 diabetes and renal failure suffer from diabetic glomerulosclerosis, but nondiabetic renal disease and atypical presentations, e.g. as irreversible acute renal failure or ischaemic nephropathy, play an increasingly important role. Known risk factors for the onset of diabetic nephropathy include (1) genetic predisposition (indicated by a history of hypertension and cardiovascular events in first-degree relatives), (2) quality of glycaemic control, (3) level of blood pressure, and (4) smoking. At the time when type 2 diabetes is diagnosed, an abnormal blood pressure profile is found in approximately 80%. In patients with established diabetic nephropathy, hypertension is the most important factor which promotes progression, and this is susceptible to intervention. Although less data are available for type 2 diabetes (compared with type 1 diabetes), ACE inhibitors appear to be the antihypertensive agent of first choice, but monotherapy is rarely sufficient to achieve the blood pressure goal. Although, at least in principle, diabetic nephropathy is a preventable condition, currently only a minority of type 2 diabetic patients in western Europe receives adequate medical treatment to prevent onset or progression of diabetic nephropathy. Consequently, novel approaches to patient management and interdisciplinary interaction are necessary to fulfil the postulate of the St Vincent declaration concerning prevention of diabetic complications.

Renal disease and hypertension in non-insulin-dependent diabetes mellitus

Recent epidemiologic data demonstrate a dramatic increase in the incidence of end-stage renal disease (ESRD) in patients with non-insulin-dependent diabetes mellitus (NIDDM), thus dispelling the mistaken belief that renal prognosis is benign in NIDDM. Currently, the leading cause of ESRD in the United States, Japan, and in most industrialized Europe is NIDDM, accounting for nearly 90% of all cases of diabetes. In addition to profound economic costs, patients with NIDDM and diabetic nephropathy have a dramatically increased morbidity and premature mortality. NIDDM-related nephropathy varies widely among racial and ethnic groups, genders and lifestyles; and gender may interact with race to affect the disease progression. While the course of insulin-dependent diabetes mellitus (IDDM) progresses through well-defined stages, the natural history of NIDDM is less well characterized. NIDDM patients with coronary heart disease have a higher urinary albumin excretion rate at the time of diagnosis and follow-up. This greater risk may also be associated with hypertension and hyperlipidemia, and genes involved in blood pressure are obvious candidate genes for diabetic nephropathy. Hyperglycemia appears to be an important factor in the development of proteinuria in NIDDM, but its role and the influence of diet are not yet clear. Tobacco smoking can also be deleterious to the diabetic patient, and is also associated with disease progression. Maintaining euglycemia, stopping smoking and controlling blood pressure may prevent or slow the progression of NIDDM-related nephropathy and reduce extrarenal injury. Treatment recommendations include early screening for hyperlipidemia, appropriate exercise and a healthy diet. Cornerstones of management should also include: (1) educating the medical community and more widely disseminating data supporting the value of early treatment of microalbuminuria; (2) developing a comprehensive, multidisciplinary team approach that involves physicians, nurses, diabetes educators and behavioral therapists; and (3) intensifying research in this field.

Kidney transplant recipients who die with functioning grafts: serum creatinine level and cause of death

How to analyze death with function (DWF) in transplant survival statistics has become an important issue. DWF is a predominant cause of late graft loss. We recognize that some deaths may be related to the transplant. However, considering DWF as a graft loss may obscure some analyses. An additional consideration is whether patients who "die with function" actually had good kidney function or whether their death was related to or hastened by impaired function. To answer this question, we studied the serum creatinine level and cause of death for kidney recipients who died with function. Between January 1, 1985, and December 31, 1994, we did 1932 kidney transplants for 1806 recipients. Of these, 220 died with function. For the 220, we assessed the time posttransplant that death occurred, the serum creatinine level before the terminal event, and the cause of death. The most common causes of death were infection (22%), myocardial infarction (17%), and sudden death (15%). Mean serum creatinine levels were less than 2 mg/100 ml at 1 year before and at the time of death for the vast majority of these recipients. Our findings demonstrate that kidney recipients who die with function have good renal function--additional support for presenting graft survival data both with and without death censored.

Diabetic nephropathy in type II diabetes

The incidence of end-stage renal failure in patients with type II diabetes has dramatically increased in recent years, both in the United States and, with some delay, in some European countries. These epidemiologic observations have thoroughly dispelled the mistaken belief that renal prognosis was benign in type II diabetes. Recent interest has focused on the early stages of nephropathy in type II diabetes. With respect to renal hemodynamics, renal morphology, and progression of established diabetic nephropathy, there are no substantial differences between types I and type II diabetes. There is good evidence that preventive measures are effective, ie, glycemic control, blood pressure control, protein restriction, and discontinuation of smoking. The high prevalence of the disease (which in principle is preventable) calls for intense efforts to (1) educate the medical community, (2) substantially improve patient education and medical care, and (3) intensify research in this field.

Increased mortality due to cardiovascular disease in type 1 diabetic patients transplanted for end-stage renal failure

The graft and patient survivals following renal transplantation in all Type 1 diabetic patients transplanted within the North-West of England between 1981 and 1990 at Manchester Royal Infirmary were studied. Fifty-two Type 1 (insulin-dependent) diabetic patients with end-stage renal failure due to diabetic nephropathy were transplanted during this period. They were compared to controls matched for age, sex, and year of transplantation and also to all 904 patients transplanted during the same period. Graft survival rates at 1 and 5 years in the diabetic patients were lower (80.8% and 62.1%, respectively), compared to controls (88.9% and 77.9%, respectively, p = 0.02) but were similar to those seen in all grafts (80.4% and 59.0%, respectively, p = NS). Actuarial patient survival rate at 5 years was lower in diabetic patients (76.3%) compared to the control group (94.2%, p = 0.003). Myocardial infarction was the main cause (60%) of death in diabetic patients. The results of this large recent series indicate that good graft and patient survival rates can be obtained in Type 1 diabetic patients, although they remain poorer than those of patients with non-diabetic renal disease. More rigorous pretransplantation cardiac assessment and treatment before acceptance of Type 1 diabetic patients for renal transplantation may help to improve patient survival.

Epidemiology, development and treatment of end-stage renal failure in type 2 (non-insulin-dependent) diabetes mellitus. The case of mainland France and of overseas French territories

The prevalence of diabetes mellitus among patients treated for end-stage renal failure by dialysis in France was studied in two stages (UREMIDIAB Study). The first stage consisted of a questionnaire which was mailed to all dialysis centres in mainland France. The response rate was 80.8%, resulting in a study population of 12,903 patients. Of these patients 884 were declared diabetic (6.9%). Later 295 of them were interviewed by seven specially-trained physicians who checked the medical records together with the nephrologist in charge. Plasma C-peptide was measured in almost all of the patients. Effectively, 1.4% were found to have Type 1 diabetes and 5.5%, Type 2. Diabetic nephropathy was found to be the only primary renal diagnosis among 93.9% of Type 1 diabetic patients and 36.8% of Type 2. Of the latter 51.6% had a non-diabetic cause of renal failure. In the second stage a survey was later conducted in 13 of 14 dialysis centres located in the remote overseas French territories. Among 934 patients 1.04% were Type 1 diabetic and 19.67% Type 2 (22.9% altogether). Type 2 diabetic patients treated overseas were essentially non-Caucasians (92.6%). The sex ratio was 0.54 in the overseas territories vs 1.4 in the mainland. We conclude that the prevalence of diabetes among people on dialysis is low in mainland France. But there are striking differences in the prevalence of Type 2 diabetes among dialysis patients in mainland France and its overseas territories. These differences are not related to access to dialysis facilities.

Epidemiology, development and treatment of end-stage renal failure in type 2 (non-insulin-dependent) diabetic patients in Europe

The aim of the present report was to compare the current patterns of incidence and prevalence of end-stage renal failure and mode of renal replacement therapy in patients with Type 1 (insulin-dependent) and Type 2 (non-insulin-dependent) diabetes mellitus in Europe. All Type 1 and Type 2 diabetic patients recorded on the Registry of the European Dialysis and Transplant Association as being alive on renal replacement therapy were analysed according to age, sex, geographic distribution, and mode of therapy (haemodialysis, peritoneal dialysis or renal transplantation). During 1990 3981 diabetic patients commenced renal replacement therapy in Europe, and at 31 December 1990 a total of 15,197 diabetic patients were receiving treatment. One-third were reported to be Type 2 diabetic patients, but the true proportion is expected to be higher. Both male and female Type 2 diabetic patients were older than Type 1 patients. Major geographic variations were observed; annual acceptance of Type 2 diabetic patients for treatment was greatest in Austria (10.7 per million) and equal to Type 1 patients, whereas the number of Type 1 diabetic patients was four times that of Type 2 patients in Sweden, Finland and Norway. Overall, the majority of Type 2 diabetic patients (80%) were treated by haemodialysis, 14% by peritoneal dialysis, and 6% had a functioning renal transplant. However, transplantation was the preferred option in young patients (48% of 25-34 year olds) and in Sweden and Norway (45% of all Type 2 patients).