An interview with Dr. G.R. Sridhar  in www.endocrineindia.com  September 2001
 
Dr G R Sridhar, is currently Consultant in Endocrinology & Diabetes at Endocrine and Diabetes Centre, Visakhapatnam. He has a large online database of 25,000 persons with endocrine diseases, including diabetes. After completing her post graduation in General Medicine, Dr Sridhar has done D.M. Endocrinology, from All India Institute of Medical Sciences, New Delhi. 

Besides being the Editor of Indian Journal of Endocrinology and Metabolism, Dr Sridhar is the co-investigator of major UGC project, 'Living with diabetes', in collaboration with Dept. of Psychology, Andhra University. Dr Sridhar is also Co-director, Ph.D. Scholars, Andhra University, Visakhapatnam and Joint Secretary for Study of Diabetes in India (1998-2001). 

Dr Sridhar has edited four books on diabetes and one book on endocrinology and also has contributed vastly to API Textbook of Medicine and RSSDI Textbook of Diabetes. Dr Sridhar has to his credit 90 publications in different journals covering various aspects of Endocrinology. 

Dr Sridhar brings you the answers to the questions on "Diabetic Nephropathy":

Q1. In your clinical practice, what is the incidence of patients with diabetic nephropathy in type 1 and type 2 diabetes respectively?

Ans. I analyzed the prevalence of diabetic renal disease in our database and will be coming to that a little while later. Large published studies have shown that in type 1 diabetes, end-stage-renal disease eventually develops in 30-40%. While the proportion in type 2 diabetes is lower (5-10%). More number of type 2 diabetes patients present with end stage renal disease. The reason is, there are more type 2 diabetes patients.

In our computerised database of individuals with diabetes mellitus at our Centre, among 2791 persons who had serum creatinine estimated, 58 had a value above 1.8 mg/dl (58/2781; 2.08%). Among the 58, 55 had clinical type 2 diabetes mellitus and three clinical type 1 diabetes. The median serum creatinine was 2.4 mg/dl (range 1.86-7.6 mg/dl). The median duration of diabetes mellitus was 10 years (range 0-26 years).

In this group of 2791 individuals, among those have a serum creatinine value lower than 1.8 mg/dl, 37 had urine 'Micral' tested. Twenty seven tested positive. Among these 27, 26 were clinical type 2 diabetes and one clinical type 1 diabetes. The median duration of diabetes was 5.5 years (range: 0-30 years).

Q2. What are the factors involved in the development of this complication?

Ans. Essentially development of diabetic nephropathy depends on the degree of glycemic control: poorer it is, greater is the chance of developing nephropathy. In addition there is evidence that genetic predisposition also exists.

Since genes cannot be changed, at least not yet, we must try to achieve as good a glycemic control as possible. Using the existing resources: life style measures, drugs, monitoring.

Q3. What screening procedures and special investigations would you recommend to diagnose diabetic nephropathy?

Ans. One should not wait for symptoms before identifying diabetic nephropathy. Periodic monitoring for microalbuminuria identifies impending complications early.

With longer duration of diabetes, attention should be paid to attain normal blood glucose and blood pressure. In addition ocular fundi should be examined to identify retinal changes, which may coexist with nephropathy.

Care should be taken to exclude diabetic nephropathy from other causes of proteinuria and nephropathy.

When proteinuria is excessive, a 24 hour urinary protein excretion can be done. Later on serum creatinine is elevated.

Renal function can be estimated by measuring glomerular filtration rate using nuclear medicine techniques.

Q4.  What are the clear symptoms which would lead to the diagnosis of diabetic nephropathy?

Ans. Don't wait for symptoms before diagnosing nephropathy. Identify it early by investigations such as microalbuminuria.

Q5. What is the significance of microalbuminuria?

Ans. Microalbuminuria started off as a forerunner of diabetic nephropathy and end stage renal disease. But now its is significance expanded and it is a marker of endothelial dysfunction. It suggests diffuse vasculopathy.

In the context of diabetes, dipstick positive microalbumin should be carefully evaluated: exclude uncontrolled diabetes, uncontrolled hypertension, urinary tract infection and local infections. Repeat microalbumin estimation to be sure it is not transient.

Q6. What guidelines would you recommend in the management of complications which may arise in patients with diabetic nephropathy?

Ans. I would much prefer to utilize the skills of a nephrologist to manage end stage renal disease.

Prevention of diabetic nephropathy is essential: achieve as near euglycemia as possible along with normotensin. Avoid smoking. Monitor periodically for urine excretion of albumin.

Angiotensin converting inhibitors (ACE-I) were shown to be useful in preventing diabetic nephropathy, especially in the early stages.

Once overt renal failure sets in, guard against overzealous glycemic control and risk hypoglycemia. When a previously stable person with diabetes goes into recurrent hypoglycemia for no apparent reason, rule out renal insufficiency.

Avoid oral hypoglycemic agents in chronic renal failure. Monitor the blood glucose periodically and administer insulin if necessary.



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