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The Big Diabetes Lie

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There has been some discussion about the significance of non-diabetic renal disease in diabetic patients. In my experience this is quite rare, but selected studies from nephrology departments show that the problem may be more common there. However, it is now generally accepted that non-diabetic renal disease is not more common in diabetic patients than in the background population (4). It has taken many years to reach this understanding. Renal biopsies are very rarely indicated.

The understanding of diabetic renal disease has been distorted by the following hypotheses:

1. It has been claimed that high blood pressure would be essential to maintain renal function—a prevailing concept in the United States for many years (24, 25).

2. It has also been alleged that hyperglycemia is not important in the genesis of diabetic renal disease—clearly an unsound and faulty statement (24).

3. It has also been claimed that genetic factors are decisive in determining renal disease—this has never been adequately substantiated (26).

4. The idea that non-diabetic renal disease like glomerulonephritis was important also hindered our understanding for many years (27).

5. P-pill users may have a greater risk of nephropathy (28, 29), which is of interest in relation to young patients with type 2 diabetes.

It is now clear that normalizing or even "sub-normalizing" blood pressure is essential. The exception seems to be for the patients with advanced renal disease where a U-formed

TABLE 3 Optimal Blood Pressure Level in Diabetic Patients

Without nephropathy < 130/80

With nephropathy Somewhat lower

FIGURE 1 The BP-lowering hexagone in diabetes (+) indicates the level of evidence. The numbers indicate sequence of treatment (1-7) (vary from patient to patient). Remember sufficient doses, clinical, and laboratory control.

curve has been documented in the IDNT-study in type 2 diabetes (30). It is also clear that hyperglycemia is a main risk factor in the genesis of diabetic renal disease. Genetic factors have not been identified and there is no reason to believe that genetic factors are decisive although they may modulate the development (26). Combining the effect of high blood pressure and hyperglycemia may be sufficient to explain the development of renal disease. Hall emphasizes that BP-lowering can reduce progression of diabetic renal disease—an observation made more than 25 years ago (25).

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