Can management strategies alter the course of diabetic nephropathy?

End Stage Renal Disease (ESRD) is a common consequence of diabetic nephropathy (DN). DN is the major cause of death in patients with IDDM, accounting for greater than 40% of deaths with this form of diabetes. There is no clearly documented therapeutic technique that will prevent or reverse progressive renal damage in IDDM. While pancreatic transplantation and "cure" of diabetes in experimental animals may be associated with some histological reversal of renal pathology, this has not been documented in humans. Most studies agree that once diabetic renal disease is present (as documented by proteinuria), progression is inevitable, albeit the rate of progression may be altered by different therapeutic methods. There is considerable hope that "tight metabolic control" will prevent the initial damage that leads to DN and ESRD, but evidence remains inconclusive. There is some evidence that careful monitoring for microalbuminuria will allow for very early detection of damage and alterations in therapy. Our studies have documented a decrease in both morbidity and mortality in IDDM in patients who have been competitive athletes, suggesting that promotion of physical fitness may be a valuable means of delaying progression of renal disease while control of BP delays progression. Early detection and aggressive therapy is recommended. Some studies utilizing diets low in sodium and/or protein appear beneficial but more studies are needed before pediatric application.

The epidemiology of diabetes in childhood with special reference to the Orient: implications for mechanism of beta cell damage.

Epidemiologic studies are providing important new insights into the etiology and clinical course of IDDM as well as providing critically needed data on the magnitude of the problem in different parts of the world. The development of national IDDM registries have documented extraordinary differences in diabetes incidence and prevalence, with the highest incidence figures in Finland (greater than 30/100,000/yr) and the lowest in the Orient with Korea reporting incidence rates below 1 and Japan between 1.0-2.4/100,000/yr. The great geographic variation in expression of diabetes in childhood is strongly supportive of environmental factors playing a major role in the etiology of disease. Our studies document a linear correlation between IDDM incidence and distance from the equator and a similar but inverse correlation with mean annual environmental temperature. Other workers find a direct correlation with dairy product consumption. Factors that may play a role in beta cell damage include viral infections, environmental toxins, nutrients and stress factors. Because of the low incidence of IDDM among children living in Asia it is most important to expand the current national registries in the Asian countries and begin a careful study of the environmental differences within Asian countries as well as comparison of studies between countries with very high incidence rates and those with the lowest rates.

Efectos del ayuno y la realimentacion sobre las concentraciones de glucosa, insulina y glucagon en adolescentes obesos. / Effects of fasting and refeeding on concentrations of glucose, insulin and glucagon in obese adolescents

Se estudiaron seis pacientes adolescentes con obesidad grave. Su estancia en el hospital se dividio en cuatro periodos dieteticos de una semana cada uno: dieta normal, ayuno total, realimentacion con 200 calorias y realimentacion con 400 calorias. Se realizo una prueba de tolerancia a la glucosa al principio y otra al final del periodo de hospitalizacion.Al final de cada periodo de variacion dietetica se les practico una prueba de arginina e insulina. Las concentraciones de la glucosa se conservaron sin diferencia en todas las condiciones experimentales cuando se les estimulo con glucosa o con arginina e insulina.Las concentraciones de la insulina plasmatica fueron mayores durante la dieta normal y disminuyeron significativamente durante el periodo de ayuno. La reaccion del glucagon fue mas baja durante la dieta normal que durante el periodo de ayuno. Estas interacciones entre insulina y glucagon permiten conservar la homeostasia de la glucosa. Los cambios observados en estas dos hormonas parecen ser secundarios a las variaciones del estado nutricional