Progression of Renal Disease in Insulin-Dependent Diabetes
| Stage | Onset | Lab | Risk Factors | Treatment |
| 1. Early Hypertrophy and Hyperfunction | Initial diagnosis | Increased glomerular filtration rate. |
Hyperglycemia Hypertension Stress Homocysteine Hypoantioxidant Pharmaceuticals Protein Diet Smoking Insulin Resistance |
Decrease: hyperglycemia hypertension Replace: kidney toxic pharmaceuticals with natural medicine if possible. Increase: antioxidants herbal kidney support, ACE inhibitors |
| 2. Renal Lesions 2. Renal Lesions |
3 years after diagnosis | Increased glomerular filtration rate. | As above | As above |
| 3. Incipient Nephropathy | 7-15 years after diagnosis | Glomerular filtration rate beginning to decline. Albumin found in urine more than .03 gm/daily. | As above | As above |
| 4. Clinical Diabetic Nephropathy | 10-30 years after diagnosis | Glomerular filtration rate continues to decrease. Urinary albumin continues to increase. | As above | As above |
| 5. End-stage Renal Disease | 20-40 years after diagnosis | Glomerular filtration rate very low. Increased serum creatinine. |
As above | As above, dialysis |
(Adapted from Selby JV, Fitzsimmons SC, Newman JM, et al. The natural history and epidemiology of diabetic nephropathy: Implications for prevention and control. JAMA 1959;263;1954-59)
Cardiovascular disease and mortality are a great risk for patients suffering from diabetic renal disease. In a study of NIDDM in Pima Indians, it was found that diabetics who had albumin in the urine (indicating renal disease) had 3.5 times greater risk for cardiovascular disease and overall mortality than the ones who had no albumin in the urine. Nephropathy leads to systemic hypertension because of hyperlipidemia and a decreased clearance of atherogenic advanced glycosylation end products.68
Diabetic patients have a fourfold chance of having both macrovascular and microvascular disease. Smoking, dyslipidemia, insulin resistance, homocysteine levels, emotional stress, and lack of general antioxidants due to the oxidation of LDL and low levels of vitamin E all need to be considered when treating diabetic patients with high cardiovascular risk factor.
The clinical signs of ischemic heart disease in diabetic patients are different than in other patients. This is one reason that thyroid hormone therapy has to be used cautiously with diabetics, due to its potential of increasing cardiac blood flow. Diabetic patients often will have a silent ischemia. It makes it more difficult to diagnose. Patients may have no pain but just nausea or sweating.
Conventional Pharmaceutical Treatment [SH]
ACE Inhibitors [C]
ACE inhibitors are the drugs of choice in diabetic hypertension patients. ACE inhibitors have shown to reduce progression to renal failure by 50% in Type I patients in stage 4 diabetic nephropathy. However, diabetics may develop severe complications with the use of antihypertensive drugs, including altered symptoms of hypoglycemia from beta-blockers, intensified fluid retention from sympathetic inhibitors, and worsened hyperglycemia from diuretics. 69
Lipid-lowering Therapy [C]
Lipid-lowering therapy improves cardiac outcomes in diabetic patients. A study in Scandinavia on the use of statin drugs and diabetic cardiac outcome was assessed. The Scandinavian study was performed on over 4,000 patients. There was a 55% reduction in major cardiovascular events, including myocardial infarction, in patients treated with simvastatin. However, statin drugs have a history of causing liver disease.70
Naturopathic Medical Treatment and Prevention [SH]
Traditional Chinese Medicine [C]
Red Yeast: Lipid lowering therapy can be very well treated with the traditional Chinese medicine red yeast that contains over nine statin compounds. Unlike its pharmaceutical counterpart, it contains only one statin isolate, and has no known history of causing liver disease.
Acupuncture: Acupuncture lowers blood pressure. Studies have shown that its hypotensive effects can last a year after the treatments have been finished, while pharmaceuticals never can be stopped.
Clinical Nutrition [C]
Inositol Hexanaicinate: Inositol hexanaicinate works well in lowering lipid levels.
B Vitamins: Homocysteine levels also should be checked because high levels can injure the endothelial cells of the vascular system, resulting in increased platelet utilization and the formation of atherosclerotic disturbances, resulting in hypertension. One study found that men with very high levels of homocysteine were three times more likely to have a myocardial infarction, even while taking in consideration lipid levels.71 Homocysteine can be lowered with the simple addition of vitamins B12 (1000 mcg), B6 (50 mg), and folic acid (1 mg).
Botanical Medicine [C]
Snakeroot (Rauwolfia serpentin): Rauwolfia serpentia is a very reliable herbal treatment to lower severe hypertension. It is also an excellent remedy for anxiety and insomnia that often accompanies a hypertensive patient. However, like most prescription drugs for hypertension, some patients do complain of feeling tired when on Rauwolfia.72
Hawthorne Berry (Cratagus oxycanthus): Moderate hypertension can be safely treated with hawthorne berry. It is extremely high in flavonoids that help limit atherosclerosis, has the ability to help regulate tension, low or high, and is able to strengthen the heart muscle, as evidenced by clinical trials on the analysis in the ejection of the heart.73,74
Diabetes in Pregnancy [B]
Gestational diabetes is diagnosed in pregnancy and limited to pregnancy. Up to 8% of pregnancies in the world develop it. The high levels of circulating hormones, such as cortisol and progestins, have shown to decrease insulin receptor binding. Human chorionic gonadotropin and human placental lactogen decrease post receptor effects of insulin. The immediate risks of gestational diabetes to the mother include increase hypertension and preeclampsia; the later risk is developing diabetes itself. The risk to the fetus is fetal macrosomia (increased fetal size).75 The postulated mechanism for this is due to the high levels of fuels, such as glucose, amino acids, lipids, and insulin.
Pregnancy is a complex metabolic state. There is a dramatic alteration in hormone levels, including increased levels of cortisol, progesterone, prolactin, estrogen, and human chorionic gonadotropin. Needless to say, there is also an increased demand of fuel from the fetus. This makes it very difficult for the mother to keep up with all the hormonal changes.
From 20 weeks onward into pregnancy, insulin resistance is common. In normal pregnancy, maternal secretion of insulin increases in late second and third trimesters to compensate for insulin resistance. Glucose not only alters pregnancy but triglycerides, cholesterol, and free fatty acids are also increased in the blood as commonly found in insulin resistance.76
Congenital abnormalities from diabetes in the early era were about 33%, but now with the drug treatment and insulin only 1.6% to 2% of diabetic pregnant women have children with congenital abnormalities. Glucose control is critical. Optimally, pre-meal glucose should be less than 100 mg/dl with the 2-hour postprandial value not exceeding 130 mg/dl. Home glucose monitoring should be done at least four times a day. Mothers who achieve very tight control, as documented with normal glycosylated hemoglobin levels, have the same chance of fetal abnormalities as non-diabetic pregnant women. 77
Naturopathic Medical Alternatives [SH]
Oral hypoglycemic drugs are contraindicated in pregnancy. However, the use of minerals, such as chromium, and herbs, such as jambul, along with a diet avoiding refined carbohydrates, should be recommended. There have been no studies that I know of that have actually studied the effects of herbal hypoglycemics during pregnancy. Historically, most of the hypoglycemic herbs have not been contraindicated in pregnancy. In my opinion, they are considered safe.
