Joslin Study Shows Kidney Disease in People with Type 1 Diabetes is Frequently Reversible in Earliest Stage; Findings May Lead to Improved Treatment

A new study by Joslin Diabetes Center researchers published in last week’s New England Journal of Medicine (NEJM) is good news for the thousands of Americans with type 1 diabetes who have microalbuminuria, the earliest sign of kidney disease.

A new study by Joslin Diabetes Center researchers published in last week’s New England Journal of Medicine (NEJM) is good news for the thousands of Americans with type 1 diabetes who have microalbuminuria, the earliest sign of kidney disease.One in three patients with type 1 diabetes develop end-stage kidney disease, which eventually requires either a kidney transplant or every-other-day dialysis treatment for life. The earliest sign of kidney disease is the leakage of small amounts of proteins from the blood into the urine, called microalbuminuria. When it appears in the urine, it was once believed that one could only hope to postpone – but not prevent – kidney disease by intensified efforts to control blood sugar, treatment with certain blood pressure drugs, and a low protein diet. However, the prognosis for patients with microalbuminuria turns out to be not so dire, according to the results from the Joslin Kidney Study being reported in the NEJM. Andrzej Krolewski, M.D., Ph.D., head of the Section on Genetics and Epidemiology at Joslin, and his colleagues found in this study of people with type 1 diabetes that early signs of microalbuminuria can be reversed with proper medical screening and diabetes control. Dr. Krolewski is Associate Professor of Medicine at Harvard Medical School (HMS) and Associate Professor of Epidemiology at Harvard School of Public Health. “In this early stage, we found kidney injury is still a dynamic process that can either get worse or get better — even revert back to normal,” said Bruce Perkins, M.D., M.P.H., F.R.C.P., and a lead author of the paper. Dr. Perkins is a Clinical Fellow in Endocrinology at HMS. In this study, 400 patients with microalbuminuria persisting over a two-year period were followed for six additional years. “Surprisingly, the leakage of protein subsided in 58 percent of them, even among those who were not taking ACE inhibitors, a type of drug known to be helpful in people with microalbuminuria,” Dr. Perkins said. “It stands to reason that these landmark studies will heighten physicians’ awareness of the importance of screening for microalbuminuria to permit aggressive early intervention, particularly intervention that leads to tight glycemic control,” Eberhard Ritz, M.D., of the University of Heidelberg in Germany, writes in an accompanying editorial in the NEJM on the Joslin study and another study appearing in the journal. Among the factors associated with a return to normal kidney function were an early diagnosis of microalbuminuria by frequent screening and very good levels of blood sugar, blood pressure and cholesterol. Although high cholesterol was known to be bad for patients with advanced kidney disease, it was not known just how important it is to keep cholesterol levels low in the earliest stages of the disease. “In view of this finding, perhaps cholesterol-lowering drugs should be given a trial,” Dr. Perkins said. “Since microalbuminuria can go away and certain factors are associated with its remission, we infer that specific mechanisms of repair exist in the kidney that enable the kidney to repair itself in the early stages. When we understand these mechanisms better, we can develop more effective treatments for preventing serious kidney disease,” Dr. Perkins said. “In the meantime, the study highlights the need for frequent screening and early intervention for microalbuminuria in patients with type 1 diabetes. Once it is identified, the treatment plan should be directed toward improving multiple factors — blood sugar control, blood pressure control, and cholesterol lowering — rather than relying on ACE-inhibitor treatment alone.” (Source: New England Journal of Medicine (NEJM): www.diabetes news.com: 13th June 2003)