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Mark Molitch Part 5, Diabetic Renal Failure

In part 5 of this Exclusive Interview, Dr. Mark Molitch explains the changes in diabetes care that have resulted in the dramatic decrease in renal failure in diabetes patients in a conversation with Diabetes in Control Publisher Steve Freed during the ADA meeting in San Diego, California.

Dr. Mark Molitch is the Martha Leland Sherwin Professor of Medicine at Northwestern in the
Division of Endocrinology, Metabolism and Molecular Medicine. He has been active in clinical research in diabetes, focusing on diabetic nephropathy, and other areas of endocrinology.

Transcript of this video segment:

Steve Freed: Have the changes in diabetes care over the years made a difference in the number of people who develop end-stage renal disease, that is those that require dialysis or transplantation?

Mark Molitch: Absolutely, there has been a dramatic change in the number of people who develop kidney disease to begin with is dramatically reduced. The ones who go on to progress in their kidney disease to require dialysis or transplant is dramatically reduced. And there’s data now from the Diabetes Control and Complications Trial, which has now been following people for over 30 years, duration of diabetes, and it’s really down for one or two percent of individuals having kidney failure. When I first started, you know almost 40 years ago now, we are talking about 20% to 30% of patients that need dialysis, so it’s been cut to 10% of what it was before, so that’s a pretty dramatic difference.

Steve Freed: The next question is, what changes have occurred that account for this improvement?

Mark Molitch: Probably at least two or maybe more. Certainly blood sugar control has made a difference, people getting onto meds, better diabetes glycemic control. I think blood pressure control has also made a big difference and trying to get blood pressure lower compared to what they used to be before. Then of course some of the drugs that are use for blood pressure control that block the RASS has also been shown to have, what appears to be some selective further benefits of (unintelligible) renin and angiotensin blockers have really made a big difference.

Steve Freed: You still looking at the long range of the DCCT trials. One of the mystifying things is that for those people that had intensive control came up better in the study and what we’re learning now after all this time that has gone by, those people that actually participated in the intensive group are still seeing benefits even though their A1C may have gone up.

Mark Molitch: The two groups in the EDIC Trial, which is the long-term follow-up, A1C sort of merged together so the intensive group from 7% to 8%, the conventional group from 9% down to 8%. So, their control over the years has been very much similar, but there is this thing of metabolic memory, if you will, that shows that very intensive control for those intensive people still seems to be showing some benefit in reducing long-term complications.

Steve Freed: Do you share that information with patients and with other doctors that, you know, it’s not something that people have to do…you know, they should do it the rest of their lives, but if they’re normal they’re going to fall off the wagon and their blood sugar are going to go up but they’ll still have the benefit.

Mark Molitch: They don’t go up that much. If you go from 7 to 8, it’s not going from 7 to 10 or 7 to 11, so I think they still have to maintain pretty good control. They can’t totally fall off the wagon.

Steve Freed: So, are there any special precautions in the management of diabetes in the patient with progressing kidney disease? Does it always have to go to end stage renal disease or can we stop it?

Mark Molitch: I think that blood pressure control and glucose control can retard the progression of that. Sometimes it stops it in its tracks; most of the time it just delays progression, but I’ve certainly had patients where it’s just kind of stopped and it’s sitting there, maybe at forty or fifty percent of baseline function and doesn’t continue to progress. I think in some individuals it kinda stops. One of the important things to remember is that many of the medications that we use need dose adjustments as the kidneys progressively fail so that you just have to be sure that as you’re adjusting dose that the patient doesn’t start getting hypoglycemic from too much medications.

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