4.1

Good control of diabetes at an early stage of the disease is important

Those with diabetes are at increased risk of chronic kidney disease and chronic renal failure. This is because elevated plasma glucose damages nephrons by conjugating cellular proteins and forming advanced glycation end products (AGE). These end products of glycosylation tend to progressively damage tissues and organs and may continue to perpetuate organ damage even when plasma glucose is well controlled at a later stage. This tells us that it is important not only to control plasma glucose well but also to control it at an early stage of diabetes before too much cellular damage has been done. A recent publication in the New England Journal of Medicine titled: Intensive Diabetes Therapy and Glomerular Filtration Rate in Type 1 Diabetes (see here) tells us that good diabetic control for 6.5 years in early Type 1 diabetes reduced the risk of renal failure 22 years later. This study was based on the trial called DCCT where those with Type 1 diabetes (having diabetes for an average of 6 years) and no microvascular complications, were divided into two groups. One group was treated intensively with insulin and they achieved an average glycosylated haemoglobin value of 7.3 percent while the other group was treated with insulin only to reduce hyperglycemic symptoms. This conventionally-treated group had an average glycosylated haemoglobin value of 9.1 percent. After six and half years, at the end of the DCCT, these two groups were treated in a similar manner and a majority of them were followed by in an observational study called the EDIC study. During this EDIC study, the differences in diabetic control between the two groups began to narrow. The group that originally had the intensive treatment now had a HbA1c of 8 percent; the conventionally treated group now had a HbA1c of 8.2 percent. When evaluated twenty-two years after the end of the DCCT study, it was found that the group treated intensively with insulin for the initial 6.5 years had a fifty percent less risk of impaired renal function and end stage renal failure.

Thus the message to us is clear: Treat patients with Type 1 diabetes with the aim of keeping their glycosylated haemoglobin levels below 7 percent (or as close to 7 percent as possible) from an early stage itself. The good that comes from these early interventions will be seen only a couple of decades later. Conversely, if we neglect good diabetic control in these early years, our efforts to do so at a later stage may not be as beneficial.

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