Diabetes: a pragmatic therapy with a goal to prevent end stage kidney disease and dialysis

The pragmatic therapy of diabetes which is to achieve satisfactory glycemic control emerges from author’s laboratory research. Cell culture studies convincingly demonstrated that high glucose levels above 200 mg/dL (> 11.1 mmol/L) cause damage to vascular endothelial cells. The severity of damage increases with duration of exposure of cultured endothelial cells to high glucose. This glucose-induced endothelial cell damage is mitigated by exposure of the endothelial cells to insulin in the presence of high glucose. There is abundant evidence, including that of author, that insulin treatment prevents diabetes-related microvascular complications including nephropathy and renal failure. Even by taking insulin multiple times, glucose level may reach normal level but only for a short time, because endogenous insulin response is insufficient. Manipulation by oral antidiabetic agents to enhance endogenous insulin release, or increase insulin sensitivity, results in exhaustion of the beta cells, thus changing an easily controllable glycemic state to a pathological uncontrollable glycemic state over the years. Even more troublesome is the lack of established information about the glucose levels that are safe for patients who have diabetes. By the term safe glucose level author means a glucose level which is least toxic to microvascular system and not likely to cause neuropathy, foot ulcer, gangrene, sexual dysfunction, and kidney failure. To achieve that glucose control is a formidable task for the patients as well as the doctors and nurses. Nevertheless, persistence is essential in diabetes management. Thus, on one hand patients must be astute in their care and doctors and nurses must be diligent in implementing and maintaining optimal glucose control in their patients. Both parties must be cohesive to achieve only one goal, which is to keep patients learn to cope with diabetes and thrive. Randomized clinical trials of glycemic control comparing one insulin against another, or insulin against oral hypoglycemic agents is not ethical. Such clinical trials will shed no light in improving diabetes care. On the other hand, it may prove to be detrimental.