Ask the doctor: Diabetics must look after their kidneys...

By Dr Martin Scurr
Updated: 17:18 EST, 6 October 2008

Dr Martin Scurr has been treating patients for more than 30 years and is one of the country's leading GPs. Here he tackles kidneys and hives...

I've had Type 2 diabetes for four years. My GP says I am losing protein from my kidneys, and has increased my dose of Ramipril, a drug for high blood pressure, to help. But why has this happened? Is there anything else that could improve the situation? What will happen if the problem persists? Anne Mohidin, Morden, Surrey.

Dr Scurr says... Diabetes Type 2 usually occurs in middle-aged or older patients. It does not usually require insulin for treatment: instead, patients must reduce their carbohydrate intake (starch and sugar), and take drugs which help their system handle sugars more efficiently. 

Because you don't need injections (this is for people with Type 1 diabetes, usually diagnosed under the age of 30), people often assume that Type 2 is less serious, and patients tend be less disciplined in the treatment - to their detriment. Not managing your condition properly can lead to kidney damage, blindness and a higher risk of heart disease and stroke. 

The high sugar levels in diabetics damage the filtering membrane of the kidneys, which then become 'leaky' to the proteins normally carried in the bloodstream. 

Kidney risk: Type 2 diabetes is often seen as less serious than Type 1 because you don't need injections. But if it isn't managed properly, there's a risk of kidney damage

Because of this, protein in the urine is routinely tested, as it is the first sign of impending kidney trouble. But this can be remedied if caught early. 

The condition diabetic nephropathy is the most common single cause of end-stage kidney failure in the West. 

End-stage means that a patient must have dialysis or have a kidney transplant. The incidence is increasing because diabetes is rising due to obesity. 

Along with diabetes, loss of kidney function is also caused by high blood pressure, so it's vital to control this. Prescribed drugs such as Ramipril are the main weapon in stabilising kidney function. 

Patients with kidney damage from diabetes are also likely to have problems with the retina of the eye, leading to blindness. Another problem is damage to the function of small nerves, causing a loss of sensation in the feet and lower legs. 

However, the most serious problem for diabetics is that their arteries are more likely to be furred up with fatty deposits, making them up to four times at risk of a heart attack or stroke. 

Doctors get frustrated when patients don't stick to their treatment. Perhaps we fail to shout about how crucial it is to control these risk factors. Yet your desire to address the problem makes you sound rather different, which I applaud, so here are two more pieces of advice. 

First, low-protein diets - lots of fruit and vegetables, and cutting back on proteins such as meat - slow the decline of kidney function in diabetics. 

Secondly, low-dose aspirin (one tablet daily) is advised for all diabetics with protein in their urine because of their high risk of cardiovascular disease. It also reduces the stickiness of certain blood cells, reducing the risk of heart attack. 

So, talk to your GP about taking aspirin and stick to your Ramipril. Also ask your GP or dietician about a low protein diet, and do slim down if you are too heavy.

My 33-year-old daughter has hives. She has wheals across her body, hot sweats and occasionally facial disfigurement. She takes anti-histamine and steroid tablets, and she is under medical supervision. What causes hives? And is there a cure? Mr D. Ashton, Middlesbrough. 

Dr Scurr says... The medical term for hives is urticaria, describing the appearance of the rash - (urtica being the botanical name for the common stinging nettle). With hives, the rash is fiercely itchy rather than painful. 

Hives can occur at any age - 20 per cent of us get them at some time in life. The condition is acute if the attack lasts less than six weeks, and chronic if it continues for longer. 

We usually find a cause in the former, but only about 10 per cent of chronic cases are solved - though they eventually just fade away. We have to be careful in those cases not to reach any false conclusions about the solution. 

It is easy to assume - wrongly - that the condition cleared up because of a dramatic dietary exclusion or a herbal remedy. 

A hive or wheal is a red or white bump on the skin which varies in size and shape over a period of hours. As some resolve and disappear, others erupt. 

They vary in size from a pinhead to as big as a dinner plate. Large, thick hives can cause gross or even dangerous swelling of the face, lips or throat. 

The hive results from the tiniest blood vessels in the skin, the capillaries, widening and becoming leaky. Fluid from the bloodstream leaks out, causing the swollen bump on the skin surface. 

The fluid is eventually reabsorbed by the normal functions of the body and the bump goes down. 

This all happens when histamine, a natural chemical within the body, is released from a type of white blood cell known as a mast cell. A variety of factors cause a mast cell to do this. 

Often, hives are triggered by an allergy to shellfish or nuts, for example, with sufferers getting symptoms within minutes of eating that food.

The allergy can also be to preservatives such as benzoates (used in tomato ketchup) or sulfites (used in many foods to prevent mildew), and drugs such as penicillin or aspirin. 

Physical stimuli such as sunshine and water can also trigger hives. 

You will realise by now that the list of possibilities of causes is enormous - which is why the detective work is not easy. 

Your daughter's doctor will have suppressed the hives with regular antihistamine drugs, aided by the steroids. This normally slowly brings the condition under control, while a possible cause is found. 

You should take into account what your daughter eats, the medications she's on, the timing of the rash, and where she lives and works. 

It's also important to exclude infections and rule out thyroid problems: 10 per cent of cases might be due to this. 

Is there a cure? It entirely depends on the cause. But even when a cause can't be found, the hives go away in the end. 

By the way... My friend and patient Simon Gray, the playwright, died on August 7. His most recent book, The Last Cigarette, is part of his memoirs, The Smoking Diaries. 

Despite his enthusiasm for tobacco, I am happy that, notwithstanding a diagnosis of lung cancer, he died when he was really rather well, quite suddenly, and of a cause unrelated to smoking.

So, in a way, he triumphed. He outflanked those dire warnings with which we regale patients who smoke heavily, and after 20 years of he and I sparring about such issues. 

The ban on smoking in public places has helped people stop. But the most useful measure in advising my patients was research revealing smokers are profitable to governments as they pay much more tax than non-smokers, yet live much shorter lives. They are not nearly so much of a burden on the state in old age - most don't have much of an old age. 

The mythology has been that smokers cost the State money in additional healthcare - but it's no contest when compared with longer lives of non-smokers. 

So I give my teenage patients who are smokers a sermon - advising that those printed warnings on the fag packet are a con: the Government wants them to smoke, to pay more and check in for an early shower. 

I then advise that if you want to be subversive, be a non-smoker. Most leave the surgery looking very thoughtful.