Making the World Dialysis-Free by the Year 2020 David Moskowitz MD - VOXXI
go to original November 29, 2012

Globesity: Fat's New Frontier - Obesity is no longer just a rich country's problem. It's now taken hold in poor and emerging countries and is rapidly developing into an insurmountable health crisis. Type 2 diabetes, heart disease and some cancers are on the march in nations ill equipped to treat sufferers or educate others about the dangers of getting too fat. It's predicted that by 2030 one billion people will be obese, so how will the world cope with its ever expanding waistline? (liberalcynic)

Diabetes has become a huge burden for Mexico, where 20-25 percent of the adult population has type 2 diabetes, formerly called adult-onset diabetes. Many children get diabetes as teenagers. Like diabetic patients everywhere, about half lose their kidneys and must go on dialysis or get a kidney transplant in order to stay alive.

Mexico, a relatively poor country, is doing a heroic job dialyzing its citizens. Mexico dialyzes 150,000 people a year. Still, 75,000 diabetic patients with end-stage kidney failure die every year in Mexico because there aren’t enough dialysis machines or money to dialyze them.
It’s not just Mexico

The astronomical incidence of diabetes in Mexico is shared by most of the populations on earth. American Indians, like the Pima Indians of Arizona, have an even higher incidence of type 2 diabetes: 50 percent. Dialysis units are being built on every Indian reservation.

Pacific Islanders have a similarly high incidence of type 2 diabetes. Diabetics from Samoa and Fiji come to Hawaii, for example, to get dialysis. This is creating a local crisis, since native Hawaiians have a similarly high incidence of diabetes, and access to dialysis machines is limited.

The ticking time-bombs, though, are India and China. Each country is supposed to have 300 million diabetic patients. No country on earth is rich enough to dialyze 150 million patients.

The explanation for this explosion in diabetes was first suggested in the early 1960s. These people are all survivors. Amerindians, an important strain in modern-day Mexicans, had to be able to survive long periods of starvation. Those who couldn’t simply died. Natural selection made sure that the survivors had a “thrifty genotype.” The result of mixing the thrifty genotype with a Western lifestyle, with its abundant calories and physical inactivity, is type 2 diabetes.

The only public health approach being widely discussed is to go back to the Stone Age, the Paleolithic. If people would just cut back on calories and exercise more, their diabetes would disappear.

Kidney disease, dialysis and diabetes

The problem is that the Western lifestyle is addictive. Our brains are hard-wired to love French fried potatoes. The fact that people can weigh 800 pounds suggests that there are powerful positive feedback loops at work with eating.

Besides turning the clock back 100 years and trying to embrace a harsh lifestyle, there is another, purely pharmacological approach. That is to deploy one of the most clinically successful drugs of all time, ACE inhibitors, on a population-wide basis. In the 1990s, my laboratory found that ACE inhibitors should be useful for three-quarters of common diseases. In particular, we should be able to prevent, or at least delay, the onset of type 2 diabetes by using the right ACE inhibitor at the right dose.

We were able to show, and published in 2002, that using high-dose quinapril could actually reverse early-stage diabetic kidney failure. If we began our treatment on patients who still had at least half of their kidney function left, then we could lower their serum creatinine, i.e. restore some of their lost kidney function.

If begun while patients still had normal creatinines, our treatment could prevent Mexican diabetic patients from having any kidney failure at all (350 patients; unpublished data). Unfortunately, we could do nothing for patients already on dialysis.

Our approach works just as well with high blood pressure. Type 2 diabetes and high blood pressure cause 90 percent of kidney failure around the world. So it should be possible to prevent 90 percent of dialysis. (The drugs we use are present in every drugstore on earth). The relatively few remaining kidney failure patients should be able to get a kidney transplant. Thus, in principle, it should be possible to make the world dialysis-free by 2020.

The first step is realizing that it can be done.

Dr. Moskowitz founded GenoMed in 2001. He studied at Harvard, Oxford (on a Marshall Scholarship), and Harvard Medical School. He trained in Medicine, Biochemistry, and Nephrology at Washington University before teaching at St. Louis University for 11 years.

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