Our 12-year-old son has had type 1 since the age of three. He also has epilepsy (on Lamictal 100mg twice a day) and a bleeding disorder. He has been having blood pressure issues for about four years and we have recently been sent to a nephrologist. His A1c was actually doing really well in 2007, 6.7%, and, at that time, under very tight control. His A1c got really elevated, above 10%, for about a year. We’re struggling to get numbers under 9% and are making some progress. Anyway, he was started on an ACE inhibitor today for his blood pressure and to help protect the kidneys. With him being so young and having so many medical issues, now even more medications, what are we looking at for his future? I am concerned about kidney disease and his future. Are there any suggestions about what we can do to prevent complications? The Nephrologist said he is at greater risk for kidney disease due to both the diabetes and high blood pressure. We work with his team and all other doctors/specialists closely. I just feel like maybe there is something more that can be done; is there?

There are big risks with hypertension already in one so young as a complication of his diabetes. If not already done, he needs a microalbumin urine assessment since this protein leakage would also bode poorly for long term health. The good news is that aggressive, modern blood pressure and/or microalbumin treatment can protect from ongoing kidney deterioration. A high A1c is a major problem with such high values usually suggesting serious compliance problems, major overeating or other dietary problems and often skipped insulin doses or poor glucose monitoring. Obviously, the high A1c suggests direct ongoing damage to the blood vessels of the kidney – and usually at the same time the brain, heart, nervous system and eyes. So, the risks are very high unless there can be sustained improvement with the A1c kept safely below 7%. Having him read Type 1 Diabetes in Children, Adolescents and Young Adults, Second Edition by Ragnar Hanas, M.D. or Type 1 Diabetes for Dummies by Alan Rubin, M.D. teaching manuals may help. Staying in close touch with your diabetes team and especially addressing the likely omitted insulin doses is key to bringing down these risks. Seeing a counselor may also be helpful. Most of our patients can get good blood pressure control with ACE inhibitors and provide kidney protection from ongoing additive damage. The key remains the chronic hyperglycemia, though.

SB