I have type 1 diabetes for over 15 years. My control has been very poor in the past 10 years with A1cs around 14%. I’ve been trying really hard to get control and my numbers have run around 6%. My last A1c was a whopping 4.8! I am very happy. The problem is, because of my past indiscretions, my kidney functions are very poor. My last creatinine was 5.6 and my nephrologist told me that it is time to start thinking about dialysis. Is it too soon to be thinking about this? I don’t really feel bad besides being more fatigued lately. I don’t want to do dialysis and I want to know what would happen if my nephrologist said it was time and I declined further treatment. I am only 35 years old and I am scared. I need a second opinion.

You have some of the same feelings as the patients I see at my university. However, it is true you are on a progressive course. It is not too soon to think about these things. At a creatinine of 5.6 mg/dl, you have lost more than 80% of your kidney function. There are many questions that need to be answered as to how you will receive kidney support. For instance, if you require dialysis, will you receive hemodialysis or peritoneal dialysis? You need to be educated about these procedures and how they work. In addition, you need to know what the prospects are for potential kidney transplantation. This is a rather long evaluation process. It is best to have it done now so that if you need it, you can spend the shortest time possible on dialysis. There are studies that show patients with type 1 diabetes who develop kidney failure do better after transplant than on dialysis.

Your blood sugars are much easier to control without a lot of kidney function. The kidneys are a route for removal of insulin from the body. When they do not work, you maintain more insulin around with a lower overall dose. When you get dialysis or transplantation, the lability of the blood sugars and the overall control may worsen. You need to be aware of how to address this. Overall, it would not be a good strategy to be idle during this time of relative calm. The above issues need to be addressed and it is best to meet them head on.

JTL