In need of help navigating life with diabetes? You can always Ask D'Mine! Yep, our weekly Q&A column by veteran type 1 and diabetes author Wil Dubois is here for you.

Today, Wil answers a question related to type 2 diabetes and how the liver's glucose-producing functionality works.

{Got your own questions? Email us at AskDMine@diabetesmine.com }

 

Gretchen, type 2 from Vermont, writes: As you probably know Wil, kidneys as well as liver, can produce glucose through gluconeogenesis. I was wondering if the frequent improvement in BG levels in elderly people might be because the kidneys were giving out, and so producing less glucose?

Wil@Ask D’Mine answers: True confession: I didn’t know about the kidneys producing glucose. Sorry to burst the bubble of anyone who thought I knew everything there is to know about diabetes. It turns out I knew everything but that. Now, that confession out of the way, where to start? Let’s start with that improving glucose in elders, then I’ll come back around to the kidneys. 

Long before my own diagnosis, my first real exposure to diabetes was through my father-in-law Tony, who was a non-compliant type 2 with a highly compliant wife. Yes, my mother-in-law was a badge-carrying member of the Diabetes Police. Heck, she was even a member of their elite SWAT team, but that’s a tale for another day.

Anyway, Tony was on oral meds, and as he aged, his doc struggled to keep Tony’s blood sugar in control. The poor doc adjusted Tony’s pills again and again and again.

Always downwards.

Which is exactly the opposite of what generally happens with type 2 diabetes. Generally, the pills are increased again and again and again. New pills are layered on top of old pills and finally the ol’ ball and chain of needle and insulin vial are resorted to.

So what was up with Tony? 

At the time I just figured the diabetes was sick of dealing with my mother-in-law so it packed its bags and moved out. (Lest you think otherwise, I loved my mother-in-law and we got along great, but if there ever was a woman who could wear out diabetes, it would have been her.)

Fast forward a decade or so and I’m into diabetes up to my ears. I have type 1 myself, and I’m working at a rural clinic helping literally hundreds of PWDs manage their diabetes. And that’s where I discovered that Tony’s case wasn’t unusual. We frequently lowered—and even stopped—the diabetes medications of elderly patients. I wondered: How does a relentless, progressive disease suddenly peter out? I thought it might be something related to the lifestyle patterns of the elderly. For many, a shift to smaller, more frequent meals, or different, generally shorter, sleep patterns, or changes in stress. But I wasn’t quite buying my own explanations. All of those things could make a difference, sure. But a big enough difference that decades of diabetes meds could just be flushed down the toilet? I knew I was missing a piece of the puzzle. A big piece.

And as I didn’t know how to explain it, my stock response to patients was, “Congratulations. You’ve outlived your diabetes.”

Now, on to kidneys. Most elderly people, healthy or less so, see a decline in kidney function as they age. And, of course I don’t need to tell all of you who have to pee in a cup every year to check your microalbumin, diabetes is rough on the kidneys.

But what about this whole thing of the kidneys producing sugar? Well, that’s a real thing, and it’s called renal gluconeogenesis. And while medical researchers knew that kidneys were capable of churning out sugar practically since the dawn of medical science, it’s only been over the last 20 years or so that the scientific community has come to realize just how large a role these little organs play in the whole sugar dance.

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The kidneys are in fact "little sugar factories."

How big a role? Quoting a 2001 study by the University of Rochester School of Medicine’s Dr. John E. Gerich, “It appears that the kidney may be roughly as important a gluconeogenic organ as the liver.” In fact, the kidneys are now estimated to be responsible for as much as 40% of all gluconeogenesis, the driving component of high fasting glucose levels. And, wait, there’s more. It turns out that in people with type 2 diabetes, for whatever reason, the kidneys produce as much as three times the sugar as the kidneys of people without diabetes. 

Holy sugar cubes, Batman! 

So imagine for a minute that I could create a diabetes medication that could lower A1C by 40% (yes, that would be me drinking piña coladas on a remote tropical beach, surrounded by bodacious bikini babes). For perspective here, Metformin, our best oral pill, can only manage to lower A1C -- at best -- by 1.5%.

Simply put, shutting down the kidneys’ production of sugar would have a profound effect on overall blood glucose, at least the internally-created part of the equation. Of course there’s more to type 2 than just gluconeogenesis. Remember that type 2 diabetes is largely a disease of insulin insufficiently, caused by pancreatic burnout, which in turn is the result of underlying insulin resistance.

But still, Gretchen, I think you are on to something here. Considering: 

  • The kidneys produce a boat-ton of glucose
  • The kidneys of people with type 2 produce three boat-tons of glucose
  • The elderly, in general, lose some degree of kidney function
  • The elderly who’ve fought a decades-long battle with diabetes most commonly lose more kidney function than other elders
  • Reducing the kidneys’ output of sugar would be significantly more effective than any oral medicine
  • The elderly often drift into smaller meals, reducing carb impact of external glucose

Would it be any wonder then that we have to reduce, and sometimes even discontinue, diabetes meds in the elderly? 

Personally, now that I know about them, I think the little sugar factories called the kidneys are the missing piece of the puzzle. So yes, Gretchen, I think that you are correct that the frequent improvement in BG levels in elderly people might be because the kidneys were giving out and so producing less glucose.Or put another way, could it be that it’s the undoing of the kidneys that does in their diabetes?

Ironic. Like I told my patients, you can outlive your type 2. But to do so, apparently, you also have to outlive your kidneys. 

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. Bottom Line: You still need the guidance and care of a licensed medical professional.