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Diabetic Kidney Disease

Diabetes is a disease that keeps the body from using glucose, a form of sugar, as it should. If glucose stays in the blood instead of breaking down, it can act like a poison. Damage to the nephrons from unused glucose in the blood is called diabetic kidney disease. Keeping blood glucose levels down can delay or prevent diabetic kidney disease.
Use of medications called angiotensin- converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) to treat high blood pressure can also slow or delay the progression of diabetic kidney disease.

DIABETES AND THE KIDNEYS 

Diabetes mellitus is a disease and occurs when your body does not make enough insulin or cannot use normal amounts of it properly. Insulin is a hormone that regulates the amount of sugar in your blood. When diabetes is not well-controlled, the sugar level in your blood goes up. High blood sugar can cause damage to many parts of your body, especially the kidneys, heart, blood vessels, eyes, feet and nerves.

What is diabetic kidney disease? 

Diabetes is a leading cause of kidney damage. The kidneys play an important role in the body: they filter the blood, removing waste products and excess salt and water. Diabetic kidney disease (diabetic nephropathy) is a complication that occurs in some people with diabetes. In this condition the filters of the kidneys become damaged. With diabetes, the small blood vessels in the body are injured. which hinders  your kidneys from cleaning your blood properly. Your body will retain more water and salt than it should, which can result in weight gain and ankle swelling. You may “leak” protein in your urine. Also, waste materials will build up in your blood.
In some cases, diabetic kidney disease can eventually cause the kidneys to stop working altogether. If that happens to you, you will need to have a kidney transplant or dialysis, a procedure that filters the blood artificially several times a week. 

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I have diabetes. Will I develop kidney disease?

About one third of people with diabetes will get chronic kidney disease (about 30 percent of patients with Type 1 (juvenile onset) diabetes and 10 to 40 percent of those with Type 2 (adult onset) diabetes.
There are several factors that can increase your risk of developing diabetic kidney disease. These include:

  • Having chronically elevated blood sugar levels
  • Having high blood pressure
  • Being overweight or obese
  • Smoking
  • Having a diabetes-related vision problem (diabetic retinopathy) or nerve damage (diabetic neuropathy)

Having a family history of kidney disease or belonging to certain ethnic groups (eg, African American, Mexican, Pima Indian) can also increase your risk of diabetic nephropathy, but the factors listed above are the ones you can do something about.
Many people with diabetes do not get kidney disease or kidney failure. Talk to your doctor about your chances of developing kidney disease.

How can I prevent diabetes from affecting my kidneys?

The best way to prevent kidney disease caused by diabetes is to:

  • Control your blood sugar level.
  • Keep blood pressure under control.
  • Check your blood pressure as often as your doctor recommends.
  • Ask your doctor to test you for kidney disease at least once each year.
  • Take medicines to help control your blood glucose, cholesterol, and blood pressure if your doctor orders them for you.
  • Follow your diet for diabetes.
  • Get regular exercise.

What are the early signs of kidney disease in patients with diabetes?

Diabetic nephropathy usually has no symptoms, and people who have the condition often produce normal amounts of urine. To detect diabetic nephropathy, healthcare providers rely on tests that measure protein levels in the urine and blood tests to evaluate the level of kidney function.
When the kidneys are working normally, they prevent protein from leaking into the urine, so finding protein in the urine is a sign that the kidneys are in trouble. The main protein that leaks out from the damaged kidneys is called albumin. In normal healthy kidneys only a tiny amount of albumin is found in the urine. A raised level of albumin in the urine is the typical first sign that the kidneys have been damaged. Often people who have diabetic nephropathy also have high blood pressure.

What are the late signs of kidney disease in patients with diabetes? 

The key complication of diabetic nephropathy is more advanced kidney disease, called chronic kidney disease. Further progression of this disease will eventually lead to total kidney failure. As your kidneys fail, the waste product levels will rise in your blood (blood urea nitrogen, known as BUN (BUN) and creatinine). You may start having nausea, vomiting, loss of appetite, weakness, increasing fatigue, itching, muscle cramps (especially in your legs) and anemia (a low blood count). You may find you need less insulin. This is because diseased kidneys cause less breakdown of insulin.

How do I know if I have diabetic kidney damage? 

Urine tests are recommended once per year in people with Type 1 diabetes, beginning about five years after diagnosis, and in people with Type 2 diabetes, starting at the time of diagnosis. The urine test is looking for the protein (albumin). If there is albumin in your urine, it means you have diabetic nephropathy.
The same urine test that is used to diagnose diabetic nephropathy will also be used to monitor your condition over time.

What will happen if my kidneys have been damaged? 

Finding out that you have early diabetic kidney disease can alert you that your kidneys are in danger. It is important to take steps to protect your kidneys before the problem advances. 

People with diabetes often focus on keeping their blood sugar levels in the right ranges. And while it is important to control blood sugar, it turns out that controlling blood pressure is at least as important. That’s because high blood sugar and high blood pressure work together to damage the blood vessels and organ systems. For these reasons, the most important things you can do to stop kidney disease and protect against other diabetes complications are to:

  • Keep your blood sugar as close to normal as possible.
  • Keep your blood pressure well-controlled.
  • Make healthy lifestyle choices.

Manage blood sugar: Keeping blood sugars close to normal can help prevent the long-term complications of diabetes mellitus. For most people, a target for fasting blood glucose and for blood glucose levels before each meal is 80 to 120 mg/dL. A blood test called A1C is also used to monitor blood sugar levels; the result provides an average of blood sugar levels over the last one to three months. An A1C of 7 percent or less is usually recommended.

Manage high blood pressure: Many people with diabetes have high blood pressure. Although high blood pressure causes few symptoms, it has two negative effects: it stresses the cardiovascular system and speeds the development of diabetic complications of the kidney and eye.

The treatment of high blood pressure varies. If you have mild hypertension, your healthcare provider may recommend weight loss, exercise, decreasing the amount of salt in the diet, quitting smoking, and decreasing alcohol intake. These measures can sometimes reduce blood pressure to normal. If these measures are not effective or your blood pressure needs to be lowered quickly, your provider will likely recommend one of several medications.

A blood pressure reading below 130/80 is the recommended goal for most people with diabetic kidney disease.

Blood pressure medications: Most people with diabetic nephropathy need at least one medication to lower their blood pressure. Several medications can be used for this purpose, but an angiotensin-converting enzyme inhibitor (ACE inhibitor) or a related drug known as an angiotensin receptor blocker (ARB) is used most commonly. ACE inhibitors and ARBs are particularly useful for people with diabetic nephropathy because they decrease the amount of protein in the urine and can prevent or slow the progression of kidney disease.

Lifestyle changes: Changing your lifestyle can have a big impact on the health of your kidneys. The following measures are recommended for everyone, but are especially important if you have kidney damage from diabetes:

  • Limit the amount of salt you eat.
  • If you smoke, quit.
  • Lose weight if you are overweight.
  • Avoid any medicines that may damage the kidneys (especially over-the-counter pain medications).

Monitor for signs of change: After beginning treatment and lifestyle changes to stop kidney disease, you will need to have repeat urine and blood tests to determine if urine protein levels have improved. If they  have not improved or your kidney function has worsened, your healthcare provider may need to adjust your medications or recommend other strategies to protect your kidneys.

How are the kidneys kept working as long as possible? 

The kidney doctor, called a nephrologist, will plan your treatment with you, your family and your dietitian. Two things to keep in mind for keeping your kidneys healthy are controlling high blood pressure in conjunction with an ACE inhibitor or an ARB, and following your renal diabetic diet. Restricting protein in your diet also might be helpful. You and your dietitian can plan your diet together.

Are there any new medications for patients with diabetic kidney disease? 

Research efforts are under way and are focused on to delaying diabetic kidney disease progression. These medications are being tested for patients with protein in the urine due to diabetes. Renal Medicine Associates is working with pharmaceutical companies that are testing some of these new medications. Ask your kidney doctor if you may qualify for any of the ongoing studies.

What is end stage kidney failure in patients with diabetes? 

End stage renal failure, or kidney failure, occurs when your kidneys are no longer able to support you in a reasonably healthy state. This happens when your kidneys function at only 10 to 15 percent.

How is end stage kidney failure treated in diabetic patients? 

Three types of treatment can be used once your kidneys have failed: kidney transplantation, hemodialysis and peritoneal dialysis. To learn more about treatment options talk to your kidney doctor.

What is the future outlook for patients with diabetes? 

Today, more and more research dollars are spent on diabetes research. Hopefully, the prevention and cure of diabetes is in our future. In the meantime, you can manage your diabetes better with:

  • Home monitoring of your blood glucose levels
  • Maintaining an awareness of controlling your blood pressure and possibly monitoring your pressure at home
  • Following your special diet and changing your life style
  • Ask your primary doctor about testing for common target affected organs ( eyes, heart, kidney, feet, etc)

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Dr. Hectro Castro