Each year in the United States, more than 100,000 people are diagnosed with kidney failure, a serious condition in which the kidneys fail to rid the body of wastes. Kidney failure is the final stage of kidney disease, also known as nephropathy.
Diabetes is the most common cause of kidney failure, accounting for nearly 45 percent of new cases. Even when diabetes is controlled, the disease can lead to nephropathy and kidney failure. Most people with diabetes do not develop nephropathy that is severe enough to cause kidney failure. About 18 million people in the United States have diabetes, and more than 150,000 people are living with kidney failure as a result of diabetes.
People with kidney failure undergo either dialysis, which substitutes for some of the filtering functions of the kidneys, or transplantation to receive a healthy donor kidney. Most U.S. citizens who develop kidney failure are eligible for federally funded care. In 2003, care for patients with kidney failure cost the Nation more than $27 billion.
African Americans, American Indians, and Hispanics/Latinos develop diabetes, nephropathy, and kidney failure at rates higher than Caucasions. Scientists have not been able to explain these higher rates. Nor can they explain fully the interplay of factors leading to diabetic nephropathy-factors including heredity, diet, and other medical conditions, such as high blood pressure. They have found that high blood pressure and high levels of blood glucose increase the risk that a person with diabetes will progress to kidney failure.
Two Types of Diabetes
There are two types of diabetes. In both types, the body does not properly process and use food. The human body normally converts food to glucose, the simple sugar that is the main source of energy for the body's cells. To enter cells, glucose needs the help of insulin, a hormone produced by the pancreas. When a person does not make enough insulin, or the body does not respond to the insulin that is present, the body cannot process glucose, and it builds up in the bloodstream. High levels of glucose in the blood lead to a diagnosis of diabetes. Both types of diabetes can lead to kidney disease.
Type 1 Diabetes : -
About 5 to 10 percent of people with diagnosed diabetes have type 1 diabetes, which tends to first occur in young adults and children. Type 1 used to be known as insulin-dependent diabetes mellitus or juvenile diabetes. In type 1 diabetes, the body stops producing insulin. People with type 1 diabetes must take daily insulin injections or use an insulin pump. They also control blood glucose levels with meal planning and physical activity. Type 1 diabetes is more likely to lead to kidney failure. Twenty to 40 percent of people with type 1 diabetes develop kidney failure by the age of 50. Some develop kidney failure before the age of 30.
Type 2 Diabetes : -
About 90 to 95 percent of people with diagnosed diabetes have type 2 diabetes, once known as noninsulin-dependent diabetes mellitus or adult-onset diabetes. Many people with type 2 diabetes do not respond normally to their own or to injected insulin-a condition called insulin resistance. Type 2 diabetes first occurs more often in people over the age of 40, but it can occur at any age-even during childhood. Many people with type 2 are overweight. Many also are not aware that they have the disease. Some people with type 2 control their blood glucose with meal planning and physical activity. Others must take pills that stimulate production of insulin, reduce insulin resistance, decrease the liver's output of glucose, or slow absorption of carbohydrate from the gastrointestinal tract. Still others require injections of insulin in addition to pills.
The Course of Kidney Disease
Diabetic kidney disease takes many years to develop. In some people, the filtering function of the kidneys is actually higher than normal in the first few years of their diabetes. This process has been called hyperfiltration.
Over several years, people who are developing kidney disease will have small amounts of the blood protein albumin begin to leak into their urine. At its first stage, this condition has been called microalbuminuria. The kidney's filtration function usually remains normal during this period.
As the disease progresses, more albumin leaks into the urine. This stage may be called overt diabetic nephropathy or macroalbuminuria. As the amount of albumin in the urine increases, filtering function usually begins to drop. The body retains various wastes as filtration falls. Creatinine is one such waste, and a blood test for creatinine can be used to estimate the decline in kidney filtration. As kidney damage develops, blood pressure often rises as well.
Overall, kidney damage rarely occurs in the first 10 years of diabetes, and usually 15 to 25 years will pass before kidney failure occurs. For people who live with diabetes for more than 25 years without any signs of kidney failure, the risk of ever developing it decreases.
Effects of High Blood Pressure
High blood pressure, or hypertension, is a major factor in the development of kidney problems in people with diabetes. Both a family history of hypertension and the presence of hypertension appear to increase chances of developing kidney disease. Hypertension also accelerates the progress of kidney disease when it already exists.
In the past, hypertension was defined as blood pressure exceeding 140 millimeters of mercury-systolic and 90 millimeters of mercury-diastolic. Professionals shorten the name of this limit to 140/90 or "140 over 90." The terms systolic and diastolic refer to pressure in the arteries during contraction of the heart (systolic) and between heartbeats (diastolic).
The American Diabetes Association and the National Heart, Lung, and Blood Institute recommend that people with diabetes keep their blood pressure below 130/80.
Hypertension can be seen not only as a cause of kidney disease, but also as a result of damage created by the disease. As kidney disease proceeds, physical changes in the kidneys lead to increased blood pressure. Therefore, a dangerous spiral, involving rising blood pressure and factors that raise blood pressure, occurs. Early detection and treatment of even mild hypertension are essential for people with diabetes.
Preventing and Slowing Kidney Disease
Blood Pressure Medicines
Scientists have made great progress in developing methods that slow the onset and progression of kidney disease in people with diabetes. Drugs used to lower blood pressure (antihypertensive drugs) can slow the progression of kidney disease significantly. Two types of drugs, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have proven effective in slowing the progression of kidney disease. Many people require two or more drugs to control their blood pressure. In addition to an ACE inhibitor or an ARB, a diuretic is very useful. Beta blockers, calcium channel blockers, and other blood pressure drugs may also be needed.
An example of an effective ACE inhibitor is captopril, which doctors commonly prescribe for treating kidney disease of diabetes. The benefits of captopril extend beyond its ability to lower blood pressure: it may directly protect the kidney's glomeruli. ACE inhibitors have lowered proteinuria and slowed deterioration even in diabetic patients who did not have high blood pressure.
An example of an effective ARB is losartan, which has also been shown to protect kidney function and lower the risk of cardiovascular events.
Any medicine that helps patients achieve a blood pressure target of 130/80 or lower provides benefits. Patients with even mild hypertension or persistent microalbuminuria should consult a physician about the use of antihypertensive medicines.
Moderate-Protein Diets
In people with diabetes, excessive consumption of protein may be harmful. Experts recommend that people with kidney disease of diabetes consume the recommended dietary allowance for protein, but avoid high-protein diets. For people with greatly reduced kidney function, a diet containing reduced amounts of protein may help delay the onset of kidney failure. Anyone following a reduced-protein diet should work with a dietitian to ensure adequate nutrition.
Intensive Management of Blood Glucose
Antihypertensive drugs and low-protein diets can slow kidney disease when significant nephropathy is present. A third treatment, known as intensive management of blood glucose or glycaemic control, has shown great promise for people with type 1 and type 2 diabetes, especially for those in early stages of nephropathy.
Intensive management is a treatment regimen that aims to keep blood glucose levels close to normal. The regimen includes testing blood glucose frequently, administering insulin frequently throughout the day on the basis of food intake and physical activity, following a diet and activity plan, and consulting a health care team frequently. Some people use an insulin pump to supply insulin throughout the day.
A number of studies have pointed to the beneficial effects of intensive management. Researchers found a 50 percent decrease in both development and progression of early diabetic kidney disease in participants who followed an intensive regimen for controlling blood glucose levels. The intensively managed patients had average blood glucose levels of 150 milligrams per deciliter-about 80 milligrams per deciliter lower than the levels observed in the conventionally managed patients.
The United Kingdom Prospective Diabetes Study, conducted from 1976 to 1997, showed conclusively that, in people with improved blood glucose control, the risk of early kidney disease was reduced by a third. Additional studies conducted over the past decades have clearly established that any programme resulting in sustained lowering of blood glucose levels will be beneficial to patients in the early stages of diabetic nephropathy.
Dialysis and Transplantation
When people with diabetes experience kidney failure, they must undergo either dialysis or a kidney transplant. As recently as the 1970s, medical experts commonly excluded people with diabetes from dialysis and transplantation, in part because the experts felt damage caused by diabetes would offset benefits of the treatments. Today, because of better control of diabetes and improved rates of survival following treatment, doctors do not hesitate to offer dialysis and kidney transplantation to people with diabetes.
Currently, the survival of kidneys transplanted into patients with diabetes is about the same as survival of transplants in people without diabetes. Dialysis for people with diabetes also works well in the short run. Even so, people with diabetes who receive transplants or dialysis experience higher morbidity and mortality because of coexisting complications of the diabetes-such as damage to the heart, eyes, and nerves.
What are the possible complications?
End-stage kidney failure
In people with proteinuria, end-stage kidney failure develops in approximately 8 in 100 people after 10 years. If this occurs then you would need kidney dialysis or a kidney transplant.
Cardiovascular diseases
All people with diabetes have an increased risk of developing cardiovascular diseases such as heart disease, stroke and peripheral vascular disease. If you have diabetes and diabetic kidney disease, then your risk of developing cardiovascular diseases is increased further. The worse the kidney disease, the further increased the risk. This is why reducing any other cardiovascular risk factors is so important if you have diabetic kidney disease (see below).
High blood pressure
Kidney disease has a tendency to increase blood pressure. And, increased blood pressure has a tendency to make kidney disease worse. Treatment of high blood pressure is one of the main treatments of diabetic kidney disease.
What is the treatment for diabetic kidney disease?
Treatments that may be advised are discussed below. Treatments aim to : -
prevent or delay the disease progressing to kidney failure. In particular, if you have microalbuminuria it does not always progress to the proteinuria phase of the disease.
reduce the risk of developing cardiovascular diseases such as heart disease and stroke
An angiotensin converting (ACE) inhibitor
There are several types and brands. These drugs work by reducing the amount of a chemical that you make in your bloodstream called angiotensin II. This chemical tends to constrict (narrow) blood vessels. Therefore, less of this chemical causes the blood vessels to relax and widen, and so the pressure of blood within the blood vessels is reduced. ACE inhibitors are drugs that are often used to treat high blood pressure. However, the way they work also seems to have a protective effect on the kidneys and heart. Therefore they help to prevent or delay the progression of the kidney disease.
An angiotensin-II receptor antagonist (AIIRA)
There are several types and brands. They work in a similar way to ACE inhibitors. One may be used instead of an ACE inhibitor if you have problems or side-effects with taking an ACE inhibitor. (For example, some people taking an ACE inhibitor develop a persistent cough.)
Good control of your blood glucose level
This will help to delay the progression of the kidney disease and to reduce your risk of developing associated cardiovascular diseases such as heart disease and stroke. Ideally, the aim is to maintain your HBA1c to less than 6.5%. See leaflets called Type 1 Diabetes and Type 2 Diabetes for details.
Good control of your blood pressure
Strict blood pressure control is likely to reduce the risk of developing cardiovascular diseases and prevent or delay the progression of kidney disease. Most people should already be taking an ACE inhibitor or angiotensin-II receptor antagonist (described above). These drugs lower blood pressure. However, if the blood pressure remains at 130/80 mmHg or more then one or more additional drugs may be advised to get the blood pressure to below this target level.
Limiting your dietary protein may be advised
Restricting the amount of protein in the diet has been shown to have a small effect at reducing the progression of the kidney disease in people with Type 1 diabetes. However, this is not routine treatment in primary care. The effect in people with Type 2 diabetes is debatable.
Other treatments to reduce risk factors
Other treatments that reduce the risk of developing associated cardiovascular diseases include:
Drug treatment to lower your cholesterol level, whatever the initial level. The aim is : -
To reduce total cholesterol to less than 4.0 mmol/l and LDL cholesterol to less than 2.0 mmol/l, OR
A 25% reduction in total cholesterol and a 30% reduction in LDL cholesterol.
Whichever of the above gives the greatest reduction.
A daily low dose of aspirin - depending on your age and other factors. This reduces the risk of blood clots forming. This helps to prevent heart attacks and strokes. See leaflet called 'Aspirin to Prevent Blood Clots'.
Where relevant, to tackle lifestyle risk factors.
This means to : -
Stop smoking if you smoke.
Eat a healthy diet.
Keep your weight and waist in check.
Take regular physical activity.
Cut back if you drink a lot of alcohol.
Good Care Makes a Difference
If you have diabetes : -
Have your doctor measure your A1C level at least twice a year. The test provides a weighted average of your blood glucose level for the previous 3 months. Aim to keep it at less than 7 percent.
Work with your doctor regarding insulin injections, medicines, meal planning, physical activity, and blood glucose monitoring.
Have your blood pressure checked several times a year. If blood pressure is high, follow your doctor's plan for keeping it near normal levels. Aim to keep it at less than 130/80.
Ask your doctor whether you might benefit from taking an ACE inhibitor or ARB.
Have your urine checked yearly for microalbumin and protein.
Have your blood checked for elevated amounts of waste products such as creatinine. The doctor should provide you with an estimate of your kidney's filtration based on the blood creatinine level.
Ask your doctor whether you should reduce the amount of protein in your diet. Ask for a referral to see a registered dietitian to help you with meal planning.
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