Diabetic Kidneys - This discussion focuses on kidney disease as a complication of diabetes

Dr. Harold Gunatillake FRCS - Health Writer

Diabetes is a very serious disease, one has to remember and a strict discipline needs to be exercised if you wish to live like the non-diabetics and enjoy a comparable life style. People having diabetes type 1 (juvenile type) have to be more careful from the time it’s diagnosed, whilst the majority who suffer late onset diabetes (type 11), in their sixties and after, need to adhere to a strict disciplined life style, too.

Twenty-six million Americans have chronic kidney disease, which has a number of causes — most often diabetes and high blood pressure. As the kidneys begin to fail, the body’s waste products build up in the bloodstream, leading to anemia, nerve damage, heart disease and other ailments.

People having diabetes run the risk of getting complications than most others, such complications as skin infections, vascular disease leading to amputations of limbs, hypertension, heart disease, stroke, cancer and kidney disease, among others. These complications are avoidable through a planned discipline.

Kidney disease
This discussion is mainly focused on kidney disease as a complication of diabetes.

Blood pressure needs to be watched weekly, whether you suffer from high blood pressure, or otherwise. Purchase your own blood pressure apparatus.

There are no early signs of kidney failure, and you need to check your kidney functions through blood and urine examination, annually. This is crucial that everyone with diabetes- and their doctors- watch for signs of kidney problems.

"Unfortunately, many people having diabetes don't realize that they have kidney disease," says Robert Stanton, MD, chief of nephrology at the Joslin Diabetes Center Clinic and associate professor of medicine at Harvard Medical School. "The obvious symptoms don't appear until the kidneys are failing." This complication is also called diabetic nephropathy and can lead to kidney failure

The obvious signs of kidney problems appear after there has been significant damage to the kidneys.  They may include foamy urine, weight gain, water retention, loss of appetite, and feeling unwell. Anyone with those symptoms needs to see a doctor right away.

You need to understand your disease by reading books on diabetes and questioning your doctor, when you visit him regarding your specific problems. Some patients are too intimidated to ask questions or request a clarification.

They may regard all medical matters to be the doctor’s purview. Or they may be fatalists who assume whatever will be, will be. In Sri Lanka the common talk among most lay people is that the specialists may not like you’re asking questions, and in most situations get angry.

Though diabetes is a serious chronic illness, you could be the master and the doctor and take charge the control and lead quite a normal healthy life.

There is good news:  Simple tests can monitor kidney function and detect early diabetic kidney disease. Treating early disease can make a huge difference. Medications, dietary changes, and good control of glucose levels and blood pressure can slow down or prevent kidney damage.

Studies have shown that strict control of your blood sugar can delay the onset of kidney disease. Your doctor may put you on insulin injections for easier and better control of your blood sugar. Control with tablets lowering blood sugar may not be sufficient when kidney damage is detected.
There are various types of insulin in the market, varying from quick acting rapid ones, to those that stabilize blood sugar levels up to 24 hrs.

The kidneys filter the blood.  They get rid of wastes (creatinine, urea, urates, chlorides (Cl), excess potassium (K) and Sodium (Na) in the body through urine, while the cleaned blood is sent back into the body.

In people with diabetes, the kidneys may be damaged so they don't filter blood as well. Small amounts of protein start to leak into the urine. This is referred to as micro-albuminuria. Blood pressure goes up, further stressing the kidneys, and larger amounts of protein are found in the urine. As these changes occur, the kidneys lose even more ability to filter the blood and waste products start to build up in the blood.

High blood glucose levels -- the defining symptom of diabetescan damage cells in the kidneys over time. Diabetes may be associated with other causes of kidney damage too, says Janet B. McGill, MD, an endocrinologist and professor of medicine at the Washington University School of Medicine, St. Louis.

Investigations
Blood electrolytes such as sodium level (Na), Potassium level (K); will be requested by your doctor
Blood urea, urates levels also help in assessing the situation.
In kidney failure the creatinine level may rise due to the poor excretion of creatinine (normal range 40120umol/L), through the kidneys.
A blood test called eGFR (for estimated glomerular filtration rate, a measure of kidney function- normal over 60 mL/min), is routinely done.

Urine tests for protein, creatinine, and albumin.
When the kidneys are damaged, tiny amounts of protein begin to leak into the urine.  Your doctor can test your urine to check for the presence of protein, creatinine, and albumin.
While getting an accurate reading used to mean collecting your urine for 24 hours, which is no longer necessary. You just need a single sample- spot check.

Creatinine/ albumin ratio in the urine is also tested- normal below2.5mg.mmol)

Micro albumin
Your urine needs to be checked for any leakage of albumin (protein) into the urine. Under normal conditions a trace may be present in the urine. Presence of micro albumin in the urine is an early sign of diabetic kidney disease.You should have your urine checked for micro albumin every year.

Certain drugs and dyes are toxic to the kidneys and should be avoided by people with kidney disease. The drugs include painkillers like acetaminophen, aspirin and ibuprofen; laxatives and antacids that contain magnesium and aluminum (Mylanta and Milk of Magnesia); ulcer drugs like Tagamet and Zantac; decongestants like Sudafed; enemas that contain phosphorus (Fleet); and Alka-Seltzer, which is high in salt. Contrast dyes used for certain tests, like angiograms and some M.R.I.’s, can also be harmful to kidney patients.

¶ When kidney disease progresses, patients can develop symptoms like changes in urination; swelling in the legs, ankles, feet, hands or face; fatigue;skin rashes and itching; a metallic taste in the mouth; nausea and vomiting; shortness of breath; feeling cold even when it is warm; dizziness and trouble concentrating; and back or leg pain. If any of these occur, they should be brought to a doctor’s attention without delay.

Treatment for Diabetes and Kidney Damage
•          Lifestyle changes. Eating a healthier diet (low GI foods) and exercising more can have a dramatic impact on blood glucose levels. Some people benefit from a diet that's low in protein. If you smoke, quit. Controlling lipids -- cholesterol and triglycerides -- may not have a direct effect on kidney function, but it can help lower the risk of heart disease.
•          Home monitoring. In addition to checking your blood glucose at home, you may need to closely monitor your blood pressure, too.
•          Medications. Drugs called ACE-inhibitors and angiotensin receptor blockers (ARBs) can help slow or prevent kidney disease in those with high blood pressure.
End stage kidney disease or kidney failure is treated with dialysis or a transplant. While kidney failure is a serious risk of diabetes, most people with diabetes never develop kidney failure. With good treatment, even people who do have severe kidney disease can sometimes delay dialysis for many years

Keep Your Blood Pressure in Balance
High blood pressure (or hypertension) can damage your kidneys. You may want to check your blood pressure at home to be sure it stays lower than 130/80. Have your health care provider check your blood pressure at least 4 times a year. Your doctor may have you take a blood pressure pill, called an ACE inhibitor, to help protect your kidneys.
(Some reference to WebMD Feature

Conclusions
If you have signs of early kidney disease with diabetes, remember to check the following and adhere to a healthy life style.

  • Check your blood pressure weekly

  • Check your blood and urine for kidney functions at least yearly.

  • ACE-inhibitors and angiotensin receptor blockers (ARBs) are the drugs of choice for early diabetic nephropathy.

  • Exercise daily. That helps to bring down blood sugar level, too

  • Keep your weight within the normal range.

  • Check blood sugar level daily and take insulin injections according to the readings. Short acting insulin’s like Act rapid and Novo rapid would be the best to control blood sugar levels until stabilized, and kidneys show stability in eGFR and creatinine levels.

  • Neglect of any of the above may end up with ‘end stage kidney failure’ and dialysis becomes imminent.

Your comments and problems on the subject are most welcome.

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