Have you got Diabetes ? Must check your kidneys then !

By Dr S.J.Acharya

There are two types of diabetes . 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.

About 90 to 95 percent of people with diagnosed diabetes have type 2 diabetes, once known as non-insulin-dependent diabetes mellitus ( NIDDM ) 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

How kidneys are affected in diabetes ?

Kidneys filter blood . High levels of blood sugar make the kidneys filter too much blood. All this extra work is hard on the filters. After many years, they start to leak. Useful protein is lost in the urine. Having small amounts of protein in the urine is called microalbuminuria. When kidney disease is diagnosed early, (during microalbuminuria), several treatments may keep kidney disease from getting worse.
Having larger amounts of protein in urine is called macroalbuminuria. When kidney disease is caught later (during macroalbuminuria), end-stage renal disease, or ESRD, usually follows.

In time, the stress of overwork causes the kidneys to lose their filtering ability. Waste products then start to build up in the blood.

Finally, the kidneys fail. This failure, ESRD( end stage renal disease ), is very serious. A person with ESRD needs to have a kidney transplant or to have the blood filtered by machine (dialysis).

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.

Who gets kidney disease?

Not everyone with diabetes develops kidney disease. Factors that can influence kidney disease development include genetics, blood sugar control, and blood pressure.
The better a person keeps diabetes and blood pressure under control, the lower the chance of getting kidney disease.

Symptoms and diagnosis of kidney disease

Kidney disease produces no symptoms until almost 85% of function is gone. Also, the symptoms of kidney disease are not specific. The first symptom of kidney disease is often fluid buildup resulting in swelling of feet and face . Other symptoms of kidney disease include loss of sleep, poor appetite, upset stomach, weakness, and difficulty in concentrating.

It is vital to see a doctor regularly. The doctor can check blood pressure, urine (for protein), blood (for waste products), and organs for other complications of diabetes.

Kidney Disease Prevention

Control blood sugar

The Diabetes Control and Complications Trial (DCCT), a 10-year study which ended in June 1993, proved among type 1 patients that improved blood glucose control can prevent the onset and delay the progression of diabetic kidney disease. Therapy that keeps blood glucose levels as close to normal as possible reduced damage to the kidneys by 35-56%.

Research has shown that tight blood sugar control reduces the risk of microalbuminuria by one third. In people who already had microalbuminuria, the risk of progressing to macroalbuminuria was cut in half. Other studies have suggested that tight control can reverse microalbuminuria.

Control Blood Pressure

Four ways to lower your blood pressure are losing weight, eating less salt, avoiding alcohol and tobacco, and getting regular exercise.
When these methods fail, certain medicines may be able to lower blood pressure. There are several kinds of blood pressure drugs. Doctors usually prefer people with diabetes to take blood pressure drugs called ACE inhibitors (angiotensin-converting enzyme (ACE) inhibitors).

ACE inhibitors slow kidney disease in addition to lowering blood pressure. In fact, these drugs are helpful even in people who do not have high blood pressure.
ACE inhibitors have lowered proteinuria and slowed deterioration even in diabetic patients who did not have high blood pressure.

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

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.
Researchers have 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.

Dialysis

Dialysis is a way of cleaning the blood with an artificial kidney. Dialysis is the more common form of kidney-replacement therapy. There are two types of dialysis: hemodialysis and peritoneal dialysis.

Hemodialysis

In hemodialysis, an artificial kidney removes waste from the blood. A surgeon must first create an "access," a place where blood can easily be taken from the body and sent to the artificial kidney for cleaning. The access, usually in the forearm, can be made from the patient's own blood vessels .The access is inside the body and cannot be seen from the outside. Usually, this surgery is done 2 to 3 months before dialysis starts so the body has time to heal.

Hemodialysis must be done 2 to 3 days per week, and lasts 3 to 5 hours each time. Blood travels through the artificial kidney, where waste products are filtered out, and the clean blood returns to the body. Usually, hemodialysis is done in a clinic, with many people receiving dialysis at the same time. Hemodialysis can also be done at home, but it requires a partner, such as a relative or friend, and special training.

Peritoneal dialysis

Another form of dialysis is called peritoneal dialysis. The lining inside the abdomen (the peritoneum) becomes the filter. A soft plastic tube is put into the abdomen by a surgeon. When the body heals, cleansing fluid (dialysate) is put into the abdomen through this tube. Waste products in the bloodstream pass through the peritoneum into the dialysate. Then the dialysate, along with the waste products is drained off. This is called an "exchange" and takes about 30-45 minutes. It is done 4 or 5 times a day. Between exchanges, the person can move around and perform daily activities.

Alternatively a machine can put the cleansing fluid into the abdomen and drain it automatically. This is usually done at night during sleep.

Peritoneal dialysis may be better treatment than hemodialysis for some people. With daily dialysis, the body does not build up too much fluid. This reduces the stress on the heart and blood vessels. A person is able to eat a more normal diet and have more time for work and travel.

Peritoneal dialysis is not for everyone, however. A person must be able to see well and do each step correctly to prevent infection in the abdomen.
Your doctor will help you decide whether hemodialysis or peritoneal dialysis is right for you. Diabetes control remains important no matter which type of dialysis is chosen.

Kidney Transplantation

Diabetes sometimes damages kidneys so badly that they no longer work. When kidneys fail, the person needs a way to replace their function, which is to clean the blood. One option is kidney transplantation.

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.

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.