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Monitoring for Diabetic Kidney Disease
What happens to the Kidneys
Dangers of Protein in the urine (Proteinuria)
Treatment of Diabetic Kidney Disease
Evolution of Kidney Disease in
Type II Diabetes
When Diabetes mellitus affects the kidneys the condition is called "Diabetic Nephropathy". There are two types of Diabetes - Insulin Dependant Diabetes Mellitus (IDDM) and Non-Insulin Dependant Diabetes Mellitus (NIDDM). Both could affect the kidneys.
Diabetic Kidney disease is the single most common cause of loss of kidney function accounting for almost 35% to 40% of all patients currently requiring dialysis in USA. Therefore, the standard of care of Diabetes should include monitoring for kidney involvement. The treatment of Diabetes should also include, besides monitoring blood sugar levels and controlling it, appropriate medications to prevent and minimize the chances for developing Diabetic Kidney Disease.
MONITORING FOR DIABETIC KIDNEY DISEASE:
The earliest indication that the kidneys are being affected by the diabetes is the appearance of the protein - Albumin - in the urine (Albuminuria). When the quantity of the Albumin is minimal it is appropriately called "Micro-Albuminuria". It may not be detected by the conventional urine test (Urinalysis). Therefore it is important that all patients with Diabetes Mellitus be tested for the presence of Micro-Albuminuria by specialized urine tests periodically and routinely.
The appearance of Micro-Albuminuria signifies:
1. The Kidneys are at risk or the development of Diabetic Nephropathy.
2. The risk of Heart disease has increased significantly - by several folds.
3. Complications pertaining to eyes are likely to occur.
4. The treatment of
Diabetes, as mentioned above, should also include measures to
a. Prevent further worsening of Micro-Albuminuria
b. Minimize and cure the Micro-Albuminuria
5. Controlling
Micro-Albuminuria could prevent complications of
Diabetes Mellitus
involving Kidneys, Heart and other organs.
Monitoring for Diabetic Kidney Disease
What happens to the Kidneys
Dangers of Protein in the urine (Proteinuria)
Treatment of Diabetic Kidney Disease Evolution of Kidney Disease in
Type II Diabetes
When Diabetes Mellitus affects the kidneys,
1. Walls of the blood vessels (capillaries) in the kidneys get progressively thicker.
2. Kidneys may start
"leaking" protein (including Albumin) into the urine (Proteinuria).
The blood protein level might decrease causing
3. Kidneys are unable to filter various chemical waste from the
blood and
"Chronic Renal
Failure" develops. In due time,
there is complete loss of
kidney function which is called "End Stage Renal Disease (ESRD)" requiring
dialysis or kidney transplantation.
Monitoring for Diabetic Kidney Disease
What happens to the Kidneys
Dangers of Protein in the urine (Proteinuria)
Treatment of Diabetic Kidney Disease Evolution of Kidney Disease in
Type II Diabetes
PLEASE READ 'HOW DO KIDNEYS WORK' FOR A BETTER
UNDERSTANDING OF WHY PROTEINURIA
IS DETRIMENTAL
Normally the kidneys do not excrete Protein more than 150mgs per day.
When the Glomeruli abnormally leak more protein then tubules are faced with
abundant protein (several thousand mgs per day!) Part of these protein
enter the cells lining the tubule. These proteins are alien to the inside of those cells.
They cause numerous deleterious changes and reactions (intracellular storm)
and lead to unregulated growth as well as death of those cells.
This leads to further scarring in the kidney. Ultimately this process,
usually over a period of several years, transforms the kidneys into a mass of
scar tissue. As the normal kidney tissue is being replaced by the scar tissue,
the kidney gradually looses its ability to do its work. Since the kidneys fail slowly
it is called CHRONIC RENAL FAILURE. (Renal = Kidney)
As the protein is being lost in the urine, elsewhere in the body more protein
(several folds more than the amount being lost in the urine) is being destroyed.
This leads to low levels of protein in the blood. Proteins in the blood are
responsible to hold fluid within the blood vessels and to counteract the natural
physical tendency of the fluid to be forced out of the blood vessels and capillaries.
Therefore, with the protein level low fluid from the blood vessel 'oozes' into the
tissues (legs, face, lungs, abdomen) causing swelling. Along with the fluid some
amount of protein and Salt (Sodium) also leak into the tissues. Such swelling
also causes further malfunction of vital organs that are 'water-logged' now.
As the water and salt accumulate in the tissues, the volume of the blood
usually shrinks. The remaining normal parts of the kidneys interpret the shrunken
blood volume as dehydration and do what they are entrusted to do - to retain more water
and salt! A vicious cycle sets in - and the swelling keeps increasing with the patient
rapidly gaining several pounds of body weight due to such retention of salt and water.
As the fluid is being lost from the blood vessels into the tissue the blood is likely to
become thick. Specific proteins that prevent blood clots from forming within
the blood vessels are also lost as part of proteinuria. Therefore, blood
clots form in the blood vessels. These clots could block circulation to various organs
(including Kidneys) and could cause Stroke, Heart-Attack, Clot in the Lung
(Pulmonary embolus)
EVOLUTION OF KIDNEY DISEASE IN TYPE II DIABETES:
TREATMENT OF DIABETIC NEPHROPATHY:
A. Treatment of Diabetes Mellitus: Adequate control of Diabetes is essential to prevent the complications involving not only the kidneys but other organs as well - including Eyes, Brain, Heart, Nerves etc. Measures to control the Diabetes should include
1. Diet
2. Exercise and reduction in excess body weight
3. Insulin or Oral agents (Tablets) to control Blood Sugar
4. Monitoring of Blood Sugar at home
5. Checking "A1-C-Hemoglobin" at least once in
four months. (This is a blood test
that your Doctor will order periodically. This test reflects over all control
of blood sugar. The higher the 'A1-C Hemoglobin' the greater is the risk
of developing various complications of Diabetes. Normal level of
A1-C Hemoglobin varies from lab to lab; but generally it is 5 to 6 )
6. If the kidneys are already affected and they are functioning poorly (as
noted by
increased
Creatinine level in the blood), then
CERTAIN Oral agents (Tablets) to control
the blood sugar should be avoided, since they increase the chances
of complications of those medications. (Examples of such medications to be
avoided
are: Metformin, Glucophage, Glyburide, Micronase)
B. Treating other (Co-Morbid) conditions that exist along with Diabetes: Usually in many Diabetics, other medical conditions may exist or in due time develop. These are called co-morbid conditions. Patient should be monitored for their development and treated promptly and adequately. Some of them might even be prevented. When ignored, such conditions will multiply the risks of complications of Diabetes by several fold!
Co-morbid conditions:
1. Obesity
2. High Cholesterol and Triglycerides (Hyperlipidemia)
3. High Blood Pressure (Hypertension)
4. Recurrent Urinary tract (Bladder) infections
5. Anemia
6. Heart disease
7. Peripheral Vascular Disease (Poor circulation in Arms and
Legs)
C. Treating Proteinuria: Proteinuria
(both overt proteinuria and micro-albuminuria) not only signifies the onset of diabetic
nephropathy but could also cause damage to the kidney. (Please read 'Proteinuria'). Controlling Diabetic-proteinuria will involve following measures:
1. Reduce Protein consumption (Diet) to 0.6 G/kg of body weight
2. Medications:
a. Immuno-Suppressive agents (Prednisone, Cyclosporin, Cytoxan, etc)
which are generally used to control the proteinuria, should NOT be used,
if the proteinuria (or Micro-Albuminuria) is due to Diabetes.
b. ACE-Inhibitors or AT1-Blockers should be used.
ACE-Inhibitors: Captopril, Vasotec, Accupril, Lotensin,
Altace, Monopril, Enalapril, etc.
AT1-Blockers: (Also known as ARBs)
Diovan, Cozaar, Hyzaar, Avapro,
Micardis etc.
3. Treat the complications of Proteinuria:
a. Reduce Salt consumption
b. Diuretics to cope with swelling of the legs
and feet
4.
Control blood sugar adequately so that A1C-Hemoglobin is 6 or less
5.
Control the blood pressure well so that it remains in normal range or
close
to normal range (120/80)
6.
For those who could not tolerate an Ace-inhibitor or AT1-Blocker
'Calcium
channel blocker' might be an alternative.
Monitoring for Diabetic Kidney Disease
What happens to the Kidneys
Dangers of Protein in the urine (Proteinuria)
Treatment of Diabetic Kidney Disease Evolution of Kidney Disease in
Type II Diabetes