Diabetic (Diabetic Nephropathy) Kidney Disease

Finding out that you have early diabetic nephropathy 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 have a lot to juggle when it comes to their healthcare. Having diabetes puts you at risk of other health problems, including heart attacks, strokes, vision loss, nerve damage, and kidney disease. While all of that may sound overwhelming, there is some good news; many of the steps you need to take to prevent one of those complications may actually help to prevent them all.


The kidneys play an important role in the body: they filter the blood, removing waste products and excess salt and water. If the kidneys become diseased, they falter in their task, leaving the blood-polluted.


In some cases, diabetic nephropathy 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.



Diabetic nephropathy symptoms 

Diabetic nephropathy usually causes 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. Often people who have diabetic nephropathy also have high blood pressure.


Diabetic nephropathy risk factors

Having a family history of kidney disease can increase your risk of diabetic nephropathy. Although you cannot do anything to change your family history, there are several factors that increase your risk of developing diabetic nephropathy that you can change. These include:

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


Diabetic nephropathy diagnosis

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 a protein called albumin. If there is a very large amount of albumin (protein) in your urine, it means you have diabetic nephropathy. You may be told that you have “microalbuminuria” or “moderately increased albuminuria”. That simply
means that you have trace amounts of protein in your urine, but it still means that you are at risk for getting diabetic nephropathy, assuming you do not have kidney disease caused by another condition.

The same urine test that is used to diagnose diabetic nephropathy will also be used to monitor your condition over time.



Diabetic nephropathy complications
The key complication of diabetic nephropathy is more advanced kidney disease, called chronic kidney disease. Chronic kidney disease can, in turn, progress even further, eventually leading to total kidney failure and the need for dialysis or kidney transplantation.


Diabetic nephropathy treatment
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 in concert to damage the blood vessels and organ systems.

For these reasons, the most important things you can do to stall kidney disease and protect against other diabetes complications are to:

• Make healthy lifestyle choices
• Keep your blood sugar as close to normal as possible
• Keep your blood pressure below 140/90, if possible.



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 diabetic nephropathy:

• Limit the amount of salt you eat
• If you smoke, quit smoking
• Lose weight if you are overweight



Manage blood sugar levels
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; however, these targets may need to be individualized.


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. Even small decreases in the A1C lower the risk of diabetes-related
complications to some degree.



Manage high blood pressure
Many people with diabetes have hypertension (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. A healthcare provider can diagnose high blood pressure by measuring blood pressure on a
regular basis.

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 high blood pressure medications. Your provider can discuss the pros and cons of each medication and the goals of treatment.


A blood pressure reading below 140/90 is the recommended goal for most people with diabetic nephropathy, but a blood pressure reading below 130/80 is suggested for many people who have more than 300 mg of albumin (protein) in their urine per day.



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 a medication known as an
angiotensin-converting enzyme inhibitor (abbreviated ACE inhibitor) or a related drug known as an angiotensin receptor blocker (ARB) are 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 diabetes-related kidney disease. In fact, the kidney benefits of ACE inhibitors and ARBs are so robust that healthcare providers sometimes prescribe them for people with diabetic nephropathy who have normal blood pressure. Still, despite their kidneyprotecting abilities, ACE inhibitors and ARBs do have their downsides. For instance, ACE inhibitors cause a persistent dry cough in 5 to 20 percent of the people who take them. Some people get used to the cough; others find it so disruptive that they cannot continue taking an ACE inhibitor.


For them, ARBs are often a good alternative, because ARBs are less likely to cause a cough. In rare cases, you can have more serious side effects with ACE inhibitors and ARBs. These include a decrease in kidney function or a condition called hyperkalemia, in which too much potassium accumulates in the blood. To monitor for these and other side effects, healthcare
providers sometimes run blood tests soon after starting these with a pregnancy, the most
important thing you can do is to keep your blood sugar and blood pressure under tight control.


However, women who are pregnant or attempting to get pregnant should not take angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), as
these drugs can cause birth defects. Instead, other medications (such as calcium channel blockers) are used during pregnancy to keep the blood pressure in check.



Diabetic kidney disease and other diabetes complications
If the steps you need to take to protect your kidneys sound overwhelming, keep this in mind; controlling your blood sugar and blood pressure can help to reduce the risk or severity of several other debilitating diabetes complications, including:

• Vision loss (due to diabetic retinopathy)
• Nerve damage (called diabetic neuropathy)
• Stroke and heart attack (both of which can be fatal)



Monitor for signs of change
After beginning treatment and lifestyle changes to stall kidney disease, you will need to have
repeat urine and blood tests to determine if urine protein levels have improved. If the urine
protein levels 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.


By Dr. Venu Madhav Reddy G. MD (Internal Medicine),

DM (Nephrology), CMC Vellore
Dr. C.V. Harinarayan
Director - Diabetes &Endocrinology
Institute of Endocrinology, Diabetes, Thyroid
and Osteoporosis, Sakra World Hospital

Associate Editor
Easy reading is damn hard writing.