Diabetes and Kidney Problems

1. Diabetes and Kidney Problems

2. What is Diabetes? • Diabetes is a condition in which there is too much sugar (glucose) in the blood. Although sugar is needed to provide energy for the body, when in excess, it causes problem. • Persons with diabetes have excess sugar because they lack or have deficient supply of insulin.

3. Diabetes “Mild Disease” Serious consequences

4. Diabetes Mellitus A Serious Disease Leading cause of new cases of blindness 25 times more prone to eye problems 6 times higher risk for Paralysis (stroke) 2-3 times higher risk for heart attack 5 times more prone to Kidney failure 20 times more prone to lower limb amputation Nerve damage causes loss of sensation

5. Renal cortex Renal Artery Renal Pelvis Renal Vein Renal Vein Kidney Renal Artery Aorta Renal papillae Vena Cava Ureter Ureter Kidney

6. Kidney- What Is It? How Does It Work? • Kidneys are a pair of highly specialized organ with a complex structure. • Each kidney contains thousands of small filtering units called “ Nephron” • Each nephron is made up of a cluster of small blood vessels (Glomerulus) enclosed by a funnel shaped tubular structure (“Bowman’s capsule” and “Loop of Henle”) • Glomerulus filters the fluid and waste products from the blood

7. Kidney- What Is It? How Does It Work? • As the filtered water, soluble substances and waste products pass through the long tubular structure, most of the water and still useful substances are taken back • The remaining water with waste products is allowed to travel through a long tube (ureter) from the kidney to the bladder where it is stored as urine till it is excreted

8. Kidney- How Is It Affected by Diabetes? • The sugar (glucose) in blood is filtered by the glomerulus. When there is too much of it as in diabetes not all of it is taken back and it remains in the tube • When blood sugar is high, sugar is passed in urine. Because it is in high amount in urine it also retains more water so persons with diabetes pass more urine • Initially the kidneys work hard to keep pace with increased load of sugar

9. Kidney- How Is It Affected by Diabetes? • As a result of many years of “toxically” high blood sugar the thin walls of the blood vessels in the glomerulus and the filtering membranes of the Bowman’s capsule themselves get damaged • When the filters are damaged , proteins that the body usually saves are now lost in urine. Albumin is the most important protein that is lost in the urine • With passing years of continued poor control the filtering mechanism is further damaged and waste products accumulate in the body – leading to kidney failure

10. Kidney- How Is It Affected by Diabetes? • Poor control of diabetes for over 5 years can lead to diabetic kidney disease • Inheritance also plays a role in determining the quickness and degree of damage. This is the reason why some people are more susceptible than others to diabetic kidney disease • Most people with diabetes also develop high blood pressure. This, in turn, causes additional damage to the kidney which further worsens high blood pressure setting another chain reaction

11. Diabetes and the Kidneys • Kidney disease caused by diabetes is called diabetes nephropathy • Because of great spare capacity, symptoms of kidney problems don’t occur until the kidney has been severely damaged • Good control of diabetes prevents or delays kidney problems • Appropriate treatment at any stage can halt further progress of the disease • It is important to detect the earliest signs of kidney problems Early signs of diabetic kidney problems can be detected only by laboratory examination of urine and blood

12. Stages of the Diabetic Kidney Disease • Stage 1 - Microalbuminuria • Small amount of the albumin is passed in the urine • Reversible with aggressive diabetes control and treatment • BP may start rising and must be treated aggressively • Stage 2 - Macroalbuminuria or Proteinuria • Increasingly larger amounts of protein are passed • Toxic waste products start accumulating in the body, reflected by rise in blood creatinine level • BP rises and must be treated aggressively • Often not reversible; further progression halted with good control

13. Stages of the Diabetic Kidney Disease • Stage 3 - End stage renal disease or kidney failure • Here the amount of urine produced decreases substantially • Waste products accumulate to toxic levels • Blood pressure rises dangerously • Patients need regular dialysis for survival • Can be reversed or halted only with kidney transplant

14. Why Monitoring Kidney Functions Is Important • In the first stage of kidney disease neither you nor your doctor can tell that anything is wrong because there are no symptoms • It is important to have routine screening tests even when you feel well • Presence of kidney disease further increases the risk for • High blood pressure several folds • Coronary heart disease several folds • A urine test for microalbuminuria is the best way to detect early kidney damage

15. Monitoring Kidney Functions • Because diabetes may remain undetected for many years, undertake the microalbuminuria test when you first learn you have diabetes and every year thereafter • Expect to have more frequent and extensive testing of kidney function if: • Your diabetes is difficult to control • Your doctor has detected microalbuminuria in an earlier test • Your blood pressure is increasing • You have associated heart disease

16. Monitoring Kidney Functions • Ensure that your doctor and diabetes care team monitor • Your blood pressure at each visit • Test for kidney functions appropriately and as required

17. Testing for Microalbuminuria • Although expensive the dipstick microalbuminuria test accurately measures small amounts of albumin in the urine • Your doctor may ask you to collect all of your urine for 24 hours. The study on 24 hours urine collection is the most helpful in detecting kidney problems

18. Checking Your Blood Pressure • Rising blood pressure worsens microalbuminuria and early kidney damage • If kidney damage is detected, it is important to treat even small increases in blood pressure effectively • Your doctors may prescribe anti-hypertensive medications even if your blood pressure has only risen within the high normal range • Along with good glucose control, early and effective treatment of increased blood pressure is as important to delay or prevent progression of diabetic kidney disease

19. Steps to Control Kidney Damage If the early signs of kidney disease are detected, you can expect your doctor to suggest the following: • Improve your blood sugar control • Keeping HbA1c values below 7% can be reverse and prevent further progress of kidney disease • Any reduction in HbA1c will help to reduce rate of progress • Take Insulin, if advised • Check for microalbuminuria and kidney function more often • Check your blood pressure more often, preferably at each visit and monitor values. The normal values are 120/80 mmHg

20. Steps to Control Kidney Damage • Take medication to treat high blood pressure • Review your dietary habits in consultation with your dieticians to reduce protein content and perhaps salt • Quit smoking

21. Quit Smoking!! • Smoking has been found to contribute significantly to increased risk for high BP, diabetic heart, eye, nerve, and kidney disease • People with diabetes who smoke are more likely to have a microalbuminuria – the first sign of diabetic kidney disease (nephropathy) • Even for people with established kidney disease smoking is harmful

22. What is Dialysis? • Dialysis is done to help get rid of the waste substances such as creatinine and urea from the blood. Dialysis can be done in two ways haemodialysis or peritoneal dialysis. • Hemodialysis - the patient's blood is passed from the artery through a tube into a machine that filters out waste products. The cleansed blood is then returned to the body through a vein. • Peritoneal dialysis - can be done at home; A special solution is run through a tube into the abdomen where waste products from the body pass through the lining of the abdomen called the peritoneum in to the injected solution, which is then drained out after a specified time period.

23. When is Dialysis Necessary? • People who have lost more than 90% of the kidney’s filtering capacity will need artificial filtrations to dispose of the waste products that will otherwise accumulate in the blood • Dialysis is done to prevent coma and death from toxic effects of the body’s accumulated waste products • Some people undergo a kidney transplant as an alternative to continuing dialysis

24. Complications of Chronic Kidney Failure • Hypoglycaemia can occur due to decreased excretion of insulin • Rapid progression to end-stage renal disease • Hyperkalemia - a dangerous state of abnormal amount of potassium ions circulating in blood • High blood pressure • Worsening coronary artery disease (Heart problem) • Low protein in the body leading to accumulation of water and salt and causing swelling of feet, puffiness of face etc

25. Symptoms of Late Diabetic Nephropathy • Fatigue (tiredness) • Insomnia (loss of sleep) • Weakness • Nausea and Vomiting • Swelling on the face,hands and legs due to fluid retention (edema) • Weight gain because of fluid accumulation • Generalized itching • Unintentional weight loss • Loss of appetite • Repeated or unexplained hypoglycaemia in a previously poorly control diabetic

26. Kidney Transplant • Kidney transplant is done for patients with end stage kidney disease • Most people with kidney failure are treated with dialysis before they are considered for a kidney transplant • The success is better when the kidney is from a live related donor as compared to a transplant from a dead donor (cadaver) • Before the transplantation the patient needs to be carefully assessed and treatment started for prevention of complications

27. Kidney Transplant • After transplantation patients are given immunosuppressive drugs to prevent rejection of the transplanted kidney • Better surgical techniques; Use of live related donor; Availability of better immunosuppressant drugs and antibiotics; And good diabetes and blood pressure control, have greatly increased the success rate of kidney transplant

28. Prevention IsBetter Than Treatment • You can protect your kidneys from damage by: • Ensuring regular usage of Insulin, if advised • Ensuring regular BP check- up and control • Ensuring regular urine check for microalbuminuria • Starting proper treatment at the first sign of microalbuminuria • Quitting Smoking