Diabetes and Kidney

---

The most common Cause of renal failure and dialysis in the west is Diabetes.

With rising Diabetes trend even developing countries are also having high incidence of Diabetes related complications.

This has caused an even more rise in renal failure in developing countries apart from the already existing other causations.

A patient who had lived with diabetes for more than 20 yrs without any complications may not develop any complications in future.

Usually complications related to Diabetes are of two types

1) microvascular (small vessels) &

2) macrovascular (large vessels)

Microvascular usually includes involvement of

• Eye- Retina involvement with decreased vision.
• Kidney- Albumin in urine and Elevation of creatinine.
• Neurons- Burning and tingling of feet, foot ulcers, loss of sensation.

Macrovascular usually involves

• Heart - heart attacks, pain
• Brain - paralysis
• Foot - gangrene
• 
  

Usually the smaller vessels in the eye are visible by fundoscopy 

Any changes in eye are deemed to be present even in other organs of microvascular category.

Hence no further invasive procedures like renal biopsy to find out the cause of renal failure are considered necessary.

Diabetes progresses to renal failure and Dialysis through a pattern of

• 1)Albumin escape in urine with normal creatinine
• 2)Heavy albumin excretion and rising creatinine and
• 3)Finally to the stage of dialysis

Usually kidney sizes are normal to enlarged in Diabetes.

Once creatinine starts to rise there is a decrease in medication requirement for sugar control. This is because insulin is broken down by kidney. Hence this controlled sugars give the approximate date of onset of renal failure.

This is interpreted as diabetes control by many alternative physicians and patients.

There are many methods to stop or at least slow down the progression of diabetic kidney disease.

• Insulin is preferred over other anti-diabetic medications.

• Metformin is to be avoided when creatinine is more than 1.5mg/dl.

Angiotensin receptor blockers (ARB) and Angiotensin converting enzyme inhibitors (ACEI) are preferred anti BP medications, they also reduce the protein excretion in urine and prevent further damage.

They are even prescribed in normal BP patients to reduce protein excretion in urine. This should not be confused with having Hypertension. The higher the dose tolerated the better it is.

The above drugs should not be given if creatinine is more than 2mg/dl or potassium is more than 5meq/L.

Initially when on these drugs creatinine and potassium has to be monitored every 3 days for each hike in dose. Once it is confirmed to have a stable creatinine, no further monitoring is required.

If the rise in creatinine is going beyond 30% of baseline value these drugs need to be controlled. Similarly potassium should also be within normal limits.

Once kidney failure has progressed to stage of dialysis most patients will no longer require any diabetic medication.

All patients with diabetes and CKD (with or without Dialysis) need cardiac evaluation as they have high risk of cardiac death at anytime and likely during dialysis.

Eye evaluation to look for diabetic changes and early laser therapy to prevent loss of vision.

Care of feet to avoid ulcers and gangrene.

Diabetics on dialysis fare poorly on dialysis compared for non diabetics. They have poor functioning access.

When creatinine reaches 5mg/dl a fistula has to be constructed for access.

With transplantation sugars rise back to normal and are poorly controlled and unless they strictly adhere to sugar control there is chance for recurrence of diabetic kidney disease in transplanted kidney (though rare).

To conclude early detection and management of diabetic renal disease and follow up with a Nephrologist can halt or slow down kidney related events.