Diabetes and CKD What is the Connection?

Discussion topics Number of people in U.S. with diabetes Diabetes and related problems Diabetes and Chronic Kidney Disease (CKD) Stages of CKD What you can do to help yourself

You are not alone 20.8 million people in U.S. have diabetes – that is 7% of the population Majority are Type 2 Diabetes to increase 165% between 2000 and 2050 There is a 1.8 times greater risk among African Americans Type 1 diabetes is due to the body’s inability to produce insulin. Type 2 develops because of the body’s failure to produce enough insulin and to properly use the insulin it produces 14.6 million people have been diagnosed 6.2 million people have not been diagnosed At least 41 million people have pre-diabetes 1 in every 3 Americans born in 2000 will develop diabetes

Possible complications of diabetes Stroke Blindness Peripheral Vascular Disease CKD High Blood Pressure Heart disease Diabetes

Diabetes and CKD Diabetes is the leading cause of CKD in U.S. Early kidney disease has no symptoms When not diagnosed it can progress to kidney failure with little or no warning Microalbuminuria or macroalbuminuria is protein in the urine. In people with diabetes – 43% have microalbuminuria and 8% have macroalbuminuria. Microalbumin can be detected much sooner than Macroalbumin. This can be detected by a simple urine test

Control your diabetes High blood sugar levels can lead to many health problems including kidney disease 30% of people with Type 1 diabetes develop CKD 10-40% of people with Type 2 diabetes develop CKD Stop here and ask everyone in the audience with Type 2 diabetes to stand up. Now count off in threes. According to statistics, every third person will develop Chronic Kidney Disease: have the people that are number 1 continue to stand, number 2 and 3s sit down. Those standing will likely develop CKD.

What is the kidney The kidneys weigh about a pound each Located in the retroperitoneal space About the size of an adult fist Shaped like a kidney bean Attached to blood stream through renal arteries Each renal lobe is made of tiny blood vessels While the kidneys are small, they provide vital functions to sustain life. The body is able to function quite well with one kidney. The retroperitoneal space is behind the abdominal wall. The kidneys are located in front of the spine on both sides. Over time elevated blood sugars damage the tiny vessels in the kidneys.

Kidney functions Remove waste Remove excess fluid Secrete Erythropoetin to make red blood cells Regulate bone metabolism Regulate blood pressure Maintain electrolyte and acid balance

How does diabetes cause CKD? Damages small blood vessels in kidneys and other organs Proteins begin to leak into the urine Ability to filter waste decreases Waste products begin to build up Kidneys may fail May need dialysis or transplant to live According to the American Diabetes Assoc, When our bodies digest the protein we eat, the process creates waste products. In the kidneys millions of tiny blood vessels with even tinier holes in them act as filters. As blood flows through the blood vessels, small molecules, such as waste products, squeeze through the holes. The waste products become part of the urine. Useful products such as protein and blood cells are too big to pass through the holes in the filter and stay in the blood. When these tiny blood vessels are damaged by elevated Blood sugars and/or high blood pressure, the holes get larger and protein, blood cells, etc begin to leak through the urine.

Signs of kidney damage Damage to kidneys may or may not involve kidney failure. Some signs of damage: Blood in urine Protein in urine (Proteinuria) Abnormal blood or other urine tests Abnormal imaging tests Abnormal kidney biopsy

CKD symptoms Decreased appetite Nausea, vomiting Weight gain/loss Change in bowel habits Decreased sensation in hands and feet (neuropathy) Tired Decreased concentration Frail appearance Decreased sexual functioning Bronze or discolored skin Symptoms can be confusing when a person has diabetes and CKD, because many of the symptoms are similar. A person may not have symptoms of kidney disease until 50-75% of kidney function is lost.

NKF definition of CKD The National Kidney Foundation defines CKD as kidney damage for 3 or more months based on findings of abnormal structure (Imaging studies) or abnormal function (blood or urine tests) OR GFR < 60 mL per minute for 3 or more months with or without evidence of Kidney damage

Detecting CKD Detect CKD with 2 simple tests: Urine test for detecting proteinuria Blood test for estimating glomerular filtration rate (eGFR) A microalbumin test is done to check for protein (albumin) in the urine. It can be done on a sample of urine collected anytime. Early detection may change treatment in an effort to preserve as much kidney function as possible. The eGFR is considered the best indicator of the level of kidney function and is a calculation of the results from a blood test.

Stages of Chronic Kidney Disease Description GFR* mL/min/1.73m2 1 Slight kidney damage with normal or increased filtration More than 90 2 Mild decrease in kidney function 60-89 3 Moderate decrease in kidney function 30-59 4 Severe decrease in kidney function 15-29 5 Kidney failure requiring dialysis or transplantation Less than 15 *GFR is glomerular filtration rate, a measurement of the kidney's function. When CKD progresses to Stage 5, it is commonly called ESRD or End Stage Renal Disease.

Stage 5 CKD or ESRD Stage 5 CKD is more commonly called ESRD or End Stage Renal Disease. Treatment required Some form of dialysis to maintain life Medications Diet modification When an individual reaches Stage 5 or ESRD (End Stage Renal Disease), they will require some form of dialysis to maintain life. This can be Hemodialysis, Peritoneal Dialysis or transplantation. 

Delayed CKD detection can lead to serious consequences Lack of treatment for early complications Diabetes - High blood pressure Cardiovascular disease - Malnutrition Late referral to nephrologist/cardiovascular specialist or dietitian Lack of patient education for prevention or treatment options Lack of access placement prior to the start of dialysis Chronic Kidney Disease in combination with any of these conditions can be devastating. Delayed detection would lead to late referrals to Kidney or Heart Specialist and possibly appropriate treatment . Education for lifestyle changes to prevent, delay or select treatments would not be offered and there would be no preparation for a dialysis access.

CKD risk factors Diabetes Hypertension Smoking High Cholesterol Family history of CKD Age Gender Racial /ethnic background African American Native American Asian American Pacific Islander Hispanic Remember elevated blood sugars cause damage to the small blood vessels in the body including the kidney. Smoking can increase BP and heart rate, reducing blood flow to the kidney and narrowing blood vessels

CKD risk factors continued Exposure to Nephrotoxic drugs Contrast Dye NSAIDS Ibuprofen Advil Motrin Naproxen Nephrotoxic drugs mean drugs that can damage the kidneys. Contrast dyes are injected by vein and are used in test such as xrays, CT scans, MRI’s and Cardiac Catheterization. It is important to drink lots of fluids before and after these tests. NSAIDS are the anti-inflamatory medications taken for arthritis or pain.

USRDS 2004 Diabetes and kidney disease are approaching epidemic levels in the U.S. (The legend refers to incidence rates of ESRD due to diabetes in cases/million population .)

USRDS 2004 So how do we decrease this increase in kidney disease? (The legend refers to incidence rates of ESRD due to diabetes in cases/million population .)

Diabetes and hypertension are the primary causes of End Stage Renal Disease.

Why CKD prevention is important with diabetes & hypertension More than 90% of Medicare patients with CKD also have diabetes, hypertension, or both Approximately 83,000 Medicare beneficiaries with diabetes in Missouri (Fee-for-Service 4/06-3/07) Diabetes and hypertension both cause CKD and make complications worse

When to get tested Type 1 Diabetes: 5 years after diagnosis, then annually* Type 2 Diabetes: at diagnosis, then annually* Hypertension: at diagnosis and initiation of therapy, then every 3 years if eGFR and microalbumin tests are normal Family history of kidney disease: every 3 years, as long as tests are normal These testing intervals are recommendations; physician opinion may differ *KDOQI Guideline 1 Ask your doctor if you have been tested KDOQI(pronounced Kay-doe-key) stands for National Kidney Foundation Disease Outcomes Quality Initiative. These guidelines are evidence based clinical practice guidelines for all stages of Chronic kidney disease

Help prevent or delay CKD Control Blood Sugar - Goal of A1C < 6.5 Eat at about the same time every day Eat a meal or snack every 3-4 hours and do not skip meals Eat the same amount of carbohydrates in meals or snacks each day Check blood sugar as instructed Take your medicine and /or insulin as directed Keep your doctor appointments; take your blood sugar record with you Remember elevated blood sugars cause damage to the small blood vessels in the body including the kidney. Eating at regular times helps to maintain level blood sugar levels

Control blood pressure Monitor your own blood pressure Try to keep it at 125/70 or lower Take medication as directed Limit salt and sodium intake High BP is like turning on a faucet full force in the kidney. Over time this damages the kidney. Limiting Salt and sodium in the diet helps to reduce the BP by reducing fluid volume.

Watch your weight Achieve and maintain desirable body weight (target BMI to normal range of 18.5-24.9 kg/m2) BMI is the measure of body fat based on height and weight that applies to both adult men and women. A person 6 foot tall weighing 183 lbs. would have a body mass index of 24.8

If you smoke STOP Smoking can increase blood pressure and heart rate, reducing blood flow to the kidney and narrow blood vessels. For help to stop smoking, join a smoking cessation class or ask your physician if you can take a medication that can assist you to stop smoking

Take an active role in your health care Monitor your own blood pressure and blood sugar Know what your levels should be See your doctor regularly Ask if you are on an ACE or an ARB for your BP Ask if you had a urine test for protein Know your eGFR If you have CKD, know what stage ACE and ARBs are classifications of Blood Pressure medications that have been associated with slowing the progression of Chronic Kidney Disease

CKD Stage 3 Limit protein and phosphorous intake High protein levels increase the workload of the kidney Limiting Protein may help reduce the amount of waste product for the kidney to filter - thus reducing the workload. In stage 3 CKD, recommended protein intake is .8g/kg body weight. For a 200 lb. person this would mean approx. 4 ounces of protein a day.

CKD Stage 4 or 5 Limit phosphorus intake in your diet High levels of phosphorus can cause damage without any symptoms Because unhealthy kidneys are no longer able to remove the phosphorus from the blood and get rid of the excess, high levels can cause bone and heart problems, weakened bones d/t low blood calcium, bone pain or itching, calcification or hardening of the tissues in the heart, arteries, joints, skin or lungs

Foods high in phosphorus Milk and dairy products Cola drinks and Dr. Pepper Chocolate Nuts and butters Pancakes, waffles and biscuits Dried beans Processed meats like hot dogs, sausage, bologna Whole grain foods Examples of milk and dairy products are Cheese, cottage cheese, ice cream, sherbet , etc

Take better care of yourself Changes in diet, fluid intake and medications can be confusing and challenging. These changes can help you feel better and slow kidney disease Go to your doctor and ask questions Take your medications as instructed Report any changes

It takes a team YOU Doctor Nurses Dietitian Community Family Support groups Working closely with your health care team can help you to retain control of your life and prevent long-term complications of Diabetes.

Now is the time to ask Questions

Information Resources National Kidney Foundation - www.kidney.org Missouri Kidney Program - http://som.missouri.edu/mokp Heartland Kidney Network - www.network12.org American Assoc. of Kidney Patients - www.aakp.org Renal Support Network - www.ikidney.com