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Diabetes&its Link to Kidney Disease

Online Health Chat with Dr. Betul Hatipoglu and Dr. George Thomas

March 10, 2011


Introduction

Cleveland_Clinic_Host: Research shows that diabetes is the leading cause of kidney disease. In honor of World Kidney Day on March 10, 2011, the Glickman Urological & Kidney Institute and the Endocrinology & Metabolism Institute invite you to an online chat about diabetes and its link to kidney function. Join endocrinologist Betul Hatipoglu, MD, and nephrologist George Thomas, MD, online for answers to your questions concerning diabetes and kidney disease.

Both Cleveland Clinic’s Glickman Urological & Kidney Institute and Endocrinology & Metabolism Institute are ranked in the top 10 nationally by U.S. News & World Report.

Dr. Betul Hatipoglu is a staff member in the Department of Endocrinology, Diabetes and Metabolism at Cleveland Clinic's main campus, having accepted that appointment in 2008. Prior to that appointment, she was an assistant professor of medicine and medical director for the pancreas and islet cell transplant program at the University of Illinois at Chicago for nearly eight years. Her clinical interests include diabetes, thyroid disease in woman, pituitary and adrenal disorders, and alternative medicine. Dr. Hatipoglu received her medical degree from Istanbul Medical School. She completed an internal medicine residency and chief residency at Michael Reese-University of Illinois at Chicago, and an endocrinology fellowship at the University of Illinois at Chicago. Dr. Hatipoglu speaks three languages -- English, Turkish and French -- and is board-certified in internal medicine, as well as endocrinology, diabetes and metabolism.

Dr. George Thomasis a staff member in the Department of Nephrology and Hypertension of the Glickman Urological & Kidney Institute at Cleveland Clinic. He attended medical school at Bharati Vidyapeeth’s Medical College in India, and completed his residency in Internal Medicine at Tufts University-St Elizabeth’s Medical Center in Boston, as well as a fellowship in Nephrology and Hypertension at Cleveland Clinic. Dr. Thomas has also completed a graduate program in public health at Johns Hopkins School of Hygiene & Public Health. He is board certified in internal medicine and nephrology, and his specialty interests include chronic kidney disease end stage renal disease, glomerular disease, hypertension, and kidney stones.

To make an appointment with Dr. Hatipoglu or any of the other specialists in the Endocrinology & Metabolism Institute at Cleveland Clinic, please call 216.444.6568 or call toll-free at 800.223.2273, ext. 46568. You can also visit us online at www.clevelandclinic.org/endocrinology.

To make an appointment with Dr. George Thomas or any of the other nephrologists in the Glickman Urological & Kidney Institute at Cleveland Clinic, please call 216.444.6771 or call toll-free at 800.223.2273, ext. 46771. You can also visit us online at www.clevelandclinic.org/glickman.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Betul Hatipoglu and Dr. George Thomas. We are thrilled to have them here today for this chat. Let’s begin with the questions.


Diabetes and Kidney Disease; What is the Connection?

Carltob: I am newly diagnosed with diabetes. What are my chances of developing kidney disease if I keep my blood glucose levels in control? Is it possible to develop it even if I control my glucose levels?

Dr__George_Thomas: You may develop kidney disease even with controlled blood glucose levels, although the risk is lower. You should also take steps to control your blood pressure and cholesterol. You should make lifestyle changes as well, including eating a low-salt diet, managing your weight, and stopping smoking. These steps can help lower your risk even further. Certain ethnic groups are more susceptible to developing kidney disease. You should follow-up regularly with your physician to monitor the amount of protein in your urine, and to have blood tests to assess your kidney function.

room23: What are the warning signs that I have kidney problems?

Dr__George_Thomas: There are no symptoms in early kidney disease. When your kidney disease progresses, you usually develop fatigue, nausea, low appetite, swelling, decreased urination, overall itching, etc.

kitty22: Are people who are on oral diabetes medications less prone to developing kidney problems than those who take insulin?

Dr__Betul_Hatipoglu: There is no difference in risk of developing kidney disease related to oral diabetes medications versus insulin. The most important risk factors are blood sugar, blood pressure, and the duration of diabetes.

don: Does protein in the urine, especially after nephrostomy, indicate kidney disease? I also have diabetes, type 2.

Dr__George_Thomas: The normal kidney excretes less than 10 to 20 milligrams of albumin in the urine. The degree and duration of protein in the urine, the duration of diabetes, and the current level of your kidney function (filtering function as assessed by your GFR) are important here. While the proteinuria in your case may be related to your diabetes, if there is a sudden worsening of kidney function and large increase in protein in the urine, along with other systemic symptoms, this may indicate another reason for your proteinuria. You should have this assessed regularly and see a nephrologist if there is progression.

polarop: I have a family history of diabetes. Is there a correlation between diabetes, kidney cell damage, and a greater risk of kidney cancer?

Dr__George_Thomas: There is an increased risk for kidney disease with diabetes, especially if there is a family history of diabetic kidney disease. The link between diabetes and kidney cancer is not well understood.

Bennie: I am overweight and have Type 2 diabetes. I have read that bariatric surgery can sometimes resolve Type 2 diabetes. If I had this procedure done and my diabetes went away, does that also mean that I will be low-risk for kidney disease? Is the main risk for kidney disease the diabetes itself?

Dr__Betul_Hatipoglu: The main risk for kidney disease related to diabetes is high blood sugar and high blood pressure. If your blood pressure is controlled after bariatric surgery and your diabetes (due to obesity) is resolved, your risk of kidney disease related to diabetes is extremely low.

star321: I was diagnosed with gestational diabetes (I did not have diabetes prior to pregnancy). Am I at increased risk of kidney damage during pregnancy?

Dr__Betul_Hatipoglu: You are not at increased risk because you did not have diabetes prior to your pregnancy. You are, however, at risk for developing diabetes after your pregnancy is over. It is important to see a physician to be screened for diabetes after your pregnancy.


Diabetes and Blood Pressure

Guy000: Does high blood pressure and diabetes increase the chances of developing kidney disease? If so, why? What are the treatments?

Dr__George_Thomas: High blood pressure and diabetes are the leading causes of kidney disease, primarily by affecting the large and small blood vessels and causing structural and functional changes in the kidney. The mainstay of treatment is good control of blood sugar, blood pressure, and cholesterol, as well as the use of a class of medication called angiotensin converting enzyme inhibitors (ACE-I) or angiotension receptor blockers (ARB) at the discretion of your treating physician, and lifestyle changes. There is a lot of research underway looking at new treatments, specifically to reverse kidney injury due to diabetes, however, these are not in clinical use yet.

jacky: Is it fair to assume that if you have low blood pressure (124/72) that your kidneys are fine? My pulse is usually around 90. (Isn’t that too high?) I’ve had Type 1 diabetes for 25 years.

Dr__George_Thomas: You still have a risk of developing kidney disease due to diabetes. You should have a urine test to check for protein and a blood test to assess your kidney function. There can be many reasons for a high pulse rate, and your physician can decide on any specific tests that may be needed based on your medical history.


Testing

mel46: Are there any tests or screenings I should do to see if I am having kidney issues related to diabetes? How often should I have them?

Dr__George_Thomas: If you have Type 1 diabetes, you should be checked annually for proteinuria beginning at five years after your diagnosis of diabetes. If you have Type 2 diabetes, you should be checked for proteinuria at the time of diagnosis and then annually. You should also have a blood test to check your kidney function. If you have proteinuria or decreased kidney function, the follow-up with your physician should be more regular to assess for progression. You should also see a nephrologist if your kidney function worsens.

efpat: Which blood test measures kidney function? Which tests for total protein?

Dr__Betul_Hatipoglu: Blood creatinine and blood urea nitrogen (BUN) are used to measure kidney function. Total protein can be useful in nephrotic syndrome patients who excrete protein in their urine.

don: Is filtering function assessed by my GFR? What does GFR mean?

Dr__George_Thomas: GFR means glomerular filtration rate. It is a formula that estimates the filtering function of your kidneys from the level of creatinine in your blood. If your GFR is less than 60 ml/minute, then you should see a kidney doctor (nephrologist), as this indicates kidney disease. Most labs now automatically report a GFR on your blood work.

missy: I have diabetes and tested positive for protein in my urine. What does this mean?

Dr__George_Thomas: The earliest sign of diabetic kidney disease is protein in the urine. If you have between 30 to 300 milligrams of albumin in your urine, it is called microalbuminuria. Above 300 milligrams is overt proteinuria. The higher your degree of proteinuria, the greater your risk of developing kidney disease or worsening kidney function. You should follow-up with your physician closely to determine the degree of proteinuria that you have and for help in better controlling your diabetes, blood pressure, and cholesterol. You should also have your urine and blood tests done periodically to follow kidney function.

petey: Is it true that if you obtain a microalbumin specimen while you have (1) a urinary tract infection, (2) an elevated temperature, (3) hematuria, or 4 done a strenuous amount of exercise that is new to your body in the past 24 hours, it can give you a false elevated result?

Dr__George_Thomas: Yes, it can. You should have your test repeated when you don't have a fever, urinary tract infection and have not exercised strenuously. Usually, check three specimens in a three to six month period, and a positive two out of three results is suggestive of having microalbuminuria.


Living with Diabetes

sweetgirl: My husband is in his mid-40s and was diagnosed with diabetes in his 20s. Is there anything he should be doing or any lifestyle changes he should be making that will reduce his chances of developing kidney disease?

Dr__Betul_Hatipoglu: Healthy diet and exercise -- which will improve blood pressure and blood sugar control, as well as weight -- will also help prevent kidney disease. A healthy diet should include high fiber and healthy fat (almonds, olive oil, flax seed oil, etc.), should avoid processed food and products that contain high fructose corn syrup, and include lean proteins (fish, chicken, beans, lentils, soy, etc.).

tom50: Is diabetes hereditary? If so, is it possible with exercise and diet to avoid getting diabetes?

Dr__Betul_Hatipoglu: Some forms of diabetes are hereditary; especially Type 2, which has a strong genetic component. Luckily, this is the one that a person can almost always prevent by maintaining a normal weight, eating a healthy diet, and exercising.

KYV: Do you have any general recommendations for diet once you have kidney impairment? For example, should you limit protein intake?

Dr__Betul_Hatipoglu

jenjen: What can be done to delay the progression of chronic kidney disease once it has been diagnosed?

Dr__George_Thomas: Good control of blood sugar, blood pressure, and cholesterol; the use of a class of medications called angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) per the advice of your treating physician; and lifestyle changes (low sodium diet less than 1.5 grams per day, weight loss, and smoking cessation) can help delay the progression of kidney disease related to diabetes.

lincut: If a person has diabetes mellitus, hypertension, and chronic kidney disease, should their diet have a protein restriction, as well as sodium restriction, and a carbohydrate count of 45 per meal?

Dr__Betul_Hatipoglu: For kidney disease, restriction of salt and protein intake is appropriate. Some sources recommend 0.6 - 0.8 g/kg/day lean protein intake. Carbohydrate restriction is recommended for diabetes control, and 45 grams per meal is a reasonable amount to consume.

terenceR: I was diagnosed with diabetes five years ago. It still is not clear to me when I should see an endocrinologist versus my regular primary care doctor. Would you clarify?

Dr__Betul_Hatipoglu: If your diabetes is well-controlled, your primary care physician should be able to continue to take care of your diabetes. Most of the primary care physicians will know when to refer a patient to an endocrinologist. Individuals with Type 1 diabetes might need an endocrinologists input periodically.

Diabetes Education

PattyH: Do you have education programs for those newly diagnosed with diabetes? Are they just available at Cleveland Clinic's main hospital or are they offered in other locations? What are the topics covered?

Dr__Betul_Hatipoglu: Cleveland Clinic has many locations that offer diabetes education classes, including a new, conveniently located, free standing Diabetes Center in the University Circle area. Topics covered include: nutrition, education, meter and insulin injection instructions, basic education about the disease state, and insulin pumps. Group and individual sessions are available.

tom50: Where can we find the schedule for the programs?

Dr__Betul_Hatipoglu: Information about the diabetes education programs at Cleveland Clinic can be found on our Diabetes Center Web page: http://my.clevelandclinic.org/endocrinology/our-departments/diabetes-center.aspx. There is a phone number available on that page to call for more information or to register or if the answers you are looking for are not included on that Web page.


General Questions

Twitter: What effect does excessive coffee consumption have on the kidneys? Does caffeine increase insulin resistance?

Dr__Betul_Hatipoglu: There are studies showing decreased insulin sensitivity with excess caffeine consumption. It is important to limit the caffeine intake to no more than two servings a day. (This includes all sources of caffeine, such as coffee, tea, chocolate, and some soft drinks.) The direct effect on the kidneys is not very well known.

JD: It was said that Advil can damage the kidneys. What can I take instead of Advil for muscle pain?

Dr__George_Thomas: All medications in the class of NSAIDs (non-steroidal anti-inflammatory drugs), including Advil and any generic form of NSAIDs, can affect the kidneys if taken for a prolonged period. I recommend discussing alternative medications with your physician, as this would depend on your medical history and the specific indication for using pain medications.

don: Do herbal teas and green/white teas have an effect on kidney stone formation?

Dr__George_Thomas: Herbal and green teas generally have lower amounts of oxalate than black tea. High amounts of oxalate can cause kidney stones, and the dietary recommendations for you would depend on the type of kidney stone that you have.

don: With litmus paper, what should the pH of urine be?

Dr__George_Thomas: Generally, the urine pH is around 6.0, and can vary depending on the acid base status of the body. The urine pH is best interpreted by your physician by taking into account your blood work results and medical history.

Bubbles: I heard that it is difficult to get an appointment with an endocrinologist, that their schedules are pretty full. Is it hard to get an appointment with an endocrinologist at Cleveland Clinic?

Dr__Betul_Hatipoglu: Cleveland Clinic recently expanded our endocrinology staff, and we now have 22 endocrinologists serving Northeastern Ohio at many different locations.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Betul Hatipoglu and Dr. George Thomas is now over. Thank you both again for taking the time to answer our questions about Diabetes and Kidney Disease.

Dr__Betul_Hatipoglu: I enjoyed answering all of your questions. Thank you for submitting them. I wish all of you days filled with healthy diet and exercise.

Dr__George_Thomas: Thank you. I hope that my answers have been helpful. On a separate note, today is World Kidney Day! Please remember to protect your kidneys and save your heart. Have a nice afternoon.

Cleveland_Clinic_Host: Some participants have asked about upcoming web chat topics. If you would like to suggest topics for 2011, please use our contact link clevelandclinic.org/webcontact to submit your suggestions. In the question/comment section, choose Health/Disease Information so that we receive your comments.


More Information

  • To make an appointment with Dr. Betul Hatipoglu or any of the other specialists in the Endocrinology & Metabolism Institute at Cleveland Clinic, please call 216.444.6568 or call toll-free at 800.223.2273, ext. 46568. You can also visit us online at www.clevelandclinic.org/endocrinology.
  • To make an appointment with Dr. George Thomas or any of the other nephrologists in the Glickman Urological & Kidney Institute at Cleveland Clinic, please call 216.444.6771 or call toll-free at 800.223.2273, ext. 46771. You can also visit us online at www.clevelandclinic.org/glickman.
  • A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.
  • If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
  • Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link www.clevelandclinic.org/webcontact.