Understanding the Diabetes Link to Kidney Disease

September 11, 2012


Cleveland_Clinic_Host: Research shows that diabetes is the most common cause of kidney failure in the U.S., and accounts for nearly one-half of people who need dialysis from kidney disease. It is recommended that those with diabetes are checked regularly for kidney complications, as diagnosis and treatment are essential to preventing progression of kidney problems.

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To make an appointment with Betul Hatipoglu, MD or any of the other specialists in our 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. Thomas or any of the other specialists in the Glickman Urological & Kidney Institute at Cleveland Clinic, please call 216.444.5600 or call toll-free at 800.223.2273, ext. 45600. You can also visit us online at www.clevelandclinic.org/urology.

About the Speakers

Betul Hatipoglu, MD, is a staff member in the Department of Endocrinology, Diabetes and Metabolism at Cleveland Clinic, having accepted that appointment in 2008. Previously, Dr. Hatipoglu was an assistant professor of medicine and medical director for pancreas and islet cell transplant program at the University of Illinois at Chicago. Dr. Hatipoglu received her medical degree from Istanbul University Medical School, Capa, Istanbul, Turkey. She completed an endocrinology fellowship at the University of Illinois at Chicago, and an internal medicine residency and chief residency at Michael Reese Hospital-University of Illinois at Chicago. Dr. Hatipoglu is board-certified in internal medicine as well as endocrinology, diabetes and metabolism. Her clinical interests include diabetes, thyroid disease in women, pituitary and adrenal disorders, and alternative medicine

George Thomas, MD, is a staff member in Cleveland Clinic’s Glickman Urological & Kidney Institute. Dr. Thomas completed his fellowship in nephrology and hypertension at Cleveland Clinic. He attended medical school at Bharati Vidyapeeth Medical College in Pune, Mumbai, India, and completed his residency in internal medicine at Saint Elizabeth’s Medical Center in Boston. Dr. Thomas also completed a graduate program at Johns Hopkins School of Hygiene & Public Health in Baltimore. Dr. Thomas is board-certified in internal medicine and internal medicine-nephrology. His specialty interests include chronic kidney disease, hypertension, resistant hypertension, dialysis, adrenal disease, hemodialysis and renal disease.

Let’s Chat About Understanding the Diabetes Link to Kidney Disease

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

Diabetes Diagnosis

sankers2: What effect does diabetes have on the body?
Dr_Hatipoglu: High blood sugar will damage many parts of the body if not controlled. The most important damage occurs in the small vessels that carry food and oxygen to the different organs, such as the kidneys, nerves and eyes. As a result of declining function in these vessels, the organs that rely on them for food and oxygen will also starts dying slowly. Diabetes will cause nonhealing open ulcers, nerve pain, blindness, kidney damage and other complication as a result of high blood sugar. If you have high blood pressure and high cholesterol, which happens a lot with diabetes, this makes things even more complicated and causes heart attacks and strokes. The good news is, if you take care of your diabetes, it will not be an enemy. You need to know about diabetes and do everything possible to control it so you can have healthy and happy life.

Sarah: Is there such a thing as ‘mild’ or ‘severe’ diabetes?
Dr_Hatipoglu: We don't usually classify diabetes to mild or severe, but we do classify diabetes as prediabetes, diabetes controlled and diabetes uncontrolled. Prediabetes is before you are diagnosed with diabetes—a phase where you could actually prevent the diabetes with diet and exercise. Controlled diabetes is when everything is within a desirable goal set by you and your physician and the guidelines. Sometimes uncontrolled diabetes can be present despite all the effort put by the patient and their physician due to the nature of different complications and organ damage. Sometimes it is almost impossible to control the blood sugars to the target; we call this ‘brittle diabetes.’

clercks: Could significant edema (of the abdomen and legs) be caused by diabetes when kidney function tests are normal?
Dr__Thomas: One of the reasons for edema could be heavy proteinuria (that is, protein spilling in the urine), which can happen in diabetes. You should have your urine checked for the amount of protein that you are spilling. If it is high, you should see a kidney doctor to check if there are any additional causes besides the diabetes that may be causing protein loss. You should also be checked for possible heart or liver problems that can also cause edema.

Diabetes Treatment

lisamchil: My son is 14 and has had type 1 diabetes for over a decade. Is there anything I can teach him to do to prevent or slow the affect on his kidneys? Please include diet considerations, as we are constantly working on blood sugar control.
Dr_Hatipoglu: As far as we know today, the most important thing he can do is blood sugar control, keeping his HbA1C (hemoglobin A1c) at goal as much as possible. Also, he is still young, but blood pressure control is as important. When it comes to diet, it is not always easy for a teenager who is growing. As he gets older he will also need to adjust his food intake. I think that, for some, eating the same amount of carbohydrates at each meal works best. For others, avoiding processed food and pasta, rice, bread and potatoes as well as sweets as much as possible (easy said than done, of course) will stabilize their sugar level. No matter what, the most important thing he can do for himself will be checking his blood sugar.

Francois: My estimated glomerular filtration rate calculated from blood creatinine in umol/L—given my age and sex (I am not Black)— for my last four blood tests during the last two years has fluctuated between 90 and 78, with the latest being 78. My blood creatinine, urea and urine tests are normal. I have no chronic kidney disease symptoms except for a little repeated decrease in volume of urine for just four or five days occurring once in the past three weeks. Extended release Risperdal® Consta® 25 mg injection works optimally for this purpose. Is it advisable to change my Risperdal®  Consta®  medication? I am a fairly healthy 74 year old male with no diabetes.
Dr__Thomas: Many medications (including Risperdal®) need adjusted dosages if there is presence of renal dysfunction. If your blood and urine tests are normal, I would advise you to continue to periodically check these tests to monitor for any changes in kidney function. I am not aware of a specific effect of Risperdal® causing decreased urine volume, but if you have persistent problems with urine flow or volume or difficulty voiding, an evaluation with a urologist would be helpful.

mile_storm: If I was diagnosed as diabetic five years ago, how do I know whether the disease is progressing in a rapid way, or is under control?
Dr_Hatipoglu: Your best guides are your blood sugars and HbA1C's(hemoglobin A1c) checked periodically. If your sugar and HbA1C levels are within good ranges, you are doing well and not dealing with worsening of your disease.

mile_storm: Would I feel differently if my diabetes disease is under control, compared to not under control?
Dr_Hatipoglu: Unfortunately, this is not always the case. If you had normal sugar levels and suddenly begin to have high or low sugars, you will feel it. You may feel tired, foggy, going to the bathroom frequently, etc. But once your body gets used to high sugars, you will not feel anything! Indeed, when we try to bring your sugars down to normal you might feel terrible .(I call it withdrawals, like those associated with alcohol withdrawal in alcoholism!) So, you really need to check and monitor your blood sugar levels and have your doctor check your HbA1C (hemoglobin A1c) periodically to be on top of the game.

Kidney Disease Prevention in Diabetes Patients

thinking: Does diabetes always lead to kidney disease?
Dr__Thomas: Long-standing diabetes, especially if poorly controlled, can affect the kidneys. Additionally, having high blood pressure increases this risk. The chances of developing diabetic kidney disease can be decreased with good blood sugar and blood pressure control, controlling your cholesterol, and managing your weight. You should have blood and urine tests done periodically to assess for protein in the urine and to check your kidney function.

jkd: What is the chance of developing kidney disease if you are a diabetic?
Dr__Thomas: The chance of developing kidney disease is higher with a longer duration of diabetes, poor control of blood sugar and associated high blood pressure. You should focus on lifestyle changes including weight loss, avoidance of smoking, good control of blood sugars and blood pressure, and cholesterol management. Your doctor may put you on specific medications to decrease the amount of protein you have in your urine.

chewy: I have diabetes and was told that I tested positive for protein in my urine. What does this mean? Should I be concerned?
Dr_Hatipoglu: A small amount of protein in the urine is the earliest sign of sugar damage in the kidney. As your blood sugar and blood pressure increase, the small vessels that feed your kidney get hit and cannot work properly. Nutrients and oxygen cannot reach the cells. As a result, small holes open in the kidney and protein starts leaking out. This is a warning for you to start taking care of your sugar and blood pressure well. Also, your doctor can prescribe some blood pressure medications (called ACE [angiotensin converting enzyme] inhibitors or ARBs [angiotensin II receptor blockers]) to slow the progress, so you can keep your kidneys healthy many years to come.

rag_mop:Is there anything I can do to prevent kidney damage if I have diabetes?
Dr__Thomas: Good blood sugar control, blood pressure control, managing cholesterol and lifestyle changes— including maintaining a health weight and stopping smoking, are ways in which you can reduce your chances of kidney and heart problems with diabetes.

pay_up: How do I protect myself from kidney disease if I have diabetes?
Dr_Hatipoglu: There are many things you could do. You could make sure your blood sugar is well controlled. You make sure your blood pressure is well controlled. You see your doctor regularly to check for microalbumin in the urine (please see previous posts for details about this). You exercise and eat healthy. With all the above, you will absolutely be able to protect your kidneys, although there might be still a small risk left to develop kidney disease no matter what you do.

jasper: How long can a diabetic prevent end stage renal disease? Can you prevent it completely? I am 40 years old, and want to know what a future with chronic kidney disease might hold.
Dr__Thomas: You can decrease your chances of progressive kidney disease by controlling blood sugar and blood pressure, and avoiding medications that could be harmful for the kidneys. You should also make lifestyle changes including losing weight, managing your cholesterol levels, and avoiding smoking. Be sure to follow regularly with a kidney doctor who can check your kidney function, check for the amount of protein in your urine, and make any changes to medications that may be needed.

jello: It was said that Advil® can damage the kidneys; what can I take instead of Advil®  for muscle pain?
Dr_Hatipoglu: You are correct, it is better to avoid a lot of analgesic use. In moderation, you could try acetaminophen (like Tylenol®, etc.).

Kidney Disease Diagnosis

spence: How do I tell if my diabetes is causing problems with my kidneys?
Dr_Hatipoglu: You may not feel any different. That is why it is very important to see your physician periodically. He or she can check your kidney function and a protein in your urine that shows up early in the disease process. Protein is one of the first clues telling us about the start of possible damage in your kidney. The microalbumin test is an easy and reliable test that your doctor could order it for you.

noqs: Can both type 1 and type 2 diabetics get kidney disease?
Dr__Thomas: Yes, both type 1 and type 2 diabetics can get kidney disease. If you have type 1 diabetes, you should be checked every year for proteinuria (protein spilling in the urine) at five years after your diagnosis of the diabetes. If you have type 2 diabetes, you should be checked for proteinuria at the time of diagnosis and then every year. Proteinuria is an early indicator of kidney damage.

jonhp: I am a diabetic and have been having problems with kidney function. My doctor referred me to a specialist, but are there recommended questions I can ask him, so I can be better prepared?
Dr__Thomas: You should be seeing a nephrologist who specializes in kidney diseases. You should ask about your level of creatinine and GFR (glomerular filtration rate), which gives you an indication of how severe your kidney disease is. You should ask about the amount of protein in your urine. You should discuss all medications that you are currently taking (including over-the-counter medications), and, specifically, whether you would benefit from a class of medications called angiotensin-converting enzyme inhibitors or angiotensin receptor blockers that can lower protein loss in the urine. You should also be discussing your blood pressure and cholesterol control in addition to blood sugar control. Importantly, do not forget to get all your previous medical records to your specialist.

get_going: What are the early signs of developing kidney disease?
Dr__Thomas: There are no specific symptoms in early kidney disease. The earliest indication that you have kidney disease, especially in diabetes, is the appearance of protein in the urine (also called proteinuria). You should get urine tests to check for proteinuria and blood tests to assess your level of kidney function. In late or advanced stages of kidney disease, you will usually experience swelling, increased fatigue, nausea, decreased appetite, etc.

frufru: What types of tests or screenings should I do to see if I am having kidney issues related to diabetes? How often should I have them?
Dr__Thomas: Blood and urine tests should be done to assess for any kidney problems. The earliest indicator of diabetic kidney disease is protein spilling in urine (proteinuria). If you have type 1 diabetes, you should be checked every year for this beginning at five years from your initial diagnosis. If you have type 2 diabetes, you should be checked every year for this beginning at the time of diagnosis.

sankers2:What else would cause kidney disease besides diabetes?
Dr__Thomas: There are many diseases that can affect the kidneys—the most common ones that we see are related to diabetes and high blood pressure. If there is indication of kidney disease from blood or urine tests, you should see a nephrologist (a physician who specializes in kidney diseases) who can order additional tests to diagnose the cause. In some cases, a kidney biopsy may be needed to verify the cause of kidney disease.

jodum: Once a patient has been diagnosed with kidney problems, how long is it before it becomes serious? Will it always progress to chronic kidney disease?
Dr__Thomas: Progression of kidney disease is more likely if you have poor control of blood sugar and blood pressure. By controlling these, adopting healthy lifestyle changes, and avoiding medications that could potentially be harmful to your kidneys, your kidney function can remain stable even if lower than normal.

laura: 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_Hatipoglu: Having normal or low blood pressure is really a good sign, but, unfortunately, it is not enough to feel relaxed about your kidney function. You still need to have blood and urine tests done periodically to make sure they are functioning properly.

Kidney Disease Treatment

hanna: What medications do I take to treat kidney disease?
Dr_Hatipoglu: When a diabetic patient starts having problem with his or her kidney function, we might recommend better blood pressure control and better blood sugar control. Today there are many good options on the market that your physician could use. The most commonly used medications are ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin II receptor blockers)—if there is no contraindication to use them. These medications work on a specific hormone system in our body that calms it down, thus helping blood pressure and delaying the progression of kidney damage from diabetes. You could be taking already one of them as there are many that belong to this family of drugs. You should ask your doctor.

Salt Use and Diabetes with Kidney Disease

serendipity: My husband has high blood pressure plus diabetes and nerve damage due to diabetes, kidney failure and liver damage. If he switches his salt to a salt substitute, would that be better for him instead of the regular salt? If there is a difference in which one he should use?
Dr__Thomas: Your husband should certainly follow a low salt diet. However, you should be careful regarding salt substitutes because many salt substitutes are high in potassium, which could lead to problems in kidney disease. (Potassium tends to build up in the body in kidney disease.) You should check the labels and ingredients to verify this. Ideally, the recommended amount of sodium is less than 1.5 to 2 grams per day


Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic experts Betul Hatipoglu, MD and George Thomas, MD is now over. Thank you Dr. Hatipoglu and Dr. Thomas for taking your time to answer our questions today about Understanding the Diabetes Link to Kidney Disease.
Dr__Thomas: It was a pleasure to answer all your questions. We hope that it was helpful for you. Thank you.
Dr_Hatipoglu: Thank you for joining us. It was a pleasure being with you, good luck to you all.

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