Kidney Disease of Diabetes
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Each year in the United States, nearly 100,000 people are diagnosed with kidney failure, a serious condition in which the kidneys fail to rid the body of wastes. Kidney failure is the final stage of a slow deterioration of the kidneys, a process known as nephropathy.
Diabetes is the most common cause of kidney failure, accounting for
more than 40 percent of new cases. Even when drugs and diet are able to
control diabetes, the disease can lead to nephropathy and kidney failure.
Most people with diabetes do not develop nephropathy that is severe enough
to cause kidney failure. About 17 million people in the United States
have diabetes, and over 100,000 people are living with kidney failure as a result
of diabetes.
People with kidney failure undergo either dialysis, which substitutes for some of the filtering functions of the kidneys, or transplantation to receive a healthy donor kidney. Most U.S. citizens who develop kidney failure are eligible for federally funded care. In 2000, care for patients with kidney failure cost the Nation nearly $20 billion.
African Americans, American Indians, and Hispanic Americans develop
diabetes, nephropathy, and kidney failure at rates higher than average.
Scientists have not been able to explain these higher rates. Nor can they
explain fully the interplay of factors leading to diabetic nephropathy--factors
including heredity, diet, and other medical conditions, such as high blood
pressure. They have found that high blood pressure and high levels of
blood glucose increase the risk that a person with diabetes will progress
to kidney failure.
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Two Types of Diabetes
There are two types of diabetes. In patients with either type, the body does not properly process and use food. The human body normally converts food to glucose, the simple sugar that is the main source of energy for the body's cells. To enter cells,
glucose needs the help of insulin, a hormone produced by the pancreas. When
a person does not make enough insulin, or the body does not respond to the
insulin that is present, the body cannot process glucose, and it builds
up in the bloodstream. High levels of glucose in the blood lead
to a diagnosis of diabetes. Both types of diabetes can lead to kidney disease.
Type 1 Diabetes
Only about 1 in 20 people with diabetes has type 1 diabetes, which tends
to occur in young adults and children. Type 1 used to be known as insulin-dependent
diabetes mellitus (IDDM) or juvenile diabetes. In type 1 diabetes, the
body stops producing insulin. People with type 1 diabetes must take
daily insulin injections or use an insulin pump. They also control blood glucose levels with meal planning and physical activity. Type 1 diabetes is more likely to lead to kidney failure. Twenty to 40 percent of people with type 1 diabetes develop kidney failure by the age of 50. Some develop kidney failure before the age of 30.
Type 2 Diabetes
About 95 percent of people with diabetes have type 2 diabetes, once known
as noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes.
Many people with type 2 diabetes do not respond normally to their own
or to injected insulin--a condition called insulin resistance. Type 2
diabetes occurs more often in people over the age of 40, and many people
with type 2 are overweight. Many also are not aware that they have the
disease. Some people with type 2 control their blood glucose with meal planning
and physical activity. Others must take pills that stimulate production
of insulin, reduce insulin resistance, decrease the liver's output of glucose, or slow absorption of carbohydrate from the gastrointestinal tract. Still others require injections of insulin. Between 1993 and 1997, more than 100,000 people in the United States were treated for kidney failure caused by type 2 diabetes.
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The Course of Kidney Disease
Diabetic kidney disease takes many years to develop. In some people, the filtering function of the kidneys is actually higher than normal in the first few years of their diabetes. This process has been called hyperfiltration.
Over several years, people who are developing kidney disease will have small amounts of the blood protein albumin begin to leak into their urine. At its first stage, this condition has been called microalbuminuria. The kidney's filtration function usually remains normal during this period.
As the disease progresses, more albumin leaks into the urine. Various names are attached to this interval of the disease such as overt diabetic nephropathy or macroalbuminuria. As the amount of albumin in the urine increases, filtering function usually begins to drop. The body retains various wastes as filtration falls. Creatinine is one such waste, and a blood test for creatinine can measure the decline in kidney filtration. As kidney damage develops, blood pressure often rises as well.
Overall, kidney damage rarely occurs in the first 10 years of diabetes, and usually 15 to 25 years will pass before kidney failure occurs. For people who live with diabetes for more than 25 years without any signs of kidney failure, the risk of ever developing it decreases.
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Effects of High Blood Pressure
High blood pressure, or hypertension, is a major factor in the development of kidney problems in people with diabetes. Both a family history of hypertension and the presence of hypertension appear to increase chances of developing kidney disease. Hypertension also accelerates the progress of kidney disease where it already exists.
In the past, hypertension was defined as blood pressure exceeding 140 millimeters of mercury-systolic and 90 millimeters of mercury-diastolic. Professionals shorten the name of this limit to 140/90 or "140 over 90." The terms systolic and diastolic refer to pressure in the arteries during contraction of the heart (systolic) and between heartbeats (diastolic).
The American Diabetes Association and the National Heart, Lung, and Blood Institute recommend that people with diabetes keep their blood pressure below 130/80.
Hypertension can be seen not only as a cause of kidney disease, but also as a result of damage created by the disease. As kidney disease proceeds, physical changes in the kidneys lead to increased blood pressure. Therefore, a dangerous spiral, involving rising blood pressure and factors that raise blood pressure, occurs. Early detection and treatment of even mild hypertension are essential for people with diabetes.
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Preventing and Slowing Kidney Disease
Blood Pressure Medicines
Scientists have made great progress in developing methods that slow
the onset and progression of kidney disease in people with diabetes. Drugs
used to lower blood pressure (antihypertensive drugs) can slow the progression
of kidney disease significantly. Two types of drugs, angiotensin-converting enzyme
(ACE) inhibitors and angiotensin receptor blockers (ARBs), have proven effective in slowing the progression of kidney disease. Many people require two or more drugs to control their blood pressure. In addition to an ACE inhibitor or an ARB, a diuretic is very useful. Beta blockers, calcium channel blockers, and other blood pressure drugs may also be needed.
An example of an effective ACE inhibitor is captopril, which doctors
commonly prescribe for treating kidney disease of diabetes. The benefits
of captopril extend beyond its ability to lower blood pressure: it may
directly protect the kidney's glomeruli. ACE inhibitors have lowered proteinuria
and slowed deterioration even in diabetic patients who did not have high
blood pressure.
An example of an effective ARB is losartan, which has also been shown to protect kidney function and lower the risk of cardiovascular events.
Any medicine that helps patients achieve a blood pressure target of 130/80 or lower provides benefits. Patients with even mild hypertension or persistent microalbuminuria should consult a physician about the use of antihypertensive medicines.
Moderate-Protein Diets
In people with diabetes, excessive consumption
of protein may be harmful. Experts recommend that people with kidney disease of diabetes consume the recommended dietary allowance (RDA) for protein, but avoid high-protein diets. For people with greatly reduced kidney function, a diet containing reduced amounts of protein may help delay the onset of kidney failure. Anyone following a reduced-protein diet should work with a dietitian to ensure adequate nutrition.
Intensive Management of Blood Glucose
Antihypertensive drugs and low-protein diets can slow kidney disease
when significant nephropathy is present. A third
treatment, known as intensive management of blood glucose or glycemic
control, has shown great promise for people with type 1 and type 2 diabetes,
especially for those in early stages of nephropathy.
Intensive management is a treatment regimen that aims to keep blood glucose
levels close to normal. The regimen includes testing blood
glucose frequently, administering insulin frequently throughout the day on the basis
of food intake and exercise, following a diet and exercise plan, and consulting a health care team frequently. Some people use an insulin pump to supply insulin throughout the day.
A number of studies have pointed to the beneficial effects of intensive
management. Two such studies, funded by the National Institute of Diabetes
and Digestive and Kidney Diseases (NIDDK) of the National Institutes of
Health, are the Diabetes Control and Complications Trial (DCCT)
and a trial led by researchers at the University of Minnesota Medical
School. A third study,
conducted in the United Kingdom, is the U.K. Prospective Diabetes Study
(UKPDS).
The DCCT, conducted from 1983 to 1993, involved 1,441 participants who had type 1 diabetes. Researchers found a 50 percent decrease in both development and progression of early diabetic kidney disease in participants who followed an intensive regimen for controlling blood glucose levels. The intensively managed patients had average blood glucose levels of 150 milligrams per deciliter--about 80 milligrams per deciliter lower than the levels observed in the conventionally managed patients.
In the Minnesota Medical School trial, researchers examined kidney tissues
of people with long-standing diabetes who received healthy kidney transplants.
After 5 years, patients who followed an intensive regimen developed significantly
fewer lesions in their glomeruli than did patients not following an intensive
regimen. This result, along with findings of the DCCT and studies performed
in Scandinavia, suggests that any program resulting in sustained lowering
of blood glucose levels will be beneficial to patients in the early stages
of diabetic nephropathy.
The UKPDS--a 20-year trial conducted in England, Ireland, and Scotland--tested the effects of intensive glucose and blood pressure control
in people with type 2 diabetes and found similar benefits for this group.
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Dialysis and Transplantation
When people with diabetes experience kidney failure,
they must undergo either dialysis or a kidney transplant. As recently as
the 1970s, medical experts commonly excluded people with diabetes from dialysis
and transplantation, in part because the experts felt damage caused by diabetes
would offset benefits of the treatments. Today, because of better control
of diabetes and improved rates of survival following treatment, doctors
do not hesitate to offer dialysis and kidney transplantation to people with
diabetes.
Currently, the survival of kidneys transplanted into patients with diabetes is about the same as survival of transplants in people without diabetes. Dialysis for people with diabetes also works well in the short run. Even so, people with diabetes who receive transplants or dialysis experience higher morbidity and mortality because of coexisting complications of the diabetes--such as damage to the heart, eyes, and nerves.
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Good Care Makes a Difference
If you have diabetes:
- Have your doctor measure your A1C level at least
twice a year. The test provides a weighted average of your
blood glucose level for the previous 3 months. Aim to keep it at less
than 7 percent.
- Work with your doctor regarding insulin injections, medicines,
meal planning, physical activity, and blood glucose monitoring.
- Have your blood pressure checked several times a year. If blood pressure
is high, follow your doctor's plan for keeping it near normal
levels. Aim to keep it at less than 130/80.
- Ask your doctor whether you might benefit from taking an ACE inhibitor or ARB.
- Have your urine checked yearly for microalbumin and protein. If there is protein in your urine, have your blood checked for elevated amounts of waste products such as creatinine. The doctor should provide you with an estimate of your kidney's filtration based on the blood creatinine level.
- Ask your doctor whether you should reduce the amount of protein in your diet. Ask for a referral to see a registered dietitian to help you with meal planning.
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Hope Through Research
The incidences of both diabetes and kidney failure caused by diabetes have been rising. Some experts predict that diabetes soon might account for half the cases of kidney failure. In light of the increasing morbidity and mortality related to diabetes and kidney failure, patients, researchers, and health care professionals will continue to benefit by addressing the relationship between the two diseases. NIDDK is a leader in supporting research in this area.
Several areas of research supported by NIDDK hold great potential. Discovery of ways to predict who will develop kidney disease may lead to greater prevention, as people with diabetes who learn they are at risk institute strategies such as intensive management and blood pressure control. Discovery of better anti-rejection drugs will improve results of kidney transplantation in patients with diabetes who develop kidney failure. For some people with type 1 diabetes, advances in transplantation--especially transplantation of insulin-producing cells of the
pancreas--could lead to a cure for both diabetes and the kidney disease of diabetes.
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National Kidney and Urologic Diseases Information Clearinghouse
3 Information Way
Bethesda, MD 20892-3580
Email: nkudic@info.niddk.nih.gov
The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health under the U.S. Department of Health and Human Services. Established in 1987, the clearinghouse provides information about diseases of the kidneys and urologic system to people with kidney and urologic disorders and to their families, health care professionals, and the public. NKUDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about kidney and urologic diseases.
Publications produced by the clearinghouse are carefully reviewed by both NIDDK scientists and outside experts.
This e-text is not copyrighted. The clearinghouse encourages users of this e-pub to duplicate and distribute as many copies as desired.
NIH Publication No. 04-3925
November 2003
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