Chadia Beaini Safa, MD
Head of Hemodialysis Unit, Bellevue Medical Center
Nephrologist, Bellevue Medical Center
The kidneys play an important role: they remove waste products from the body, balance the body’s fluids, release hormones that regulate blood pressure, produce the active form of vitamin D and control the production of red blood cells. Finding out that you have early diabetic nephropathy can alert you that your kidneys are in danger. It is important to take steps to protect your kidneys before the problem advances.
Diabetic nephropathy occurs in type 1 (formerly called insulin-dependent or juvenile onset) and type 2 (formerly called non-insulin-dependent or adult onset) diabetes mellitus, and in other secondary forms of diabetes mellitus, in which duration of diabetes is long enough and level of glycemia high enough to result in complications.
Diabetic kidney disease or diabetic nephropathy is defined by characteristic structural and functional changes. The major clinical manifestations of diabetic nephropathy are albuminuria and progressive chronic kidney disease, which can be slowed or prevented with optimal therapy.
Diabetic nephropathy usually causes no symptoms and people continue to produce normal amounts of urine. To detect diabetic nephropathy, tests that measure protein levels in the urine and blood tests to evaluate the level of kidney function should be done regularly. When the kidneys are working normally, they prevent proteins from leaking into the urine, so finding proteins in the urine is a sign that the kidneys are in trouble. The earliest clinical manifestation of renal involvement in diabetes is an increase in albumin excretion: moderately increased albuminuria or microalbuminuria (defined as urinary albumin excretion between 30 and 300 mg/day) or severely increased macroalbuminuria (defined as urinary albumin excretion above 300 mg/day). Moderately increased albuminuria precedes the development of severely increased albuminuria and it predicts the development of nephropathy. The onset of severely increased albuminuria is often followed by a slowly progressive decline in the renal function and, given enough time, end-stage renal disease in the absence of effective therapy. At an advanced stage of chronic kidney disease, uremic signs and symptoms can be present such as declining nutritional status, volume overload, fatigue and malaise, mild cognitive impairment, refractory acidosis, hyperkalemia, and hyperphosphatemia.
The first step in the prevention and treatment of diabetic nephropathy is proper glycemic control, which can partially reserve the glomerular hypertrophy and hyperfiltration, decrease protein excretion and slow the progression of renal function decline.
And while it is important to control blood sugar, it turns out that controlling blood pressure is at least as important. That’s because high blood sugar and high blood pressure work in concert to damage the blood vessels and organ systems.
Also, aggressive lipid lowering is an important part of the medical management of all diabetic patients since diabetes is considered a coronary heart disease equivalent.
In addition, changing the lifestyle has a big impact on the prevention and treatment of the diabetic nephropathy, the following measures are recommended:
Quit smoking, limit the amount of salt in the daily diet, reduce alcohol intake, eat more fruits and vegetables, lose weight if you carry excess weight, do regular aerobic exercise (walking, running) for 20 to 30 minutes most days of the week and do a protein restriction diet if overt kidney disease is present.
The optimal therapy of diabetic nephropathy continues to evolve and the best treatment is prevention before overt chronic kidney disease happens.