Kidney Disease

Diabetes nephropathy, also known as diabetic kidney disease, affects 20-40 percent of people with diabetes. The leading cause of chronic kidney disease and end-stage kidney disease is diabetes nephropathy. Although there is a genetic predisposition to diabetic nephropathy, chronic high blood glucose is the most important risk factor.^1,2,3,4,5

Facts

• 30-40 percent of people with type 1 have diabetic nephropathy
• 25-40 percent of people with type 2 have diabetic nephropathy

The kidneys are two bean-shaped organs on either side of the spine in the lower back that serve as the body’s filtration system. One of the main jobs of the kidneys is to filter waste, chemicals and extra fluid from the blood. The waste products are removed from the body through the urine. The kidneys also help to regulate blood pressure and make hormones.

Each kidney is made up of about one million tiny filtration systems called nephrons. Each nephron has a glomerulus and tubule. When blood enters the kidney, it is filtered by the glomerulus and then the tubule returns the substances the body needs back into the blood and removes the waste.

Chronic high blood glucose levels slowly damage these tiny filtering systems. If the kidneys are unable to filter the waste, chemicals and extra fluid out of the body properly, these build up in the blood. In addition, the kidneys leak proteins that the body needs in the urine.

Early stages of diabetic nephropathy don’t often have symptoms.  However, as the disease progresses to later stages, it can affect other systems in the body. As the kidney disease progresses the person may experience:

• High blood pressure
• Protein in their urine (as measured by the doctor)
• Swelling in hands, feet, ankles and eyes
• Increase in urination
• Decreased appetite
• Fatigue
• Sleep problems
• Shortness of breath
• Difficulty concentrating
• Nausea or vomiting
• Itching

Diagnosis

Chronic kidney disease is diagnosed when there is high urinary albumin (a type of protein that’s normally in the blood) and/or low estimated glomerular filtration rate (a measure of kidney function).^2,6

The doctor will order a urine test in the office (the person urinates in a cup) to measure how much protein (albumin) is in the urine (called albumin-to-creatinine ratio or UACR). Albumin is a protein found in the blood that helps the body to build muscle, repair tissue and fight infection. It should be in the blood, not the urine. When there is albumin in the urine it is a sign of kidney disease, called albuminuria or proteinuria.^2,6

In addition, the doctor will also measure the estimated glomerular filtration rate (eGFR), which is measured with a blood test and shows the filtration of the kidney (how well the kidney is functioning). This helps to identify the stage of kidney disease.^2,6

Treatment

Treatment of kidney disease is based on the stage of kidney disease. In all stages of kidney disease, keeping blood glucose levels in the target range as much as possible is key. In addition to a healthy lifestyle (getting regular physical activity, getting enough sleep, managing stress, etc.), managing blood pressure and cholesterol, modifications in daily protein and/or salt intake may be recommended. There are certain over-the-counter medications that should be avoided.⁶

In the early stages of kidney disease, medications may be prescribed to help manage blood pressure. These medicines can also reduce the risk of albuminuria and the risk of kidney disease progressing. Newer glucose-lowering medications, called sodium-glucose cotransporter- 2 inhibitor (SGLT-2 inhibitor) and glucose-like peptide receptor agonist (GLP-1 agonist), that are used to treat type 2 diabetes (some people with type 1 use them off-label in addition to insulin) also act to protect kidneys and help the kidney disease from progressing.⁶ Getting early treatment is key to delaying further damage and progression of the disease.

As chronic kidney disease progresses to later stages, (end-stage renal disease or ESRD) kidney dialysis may be needed. This treatment filters blood, removing waste, chemicals and extra fluid from the blood because the kidneys aren’t able to anymore. There are options to have treatment at a hospital or dialysis center as well as at home after training—the doctor will determine which option is best. A kidney transplant may also be an option. If a person has a kidney transplant, a pancreas transplant is often performed at the same time. Additional ongoing medications will be needed after the transplant.⁶

Prevention of Kidney Disease⁶

Although a person’s genetics plays a role in the development of kidney complications, there are many things we can do that can reduce the risk of developing nephropathy and its progression:

• Keep blood glucose as close to target range as possible
• Stop smoking
• Manage blood pressure
• Manage cholesterol
• Maintaining a healthy lifestyle—regular physical activity, managing stress, etc.
• Take medicine(s) as recommended (e.g., blood pressure medication)
• Eat a healthy diet (including specific recommendations from a dietician)
• Have kidney function checked regularly (urinary albumin and estimated glomerular filtration rate (eGFR).
  • Type 1 diabetes – after five years of diagnosis at least once per year
  • Type 2 diabetes – at least once per year

Psychosocial Aspects of Nephropathy

Dealing with nephropathy can be overwhelming, especially in later stages. There may be issues in physical functioning as well as social limitations.⁷ People with diabetes living with kidney disease also reported a lower quality of life.⁸ Over one-quarter of people with diabetic nephropathy reported having depression.⁹

If you have any diabetes and kidney disease, you may want to get some extra support to help you cope. Many people have difficulty with the news of nephropathy or that it has progressed. They often need extra support adjusting to their new normal. Talk to your diabetes health care provider about how you are feeling and your worries. They can recommend some practical tips for adjusting to your new norm and also refer you to a mental health provider that has experience in helping patients deal with diabetes complications. Taking care of yourself both medically and psychologically can help improve your overall quality of life.

 1. Afkarian M, Zelnick LR, Hall YN, et.al. Clinical manifestations of kidney disease among US adults with diabetes. Journal of the American Medical Association. 2016;316(6):602–610.
2. Gross J.L., de Azevedo M.J., Silveiro S.P., Canani L.H., Caramori M.L., Zelmanovitz T. Diabetic Nephropathy: Diagnosis, Prevention, and Treatment. Diabetes Care. 2005;28:164. doi: 10.2337/diacare.28.1.164.
3. Van der Kloet F.M., Tempels F.W.A., Ismail N., van der Heijden R., Kasper P.T., Rojas-Cherto M., van Doorn R., Spijksma G., Koek M., van der Greef J., et al. Discovery of early-stage biomarkers for diabetic kidney disease using ms-based metabolomics (FinnDiane study) Metabolomics. 2012;8:109–119. doi: 10.1007/s11306-011-0291.
4. 16. Parving H.H., Lehnert H., Brochner-Mortensen J., Gomis R., Andersen S., Arner P. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N. Engl. J. Med. 2001;345:870–878. doi: 10.1056/NEJMoa011489.
5. Schena F.P., Gesualdo L. Pathogenetic mechanisms of diabetic nephropathy. J. Am. Soc. Nephrol. 2005;16(Suppl. S1):S30–S33. doi: 10.1681/ASN.2004110970.
6. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes−2020. American Diabetes Association .Diabetes Care Jan 2020, 43 (Supplement 1) S135-S151; DOI: 10.2337/dc20-S011
7. Tsutsui H, Nomura K, Ohkubo T, Ozaki N, Kusunoki M, Ishiguro T, Oshida Y. Identification of physical and psychosocial problems associated with diabetic nephropathy using the International Classification of Functioning, Disability and Health Core Set for Diabetes Mellitus. Clin Exp Nephrol. 2016 Apr;20(2):187-94. doi: 10.1007/s10157-015-1143-x. Epub 2015 Jul 4. PMID: 26141244.
8. Tönnies T, Stahl-Pehe A, Baechle C, Castillo K, Yossa R, Holl RW, Rosenbauer J. Diabetic nephropathy and quality of life among youths with long-duration type 1 diabetes: A population-based cross-sectional study. Pediatr Diabetes. 2019 Aug;20(5):613-621. doi: 10.1111/pedi.12837. Epub 2019 Apr 16. PMID: 30806008.
9. Palmer S, Vecchio M, Craig JC, et al.. Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies. Kidney Int 2013;84:179–191

Educational content related to diabetes complications is made possible with support from Allergan, an active partner of Beyond Type 1 at the time of publication. Editorial control rests solely on Beyond Type 1.

WRITTEN BY Alicia McAuliffe-Fogarty, PhD, CPsychol, POSTED 12/13/20, UPDATED 08/04/23

Dr. Alicia McAuliffe-Fogarty was diagnosed with type 1 diabetes in 1987. She is a clinical health psychologist specializing in diabetes, completing her fellowships at the Yale University School of Medicine. Dr. McAuliffe-Fogarty founded the Circle of Life Camp for children with diabetes, was vice president of the Lifestyle Management Team at the American Diabetes Association and vice president of patient-centered research at the T1D Exchange. She is a clinical and scientific consultant to nonprofit and biotech/pharmaceutical companies leading research, strategy, content creation and program development.