- Diabetic kidney disease is the most common cause of kidney failure in Australia
- Classical diabetic kidney disease is first identified by the detection of protein in the urine
- Diabetic kidney disease represents a diverse group of diseases
- Protein in the urine and reduced kidney function are strong predictors of developing kidney failure and cardiovascular disease.
- Patients with diabetic kidney disease are susceptible to episodes of acute kidney injury (AKI).
- Recurrent episodes of AKI in diabetic kidney disease can result in an irreversible damage to the kidney.
- Heart disease is common in diabetic kidney disease. Diabetic kidney disease worsens diabetic heart disease; heart disease worsens diabetic kidney disease
- Control of both blood sugar and blood pressure help slow down the development and progression of both kidney disease and heart disease in diabetes
- Medications including angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) are useful treatments in diabetic kidney and heart disease
- Care for patients with diabetes and kidney disease requires careful planning
1. Diabetes is the most common cause of kidney failure in Australia
Diabetes is the leading cause of end stage kidney disease in Australia. “Approximately 5000 Australians receive dialysis or have a kidney transplant as a consequence of diabetes. For every diabetic patient with kidney failure, there are approximately 50 diabetic patients with earlier stages of kidney disease”.
- Diabetic kidney disease in Australia: Current burden and future projections. S White et al. Nephrology 19 450–458. 2014
2. Classical diabetic kidney disease is first identified by the detection of protein in the urine
Classical diabetic kidney disease is usually detected when protein appears in the urine (proteinuria). Without specific treatments, the amount of protein in the urine will increase over time and kidney function will begin to decline. Control of blood pressure and blood sugar are important treatments to preserve kidney function, to reduce the amount of protein in the urine and to prevent or delay the onset of kidney failure.
3. Diabetic kidney disease represents a diverse group of diseases
Damage to the kidneys in diabetes can result from a persistent reduction in blood flow to the kidneys. Conditions such as heart failure, renal artery stenosis and hypertension can cause reductions in blood flow to the kidneys. Occasionally patients with diabetes may have other causes of kidney damage.
- Spectrum of renal disease in diabetes. J Teng et al Nephrology 19 528–536, 2014
4. Protein in the urine and reduced kidney function are strong predictors of developing kidney failure and cardiovascular disease.
Proteinuria and reduced kidney function are each predictors of kidney failure, and the combination of both is a significantly stronger predictor than either measure alone. Proteinuria and reduced renal function are also well-recognized predictors of increased risk of cardiovascular disease in patients with diabetes.
- Albuminuria and Estimated Glomerular Filtration Rate as Predictors of Diabetic End-Stage Renal Disease and Death. AM. Berhane, et al: Clin J Am Soc Nephrol 6: 2444–2451, 2011
- Albuminuria and kidney function predict cardiovascular and renal outcomes in diabetes Ninomiya T, et al:. J Am Soc Nephrol 20: 1813–1821, 2009.
- Kidney disease and increased mortality risk in type 2 diabetes. Afkarian M, et al. J. Am. Soc. Nephrol.; 24: 302–8, 2013.
- Chronic kidney disease as a coronary disease equivalent–a comparison with diabetes over a decade. Debella YT, et al. Clin. J. Am. Soc. Nephrol.; 6: 1385–92, 2011.
- Albuminuria, a therapeutic target for cardiovascular protection in type 2 diabetic patients with nephropathy de Zeeuw D, et al. Circulation 110: 921–927, 2004
5. Patients with diabetic kidney disease are susceptible to acute kidney injury (AKI).
Patients with diabetic kidney disease are at higher risk of developing an acute deterioration of kidney function. Potential insults to the kidney include acute heart attacks, heart failure, some medications and episodes of infection. Patient with diabetic kidney disease are often exposed to multiple events that lead to AKI.
- A meta-analysis of the association of estimated GFR, albuminuria, diabetes mellitus, and hypertension with AKI. Matthew et al. Am J Kidney Dis; 66(4): 602–612. 2015
6. Recurrent episodes of AKI in diabetic kidney disease can result in irreversible damage to the kidney.
Each episode of AKI can permanently damage the kidney and cause an irreversible reduction in kidney function.
- Acute Kidney Injury Episodes and Chronic Kidney Disease Risk in Diabetes Mellitus. Thacker CV et al Clin J Am Soc Nephrol 6: 2567–2572, 2011
7. Heart disease is common in diabetic kidney disease. Diabetic kidney disease worsens diabetic heart failure; heart failure worsens diabetic kidney disease.
Kidney and heart disease often coexist, reflecting common factors in their causation including diabetes, hypertension and atherosclerosis. The cardio-renal syndrome describes the dependent relationship between the heart and kidneys whereby a reduction in function in either may cause a deterioration in the function of the other.
- Cardio-renal syndromes: Report from the consensus conference of the acute dialysis quality initiative. Ronco C, et al: Eur Heart J 31: 703–711, 2010
- Heart Failure and Nephropathy: Catastrophic and Interrelated Complications of Diabetes Gilbert RE et al Clin J Am Soc Nephrol 1: 193–208, 2006
- A Patient with Heart Failure and Worsening Kidney Function: Sarnak MJ et al: Clin J Am Soc Nephrol 9: 1790–1798, 2014
8. Good control of blood sugar levels and blood pressure help slow down the deterioration of both diabetic kidney disease and heart disease.
Good blood glucose and blood pressure control slow down the deterioration in kidney function and heart disease. In general, the better the control of blood pressure and blood sugar, the greater the benefit to the kidneys and heart.
- Stratton IM, et al: Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): Prospective observational study. BMJ 321: 405–412, 2000
- UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 317: 703–713, 1998
- Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): Prospective observational study. Adler AI, et al: BMJ 321: 412–419, 2000
- Impact of achieved blood pressure on cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial. Berl T, et al: J Am Soc Nephrol 16: 2170–2179, 2005
9. ACEI and angiotensin II receptor blockers (ARB) are useful medications in diabetic kidney disease and diabetic heart disease.
A large body of evidence supports the use of ACEIS and ARB to treat diabetic kidney and heart disease. Important studies have shown a reduction in the incidence of progressive kidney disease, kidney failure, and hospitalization for heart failure in patients who received these agents. Not all patients can use these medications.
- Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy Brenner BM et al. N Eng J Med 345: 861–869, 2001
- The effect of ibresartan on the development of diabetic nephropathy in patients with Type 2 diabetes. Parving HH et al: N Engl J Med 345 870-8, 2001
- Renoprotective effect of the angiotensin receptor antagonist ibresartan in patients with nephropathy due to type 2 diabetes. Lewis E et al N Engl J Med 345 851-60, 2001
10. Care for patients with diabetes and kidney disease requires careful planning.
Many patients with diabetic kidney disease will eventually require dialysis and may benefit from kidney transplantation. Close collaboration between patients and their health providers in both the community and hospitals helps reduce the risk of developing both kidney and heart failure. Care is aimed at optimizing blood pressure, sugar control and reducing other risk factors associated with kidney and heart disease. Specific attention to minimize the risk of developing acute kidney injury is also essential to preserve kidney function in diabetes. Despite appropriate clinical care some patients with diabetes will develop kidney failure. The development of kidney failure should be anticipated such that the most appropriate form of treatment for the patient can be planned for.
- Optimal Preparation for ESRD Andrew S. Narva Clin J Am Soc Nephrol 4: S110–113, 2009