2Discussion topics Number of people in U.S. with diabetes Diabetes and related problemsDiabetes and Chronic Kidney Disease (CKD)Stages of CKDWhat you can do to help yourself
3You are not alone 20.8 million people in U.S. have diabetes – that is 7% of the populationMajority are Type 2Diabetes to increase 165% between 2000 and 2050There is a 1.8 times greater risk among African AmericansType 1 diabetes is due to the body’s inability to produce insulin. Type 2 develops because of the body’s failure to produce enough insulin and to properly use the insulin it produces14.6 million people have been diagnosed6.2 million people have not been diagnosedAt least 41 million people have pre-diabetes1 in every 3 Americans born in 2000 will develop diabetes
4Possible complications of diabetes StrokeBlindnessPeripheralVascularDiseaseCKDHigh Blood PressureHeart diseaseDiabetes
5Diabetes and CKD Diabetes is the leading cause of CKD in U.S. Early kidney disease has no symptomsWhen not diagnosed it can progress to kidney failure with little or no warningMicroalbuminuria or macroalbuminuria is protein in the urine. In people with diabetes – 43% have microalbuminuria and 8% have macroalbuminuria. Microalbumin can be detected much sooner than Macroalbumin. This can be detected by a simple urine test
6Control your diabetesHigh blood sugar levels can lead to many health problems including kidney disease30% of people with Type 1 diabetes develop CKD10-40% of people with Type 2 diabetes develop CKDStop here and ask everyone in the audience with Type 2 diabetes to stand up. Now count off in threes. According to statistics, every third person will develop Chronic Kidney Disease: have the people that are number 1 continue to stand, number 2 and 3s sit down. Those standing will likely develop CKD.
7What is the kidney The kidneys weigh about a pound each Located in the retroperitoneal spaceAbout the size of an adult fistShaped like a kidney beanAttached to blood stream through renal arteriesEach renal lobe is made of tiny blood vesselsWhile the kidneys are small, they provide vital functions to sustain life. The body is able to function quite well with one kidney. The retroperitoneal space is behind the abdominal wall. The kidneys are located in front of the spine on both sides. Over time elevated blood sugars damage the tiny vessels in the kidneys.
8Kidney functions Remove waste Remove excess fluid Secrete Erythropoetin to make red blood cellsRegulate bone metabolismRegulate blood pressureMaintain electrolyte and acid balance
9How does diabetes cause CKD? Damages small blood vessels in kidneys and other organsProteins begin to leak into the urineAbility to filter waste decreasesWaste products begin to build upKidneys may failMay need dialysis or transplant to liveAccording to the American Diabetes Assoc, When our bodies digest the protein we eat, the process creates waste products. In the kidneys millions of tiny blood vessels with even tinier holes in them act as filters. As blood flows through the blood vessels, small molecules, such as waste products, squeeze through the holes. The waste products become part of the urine. Useful products such as protein and blood cells are too big to pass through the holes in the filter and stay in the blood. When these tiny blood vessels are damaged by elevated Blood sugars and/or high blood pressure, the holes get larger and protein, blood cells, etc begin to leak through the urine.
10Signs of kidney damageDamage to kidneys may or may not involve kidney failure. Some signs of damage:Blood in urineProtein in urine (Proteinuria)Abnormal blood or other urine testsAbnormal imaging testsAbnormal kidney biopsy
11CKD symptoms Decreased appetite Nausea, vomiting Weight gain/loss Change in bowel habitsDecreased sensation in hands and feet (neuropathy)TiredDecreased concentrationFrail appearanceDecreased sexual functioningBronze or discolored skinSymptoms can be confusing when a person has diabetes and CKD, because many of the symptoms are similar. A person may not have symptoms of kidney disease until 50-75% of kidney function is lost.
12NKF definition of CKDThe National Kidney Foundation defines CKD as kidney damage for 3 or more months based on findings of abnormal structure (Imaging studies) or abnormal function (blood or urine tests)ORGFR < 60 mL per minute for 3 or more months with or without evidence of Kidney damage
13Detecting CKD Detect CKD with 2 simple tests: Urine test for detecting proteinuriaBlood test for estimating glomerular filtration rate (eGFR)A microalbumin test is done to check for protein (albumin) in the urine. It can be done on a sample of urine collected anytime. Early detection may change treatment in an effort to preserve as much kidney function as possible.The eGFR is considered the best indicator of the level of kidney function and is a calculation of the results from a blood test.
14Stages of Chronic Kidney Disease DescriptionGFR* mL/min/1.73m21Slight kidney damage with normal or increased filtrationMore than 902Mild decrease in kidney function60-893Moderate decrease in kidney function30-594Severe decrease in kidney function15-295Kidney failure requiring dialysis or transplantationLess than 15*GFR is glomerular filtration rate, a measurement of the kidney's function.When CKD progresses to Stage 5, it is commonly called ESRD or End Stage Renal Disease.
15Stage 5 CKD or ESRDStage 5 CKD is more commonly called ESRD or End Stage Renal Disease.Treatment requiredSome form of dialysis to maintain lifeMedicationsDiet modificationWhen an individual reaches Stage 5 or ESRD (End Stage Renal Disease), they will require some form of dialysis to maintain life. This can be Hemodialysis, Peritoneal Dialysis or transplantation.
16Delayed CKD detection can lead to serious consequences Lack of treatment for early complicationsDiabetes High blood pressureCardiovascular disease MalnutritionLate referral to nephrologist/cardiovascular specialist or dietitianLack of patient education for prevention or treatment optionsLack of access placement prior to the start of dialysisChronic Kidney Disease in combination with any of these conditions can be devastating. Delayed detection would lead to late referrals to Kidney or Heart Specialist and possibly appropriate treatment . Education for lifestyle changes to prevent, delay or select treatments would not be offered and there would be no preparation for a dialysis access.
17CKD risk factors Diabetes Hypertension Smoking High Cholesterol Family history of CKDAgeGenderRacial /ethnic backgroundAfrican AmericanNative AmericanAsian AmericanPacific IslanderHispanicRemember elevated blood sugars cause damage to the small blood vessels in the body including the kidney. Smoking can increase BP and heart rate, reducing blood flow to the kidney and narrowing blood vessels
18CKD risk factors continued Exposure to Nephrotoxic drugsContrast DyeNSAIDSIbuprofenAdvilMotrinNaproxenNephrotoxic drugs mean drugs that can damage the kidneys. Contrast dyes are injected by vein and are used in test such as xrays, CT scans, MRI’s and Cardiac Catheterization. It is important to drink lots of fluids before and after these tests. NSAIDS are the anti-inflamatory medications taken for arthritis or pain.
19USRDS 2004Diabetes and kidney disease are approaching epidemic levels in the U.S.(The legend refers to incidence rates of ESRD due to diabetes in cases/million population .)
20USRDS 2004 So how do we decrease this increase in kidney disease? (The legend refers to incidence rates of ESRD due to diabetes in cases/million population .)
21Diabetes and hypertension are the primary causes of End Stage Renal Disease.
22Why CKD prevention is important with diabetes & hypertension More than 90% of Medicare patients with CKD also have diabetes, hypertension, or bothApproximately 83,000 Medicare beneficiaries with diabetes in Missouri (Fee-for-Service 4/06-3/07)Diabetes and hypertension both cause CKD and make complications worse
23When to get testedType 1 Diabetes: 5 years after diagnosis, then annually*Type 2 Diabetes: at diagnosis, then annually*Hypertension: at diagnosis and initiation of therapy, then every 3 years if eGFR and microalbumin tests are normalFamily history of kidney disease: every 3 years, as long as tests are normalThese testing intervals are recommendations; physician opinion may differ*KDOQI Guideline 1Ask your doctor if you have been testedKDOQI(pronounced Kay-doe-key) stands for National Kidney Foundation Disease Outcomes Quality Initiative. These guidelines are evidence based clinical practice guidelines for all stages of Chronic kidney disease
24Help prevent or delay CKD Control Blood Sugar - Goal of A1C < 6.5Eat at about the same time every dayEat a meal or snack every 3-4 hours and do not skip mealsEat the same amount of carbohydrates in meals or snacks each dayCheck blood sugar as instructedTake your medicine and /or insulin as directedKeep your doctor appointments; take your blood sugar record with youRemember elevated blood sugars cause damage to the small blood vessels in the body including the kidney. Eating at regular times helps to maintain level blood sugar levels
25Control blood pressure Monitor your own blood pressureTry to keep it at 125/70 or lowerTake medication as directedLimit salt and sodium intakeHigh BP is like turning on a faucet full force in the kidney. Over time this damages the kidney. Limiting Salt and sodium in the diet helps to reduce the BP by reducing fluid volume.
26Watch your weightAchieve and maintain desirable body weight (target BMI to normal range of kg/m2)BMI is the measure of body fat based on height and weight that applies to both adult men and women.A person 6 foot tall weighing 183 lbs. would have a body mass index of 24.8
27If you smokeSTOPSmoking can increase blood pressure and heart rate, reducing blood flow to the kidney and narrow blood vessels. For help to stop smoking, join a smoking cessation class or ask your physician if you can take a medication that can assist you to stop smoking
28Take an active role in your health care Monitor your own blood pressure and blood sugarKnow what your levels should beSee your doctor regularlyAsk if you are on an ACE or an ARB for your BPAsk if you had a urine test for proteinKnow your eGFRIf you have CKD, know what stageACE and ARBs are classifications of Blood Pressure medications that have been associated with slowing the progression of Chronic Kidney Disease
29CKD Stage 3 Limit protein and phosphorous intake High protein levels increase the workload of the kidneyLimiting Protein may help reduce the amount of waste product for the kidney to filter - thus reducing the workload. In stage 3 CKD, recommended protein intake is .8g/kg body weight. For a 200 lb. person this would mean approx. 4 ounces of protein a day.
30CKD Stage 4 or 5 Limit phosphorus intake in your diet High levels of phosphorus can cause damage without any symptomsBecause unhealthy kidneys are no longer able to remove the phosphorus from the blood and get rid of the excess, high levels can cause bone and heart problems, weakened bones d/t low blood calcium, bone pain or itching, calcification or hardening of the tissues in the heart, arteries, joints, skin or lungs
31Foods high in phosphorus Milk and dairy productsCola drinks and Dr. PepperChocolateNuts and buttersPancakes, waffles and biscuitsDried beansProcessed meats like hot dogs, sausage, bolognaWhole grain foodsExamples of milk and dairy products are Cheese, cottage cheese, ice cream, sherbet , etc
32Take better care of yourself Changes in diet, fluid intake and medications can be confusing and challenging.These changes can help you feel better and slow kidney diseaseGo to your doctor and ask questionsTake your medications as instructedReport any changes
33It takes a teamYOUDoctorNursesDietitianCommunityFamilySupport groupsWorking closely with your health care team can help you to retain control of your life and prevent long-term complications of Diabetes.