1. Diabetes and CKD What is the Connection?

2. Discussion topics Number of people in U.S. with diabetes
Diabetes and related problems
Diabetes and Chronic Kidney Disease (CKD)
Stages of CKD
What you can do to help yourself

3. You are not alone 20.8 million people in U.S. have diabetes –
that is 7% of the population
Majority are Type 2
Diabetes to increase 165% between 2000 and 2050
There is a 1.8 times greater risk among African Americans
Type 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 produces
14.6 million people have been diagnosed
6.2 million people have not been diagnosed
At least 41 million people have pre-diabetes
1 in every 3 Americans born in 2000 will develop diabetes

4. Possible complications of diabetes
Stroke
Blindness
Peripheral
Vascular
Disease
CKD
High Blood Pressure
Heart disease
Diabetes

5. Diabetes and CKD Diabetes is the leading cause of CKD in U.S.
Early kidney disease has no symptoms
When not diagnosed it can progress to kidney failure with little or no warning
Microalbuminuria 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

6. Control your diabetes
High blood sugar levels can lead to many health problems including kidney disease
30% of people with Type 1 diabetes develop CKD
10-40% of people with Type 2 diabetes develop CKD
Stop 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.

7. What is the kidney The kidneys weigh about a pound each
Located in the retroperitoneal space
About the size of an adult fist
Shaped like a kidney bean
Attached to blood stream through renal arteries
Each renal lobe is made of tiny blood vessels
While 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.

8. Kidney functions Remove waste Remove excess fluid
Secrete Erythropoetin to make red blood cells
Regulate bone metabolism
Regulate blood pressure
Maintain electrolyte and acid balance

9. How does diabetes cause CKD?
Damages small blood vessels in kidneys and other organs
Proteins begin to leak into the urine
Ability to filter waste decreases
Waste products begin to build up
Kidneys may fail
May need dialysis or transplant to live
According 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.

10. Signs of kidney damage
Damage to kidneys may or may not involve kidney failure. Some signs of damage:
Blood in urine
Protein in urine (Proteinuria)
Abnormal blood or other urine tests
Abnormal imaging tests
Abnormal kidney biopsy

11. CKD symptoms Decreased appetite Nausea, vomiting Weight gain/loss
Change in bowel habits
Decreased sensation in hands and feet (neuropathy)
Tired
Decreased concentration
Frail appearance
Decreased sexual functioning
Bronze or discolored skin
Symptoms 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.

12. NKF definition of CKD
The 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) OR
GFR < 60 mL per minute for 3 or more months with or without evidence of Kidney damage

13. Detecting CKD Detect CKD with 2 simple tests:
Urine test for detecting proteinuria
Blood 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.

14. Stages of Chronic Kidney Disease
Description
GFR* mL/min/1.73m2 1
Slight kidney damage with normal or increased filtration
More than 90 2
Mild decrease in kidney function
60-89 3
Moderate decrease in kidney function
30-59 4
Severe decrease in kidney function
15-29 5
Kidney failure requiring dialysis or transplantation
Less 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.

15. Stage 5 CKD or ESRD
Stage 5 CKD is more commonly called ESRD or End Stage Renal Disease.
Treatment required
Some form of dialysis to maintain life
Medications
Diet modification
When 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. 

16. Delayed CKD detection can lead to serious consequences
Lack of treatment for early complications
Diabetes High blood pressure
Cardiovascular disease Malnutrition
Late referral to nephrologist/cardiovascular specialist or dietitian
Lack of patient education for prevention or treatment options
Lack of access placement prior to the start of dialysis
Chronic 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.

17. CKD risk factors Diabetes Hypertension Smoking High Cholesterol
Family history of CKD
Age
Gender
Racial /ethnic background
African American
Native American
Asian American
Pacific Islander
Hispanic
Remember 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

18. CKD risk factors continued
Exposure to Nephrotoxic drugs
Contrast Dye
NSAIDS
Ibuprofen
Advil
Motrin
Naproxen
Nephrotoxic 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.

19. USRDS 2004
Diabetes 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 .)

20. USRDS 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 .)

21. Diabetes and hypertension are the primary causes of End Stage Renal Disease.

22. Why CKD prevention is important with diabetes & hypertension
More than 90% of Medicare patients with CKD also have diabetes, hypertension, or both
Approximately 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

23. When to get tested
Type 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 normal
Family history of kidney disease: every 3 years, as long as tests are normal
These testing intervals are recommendations; physician opinion may differ
*KDOQI Guideline 1
Ask your doctor if you have been tested
KDOQI(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

24. Help prevent or delay CKD
Control Blood Sugar - Goal of A1C < 6.5
Eat at about the same time every day
Eat a meal or snack every 3-4 hours and do not skip meals
Eat the same amount of carbohydrates in meals or snacks each day
Check blood sugar as instructed
Take your medicine and /or insulin as directed
Keep your doctor appointments; take your blood sugar record with you
Remember 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

25. Control blood pressure
Monitor your own blood pressure
Try to keep it at 125/70 or lower
Take medication as directed
Limit salt and sodium intake
High 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.

26. Watch your weight
Achieve 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

27. If you smoke
STOP
Smoking 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

28. Take an active role in your health care
Monitor your own blood pressure and blood sugar
Know what your levels should be
See your doctor regularly
Ask if you are on an ACE or an ARB for your BP
Ask if you had a urine test for protein
Know your eGFR
If you have CKD, know what stage
ACE and ARBs are classifications of Blood Pressure medications that have been associated with slowing the progression of Chronic Kidney Disease

29. CKD Stage 3 Limit protein and phosphorous intake
High protein levels increase the workload of the kidney
Limiting 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.

30. CKD Stage 4 or 5 Limit phosphorus intake in your diet
High levels of phosphorus can cause damage without any symptoms
Because 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

31. Foods high in phosphorus
Milk and dairy products
Cola drinks and Dr. Pepper
Chocolate
Nuts and butters
Pancakes, waffles and biscuits
Dried beans
Processed meats like hot dogs, sausage, bologna
Whole grain foods
Examples of milk and dairy products are Cheese, cottage cheese, ice cream, sherbet , etc

32. Take 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 disease
Go to your doctor and ask questions
Take your medications as instructed
Report any changes

33. It takes a team
YOU
Doctor
Nurses
Dietitian
Community
Family
Support groups
Working closely with your health care team can help you to retain control of your life and prevent long-term complications of Diabetes.

34. Now is the time to ask
Questions

35. Information Resources
National Kidney Foundation -
Missouri Kidney Program -
Heartland Kidney Network -
American Assoc. of Kidney Patients -
Renal Support Network -