Look, listen and learn online - view How diabetes occurs (Virtual Medical Centre) or visit The Diabetes Channel (excellent education videos). Audio fact sheets available via Australian Diabetes Council.

View our Facts Sheets *Chronic Kidney Disease *Kidney Health and Blood Pressure *Proteinuria *Your heart and CKD

Kidney Health Australia works closely with Diabetes Australia and the Australian Diabetes Council, to collaborate and to educate, that diabetes is a major cause of kidney failure. This condition is known as Diabetic Kidney Disease or Diabetic Nephropathy.

What are the signs of Diabetic Kidney Disease?
It is very important that any kidney disease is detected early. Appropriate treatment in the early stages of kidney disease can help to increase the life of your kidneys. Early signs of reduced kidney function can be:

• High blood pressure
• Changes in the amount and number of times urine is passed e.g. at night
• Changes to the appearance of urine
• Blood in the urine
• Puffiness e.g. legs and ankles
• Pain in the kidney area
• Tiredness and difficulty sleeping
• Loss of appetite
• Headaches
• Lack of concentration
• Difficulty sleeping
• Itching
• Shortness of breath
• Nausea and vomiting
• Less need for insulin or pills for your diabetes (but not in the early stages of kidney disease)

Diabetic Kidney Disease worsens diabetic complications such as nerve and eye damage, as well as increasing the risk of cardiovascular (heart) problems. Diabetic nephropathy damages blood vessels including those in your kidney filters and if severe, can lead to kidney failure. Signs that you and your doctor will monitor, in particular for diabetic kidney disease are:

• Increasing amounts of albumin (or protein) in urine  A slightly raised level of the protein ‘albumin’ in the urine (albuminuria) is an early warning sign. As the filters thicken, larger amounts of albumin and other proteins are lost (proteinuria). Proteinuria can lead to problems with the body’s fluid balance and result in swelling (oedema), often in the legs, feet, face and hands.
  
• Increased urine protein  Associated with damage to other parts of the kidney causing scarring and reduced kidney function. This damage is similar for Type 1 and Type 2 diabetes and can only be seen under a high-powered microscope so your doctor may speak to you about having a kidney biopsy.
  
• Rising blood pressure  Slowly increasing protein is usually linked with a rise in blood pressure. This rise is small at first and may only be detected by taking blood pressure over 24-hours. Even small rises in blood pressure need to be treated, as uncontrolled high blood pressure increases the risk of kidney damage.
  
• Declining kidney function  The kidney filtration rate does not usually begin to fall until diabetic kidney disease is well established. Once filtration is reduced, it tends to fall at a steady rate unless the right treatment is given in which case the kidney damage will stabilise until diabetic kidney disease is well established. Maintaining normal blood glucose levels is important in helping reduce kidney problems in people with diabetes.

What are the complications of diabetic kidney disease?
If you have diabetic kidney disease, the other complications of diabetes can be made worse, including:-

Cardiovascular disease  Cardiovascular or heart disease includes all diseases and conditions of the heart and blood vessels, such as arteries and veins. The most common diseases and conditions include heart attack, heart failure, stroke and blockages in the blood vessels. The risk of cardiovascular disease is much higher in people with chronic kidney disease, particularly if they have diabetes.

Retinopathy  This is a complication causing blindness or visual impairment. There is an increased risk of retinopathy for people with Type 1 diabetes and diabetic kidney disease. This risk is not yet well understood for Type 2 diabetes. Some ethnic backgrounds may put people with diabetic kidney disease at greater risk of retinopathy.

Neuropathy  People with diabetes may be at more risk of damage to their nerve fibres (neuropathy). This can cause weakness in the arms and legs or problems in organs, e.g. digestive tract, heart and sexual organs.

Diabetes also affects your kidneys in other ways
Changes to the immune system that occur in diabetes make a person more vulnerable to kidney and Urinary Tract Infections (UTIs). Nerve damage can also affect your bladder making it more difficult to pass urine. Urine build up in the bladder can create a back flow into your kidneys resulting in scarring.

If you have diabetes, your chance of kidney damage greatly increases if you smoke and/or have high blood pressure, high cholesterol or proteinuria. It is also affected by:

• Family history and genetic factors  Some studies suggest that if there is a family history of high blood pressure or cardiovascular disease, your risk of diabetic nephropathy increases. Currently the genes for diabetic nephropathy have not been identified, but if your parent(s) have this condition, then you are more likely to have it.
• Hyperglycaemia  Also known as high blood sugar is a strong risk factor for developing diabetic nephropathy. It damages the small blood vessels in the kidneys, particularly to the capillaries in the kidney filters. Control of blood sugar levels may slow down the development of diabetic nephropathy. If you have diabetic nephropathy, regular monitoring of your blood sugar levels is very important. You may need adjustments to your diabetic medication as insulin is excreted via the kidneys. Good control of blood sugar levels and blood pressure can reduce, or in some cases, prevent further kidney damage.

Diabetic kidney disease can be grouped into 4 ‘stages’
These four groupings are only a guide as there can be individual variations. It is common for people with diabetes to have a small amount of kidney damage but most people do not progress to kidney failure. Treatment for kidney failure includes medication and dietary changes as well as dialysis or transplantation.

The clinical features and pathway followed in Type 2 diabetes with kidney involvement, is similar to that of of Type 1 diabetes. Type 2 is most common if you are over the age of forty, particularly if you are overweight, as it is strongly linked to obesity and lack of physical activity.

Stage of kidney function	Approx time after diagnosis	Function
Normal function	0 – 15 years	Normal
Early Kidney Disease	5 – 15 years	Albumin present in urine Small rise in blood pressure Normal or close to normal kidney function
Proteinuria	10 – 20 years	High levels of urine protein High blood pressure Reduced kidney function
End Stage Kidney Disease	15 – 30 years	Very high urine protein Very high blood pressure Kidney failure

Which factors increase the risk of diabetic kidney disease?
About one third of all people with diabetes develop Diabetic Kidney Disease, which may affect your kidney function by causing:

Damage to blood vessels  Even with the use of injected insulin, diabetes can cause damage to the small blood vessels in the body. The tiny blood vessels in the filters of the kidney (the glomeruli) may also be affected. In the early stage, this damage causes small amounts of protein in the urine. At a later stage, so much protein can be lost from the blood that water moves into the body tissues and causes swelling. After a number of years, the kidney filters can fail completely.

Damage to nerves Diabetes can also damage the nerves in many parts of the body. When the bladder is affected, it may be difficult to pass urine. If urine builds up in the bladder, the pressure can make it to flow back into the kidneys causing scarring and kidney damage.

Some of the factors increasing the risk of diabetic kidney disease cannot be changed, including:

Duration of diabetes  Early signs of Chronic Kidney Disease in people with diabetes is less than 10% in the first ten years and rises to between 20–30% over the next ten years. If diabetes is diagnosed late, urine protein may be present.

Family history and genetic factors  The genes for diabetic kidney disease have not been identified. However some studies suggest that for people with diabetes, a family history of high blood pressure or heart disease can increase the risk of diabetic kidney disease.

Age  A natural, slow decline is the kidneys’ ability to filter blood occurs as you get older. During adulthood, approximately 8% of kidney function appears to be lost with each decade of life.

Aboriginal and Torres Strait Islander heritage  Diabetes is more common in people of Aboriginal or Torres Strait Island descent.

Good news - you can lower the risk of Diabetic Kidney Disease The risk of Type 2 diabetes can be reduced by up to 60% by adopting a healthy and active lifestyle, especially losing weight. Some of the risk factors for developing diabetic kidney disease relate everyday choices. There are lots of things you can do to lower your risk of diabetic nephropathy. This may mean using medication as well as making healthy lifestyle choices.

Take control of your own health - your health care team will give you advice about how YOU can take positive steps to avoid this diagnosis. If you have diabetes, you should have a blood test for kidney function and have your urine checked for microalbuminuria at least once a year. Some other important actions are:

• ensure your insulin levels and diabetic control is excellent
• be aware of and maintain good blood pressure control
• be a non-smoker QUIT 13 78 48 ask for free Quit Pack
• treat urine infections (UTIs) immediately
• Eat low GI carbohydrates choose the right foods - consult your doctor or dietitian about a suitable diet

  to maintain a healthy weight and maintain healthy cholesterol levels
• drink alcohol in moderation
• maintain a positive 'stay well' attitude, do things to relax and reduce stress in your daily life

Key points on why it is important to do these things, to avoid kidney failure!

Control your blood sugar levels  Hyperglycaemia or high blood sugar is a strong risk factor for kidney damage. It affects the small blood vessels in the kidneys, particularly those in the kidney filters. Controlling blood sugar levels can slow down the development of diabetic kidney disease.

Maintain healthy blood pressure  Diabetes causes high blood pressure. High blood pressure can cause kidney damage and kidney damage can cause higher blood pressure. High blood pressure can also lead to heart attacks, strokes and loss of vision if left untreated. You may have high blood pressure and feel perfectly well. In recent years, the use of an angiotensin converting enzyme (ACE) inhibitor and an angiotensin receptor blocker (ARB) has proven effective treatment for high blood pressure. These drugs lower blood pressure by widening the arteries. They also help to protect kidney function.

Control proteinuria  Any treatment that lowers levels of protein in the urine can help to reduce the rate of progression to kidney failure. Two important drugs used to treat proteinuria are angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB). These drugs should be used even if blood pressure is in the desired range. Reduction in salt intake to ‘low normal’ can also help to reduce proteinuria.

Make regular moderate physical activity a habit  Keep fit, as it makes your insulin work better, lowers blood glucose levels, controls blood fats (cholesterol and triglycerides), can lower blood pressure and body weight, increases bone strength and increases a general sense of well-being.

Control cholesterol levels  Some studies have shown that high cholesterol can increase the progression of diabetic kidney disease. It is important to control your blood cholesterol and triglyceride levels with diet and medication if necessary. Cholesterol is a type of fat or lipid. There are two types of cholesterol – low-density lipoprotein (LDL) or ‘bad’ cholesterol and high-density lipoprotein (HDL) or ‘good’ cholesterol. *Triglycerides are a form of stored body fat.

People with diabetes generally have similar total cholesterol levels and similar rates of the 'good' (HDL) cholesterol as the general population. However, people with diabetes have higher levels of 'bad' (LDL) cholesterol and higher levels of *triglycerides, than people without diabetes. This is because diabetes can upset the balance between 'good' (HDL) and 'bad' (LDL) cholesterol levels.

*Cholesterol and triglycerides. Triglyceride is a type of fat found in the blood. It is the main constituent of vegetable oil and human and animal fats. People with diabetes usually have higher than normal levels of triglycerides as increased glucose in the blood makes it harder for the body to absorb fat from the bloodstream.

Apart from increasing your daily exercise and aerobic activities to reduce weight, practical ways to reduce your bad cholesterol and lower triglyceride levels (and help keep blood glucose levels low) are to:

• choose only reduced fat or low fat milk, cheese, yoghurt, ice-cream and custard
• choose only lean meat and chicken and trim/remove any fat before cooking
• eat more oat based cereals and wholegrain breads rather than white refined flour or wheat products
• choose tomato and soy based sauces - rather than creamy sauces or soups
• at every meal include fresh or frozen vegetables and some fruits - low GI varieties are best
• avoid - any high sugar snacks, especially if they are also high in fat
• in particular avoid butter, creams, copha, coconut milk or cream, hard cooking margarines, pastries, cakes, chocolate, biscuits, savoury packet snacks, processed deli meats and take away foods
• minimise salt use in cooking, consider 'low salt' or 'no added salt' products
• drink water instead of high sugar drinks of any kind

See our pages on Measure up with CKD for other tips on improving your health and fitness.