As many of us are already painfully aware, diabetes affects everything in the body. But there are some areas that it affects more often than others, and for that reason we monitor a variety of things to make sure everything is working up to par. For people with diabetes, some of the biggest risks for complications include cardiovascular disease, kidney disease, retinopathy, and neuropathy.1
If you have diabetes or love someone with diabetes, none of this is news to you. And this article is not meant to increase your stress! We want to provide you with the knowledge that you need to protect yourself or your loved one from having to deal with complications from diabetes. Hopefully this will guide you in the prevention of reduced kidney function that can occur with diabetes.
Monitoring Urine Albumin Creatinine
Usually, every six to twelve months when you’re at your endocrinologist or diabetologist, you’re asked to provide a sample of your urine. What they’re screening for is extra protein, called albumin, spilling into the urine that can occur when the kidneys are not working properly. It used to be that they would measure microalbumin, which showed the level of small proteins spilled into the urine. This was a simple dipstick that was usually done in the doctor’s office, but the levels of small proteins could be higher depending on hydration status, and false positives occurred often.
Due to the rate of false positives that were confirmed by a 24-hour urine collection to be negative, the new standard is the Urine Albumin to Creatinine Ratio (UACR).1 I am personally really grateful for this one, because collecting a 24-hour urine involves you storing your urine in the fridge… Normal UACR is <30 mg/g, and if the level is higher than 30 mg/g, it’s recommended to confirm the accuracy over a three-to-six-month period. This is because the UACR can be higher due to exercise, infection, fever, menstruation, and other medical conditions.
Other Kidney Function Indicators
In addition to UACR, the estimated Glomerular Filtration Rate (eGFR) can provide insight into kidney function. This is something that is calculated based on the level of creatinine in the bloodstream, and a lower-than-normal GFR is associated with kidney and cardiovascular disease.2 This is typically measured annually with the yearly labs that your doctor orders. It’s also important to keep an eye on blood pressure.
Preventing or Slowing Kidney Disease
Maintaining blood sugars and blood pressure within the recommended targets are important to reduce the risk of kidney and cardiovascular diseases.1,2 If your kidney function labs start to look concerning, there are some medications that have been proven to help protect kidney function. Until the recent development of SLGT-2 inhibitors, the only medications that were found to be mildly protective against kidney disease progression were ACE Inhibitors and ARBs. But the SGLT-2’s have been proven to be more effective, and are likely now to be considered prior to ACEs or ARBs.
Medications for Prevention of Kidney Disease Progression:
- Angiotensin Converting Enzyme (ACE) Inhibitors – often the first line of treatment for blood pressure due to its protective kidney outcomes; can cause dry cough side effect and if that occurs, ARB’s are used; not as strong of protection for severe renal disease as SGLT-2.
- Angiotensin Receptor Blockers (ARBs) – often the first or second line of treatment for blood pressure due to its protective kidney outcomes; may be used first or to replace ACE due to side effects; not as strong of protection for severe renal disease as SGLT-2.
- SGLT-2 Inhibitors – lower blood pressure, lower glucose reabsorption in the kidneys, promotes weight loss, and slows GFR loss.1
- GLP-1 Agonists – have been shown to slow kidney damage, but ongoing studies are not complete.1
Chronic Kidney Disease
People with diabetes are at a higher risk for acute kidney injury, but this is transient and relatively easy to treat. If you end up with chronic kidney disease, there are other things that help protect your remaining kidney function including a proper diet low in sodium, low in protein, and sometimes low in potassium as well.1 These recommendations and treatments will vary and are dependent on the individual’s other conditions and medication use. Additionally, if you are on dialysis, there are different recommendations for medications, diet, and typically a reduction in insulin.3
Unfortunately, both end-stage kidney disease and dialysis make managing insulin-dependent diabetes more complicated to navigate. In February 2022, a literature review of insulin dose adjustments for initiating dialysis was published that helps outline the recommendations.4 The recommendations include reducing basal insulin by 25% on dialysis days and increasing insulin if dextrose-based dialysate is used. More research is needed in this area, and the authors suggest gaps in insulin dosing standards, administration techniques, and different product selection for people with diabetes with end-stage kidney disease.4
Knowledge is Power
At CWD, we believe in providing education, support, and inspiration for families and all people living with diabetes. CWD’s Founder, Jeff Hitchcock, often says that one of his guiding principles for diabetes management comes from one of the early leaders in diabetes care – Dr. Elliott Joslin – who famously said, “The diabetic who knows the most, lives the longest.” While this quote does not align with current beliefs in the use of the term “diabetic” vs. person with diabetes, it still rings true that in order to maintain health as a person with diabetes, you have to learn a lot about diabetes.
Even with my 32 years of personal experience with type 1 diabetes, my four-year nursing degree, and various training in professional roles as a clinical diabetes care and education specialist (CDCES), I am still learning new things about diabetes. Science is a continuous process, and even those who are incredibly knowledgeable about everything diabetes are still asking new questions and finding new answers that help make diabetes more manageable.
We need to keep asking questions and finding answers so that we can continue to make life easier for people with diabetes, enabling them to live a healthier, better quality of life for longer. Diabetes can be managed perfectly when you’re hooked up to IV insulin, continuous glucose monitors, and your meals and exercise are all controlled and repetitive. But that’s not a life that many would choose, and one I would not wish on anyone.
So keep an eye on your kidneys, your blood sugars, blood pressure, and all the other things we watch to stay healthy and keep your life as “normal” as it can be.
- American Diabetes Association Standards of Medical Care in Diabetes – 2022
- Monitoring Kidney Function and Albuminuria in Patients With Diabetes
- Updates on the Management of Diabetes in Dialysis Patients
- Systematic literature review of insulin dose adjustments when initiating hemodialysis or peritoneal dialysis
Written and clinically reviewed by Marissa Town, RN, BSN, CDCES