Diabetes and CKD What is the Connection?

Publication MO-09-11-CKD

This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy

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

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

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

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

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

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

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

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

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

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

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

Detecting CKD

Detect CKD with 2 simple tests: – Urine test for detecting proteinuria – Blood test for estimating glomerular filtration rate (eGFR)

Stages of Chronic Kidney Disease

Stage 1 2 3 4 5 Description GFR* mL/min/1.73m

2 Slight kidney damage with normal or increased filtration More than 90 Mild decrease in kidney function Moderate decrease in kidney function Severe decrease in kidney function Kidney failure requiring dialysis or transplantation 60-89 30-59 15-29 Less than 15 *GFR is glomerular filtration rate, a measurement of the kidney's function.

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

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

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

CKD risk factors continued

Exposure to Nephrotoxic drugs – Contrast Dye – NSAIDS – Ibuprofen – Advil – Motrin – Naproxen

USRDS 2004

USRDS 2004

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

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

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

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

Watch your weight

Achieve and maintain desirable body weight (target BMI to normal range of 18.5-24.9 kg/m2)

If you smoke

STOP

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

CKD Stage 3

Limit protein and phosphorous intake – High protein levels increase the workload of the kidney

CKD Stage 4 or 5

Limit phosphorus intake in your diet – High levels of phosphorus can cause damage without any symptoms

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

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

It takes a team

Doctor Support groups YOU Family Community Nurses Dietitian

Now is the time to ask

Questions

Information Resources

National Kidney Foundation - www.kidney.org

Missouri Kidney Program - http://som.missouri.edu/mokp Heartland Kidney Network - www.network12.org

American Assoc. of Kidney Patients - www.aakp.org

Renal Support Network - www.ikidney.com