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Preventing Kidney Failure in the diabetic patient - for the predialysis patient Dr Stephen Chew Tec Huan Consultant Nephrolgist and Physician Singapore

26TH October 2001

PATIENT INFORMATION SHEET ON DIABETIC KIDNEY DISEASE

Diabetes can affect the kidneys in up to 40% of diabetic patients. Not every patient with diabetes will get kidney disease. Diabetes is more likely to affect the kidneys in the older diabetic patient, in male diabetics or in those with longer duration of diabetes. Furthermore, patients who have diabetes are more likely to have kidney disease if they had a family member with diabetic kidney disease as well. These factors (the age, gender, duration of diabetes and family history of diabetic kidney disease) however, are things that patients cannot change. The situation however is not far from hopeless. There are specific things that a patient can do to prevent kidney disease in the first place, or at least control to prevent the kidney from getting worse in the first place.

1. The first priority is to control the glucose level. Poor glucose control is the first thing that causes a patient to develop diabetic kidney disease, and importantly, good glucose control conversely prevents to a large extent the development of kidney disease in the first place. The patient can take control as much as possible by monitoring the glucose level at home, and he should bring this information with him at the clinic visit so that treatment can be adjusted appropriately. Single glucose readings at a clinic are not as good as multiple measures of the glucose by the patient himself at home. Many measures give a better overall feel of just how well the control of the glucose is. Single readings at a clinic may either be misinterpreted as poor control, which can lead the physician to increase medication leading to potential overtreatment, or good control, which may lead to potential under-treatment of the disease. There must be appropriate changes in the diet, and patients should understand at least from a dietician of the kinds of foods that they should take and those they avoid. It is important for patients to understand that it is really in the early phases of the disease that tight glucose control is critical for the prevention of developing kidney disease in the first place. Once kidney disease sets in, the importance of glucose control in preventing further kidney damage is progressively less important.

2. Patients must control the blood pressure. High blood pressure is very common in diabetics. The kidneys in diabetics are very sensitive to high blood pressure. High blood pressure can cause kidney damage particularly in the diabetic, and furthermore, can cause the damage to progress even faster. It is essential to control the blood pressure. Unfortunately, most patients will not even know that they have high blood pressure. High blood pressure is usually asymptomatic. The only way to detect it is to actually measure it. Controlling blood pressure in the diabetic is usually quite difficult, and this may require a patient to take up to 4 to 5 types of medication just to be able to reach reasonable blood pressure levels. Patients can also help themselves in very specific ways. The first is to measure their own blood pressure at home, just like they would measure their own glucose level at home. They should bring these measures of the blood pressure to their clinic nurse or doctor who can appropriately adjust treatment. They need to avoid excess salt intake in their diets, as high salt diets aggravates high blood pressure.

3. Special drugs that protect the kidneys are available for patients who have developed diabetic kidney disease. Whether or not these are suitable for you as an individual patient is best discussed with the physician attending to you.

4. If you are not smoking then good for you. If you are, then it's best to quit. Smoking causes many problems. It is well known that it is a cause of heart attacks and strokes and lung cancer. Heart disease is already very common in the diabetic patient, and smoking compounds these problems. In addition however, smoking itself can aggravate kidney disease. Smokers please quit!

Patients therefore must take control of their disease. Kidney disease must be attacked from many fronts and not just one way. To summarize 1. Aim for good glucose control; watch the diet and monitor the glucose levels at home 2. Treat the blood pressure aggressively, and monitor the blood pressure levels at home as well 3. Special drugs are available 4. Avoid smoking, or quit if you are.