Kidney disease affects more than one third of people with diabetes and is the most common cause of renal failure on a global scale. People with diabetes can get kidney disease as result of poor control of glucose levels or other secondary causes like infections, autoimmune diseases, harmful medications etc. Preventing diabetic kidney disease needs a proactive approach with optimal management of lifestyle, medications to control the risk factors, and regular screening.
Lifestyle changes are key in control of the metabolic risk factors for the kidney disease. Portion control of carbohydrates with increasing the vegetables, and lean proteins is important for good glycemic control. Eliminate simple carbs and processed sugars. Salt restriction is necessary for control of hypertension. A physical activity schedule involving aerobic and resistance training with at least 150 minutes of moderate activity is necessary. Weight loss of even 5% can improve the insulin sensitivity and reduce the blood pressure.
Adequate hydration is important for renal health. People with diabetes are at a higher risk for urinary infections. It is important to screen and treat the urinary infections promptly as ascending infections often cause renal dysfunction. Especially people with additional risk factors like urinary stones, phimosis, and urethral strictures etc. need to be extra cautious. Medications such as NSAIDs, antifungals, and antibiotics which can potentially lead to renal injury should be used cautiously under medical supervision.
When choosing the medications in patients with diabetes, the risk for kidney disease needs to be considered. We have medications like SGLT2 inhibitors , and GLP1 receptor agonists which can reduce the progression of kidney damage independent of the glucose control they provide. For patients with early signs of renal damage like proteinuria, these medications can delay and potentially prevent the onset of kidney disease. In addition, we need to control the cholesterol levels to optimal targets for reduction of cardiovascular events in addition to renal protection. Medications used for control of blood pressure like ACE inhibitors and ARBs also reduce the proteinuria and help in prevention of progression of the kidney disease. We have a new class of medications called non-steroidal MR blockers e.g. Finerenone which also reduce the proteinuria and prevent kidney disease progression.
With the help of lifestyle measures and appropriate medications, we should target optimal glucose levels with Hba1c <7% for most adults and to keep the blood pressure < 130/80 mm Hg.
Regular screening for kidney disease helps in early detection. Annual screening for proteinuria (using urine albumin to creatinine ratio) and estimated glomerular filtration rate (calculated based on serum creatinine level) is imperative for people with type 2 diabetes. Timing of the intervention plays an important role in prevention of kidney damage. Educating the patients about complication screening during clinic visits for diabetes helps a lot.
At a community level educating the public with collaboration of dieticians, primary care physicians, endocrinologists, and nephrologists is imperative in spreading the awareness. Promoting widespread access to screening tests boosts efforts in early diagnosis and prevention. We need to think of primordial prevention. Identifying the people with metabolic risk factors, and preventing diabetes, and hypertension through lifestyle measures will have a greater impact than interventions at a later stage.
To summarize, prevention diabetic kidney disease revolves around improvement of lifestyle, optimization of the metabolic risk factors through medications, and regular screening to diagnosed the kidney disease in a very early stage. With early diagnosis and optimal management, we can preserve the renal health and improve the quality of life for people with diabetes.
Dr. Varun Suryadevara, Endocrinologist, MBBS MD Internal Medicine DM Endocrinology, Apollo Hospitals, Bangalore
