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  Diabetic Nephropathy
  
  Topic Overview
  
  What is diabetic nephropathy?
  
  Nephropathy means
  kidney disease or damage. Diabetic nephropathy is damage to your kidneys caused
  by
  diabetes. In severe cases it can lead to kidney
  failure. But not everyone with diabetes has kidney damage.
  
  What causes diabetic nephropathy?
  
  The kidneys have
  many tiny blood vessels that filter waste from your blood. High blood sugar
  from diabetes can destroy these blood vessels. Over time, the kidney isn't able
  to do its job as well. Later it may stop working completely. This is called
  kidney failure.
  
  Certain things make you more likely to get diabetic nephropathy. If you
  also have
  high blood pressure or high cholesterol, or if you smoke, your risk is
  higher. Also, Native Americans, African Americans, and Hispanics (especially
  Mexican Americans) have a higher risk.
  
  What are the symptoms?
  
  There are no symptoms in
  the early stages. So it's important to have regular urine tests to find kidney
  damage early. Sometimes early kidney damage can be reversed.
  
  As your kidneys are less
  able to do their job, you may notice swelling in your body, most often in your
  feet and legs.
  
  How is diabetic nephropathy diagnosed?
  
  The problem
  is diagnosed using simple tests that check for a protein called
  albumin in the urine. Urine doesn't usually contain
  protein. But in the early stages of kidney damage—before you have any
  symptoms—some protein may be found in your urine, because your kidneys aren't
  able to filter it out the way they should.
  
  Finding kidney damage
  early can keep it from getting worse. So it's important for people with
  diabetes to have regular testing, usually every year.
  
  How is it treated?
  
  The main treatment is medicine
  to lower your blood pressure and prevent or slow the damage to your kidneys.
  These medicines include:
  
  Angiotensin-converting enzyme inhibitors,
  also called ACE inhibitors.
  
  Angiotensin II receptor blockers, also
  called ARBs.
  
  As damage to the kidneys gets worse,
  your blood pressure rises. Your
  cholesterol and
  triglyceride levels rise too. You may need to take more than one medicine to treat these complications.
  
  And there are other steps
  you can take. For example:
  
  Keep your blood sugar levels within your target range. This can help slow the damage to the small blood vessels in the kidneys.
  
  Work with your doctor to keep your blood
  pressure under control. Your doctor will give you a goal for your blood pressure. Your goal will be based on your health and your age. An
  example of a goal is to keep your blood pressure below 140/90.
  
  Keep your heart healthy by eating healthy foods and exercising regularly. Preventing heart disease is important, because
  people with diabetes are more likely to have heart and blood
  vessel diseases. And people with kidney disease are at an even higher risk for
  heart disease.
  
  Watch how much protein you eat. Eating too much is
  hard on your kidneys. If diabetes has affected your kidneys, limiting how much
  protein you eat may help you preserve kidney function. Talk to your doctor or
  dietitian about how much protein is best for you.
  
  Watch how much salt you eat. Eating less salt helps keep high
  blood pressure from getting worse.
  
  Don't smoke or use other
  tobacco products.
  
  How can diabetic nephropathy be prevented?
  
  The
  best way to prevent kidney damage is to keep your blood sugar in your target range and your blood pressure under control. You do this by eating healthy foods, staying at a healthy weight, exercising regularly, and
  taking your medicines as directed.
  
  At the first sign of protein in
  your urine, you can take high blood pressure medicines to keep kidney damage
  from getting worse.
  
  Symptoms
  
  There are no symptoms in the early stages of
  diabetic nephropathy. If you have kidney damage, you may have small amounts of protein leaking into your urine (albuminuria).
  Normally, protein is not found in urine except during periods of high fever,
  strenuous exercise, pregnancy, or infection.
  
  Not everyone with diabetes will develop diabetic nephropathy. In people with
  type 1 diabetes, diabetic nephropathy is more likely to develop
  5 to 10 years or more after the onset of diabetes. People with
  type 2 diabetes may find out that they already have a
  small amount of protein in the urine at the time diabetes is
  diagnosed, because they may have had diabetes for several years.
  
  As diabetic nephropathy progresses, your kidneys cannot do their job as well.
  They cannot clear toxins or drugs from your body as well. And they cannot balance the chemicals in your blood very well. You may:
  
  You may have symptoms if your nephropathy gets worse. These
  symptoms include:
  
  Swelling (edema), first in the feet and legs and later throughout
  your body.
  
  Poor appetite.
  
  Weight
  loss.
  
  Weakness.
  
  Feeling tired or worn
  out.
  
  Nausea or vomiting.
  
  Trouble sleeping.
  
  If the kidneys are severely damaged, blood sugar levels may drop because
  the kidneys cannot remove excess
  insulin or filter oral medicines that increase insulin
  production.
  
  Exams and Tests
  
  Diabetic nephropathy is diagnosed using tests that check for a protein (albumin)
  in the urine, which points to kidney damage. Your urine will be
  checked for protein (urinalysis) when you are diagnosed with
  diabetes.
  
  An albumin urine test can detect
  very small amounts of protein in the urine that cannot be detected by a routine
  urine test, allowing early detection of nephropathy. Early detection is
  important, to prevent further damage to the kidneys. The results of two tests,
  done within a 3- to 6-month period, are needed to diagnose nephropathy.
  
  When to begin checking for protein in the urine depends on the type of
  diabetes you have. After testing begins, it should be done every year.footnote 1
  
  Albumin testing
  
  Type of diabetes
  
  When to begin yearly
  testing
  
  Type 1 diabetes
  
  After you have had diabetes for
  5 years
  
  Type 2 diabetes
  
  When you are diagnosed with
  diabetes
  
  Diabetes present during
  childhood
  
  After age 10 and after the child has had diabetes for 5 years
  
  An albuminuria dipstick test is a simple test that can
  detect small amounts of protein in the urine. The strip changes color if protein is present, providing an
  estimate of the amount of protein. A spot urine test for albuminuria is a
  more precise lab test that can measure the exact amount of protein in a
  urine sample. Either of these tests may be used to test your urine for protein.
  
  You will also have a
  creatinine test done every year. The creatinine test
  is a blood test that shows how well your kidneys are working.
  
  If
  your doctor suspects that the protein in your urine may be caused by a disease
  other than diabetes, other blood and urine tests may be done. You may have a
  small sample of kidney tissue removed and examined (kidney biopsy).
  
  Other tests
  
  It is important to check your blood
  pressure regularly, both at home and in your doctor's office, because blood
  pressure rises as kidney damage progresses. Keeping your blood pressure at or
  below your target can prevent or slow kidney damage.
  
  Your doctor might suggest a cholesterol and triglyceride test based on your age or your risk for heart disease. Talk to your doctor about when a cholesterol test is right for you.
  
  Treatment Overview
  
  Diabetic nephropathy is treated with medicines that lower blood pressure and
  protect the kidneys. These medicines may slow down kidney damage and are started
  as soon as any amount of protein is found in the urine. The
  use of these medicines before nephropathy occurs may also help prevent
  nephropathy in people who have normal blood pressure.
  
  If you have
  high blood pressure, two or more medicines may be
  needed to lower your blood pressure enough to protect the kidneys. Medicines
  are added one at a time as needed.
  
  It is also important to keep your blood sugar within your target range. Maintaining blood sugar levels within your target range prevents
  damage to the small blood vessels in the kidneys.
  
  Limiting the
  amount of salt in your diet can help keep your high blood pressure from
  getting worse. You may also want to restrict the amount of protein in your
  diet. If diabetes has affected your kidneys, limiting how much protein you eat
  may help you preserve kidney function. Talk to your doctor or
  dietitian about how much protein is best for you.
  
  Initial treatment
  
  Medicines that are used to treat
  diabetic nephropathy are also used to control blood
  pressure. If you have a very small amount of protein in your urine, these
  medicines may reverse the kidney damage. Medicines used for initial treatment
  of diabetic nephropathy include:
  
  Angiotensin-converting enzyme (ACE) inhibitors, such
  as captopril, enalapril, lisinopril, and ramipril. ACE
  inhibitors can lower the amount of protein being lost in the urine. Also, they
  may reduce your risk of heart and blood vessel (cardiovascular) disease.
  
  If you also have high blood pressure, two or more
  medicines may be needed to lower your blood pressure enough to protect your
  kidneys. Medicines are added one at a time as needed.
  
  If you take other
  medicines, avoid ones that damage or stress the kidneys, especially
  nonsteroidal anti-inflammatory drugs (NSAIDs).
  
  It is also important to keep your blood sugar within your target range to prevent damage to the small blood vessels in the kidneys.
  
  Ongoing treatment
  
  As
  diabetic nephropathy progresses, blood pressure
  usually rises, making it necessary to add more medicine to control blood
  pressure.
  
  Your doctor
  may advise you to take the following medicines that lower blood pressure. You
  may need to take different combinations of these medicines to best control your
  blood pressure. By lowering your blood pressure, you may reduce your risk of
  kidney damage. Medicines include:
  
  Calcium channel blockers, which lower blood pressure by
  making it easier for blood to flow through the vessels. Examples include
  amlodipine, diltiazem, or verapamil.
  
  Diuretics. Medicines such as
  chlorthalidone, hydrochlorothiazide, or spironolactone help lower blood
  pressure by removing sodium and water from the body.
  
  Beta-blockers lower blood pressure by slowing down
  your heartbeat and reducing the amount of blood pumped with each heartbeat.
  Examples include atenolol, carvedilol, or metoprolol.
  
  Continue to avoid other medicines that may damage
  or stress the kidneys, especially
  nonsteroidal anti-inflammatory drugs (NSAIDs). And it is still important to keep your blood sugar within your target range, eat healthy foods, get regular exercise, and not smoke.
  
  Treatment if the condition gets worse
  
  If damage to
  the blood vessels in the kidneys continues,
  kidney failure may eventually develop. When that occurs,
  it is likely that you will need
  dialysis treatment (renal replacement therapy)—an
  artificial method of filtering the blood—or a kidney transplant to survive. To
  learn more, see the topic
  Chronic Kidney Disease.
  
  What to think about
  
  Diabetic nephropathy can
  get worse during pregnancy and can affect the growth
  and development of the fetus. If your nephropathy is not severe, your kidney
  function may return to its prepregnancy level after the baby is born. If you
  have severe nephropathy, pregnancy may lead to permanent worsening of your
  kidney function.
  
  If you have
  nephropathy and are pregnant or are planning to become pregnant, talk with your
  doctor about which medicines you can take. You may not be able to take some
  medicines (for example, angiotensin-converting enzyme [ACE] inhibitors or angiotensin II receptor blockers [ARBs]) during pregnancy, because they
  may harm your developing baby.
  
  Avoiding X-ray tests that require IV
  contrast material, such as angiograms, intravenous
  pyelography (IVP), and some CT scans. IV contrast can cause further kidney
  damage. If you do need to have these types of tests, make sure your doctor
  knows that you have diabetic nephropathy.
  
  Avoiding situations where
  you risk losing large amounts of blood, such as unnecessary surgeries. Do not
  donate blood or plasma.
  
  Lowering your blood pressure, because high
  blood pressure can make kidney damage even worse.
  
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