Diabetic Nephropathy

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1 University Hospitals of Leicester NHS Trust Leicester General Hospital a patients guide Renal Services & Urology Directorate Diabetic Nephropathy 3/05/JP

2 Questions regularly asked by Patients What do Kidneys do? They filter the blood to make urine which allows the body to get rid of excess water, waste products and some salts. They help to control blood pressure. They stimulate the bone marrow to make red blood cells and prevent anaemia. They help bones hold on to calcium by activating vitamin D. What is Diabetic Nephropathy? This is damage to both kidneys caused by diabetes. It can occur in patients whose diabetes is treated with diet, tablets or insulin. It does not usually occur until a person has had diabetes for about 10 years, but, since some people can have had diabetes for a long time without knowing, it can appear much sooner after diagnosis.

3 Do all Diabetic Patients get Nephropathy? No Overall about one in four people with diabetes will get diabetic nephropathy. Some people are more likely to be affected than others. It tends to run in families - especially in those with a family history of high blood pressure. What makes you think I have Diabetic Nephropathy? The usual reason is that protein has been found in your urine when a sample was tested in the diabetic clinic. Tests are now used to identify very small amounts of protein in the urine (microalbuminuria) the earliest stage of the condition. Sometimes the blood tests that have been done in the diabetic clinic have shown that the kidneys are not working as they should. Although this could be due to diabetic nephropathy, it can also mean that the kidneys have been damaged by something else e.g. infection, kidney stones etc. Further tests are usually suggested in order to help the doctor to make the correct diagnosis before starting treatment.

4 Questions regularly asked by Patients What will happen to my Kidneys? Without treatment diabetic nephropathy tends to get worse but the rate at which it does so varies from person to person. First the kidneys leak more protein into the urine which may cause swelling (oedema), initially of the ankles. As this happens the blood pressure rises. This is a bad thing because high blood pressure can by itself damage the kidneys. It also increases the risk of other diabetic complications e.g. diabetic eye damage (retinopathy), and stroke and heart attack. Eventually the kidneys may become so damaged that they are unable to do their job properly (see first section). This is called renal failure. There is a build-up of waste products in the blood which can cause people to feel unwell with nausea (sickness) and itching. They may become anaemic which can cause tiredness. As more fluid builds up it can get into the lungs causing breathlessness. Bone pain may occur as calcium is lost from the bones. People often notice that their diabetic control changes - sometimes becoming easier to manage, but often with more frequent hypoglycaemia (low blood sugar reactions). The diabetic treatment often has to be changed. Metformin (Glucophage) tablets must not be given to people in renal failure, so different treatment may be prescribed. The dose of other tablets or insulin may need to be reduced. The kidneys can become severely damaged by this disease and people with diabetic nephropathy may eventually need dialysis or a kidney transplant.

5 What treatment can you offer and does it work? Treatment is available at all stages of diabetic nephropathy, but in general the earlier it is started, the more effective it is. For Early Diabetic Nephropathy (Microalbuminuria) There is now no doubt that treatment at this stage in people with insulin dependent diabetes, with tablets called ACE inhibitors reduces the amount of protein leaking into the urine and at least slows down the rate at which the kidneys fail. Although these tablets may be used to treat high blood pressure, they seem to work even when the blood pressure is normal. It is less clear whether ACE inhibitors have such a good effect in people whose diabetes has not always been treated with insulin (type 2 diabetes), but we would use them if the blood pressure were even only slightly raised.

6 Questions regularly asked by Patients General Treatment for people with Diabetic Nephropathy 1 Treatment of high blood pressure 2 Control of diabetes 3 Correct other factors which increase the risk of a heart attack 4 Prevent other diabetic complications 1 Blood Pressure As we have explained, even slightly high blood pressure can make diabetic kidney damage worse, so we try to get blood pressure into the normal range and keep it there. Not only should this protect the kidneys, but it should also reduce the risk of stroke and heart attack. Treatment with ACE Inhibitors or AT II blockers, (see table back page), are particularly beneficial in people with diabetes as they lower the blood pressure and lower the protein in the urine which helps the kidneys. However, often people need several blood pressure tablets, therefore these tablets may not be suitable for you.

7 How do you treat high blood pressure in diabetic nephropathy? If you are overweight, try to lose some weight Cut down on salt in your diet. This has been shown to lower blood pressure in diabetic patients. Don t add salt to your food at the table and try to cook without adding salt. DO NOT USE SALT SUBSTITUTES (e.g. Lo Salt). They contain potassium which can be dangerous. Don t drink too much alcohol. Do not drink more than 20 units a week (one unit is about half a pint of beer or one glass of wine). Stop smoking. If you have high blood pressure you are more at risk of heart attacks and strokes and this risk will be reduced by stopping smoking. Remember only you can stop smoking! Take regular physical exercise. Treatment with tablets. In the later stages of diabetic nephropathy almost all patients will be offered treatment with one or more tablets to try to keep their blood pressure under control. It is often necessary to use several different tablets together to do this. We know that each tablet can cause side-effects and so when several tablets are taken together the chances of noticing a sideeffect are increased. The table (at the back of this booklet) shows the main groups of tablets used for the treatment of high blood pressure. It lists the uses, those people who should not normally take them, and the commonest sideeffects. If you have any worries about your treatment you should mention this to a member of the clinic team.

8 Questions regularly asked by Patients 2 Control of Diabetes Remember that improving diabetic control will probably help to prevent further kidney damage. It will also help to prevent other diabetic complications e.g. diabetic eye damage and damage to the nerves which can lead to foot ulcers. Good blood glucose control is very important in the preventing narrowing of large arteries (blood vessels), which causes heart attacks strokes and gangrene of the legs. Members of the diabetes team are available to help you to improve your control. 3 Correct other risk factors for narrowing of large arteries As we have mentioned, people with diabetes are at increased risk of narrowing of large blood vessels. This may lead to angina, strokes or problems with blood supply to the legs. Besides good control of blood pressure and diabetes, it is important to stop smoking if you smoke and to have the blood fat (cholesterol) level checked regularly. If the cholesterol level is above target, and you are already eating a low fat diet, we may recommend a tablet treatment to lower the blood cholesterol level.

9 4 Detect and Treat any other Diabetic Complications People who have diabetic nephropathy often have some diabetic eye damage (retinopathy) and damage to the nerves (neuropathy) as well. It is very important that you are seen regularly in the clinics for examination of your eyes and feet. You should inspect your own feet regularly and report any ulcers or blisters immediately. Your shoes should fit properly. Members of the Diabetes team will be happy to advise you.

10 Questions regularly asked by Patients Who will be looking after me? The Team Approach to Managing Diabetic Nephropathy From what you have read you will see that there are lots of things to deal with when you come to clinic. That is why you may be asked to see several different people during the same visit, all of whom are experts in their particular area. The Team Doctors Consultant Nephrologist (Kidney Specialist) Consultant Diabetologist (Diabetes Specialist) Doctors training to become specialists Nurses Renal Specialist Nurses Diabetes Specialist Nurses Clinic Nurses Dietitians Renal Specialist Dietitian Diabetes Specialist Dietitian Retinal Photographers Take photographs of your eyes Podiatrists Treat diabetic foot problems Orthotists Assess you for and provide special shoes if necessary Phlebotomists Take blood samples W E A R E H E R E T O H E L P Y O U

11 Drugs Used for High Blood Pressure Tablet Recommended Not used Possible Type in in Side Effects ACE inhibitors Diabetes mellitus Pregnant women Cough (e.g. ramipril, High potassium lisinopril) levels AT II blockers Diabetes or Pregnant women High potassium (e.g. losartan) heart problems levels Calcium Angina Ankle swelling antagonists Flushing (e.g. amlodipine, Constipation nifedipine) Alpha blockers Prostate problems Sleepiness (e.g. doxazosin) Dry mouth Dizziness on standing Beta blockers Angina Asthma Cold fingers (e.g. atenolol, /toes bisoprolol) Vivid dreams Tiredness Impotence Centrally acting agents (e.g. moxondine) Diuretics Older people Gout (e.g. frusemide, Work well with bendrofluazide) ACE inhibitors

12 Contact Numbers Comments or Questions If you have any comment or questions, please speak to us at the clinic, whilst attending for dialysis or ask your nurse. You may find it helpful to note any comment or questions below: Leicester Kidney Patient Association (LKPA) Phone: Renal Secretary British Kidney Patient Association Bordon Hants GU35 9JZ Phone: or: Fax: Renal/Urology Bleepholder Phone: (via switchboard) and ask the operator for the Renal Bleepholder Further information can be obtained from: The National Kidney Federation 6 Stanley Street Worksop Notts, S81 7HX Phone: Fax: nfk@kidney.org.uk Helpline: (Price3/05)23050KR Written by Clinical Governance and RENAL SHARED GOVERNANCE COUNCIL