Nephropathy – Part 3

When kidney damage is caught in its early stages, it can be slowed with treatment. Once larger amounts of protein appear in the urine, kidney damage will slowly get worse. Follow your doctor's advice to keep your condition from getting worse. The following are excellent steps to prevent as much damage as possible. Some of these steps should be started as soon as you have been diagnosed with diabetes.

Control your blood pressure - Keeping your blood pressure under control (below 130/80) is one of the best ways to slow kidney damage.

1. Your doctor may prescribe medicines to lower your blood pressure and protect your kidneys from more damage.
2. Taking these medicines, even when your blood pressure is in a healthy range, helps slow kidney damage.

Control your blood glucose level - You can also slow kidney damage by controlling your blood glucose level, which you can do by:

1. Eating healthy foods
2. Getting regular exercise
3. Taking medicine or insulin as instructed by your doctor

Checking your blood glucose level as often as instructed and keeping a record of your blood glucose numbers so that you know how meals and activities affect your level.

Other ways to protect your kidneys -

1. Before having an MRI, CT scan, or other imaging test in which you receive a contrast dye, tell the health care provider who is ordering the test that you have diabetes. Contrast dye can cause more damage to your kidneys.
2. Before taking an NSAID pain medicine, such as ibuprofen or naproxen, ask your health care provider if there is another kind of medicine that you can take instead. NSAIDs can damage the kidneys, especially when you use them often.
3. Know the signs of urinary tract infections and get them treated right away.
   
   Many resources can help you understand more about diabetes. You can also learn ways to manage your kidney disease. Education is a key to keeping your kidneys healthy. The links following are a few of the sources:

1. American Diabetes Association: http://www.diabetes.org
2. National Diabetes Information Clearinghouse: http://www.diabetes.niddk.nih.gov
3. National Kidney Foundation: http://www.kidney.org
   
   

Your doctor may need to stop some of your medicines because they can harm your kidneys if diabetic nephropathy is getting worse. Diabetic kidney disease is a major cause of sickness and death in people with diabetes. It can lead to the need for dialysis or a kidney transplant.

Talk to your doctor if you have diabetes and you have not had a urine test to check for protein. If necessary, ask for a referral to an urologist or even a specialist in kidney diseases – a nephrologist.

Some of the other names for this include - Diabetic nephropathy; Nephropathy - diabetic; Diabetic glomerulosclerosis; Kimmelstiel-Wilson disease.

When kidney disease is diagnosed early, during microalbuminuria, several treatments may keep kidney disease from getting worse. Having larger amounts of protein in the urine is called macroalbuminuria. When kidney disease is caught later during macroalbuminuria, end-stage renal disease, or ESRD, usually follows.

In time, the stress of overwork causes the kidneys to lose their filtering ability. Waste products then start to build up in the blood. Finally, the kidneys fail. This failure, ESRD, is very serious. A person with ESRD needs to have a kidney transplant or to have the blood filtered by machine (dialysis).

Nephropathy – Part 2

Kidney disease or kidney damage that occurs in people with diabetes is called diabetic nephropathy. This condition is a complication of diabetes. Each kidney is made of hundreds of thousands of small units called nephrons. These structures filter your blood, help remove waste from the body, and control fluid balance. In people with diabetes, the nephrons slowly thicken and become scarred over time. The kidneys begin to leak and protein (albumin) passes into the urine. This damage can happen years before any symptoms begin.

Kidney damage is more likely if you:

1. Have uncontrolled blood sugar
2. Have high blood pressure
3. Have type 1 diabetes that began before you were 20 years old
4. Have family members who also have diabetes and kidney problems
5. Smoke
6. Are African American, Mexican American, or Native American

Looking at the list above, two things should stand out because of their importance. First, you must manage your blood glucose levels. Second, you must manage your blood pressure.

Often, there are no symptoms as the kidney damage starts and slowly gets worse. Kidney damage can begin 5 to 10 years before symptoms start. People who have more severe and long-term (chronic) kidney disease may have symptoms such as:

1. Fatigue most of the time
2. General ill feeling
3. Headache
4. Nausea and vomiting
5. Poor appetite
6. Swelling of the legs
7. Itchy skin

Other symptoms and signs of nephropathy when kidney function is impaired include:

• Cola- or tea-colored urine (caused by red blood cells in the urine)
• Repeated episodes of cola- or tea-colored urine, sometimes even visible blood in your urine, usually during or after an upper respiratory or other type of infection
• Pain in the side(s) of your back below your ribs (flank)
• Foam in the toilet water from protein in your urine
• Swelling (edema) in your hands and feet
• High blood pressure

Your health care provider will order tests to detect signs of kidney problems. A urine test looks for a protein called albumin leaking into the urine.

• Too much albumin in the urine is often a sign of kidney damage.
• This test is also called a microalbuminuria test because it measures small amounts of albumin.

Your doctor will also check your blood pressure. This is because if you have diabetic nephropathy, you likely also have high blood pressure. A kidney biopsy may be ordered to confirm the diagnosis or look for other causes of kidney damage. If you have diabetes, your doctor will also check your kidneys by using the following blood tests at least annually:

• BUN - Blood urea nitrogen test is used to evaluate kidney function, to help diagnose kidney disease, and to monitor acute or chronic kidney dysfunction or failure.
• Serum creatinine - This test measures how effectively the kidneys are filtering small molecules like creatinine out of the blood.

If you have diabetes, make sure that your doctor does these tests described above, because you want the doctor to catch these signs early and this will allow you and your doctor to take precautionary steps to prevent further damage. It may be necessary to get a referral to an urologist to obtain the best care.

Treatment and other preventive steps will be discussed in the next blog.

Nephropathy – Part 1

The definition of kidney disease varies some depending on the type and cause. Diabetic nephropathy is this topic, but I would be remiss if I do not include more. According to several sources, several causes must be considered in any definition.

IgA nephropathy - is the most common glomerulonephritis throughout the world.

Acute glomerulonephritis is an inflammatory disease of both kidneys predominantly affecting children from ages two to 12. Chronic glomerulonephritis can develop over a period of 10-20 years and is most often associated with other systemic disease, including diabetes, malaria, hepatitis, or systemic lupus erythematosus.

Acute glomerulonephritis is an inflammation of the glomeruli, bundles of tiny vessels inside the kidneys. The damaged glomeruli cannot effectively filter waste products and excess water from the bloodstream to make urine. The kidneys appear enlarged, fatty, and congested. Diabetic nephropathy will be the discussion in the next blog, based on this definition.

For more information, please enter the word 'glomerulonephritis' into the Search box of this medical dictionary. You may wish to use the medical dictionary for other terms below, as some are dependent on a correct meaning. You may wish to bookmark the dictionary as in future blogs, you may wish to use it again.

Analgesics - One cause of nephropathy is the long-term usage of analgesics. The pain medicines which can cause kidney problems include aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs, or NSAIDs. This form of nephropathy is "chronic analgesic nephritis," a chronic inflammatory change characterized by loss and atrophy of tubules and interstitial fibrosis and inflammation. Specifically, long-term use of the analgesic phenacetin has been linked to renal papillary necrosis (necrotizing papillitis).

Iodinated contrast media - Kidney disease induced by iodinated contrast media (ICM) is called CIN (= contrast induced nephropathy) or contrast-indueced AKI (= acute kidney injury). Currently, the underlying mechanisms are unclear. But there is a body of evidence that several factors including apoptosis-induction seem to play a role.

Xanthine oxidase deficiency - Another possible cause of Kidney disease is due to decreased function of xanthine oxidase in the purine degradation pathway. Xanthine oxidase will degrade hypoxanthine to xanthine and then to uric acid. Xanthine is not very soluble in water; therefore, an increase in xanthine forms crystals (which can lead to kidney stones) and result in damage of the kidney. Xanthine oxidase inhibitors, like allopurinol, can cause nephropathy.

Polycystic Disease of the Kidneys - Additional possible cause of nephropathy is due to the formation of cysts or pockets containing fluid within the kidneys. These cysts get enlarged with the progression of aging causing renal failure. Cysts may also form in other organs including the liver, brain, and ovaries. Polycystic Kidney Disease is a genetic disease caused by mutations in the PKD1, PKD2, and PKHD1 genes. This disease affects about half a million people in the US. Polycystic kidneys are susceptible to infections and cancer.

Toxicity of Chemotherapy Agents - Nephropathy can be associated with some therapies used to treat cancer. The most common form of kidney disease in cancer patients is Acute Kidney Injury (AKI) which can usually be due to volume depletion from vomiting and diarrhea that occur following chemotherapy or occasionally due to kidney toxicities of chemotherapeutic agents. Kidney failure from break down of cancer cells, usually after chemotherapy, is unique to onconephrology. Several chemotherapeutic agents, for example Cisplatin, are associated with acute and chronic kidney injuries.[3] Newer agents such as anti Vascular Endothelial Growth Factor (anti VEGF) are also associated with similar injuries, as well as proteinuria, hypertension and thrombotic microangiopathy.

Complications from Diabetes

In the last month, I have been writing about some of the complications of diabetes or related problems of diabetes. I will list several of the blogs about complications of diabetes, retinopathy and related, neuropathy which affects me and then I will write about those I have not written about in detail. This will be about nephropathy or kidney damage, atherosclerosis, and deafness are the most common, and many don't include deafness. The first three and deafness are grouped together under the term microvascular complications because they result from damage to the small blood vessels. The macrovascular complication is atherosclerosis, which is caused by damage to the large blood vessels.

There are several others that affect type 1 diabetes and seldom affect those with type 2 diabetes. Then there are those that affect both types, depression, hypoglycemia, hyperglycemia, and a few others. Over the next few months, I hope to write about all the complications.

Retinopathy – eye damage & diseases Your eyesight is too important to ignore and keeping your blood glucose levels near normal is the best treatment for your eyes.

http://bobsdiabetes.blogspot.com/2014/01/eye-disease-diabetic-retinopathy.html

http://bobsdiabetes.blogspot.com/2014/01/eye-disease-diabetic-macular-edema.html

http://bobsdiabetes.blogspot.com/2014/01/eye-disease-glaucoma.html

The above three blogs are about eye diseases affected by high blood glucose levels.

http://bobsdiabetes.blogspot.com/2014/01/many-patients-claim-not-informed-about.html

http://bobsdiabetes.blogspot.com/2013/08/is-there-best-way.html

http://bobsdiabetes.blogspot.com/2013/08/is-there-best-way-part-2.html

Neuropathy – nerve damage About two-thirds of the people with diabetes do develop neuropathy. Some are more affected by this while others are able to continue doing what they have been doing and are able to exercise. Others are prevented from exercising because of the pain level. I urge everyone to read the nine blogs as they contain a lot of information.

http://bobsdiabetes.blogspot.com/2012/01/diabetic-neuropathy-part-1.html

http://bobsdiabetes.blogspot.com/2012/01/diabetic-neuropathy-part-2.html

http://bobsdiabetes.blogspot.com/2012/01/diabetic-neuropathy-part-3.html

http://bobsdiabetes.blogspot.com/2012/01/diabetic-neuropathy-part-4.html

http://bobsdiabetes.blogspot.com/2012/01/diabetic-neuropathy-part-5.html

http://bobsdiabetes.blogspot.com/2012/05/neuropathy-causes.html

http://bobsdiabetes.blogspot.com/2012/05/what-is-diabetic-neuropathy-part-1.html

http://bobsdiabetes.blogspot.com/2012/05/what-is-diabetic-neuropathy-part-2.html

http://bobsdiabetes.blogspot.com/2012/05/what-is-diabetic-neuropathy-part-3.html

In the next blogs, I will write about nephropathy. In my research, I apparently have not really done much reading about nephropathy, as I made some surprising discoveries. Hope that you will learn from the information as well.

New Non-ADA Diabetes Treatment Guidelines

When I first saw this, I had to wonder why other medical organizations would do this. “The Guiding Principles for the Care of People With or at Risk for Diabetes was produced by the National Diabetes Education Program (NDEP), a federally funded program sponsored by the U.S. Department of Health and Human Services’ National Institutes of Health and Centers for Disease Control and Prevention. NDEP’s partnership network includes over 200 partners working together to improve the treatment and outcomes for people with diabetes, promote early diagnosis, and prevent or delay the onset of type 2 diabetes.”

The information article appeared in Diabetes-in-Control and the guidelines are in a PDF file that can be downloaded here. It was a real surprise in the number of medical and other care providers organizations included. I was not disappointment to find the American Diabetes Association and the Academy of Certified Diabetes Educators missing from the list of partners. Admittedly, I was not disappointed in finding a few other medical organizations on the list.

Judith Fradkin, M.D., director of the Division of Diabetes, Endocrinology and Metabolic Diseases in the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health says, "With these Guiding Principles, we aren’t creating new guidelines, but clarifying where there is general agreement across myriad diabetes guidelines. Guiding Principles represents a set of sound practices. Our goal in developing this resource is to help clinicians help their patients with diabetes."

Two of the medical societies endorsing the principles include the American Diabetes Association, the American Association of Clinical Endocrinologists, but they are not partners in the guidelines. From my further reading, yes, this is a government move maybe to force the ADA and AACE into making some changes. Once the government becomes involved in guidelines, we all know that the patients suffer when the government becomes involved.

“Medical societies endorsing the principles include the American Diabetes Association, the American Association of Clinical Endocrinologists, the Endocrine Society, the American Geriatrics Society, the American Association of Diabetes Educators, the American College of Obstetricians and Gynecologists, the American Association of Nurse Practitioners, and the American Heart Association. In addition, representatives of the American College of Physicians and the American Academy of Family 

 

Physicians participated on the writing committee. While these organizations have policies on endorsing guidelines that this document has not fulfilled, they nonetheless have said they plan to promote it.

The 10 principles are:

1. Identify people with undiagnosed diabetes and prediabetes.
2. Manage prediabetes to prevent or delay the onset of type 2 diabetes.
3. Provide ongoing self-management education and support for people with or at risk for diabetes and its complications.
4. Provide individualized nutrition therapy for people with or at risk for diabetes.
5. Encourage regular physical activity for people with or at risk for diabetes.
6. Control blood glucose to prevent or delay the onset of diabetes complications and avert symptoms of hyperglycemia and hypoglycemia.
7. Provide blood-pressure and cholesterol screening and control, and smoking-cessation and other therapies to reduce cardiovascular disease risk
8. Provide regular assessments to detect and monitor diabetes microvascular complications and treatments to slow their progression.
9. Consider the needs of special populations -- children, women of childbearing age, older adults, and high-risk racial and ethnic groups.
10. Provide patient-centered diabetes care.”

It will be interesting to see how this affects the actions of doctors that are not members of the ADA and other doctors that do not follow the ADA Guidelines.

Is the High Carbohydrates Era Finally Ending?

Yes, the high carbohydrate advice is slowing, but it is still not ending. With the Academy of Nutrition and Dietetics being a puppet of Big Food, it will take more than a few people advocating for the healthiness of low carbohydrates for people with type 2 diabetes to move the dial.

Dr. Osama Hamdy, Medical Director, Obesity Clinical Program, Director of Inpatient Diabetes Management at Joslin Diabetes Center, Assistant Professor of Medicine at Harvard Medical School does say that a low carbohydrate diet is beneficial for people with diabetes. We need more medical professionals saying this and pointing out that the Dietary Guidelines produced every five years for the USDA and HHS are based on weak scientific evidence.

The guidelines were started in 1977, when the Select Committee On Nutrition and Human Needs of the US Senate chaired by Senator George McGovern recommended that people increase their carbohydrate intake to 55 to 60 percent of the total caloric intake, while reducing fat consumption from approximately 40 percent to 30 percent of the total daily calories. The aims of these recommendations were to reduce health care costs and maximize the quality of life of Americans.

The proposed cost saving was predicted to result from the possible reduction in the incidence of heart disease, cancer, as well as other killer diseases. Despite controversy, the United States Department of Agriculture (USDA) created in 1980 a food pyramid representing the optimal number of servings to be eaten each day from each of the basic food groups. Carbohydrates were placed at the base of the pyramid (making up the largest portion of caloric intake, 6 to 11 servings per day), and fats were placed at the tip of the pyramid to show that they should be “used sparingly.”

As we all know now, these recommendations turned out to be the opposite of what the USDA expected. What has been aptly described as a “national nutritional experiment” contributed to the increased prevalence of obesity. And, contrary to the main aims of the recommendations, the prevalence of type 2 diabetes and cardiovascular disease went up significantly.

What happened should have been expected. An increase in carbohydrate intake results in an increased insulin response to carbohydrates, which through its fat-storage promoting action increases obesity. And, it has been shown, that accumulation of fat inside the belly (visceral fat) is associated with chronic inflammation that is directly related to type 2 diabetes and heart attacks.

The problem is especially severe for people who already have type 2 diabetes. We know today that increasing the carbohydrate load in the diabetes diet increases what is called glucose toxicity and consequently increases insulin resistance, triglycerides level and reduces beneficial HDL-cholesterol.

Now that we are past the history, Dr. Hamdy isn't really for low carbohydrate food plans. He only advocates a small reduction from 55 to 60% to 40 to 45% which is only a quarter reduction instead of much lower that was advocated by Drs. Elliot P. Joslin and Fredrick Allen, the fathers of diabetes science, successfully treated their patients diagnosed with fatty diabetes (later known as type 2 diabetes) with a diet very low in carbohydrates. Bold is my emphasis.

How Dr. Hamdy considers this much of a reduction leaves me wondering why he even makes that statement. I also have to wonder where he found the information that most medical societies have departed from the recommendation of high carbohydrates intake. A few, yes, and they still believe in low fat which is also harmful and makes for slow weight loss.

Dr. Hamdy is more right when he writes - “Unfortunately, many healthcare providers and dietitians across the nation still recommend high carbohydrate intake for patients with diabetes, a recommendation that may harm their patients and contribute to increasing obesity and worsen diabetes control and consequently increase the chance of developing diabetes complications.” He may as well be writing about his position of high carbohydrates

Understanding the “Experts”

I will say this now – I never want to be classified as an “expert.” I see “experts” making irrational statements, promoting statements either based on lack of evidence, or constantly denying studies that refute their beliefs or would jeopardize their status and from whom they receive monetary incentives (conflicts of interest). I would much prefer being an ordinary citizen that can see the lies and conflicts of interest and be able to write about these harms that the “experts” advocate.

An example of this happening is this British study. The study has found a correlation between the amount of fluoride in public drinking water and a rise in incidence of hypothyroidism. The findings were published in the Journal of Epidemiology & Community Health. The researchers found that in locales where tap water fluoride levels exceeded 0.3 mg/L, the risk for having an under active thyroid rose by 30%. The research team also found that hypothyroidism rates were nearly double in urbanized regions that had fluoridated tap water, compared with regions that did not. The key here is a correlation and this does not mean a cause.

However, a representative of the American Dental Association (ADA) took issue with the British report. "Public health policy is built on a strong base of scientific evidence, not a single study," Edmond Hewlett, DDS, ADA representative and a professor at the UCLA School of Dentistry, told HealthDay. "Currently, the best available scientific evidence indicates that optimally fluoridated water does not have an adverse effect on the thyroid gland or its function."

Yes, I agree that the ADA has strong evidence because Big Chemical paid for most dental studies about fluoride and when I have asked dentists about the health side effects of using fluoride in the past, I was always told that there are many studies showing the healthful benefits of using fluoride and having fluoride in the city water supply. When I have asked for copies of these studies, I was just told that the studies were not for the public, but they did exist. In the recent past, several cities have debated eliminating fluoride from the water supply. This brought out the dental profession in full force to argue against this happening.

Conflict of interest keeps rearing its ugly head without me having to look for it lately. I guess having been a bean counter and technical writer makes me more aware of information that appears on the surface as being correct, but on further investigation, the conflict of interest is exposed. This is often not the most comforting and too often, I choose not to write about a topic as a result.

The above statement by Edmond Hewlett, DDS, ADA representative when he said, "Public health policy is built on a strong base of scientific evidence, not a single study," really bothers me and points out how poor scientific evidence can be. If the USDA and its Dietary Guidelines Advisory Committee (DGAC) used strong scientific evidence for the food guidelines, maybe we would not have the obesity epidemic we have today. This is the reason for the Healthy Nation Coalition which is calling on the DGAC to pay attention to scientific evidence which at present still is very conflicting because Big Food still calls the tune.

What this means is that research needs to be done without the influence of Big Food and their minions. Pure independent research is the answer.