Kidney Health 
Each year in the United States, more than 100,000 people are diagnosed with kidney failure, a serious condition in which the kidneys fail to rid the body of wastes. Kidney failure is the final stage of chronic kidney disease (CKD).
Diabetes is the leading cause of kidney disease in the United States. About 30 percent of patients with Type 1 diabetes and 10 to 40 percent of those with Type 2 diabetes will suffer from kidney failure. There are currently about 180,000 people living with kidney failure as a result of diabetes.
Most people know the primary function of the kidneys is to remove waste products and excess fluid from the body, but don’t realize their many other functions:
-
Remove drugs and other toxins from the body
-
Balance the body's fluids
-
Release hormones that regulate blood pressure
-
Produce a form of vitamin D that promotes strong, healthy bones
-
Controls the production of red blood cells
There are two kidneys, each about the size of a fist, located on either side of the spine at the lowest level of the rib cage.
The artery brings blood and wastes from the bloodstream into the kidneys. Each kidney is made up of a million tiny nephrons. Each nephron has a group of tiny blood vessels called a glomerulus which act as the filtering unit in charge of cleaning the blood as it flows through the kidney. The rate at which the glomerulus filters the blood is called the glomerular filtration rate or “GFR”.
After filtration, the remaining fluid passes into a tubule where chemicals and water are either added to, or removed from, according to the body's needs. Clean blood leaves the kidneys and goes back into the bloodstream through the vein. Waste and extra fluid are removed from the body via urine.
The kidneys filter about 200 quarts of fluid every 24 hours. About two quarts of liquid are removed from the body in the form of urine, and about 198 quarts are recovered.
Risk Factors for Kidney Disease
You may have an increased risk for kidney disease if you:
-
Are older
-
Have diabetes
-
Have high blood pressure
-
Have a family member who has chronic kidney disease
-
Are African American, Hispanic American, Asians and Pacific Islander or American Indian.
If you are in one of these groups or think you may have an increased risk for kidney disease, ask your doctor about getting tested.
Kidney Disease
Kidney disease is defined as having a kidney abnormality or "marker" such as protein in the urine and decreased kidney function for three months or longer. There are many causes of chronic kidney disease. The kidneys may be affected by diseases such as diabetes and high blood pressure. Drugs and toxins can also cause kidney problems including over-the-counter pain relievers taken in large doses taken over an extended period of time. Some kidney conditions are inherited.
Most people with diabetes do not develop kidney disease severe enough to progress to kidney failure. Kidney damage rarely occurs in the first 10 years of diabetes. If kidney disease is diagnosed, it is usually 15 - 25 years before kidney failure occurs. People who live with diabetes for more than 25 years without any signs of kidney disease have a decreased risk of kidney failure.
How diabetes affects the kidneys
Diabetes affects the vascular system and the small blood vessels in the body may be damaged. When the blood vessels in the kidneys are damaged, they cannot clean the blood properly. The body retains more water and salt, which can result in weight gain and ankle swelling. Waste materials will begin to build up in the blood and also result in protein in the urine.
Diabetes may also cause damage to nerves in the body which can create difficulty in emptying the bladder of urine. Pressure from a full bladder can back up and injure the kidneys. If urine remains in the bladder for a long time, an infection can develop from the rapid growth of bacteria in urine with high sugar levels.
Signs of kidney disease in patients with diabetes
Diabetic kidney disease takes many years to develop. In some people, the filtering function of the kidneys is actually higher than normal in the first few years of their diabetes.
The signs of diabetic kidney disease usually show up as an increased excretion of albumin (a protein) in the urine long before any symptoms present.
1. Albumin/protein in the urine
2. High blood pressure
3. Ankle and leg swelling, leg cramps
4. Going to the bathroom more often at night
5. High levels of Blood Urea Nitrogen (BUN) and creatinine in blood
6. Less need for insulin or other diabetic medications
7. Morning sickness, nausea and vomiting
8. Weakness, paleness and anemia
9. Itching
Maintaining Kidney Health
People with diabetes should see their doctor at least 4 times yearly. Like most complications of diabetes, the impact can be mitigated by good self care, glucose control and knowing the causes and symptoms of kidney disease.
-
Measure A1C levels 2 – 4 times yearly. This test provides an average of blood glucose level for the previous 8 – 12 weeks. People with diabetes should aim to keep it at less than 7 percent. More on A1C [link]
-
Create an effective management plan with your health professionals regarding insulin injections or oral medications, other medicines, meal planning, physical activity, and blood glucose monitoring.
-
Check blood pressure at every visit. If blood pressure is high, a course of treatment should be established.
More on blood pressure.
-
Drink plenty of water.
Get prompt treatment for urinary tract infections You may have an infection if you have these symptoms:
o Pain or burning when you urinate
o A frequent urge to go to the bathroom
o Urine that looks cloudy or reddish
o Fever or a shaky feeling
o Pain in your back or on your side below the ribs
-
Avoid any medicines that may damage the kidneys (especially over-the-counter pain medications)
-
Discuss whether a reduction in the amount of protein in diet is appropriate and ask for a referral to see a registered dietitian for help with meal planning.
Early detection and treatment of chronic kidney disease are the keys to keeping kidney disease from progressing to kidney failure. Some simple tests can be done to detect early kidney disease. They are:
-
A test for albumin (protein) in the urine. Urine albumin is measured by comparing the amount of albumin to the amount of creatinine in a single urine sample. When the kidneys are healthy, the urine will contain large amounts of creatinine but almost no albumin. Even a small increase in the ratio of albumin to creatinine is a sign of kidney damage. If you have a positive result, the doctor should schedule a follow-up test over several weeks because fever or increased physical activity may also cause excess protein in urine. Kidney disease is present when urine contains more than 30 milligrams of albumin per gram of creatinine, with or without decreased eGFR.
-
A test for blood creatinine which is a waste product and can be found in a blood sample. The calculation of eGFR is based on the amount of creatinine in your blood. Your doctor should use your results, along with your age, race, gender and other factors, to calculate your glomerular filtration rate (GFR). The GFR tells how much kidney function you have. To access the GFR calculator, click here. The higher the level of creatinine, the lower the eGFR. Kidney disease is considered to be present when eGFR is less than 60 milliliters per minute.
Emotional Cost of Kidney Disease
As a person with diabetes you are probably used to having to adjust routines to deal with glucose testing, medications and diet. Kidney disease adds new tasks to that process. You have to learn about a whole new set of anatomy and terms. You may have to make additional changes to your diet, add new medications to your routine and deal with potential side effects. If you have to undergo dialysis you will need to make scheduling adjustments and possibly learn a new skill set.
You also have to go on LIVING! Continuing with your work, studies, family commitments and hobbies are important to your long term health and happiness.
It is normal to have concerns about your condition, how you will feel, whether the treatment will hurt, what to expect during treatment and how long you can live with the disease.
The health care are trained to help you make these adjustments and to help you understand all areas of your care. So be sure to discuss all your concerns with the health care team at the treatment center. Make sure to write your questions down as you think of them so you have them for handy reference (it’s easy to forget in the stark light of the doctor’s office).
If you are going to have dialysis or are preparing for a transplant ask to visit the appropriate centers. This can help allay your anxiety, answer questions and help you make the right choices for your health and wellbeing.
Finally, speak to others who have been through the same experience. There is nothing like peer support to allay your concerns and get tips on new coping mechanisms.
Call your local National Kidney Foundation for information and a list of the programs and services available. Find out who your local NKF is by visiting the NKF website at www.kidney.org or by calling 800.622.9010.
Treatment of Kidney Disease
Careful control of diabetes and high blood pressure can help prevent kidney disease or keep it from getting worse. Prescription medications cannot reverse chronic kidney disease, but they are used to treat symptoms and complications and to slow damage to the kidneys.
Because most people with CKD have problems with high blood pressure (either before the onset of KD or during the course of the disease) high blood pressure medicines are commonly prescribed.
Your doctor may need to prescribe several different medications before they find one that effectively controls your blood pressure with a minimum of side effects. Most people take a combination of medicines for the best results.
-
Angiotensin-converting enzyme (ACE) inhibitors block an enzyme needed to form a substance that narrows blood vessels. The drug causes blood vessels to relax and widen, making it easier for blood to flow through the vessels, which reduces blood pressure. These medicines also increase the release of water and sodium to the urine, which also lowers blood pressure.
-
Angiotensin II receptor blockers (ARBs) reduce blood pressure as effectively as ACE inhibitors but are less likely to cause the cough which can be a side effect of ACE inhibitors.
Diuretics cause the kidneys to remove sodium and water from the body, which relaxes the blood vessel walls and helps lower blood pressure.
-
Beta-blockers lower the heart rate, the amount of blood the heart pumps out, and the force of the heartbeat, all of which lower blood pressure.
-
Calcium channel blockers relax and widen blood vessels making it easier for blood to flow through the vessels lowering blood pressure.
-
Vasodilators open up the blood vessels allowing blood to flow more easily, lowering blood pressure. Some of these types of medicines are combined with other medicines to counteract the body's natural tendency to retain fluid and increase heart rate when there is a sudden drop in blood pressure.
-
Direct renin inhibitors block the enzyme renin from triggering a process that regulates blood pressure.
Kidney Specialists
Kidney disease may progress to kidney failure which is very serious. There are still options for treatment but they are much less pleasant than practicing good diabetes and high blood pressure control. If you are diagnosed with kidney disease it is a good idea to add a kidney specialist or nephrologist to your health care team.
Your primary care physician or your endocrinologist is an obvious place to begin your search for a nephrologist. Your Certified Diabetes Educator or dietitian may also have a list.
-
Call the department of nephrology at a nearby hospital or university medical center.
-
Contact your state or county medical association for a list of nephrologists. They may have specific information on experience.
-
-
Contact your insurance company or health plan to learn whether it has a list of kidney care specialists who are covered under your plan.
Kidney Failure and Treatment
One treatment for kidney failure is dialysis. Dialysis is a treatment that does some of the work your kidneys used to do. Two types of dialysis are available. You and your doctor will decide what type will work best for you based on your medical condition, lifestyle and personal preference.
Hemodialysis
Hemodialysis is a method where you are connected to a dialysis machine and your blood flows through a tube in your arm to a dialyzer that filters out the waste products and extra fluid. The clean blood flows back to your arm. Hemodialysis treatments are usually performed three times a week and take between 3 – 5 hours depending on the stage of your kidney disease.
Hemodialysis requires the installation of a special “port” so you can be connected to the equipment. There are three general types of ports:
A fistula is the recommended choice because it poses fewer problems and last longer, though it requires a surgical procedure. It is made by joining an artery to a nearby vein under your skin to make a bigger blood vessel.
A fistula should be inserted several months before starting dialysis so it has plenty of time to heal. An evaluation by a vascular surgeon will need to be conducted and an ultrasound evaluation of your vessels may be ordered to see determine the ideal ones for the fistula. This evaluation is called "vessel mapping."
A graft may be used if your blood vessels are not suitable for a fistula. This involves joining an artery and nearby vein with a small,
soft tube made of synthetic material. The graft is entirely beneath your skin.
A catheter is the final type used for short term dialysis or as permanent access is a fistula or graft cannot be used. A tube is inserted into a large vein in your neck or chest and the ends of the tubes sit on your skin outside your body.
Hemodialysis treatment may be performed at a dialysis unit or at home. Some people prefer home dialysis because it provides more flexibility. However your home must have the appropriate space for the equipment as well as good water drainage and electric power to operate the dialysis and water purification units.
You will also need to have someone assist you in the process. This can be a family member, friend or an individual you hire. You can be trained to do dialysis at home.
Home dialysis also provides two more options for treatment:
- Short daily home hemodialysis involves more treatments each week for shorter periods. For example, instead of 3 treatments lasting 3 – 5 hours you might do 6 treatments a week for 1½ to 2½ hours. Some people find this method improves their quality of life because smaller parcels of time are taken up with treatment. Many people also find they sleep better and have better control of blood phosphorus levels, blood pressure and anemia.
- Night time home hemodialysis involves long, slower treatments, usually for 6-8 hours, which are done while sleeping. Many people sleep better and have better control of blood phosphorus levels, blood pressure and anemia with this method of dialysis.
Peritoneal dialysis
Peritoneal dialysis is a home-based treatment that many people select because it allows them greater flexibility in treatment. In peritoneal dialysis (PD), your blood is cleaned inside your body with the lining of your abdomen (the peritoneum) acting as a natural filter.
A soft tube called a PD catheter is surgically (minor) placed into your belly. During dialysis, a cleansing solution called dialysate flows into your abdomen through this tube. Wastes and extra fluid pass from your blood into the cleansing solution. After several hours, you drain the used solution from your abdomen and throw it away. You then refill with fresh cleansing solution and begin the process again. Removing the used solution and adding fresh solution takes about a half hour and is called an “exchange.” Peritoneal dialysis can be done at home, at work, at school or even during travel.
There are two types of PD: Continuous Cycling Peritoneal Dialysis which requires the use of a machine and Continuous Ambulatory Peritoneal Dialysis which does not.
Medicines used during dialysis
Anemia often develops in advanced cases of kidney disease and your doctor may prescribe:
-
Erythropoietin (rhEPO) which stimulates the production of new red blood cells and may decrease the need for blood transfusions. This therapy may also be started before dialysis is needed if anemia is a complication of CKD.
-
Iron therapy is used to increase levels of iron when rhEPO therapy alone is not effective.
-
Vitamin D helps keep bones strong and healthy.
A nephrologist can explain the different treatment approaches and help patients make the best treatment choices for themselves and their families.
Kidney Transplant
A kidney transplant is another treatment option for kidney disease and they have high rates of success. A kidney transplant is only a treatment, it is not a cure. You may opt for a kidney transplant at any stage of your kidney disease though that option is much easier if you have a relative or friend willing to act as a living donor. Studies have shown patients do better when they receive a live donor kidney. The living donor must have a complete evaluation to make sure their health will not be harmed by removing the kidney. This evaluation process is different for each transplant center.
If you don’t have a live donor you must get placed on a transplant list. Don’t assume that your dialysis center will automatically get you on the list. Before you get on the national and local transplant list, you will have to undergo a rigorous medical examination to make certain you are a good candidate so this is a treatment step you need to discuss with your nephrologist.
You can get on the waiting list at multiple centers in different parts of the country, but you may incur additional costs for testing, evaluation and travel. Regardless of where you are registered, matching kidneys go to local residents first, then regional residents, and then are made available nationally. Additional criteria include tissue matching, length of time you have been on the list and how seriously you need a new kidney to live. A national registry system has been established so no one is discriminated against.
Waiting for a donor kidney can take time and is difficult emotionally. Many transplant centers have educational materials and support groups to help you through this period. Some have programs that will connect you with mentors who have been through the process.
Read the article by Kidney Transplant Survivor Bob Brooks.
While you are waiting for your kidney, stay in touch with your transplant team and keep them apprised of any changes in your health. If you're waiting for a donated kidney, make sure the transplant team knows how to reach you at all times. Keep your packed hospital bag handy, and make arrangements for transportation to the transplant center in advance.
Kidney transplants have high success rates even among people with diabetes. The current
survival rate of kidneys transplanted into people with diabetes is about the same as people without diabetes. In spite of medical progress in the area of kidney disease people with diabetes who receive transplants or dialysis do experience higher (eventual) mortality rates because of additional complications of diabetes such as damage to the heart, eyes, and nerves.
Kidney transplants are performed with general anesthesia and the surgical team monitors your heart rate, blood pressure and blood oxygen level throughout the procedure. Kidney transplant surgery usually lasts about three to four hours. During the surgery:
-
The surgeon makes an incision in your lower abdomen. Unless your own kidneys are causing complications such as high blood pressure or infection, they are left in place and the new kidney is placed closer to the hip bone.
-
The blood vessels of the new kidney are attached to blood vessels in the lower part of your abdomen, just above one of your legs.
-
The new kidney's ureter (the tube that links the kidney to the bladder) is connected to your bladder.
After your kidney transplant you’ll find that you feel better almost immediately though you will have some soreness or pain around the incision site. But you are still facing plenty of challenges and some different routines.
You will spend several days to a week in the hospital during which doctors and nurses will monitor your condition for signs of complications. Your new kidney will make urine like your own kidneys did when they were healthy. This can start immediately or take a few days.
After you leave the hospital you will need to have close monitoring for a few weeks. The transplant team will develop a checkup schedule. If you live in another town, you may need to make arrangements to stay close to the transplant center during this immediate follow-up period.
After your surgery you will need to take a class of drugs called immune-suppressants for the rest of your life. These medications help keep your immune system from attacking your new kidney. Medications that suppress your immune system make your body more vulnerable to infection, so your doctor may also prescribe antibacterial, antiviral and antifungal medications. You will probably also need to stay on blood pressure medications.
Your appetite will improve so your new kidney will break down insulin better than your injured one so you may need a higher dose of insulin.
If your new kidney fails, dialysis treatment can be started while you wait for another kidney.
Financial Aid for Dialysis and Transplants
Dialysis and kidney transplants are expensive propositions. If you are uninsured or underinsured many of the costs of dialysis and kidney transplant are covered by the federal government through Medicare. Medicare has an official (and lengthy)
government booklet which outlines:
People with kidney failure can enroll in Medicare at their local Social Security office, or by calling 800.772.1213. Before signing up, your dialysis clinic or transplant program must complete a form and have it signed by your doctor verifying you have started dialysis or received a kidney transplant.
When does Medicare begin to pay?
Medicare will begin to cover dialysis treatments or a kidney transplant when:
-
You start your third full month of in-center hemodialysis
-
You start a home dialysis training course at a Medicare-approved facility within the first three months of treatment, and you plan to do home dialysis
-
You are admitted to a Medicare-approved hospital for a transplant, or up to two months before admittance if pre-transplant health care and testing has already been started
-
Immediately if you are already on Medicare
How much will Medicare cover?
Medicare may pay up to 80% of the costs associated with dialysis and kidney transplant. But Medicare alone is not enough to cover the full costs. Many other sources of coverage are available to help pay for what Medicare does not cover, including:
-
Employer health insurance, private health insurance, COBRA
-
State programs such as Medicaid and high-risk insurance pools
-
Veteran’s benefits
-
State kidney programs
-
Medigap (Medicare supplemental health insurance)
To learn more about all your options for insurance coverage, you can speak to:
-
Your state insurance commissioner and ask what options are available to you where you live
-
An independent insurance broker
-
The National Kidney Foundation (NKF) at 800.622.9010, or your local NKF office
-
A financial aid coordinator at your dialysis center or transplant center
-
Your county or state social service department or Medicaid office
Resources
