While we navigate the challenging and unprecedented times of life with COVID-19, it is vital that we not allow this pandemic to distract people with diabetes from managing critical health concerns.
Did you know that high blood glucose and blood pressure can create the perfect storm for developing chronic kidney disease? Chronic kidney disease is commonly caused by high blood glucose and high blood pressure over a long period of time. The pressure from the high blood glucose and blood pressure damages the blood vessels within the kidney leading to waste builds up in the body. Remember, the blood vessels within the kidney clean our blood.
NT, a 72-year-old male, has been living with diabetes for 25 years. Recently, he was surprised when he found out he had chronic kidney disease due to his diabetes (diabetic nephropathy) and hypertension. He realized early on he had been in denial he had diabetes. However, he had been so proactive over the last several years with self-managing his diabetes; He simply could not believe he had chronic kidney disease.
So what markers will the primary care provider access to screen for chronic kidney disease?
1- urinary albumin (measured by urine albumin (mg/dL) to urine creatinine ratio (g/dL) = UACR).
a. Albuminuria is present when UACR is greater than 30 mg/g
2- estimated glomerular filtration rate (eGFR) (goal > 60 mL/min/1.73 m2)
For persons with chronic kidney disease, referral to nephrologist (physician specializing in kidneys) is made when eGFR < 30 mL/mini/1.73 m2)
These markers are assessed at least once a year for all persons with type 2 diabetes and persons with type 1 diabetes for a duration of five years or longer. A person may have chronic kidney disease if UACR is > 30 mg/g and/or eGFR < 60 mL/min/1.73 m2).
Who are the health care team members that can help you prevent kidney disease? Primary care provider, endocrinologist, and diabetes care and education specialist (CDCES) (formerly known as diabetes educators: nurse, registered dietitian nutritionist (RDN), pharmacist, behavioral health specialist).
What prevention steps can be taken? Remember, the major contributors to diabetes related chronic kidney disease is high blood glucose and high blood pressure. The following are recommended goals and medications for each contributor. It is worth noting referring to an RDN CDCES is critical for comprehensive nutritional guidance.
- Managing blood pressure to reduce risk or slow progression of chronic kidney disease
- Overall target range for blood pressure in person with diabetes: <140/90
- Lifestyle: what practical steps can be taken from a nutrition standpoint to assist in keeping blood pressure healthy
- Dietary Approach to Stop Hypertension (DASH) diet
- Eating plan rich in fruits and vegetables, low fat and nonfat diary, whole grains, along with nuts, beans and seeds
- Cut back on foods high in saturated fat, such as fatty meats, full fat dairy foods and tropical oils as well as sugar-sweetened beverages and sweets
- Limiting sodium to less than 2,300 mg per day or 1,500 mg per day
- Medications for lowering blood pressure with focus on classes shown to be of benefit with chronic kidney disease. For a person with diabetes who has a blood pressure < 140/90, and UACR and estimated glomerular filtration rate within normal range, it is not recommended to initiate an ACE-inhibitor or ARB for primary prevention of chronic kidney disease. Also, ACE inhibitor and ARB medications continue to be safe in light of the current pandemic with COVID-19. Your healthcare professional will periodically monitor your serum potassium and creatinine while taking ACE-inhibitor or ARB.
- Angiotensin Converting Enzyme Inhibitor (ACE-inhibitor):
- Lisinopril (Zestril) or enalapril (Vasotec)
- Angiotensin Receptor Blocker (ARB):
- Valsartan (Diovan) or losartan (Cozaar)
- Managing blood glucose to reduce risk or slow progression of chronic kidney disease
- Overall glucose targets: hemoglobin A1c <7%, fasting and prior to meals 80 – 130 mg/dL, 2 hours after eating < 180 mg/dL (these target values/ranges should be individualized for each person with diabetes)
- Lifestyle: what practical steps can be taken from a nutrition standpoint
- Carbohydrate counting
- Working with a CDCES to learn how to count carbohydrates
- Typically recommend 30 – 45 grams of carbohydrates per meal, and 15 grams of carbohydrates per snack
- Healthy Eating Behaviors
- Learning portion management
- Plate Method: ½ plate nonstarchy veggies, ¼ plate protein, ¼ plate of starch (carbohydrate), diary product (i.e. milk or yogurt) and fruit
- Mediterranean diet
- High in vegetables, fruits, whole grains, beans, nuts, seeds, and olive oil
- Plant based, not meat based
- Main components:
- Daily intake of vegetables, fruits, whole grains and healthy fats
- Weekly intake of fish, poultry, beans and eggs
- Moderate portions of dairy products
- Limited intake of red met
- Glucagon -like peptide receptor agonist (GLP-1 agonist) drug class
- In persons with diabetes and chronic kidney disease who have increased risk of cardiovascular (heart) event, GLP-1 agonist may reduce risk of progression of albuminuria, cardiovascular events or both
- Liraglutide (Victoza)
- Semaglutide (Ozempic)
- Sodium-glucose cotransporter 2 inhibitor (SGLT-2 inhibitor) drug class can decrease progression of chronic kidney disease
- Useful if estimated glomerular filtration rate is >/= 30 mL/min/1.73 m2 and urinary albumin > 30 mg/g creatinine particularly if urinary albumin > 300 mg/g creatinine
- Specific medications include empagliflozin (Jardiance), dapagliflozin (Farxiga), canagliflozin (Invokana)
Along with healthy eating and medications, moving your body each day is key for staying healthy. The 2020 ADA Standards of Care Guidelines recommends at least 150 minutes a week, that’s less than 22 minutes each day, of moderate-intensity physical activity such as brisk walking. This will not only help you manage your weight and lower your stress, but also help lower your blood glucose and blood pressure, which will essentially help reduce your risk for chronic kidney disease and many other potential complications.
Back to NT, after sharing with his physician, and CDCES his concerns and fears, he felt less guilt and hopelessness. His diabetes treatment plan was adjusted to add Jardiance 10 mg once daily. He felt empowered and motivated to continue proactively self-managing his diabetes, hypertension and chronic kidney disease.
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