One in nine adults in Western world has chronic kidney disease (CKD). However, a lot of people do not realize that they have reduced kidney function. Therefore, they do not realize that they can take steps to protect their kidneys from further damage. The progression of CKD has crucial importance.

What is CKD?
It means decreased function of the kidneys. Overtime, the condition may progress and kidneys suffer major damage. The purpose of this road map is not produce fear but provide patients with information that will help them to take control of their healthcare and do what is necessary to preserve and protect their kidney function. There lots of healthy conditions that may lead to CKD and at the same time many things that patients should know and will significantly impact their kidney function.

Probably the most common misconception about CKD is that patients do not have to worry about it at the moment of diagnosis. They believe that their kidneys functioning well , everything is fine in a way that kidney failure won’t happen to them. Patients should not let this happen to them. There are things that patient can do to maintain or improve their health and at the same time to protect their kidneys from further deterioration. CKD does not go away. This is not something you can watch for a while and then suddenly everything becomes “normal” again and no one has to worry about CKD. On the contrary, CKD means greater risk for kidney failure. No actions mean increased chances for kidneys to fail. It is very important that the patient is involved in his health care, learning and doing what is needed which will make a difference in his overall health.

There are several conditions and diseases that can eventually lead to CKD. Nowdays, diabetes and hypertension are the most common causes of CKD. Diabetes Mellitus is responsible for the 44% of patients that start hemodialysis in the United States and for the 38% of patients under any stage of CKD. The above does not mean that who ever has diabetes or hypertension will develop CKD.  On the other had it does mean that the above person has to have under consideration what is necessary to maintain his health.

Diabetes is a condition in which patient has high blood glucose (sugar) levels caused either a reduction or lack of insulin or resistance to it in the body. High glucose can significantly affect the structure and function of blood vessels. Very close to the western style of life is diabetes type II where the body does not react to insulin in normal fashion and is often associated with obesity and occurs often after the age of 30. Over the time insulin deficiency results in abnormal metabolism of carbohydrates, fat and protein and small vessel of the kidney can be affected causing destruction of the filters of the kidney.

Hypertension (high blood pressure) provokes damage to the blood vessels, causing ischemia and accelerating the progression of kidney disease.

Glomerulonephritis is an inflammation of the filters of the kidneys autoimmune or unknown cause. It may cause nephrotic syndrome and CKD. Definite diagnosis can be made by kidney biopsy.

Hereditary diseases, such as polycystic kidney disease (PKD) may also cause CKD. PKD, most common disease in this category, characterized by abnormal sacs , called cysts which contain fluid, gas or tissue. As these cysts grow, they block normal kidney function. Cysts may be infected and can bleed.

Autoimmune diseases such as Systemic Lupus Erythematosus may cause inflammation in all organs in the body, including the kidneys.

Common questions regarding diabetes

If I do not watch my blood sugar levels, what can happen to my kidneys?
If you have diabetes, it is because your body does not make enough insulin or cannot properly use the insulin it does make. Your body uses insulin to convert sugar into energy. If your body does not have the insulin it needs to do this, the sugar stays in your blood and damages part of your body. In that case your kidney’s glomeruli (the filtering system of the kidney) may be damaged.

How else can diabetes damage my kidneys?
An early sigh of kidney damage is when your kidneys leak small amounts of a protein called albumin into the urine. This is called microalbuminuria. With more damage, the kidneys leak more and more protein. This condition is called proteinuria. This damage gets worse until the kidneys fail. When there is protein I the urine, it increases the chance of heart disease.

>How can I prevent diabetic kidney problems?

• Keep sugar as close to normal as you can.
• Keep your blood pressure below 130/80 to help prevent kidney damage. Keep your blood pressure under control will also slow damage to your eyes, heart and blood vessels.
• Follow the health eating plan you work and in particular reduce the salt in your diet.
• Have your kidneys check at least twice a year by having your urine tested for small amounts of protein.
• See a doctor immediately if you think you have a kidney infection (pain or burning when you urinate, frequent urge to go to the bathroom, urine that looks cloudy, reddish or brown, fever, pain in your back)

The early signs of CKD may not be clear enough and therefore many people do not realize their problem. The symptoms may include high blood pressure, swelling, blood in the urine. The only way to find out is a blood test for creatinine and urine test for detecting protein in the urine. It is important for anyone to have an active role in his healthcare and understands his condition, whatever challenges he faces, it will be less complicated to adjust to.

What tests may be performed to gauge kidney function?

• Complete blood count (CBC)
  It is a very common test that tells a lot about what is happening with the kidneys. There are three bacic types of cells in the blood: red cells that carry oxygen to body tissues and remove carbon dioxide, white cells that fight infections and any invador of the body and platelets that help stop bleeding. There are important to perform vital bodily functions.
• Creatinine and creatinine clearance
  Creatinine is filtered out of the blood by the kidneys and then passed out of the body in the urine. It is a waste product of muscle tissue. A creatinine clearance test measures how well creatinine is removed from the blood by the kidneys and provides a more precise measure of how well the kidneys are working.
• 24-hour urine collection for protein in the urine
  The amount of protein in the urine produced in 24 hours is measured in the laboratory. Normally there is little or no protein in the urine. Increased amounts of protein indicated impaired kidney function. Protein in the urine is called proteinuria. Very small amounts of protein in the urine are referred to as microalbumin. Microalbumin is an early sign of diabetic nephropathy in patients with diabetes.
• Urea, blood electrolyte tests
  Urea is a waste product formed when protein is broken down in the body. Urea is produced in the liver and eliminated from the body in the urine. If the kidneys are not able to remove urea from the blood normally ,its levels increases. It is a blood test. Electrolytes are also filtered out of the body by the kidneys. If there is altered levels of the following electrolytes in the blood, it may mean the kidneys are not functioning well: potassium, sodium, phosphate, calcium, magnesium.
• Kidney biopsy
  A diagnostic test where a small piece of kidney tissue is removed by a needle. The tissue is looked at under a microscope to determine the cause of kidney failure.
• Hba1C
  A blood test that gives an estimate of blood glucose control over several months.

How is percentage of kidney function measured?
It is measured by comparing the amount of waste products in the urine to the amount in the blood stream. The waste product most frequently measured for this purpose is creatinine, which is a a waste product of muscle tissue. Creatinine clearance is used to describe the ratio of the amount of creatinine in the urine to that in the blood plasma and is a tool to calculate kidney function. A normal creatinine clearance ranges from 80-130. Instead the doctor may uses a blood value and adjusts for the person’s size, age, gender and race. This formula is called Glomerular Filtration Rate (GFR). There are five stages of CKD based on GFR:

• Stage 1: GFR> 90
• Stage 2: GFR 60-90
• Stage 3: GFR 30-60
• Stage 4: GFR 15-30
• Stage 5: GFR <15

What can a person with CKD do to protect the function of his kidneys?

• Control high blood pressure (medication, life style)
• Control blood sugar
• Reduce amount of protein
• Maintain healthy levels of fat (lipids)
• Exercice
• Quit smoking

Medications

How does high blood pressure damage the kidneys?

HTN is a condition that can damage your kidneys. Your kidneys act like a filtering system to get rid of excess water and wastes in the blood. Blood pressure is the force, or pressure, of the blood on the walls of your blood vessels. Over time, uncontrolled high blood pressure can damage the blood vessels and nephrons (filtering units) in the kidneys. The damaged nephrons can not do their job of filtering out all of the wastes , sodium and excess fluids from your blood. The excess fluid and sodium stays in your bloodstream putting extra pressure on the walls of your blood vessels- raising your blood pressure even more. This extra pressure leads to further kidney damage. High blood pressure also affects many other organs, slowly destroying them. This includes the heart, brain and eyes.

My doctor told me that controlling my kidney disease means controlling my blood pressure. What does this mean?

Blood pressure is considered high if the top number (systolic pressure) is equal to or greater than 130 mmHg or the bottom number (diastolic pressure), is more than or equal to 80 mmHg. HTN can be both a cause and result of kidney disease. Patients with protein in their urine should have blood pressure controlled to 130/85 mmHg or lowered to 125/75 mmHg. This can help preserve kidney function and protect the kidneys from further damage.

HTN aggravates atherosclerosis, increases the workload on the heart and may lead to heart failure. HTN increases the risk of coronary artery disease, aneurysms, stroke, kidney disease, and eye problems. Most patients with HTN eventually develop microalbuminaria.

Are there medicines to slow down kidney damage?

Yes. The strategy to control blood pressure is to use medicines that have additional benefits. Angiotensin is a hormone your body makes that constricts smooth muscles in the vessels of the kidney and in other vessels as well. There are two types of drugs that can block this hormone: angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). ACE inhibitors decrease your blood pressure by opening or dilating blood vessels. ARBs work by blocking the hormone that causes blood vessels to narrow. Both types of drugs have been shown to help reduce the progression of kidney disease, especially in diabetics.

Calcium channel blockers (dilates the blood vessels by relaxing the muscles in the vessel walls ) are also useful antihypertensive drugs, but are generally recommended for use once you are already on an ACE inhibitor or ARB. Other drugs such as b blockers are also used. Diuretics are also used to remove extra sodium and fluid from the body. Eliminating excess fluid may lower your blood pressure and assist the other drugs mentioned above.

Blood pressure can also be reduced with diet, especially one lower in salt, and exercise which is very important. But most people with hypertension will also need to take medication over the course of their lifetime in order to achieve optimal blood pressure and slow the progression of CKD.

A friendly note: Do not let this information overwhelm you. Education is the key to living life and knowledge is power! Having diabetes and HTN does not mean you will experience kidney failure. On the other hand persons with diabetes and HTN must be extra alert about their kidney health!