Hello everyone! Today, we are discussing
about the kidney disease, and the
diabetic nephropathy, we call it. So, we'll
talk about how and why it happens,
and symptoms of diabetic kidney disease
and we're going to touch base on the
stages of the kidney disease, the risk
factors, how to prevent, and how to not
end up with dialysis, and we're gonna
talk about dietary measures at the end.
So, it's not a very super short video, but
it's not very exhausting either. So, if
you really want to get to the bottom of
this issue you better stick around until
the end of this video, and you will be a
pro, I promise,
understanding the kidney disease. Let's
get started. I'm Doctor Ahmet Ergin. I'm an
endocrinologist who has great passion in
helping people with diabetes all around
the world. As you may know diabetes is
the leading cause of kidney disease, at
least in the USA. About one third of
patients with diabetes, currently has
kidney disease,
whether they know or not.
More commonly,
my relatively new patients have little
to no idea until I tell them that they
have kidney disease. They get upset
because they just didn't know or didn't
hear that from their GP before and I'm
the bad guy just breaking the news. The
unawareness is so common among the people
that even with stage 4 kidney disease,
they have no idea. Less than 40%
of these individuals are aware of their
disease. I want my patients to know
everything about what is going on.
Anyhow, diabetic nephropathy affects your
kidneys ability to do the usual work of
removing the waste products, and extra
fluid from your body. As a result, you
start feeling sluggish, tired, and swollen
when those substances are not removed.
The best way to prevent or delay the
diabetic nephropathy is by maintaining a
blood sugar, as close to normal as
possible, and treating your cholesterol,
obesity, and high blood pressure. Easier
said that done, right? We'll talk more
about that later. Over many years, though,
diabetes, slowly damages your kidneys.
Acting early may prevent or slow the
disease progress
and reduce the chance of ending up with
dialysis. When your kidney disease
progresses to total kidney failure, we
call that end-stage kidney disease. At that point,
patient will need dialysis permanent.ly
The whole purpose of this video is that,
you guys, hopefully, will not need to go
to dialysis,
after understanding this disease process
and taking the appropriate actions. But
more than 50,000 people with end-stage
kidney disease from diabetes, are on
dialysis right now in the US. So, do not
wait for your doctor to do something.
Like I said, half the time your doctor
may not even tell you that you have
kidney disease, until you have stage 4
kidney disease. Don't ask me why. That
brings us to the stages of kidney
disease, so let's talk about that. So, most
of the time, doctors will detect a
protein in the urine, as a first sign of
chronic kidney disease, okay. So, that's
like even before any stage. At that stage,
your GFR, which is your Glomerular
Filtration Rate, will possibly be normal
or even higher than expected. So, do not
assume that your kidneys are completely
normal, because your GFR is not
highlighted in red on your report.
So, don't try to doctor yourself. So, when
your albumin in the urine is between
30 to 300 milligram per gram, you have
something called microalbuminuria. And if
the number goes above 300, then we call that
macroalbuminuria. Should this happen, the
worsening of chronic kidney disease
becomes faster. So, normal kidney function,
look at the GFR, is considered to be
above 90. When the GFR goes between 60
and 90, this is called stage 2 kidney
disease. When your GFR goes between 30 or
goes below that 60 range, between 60 and
30, that's stage 3. So, when the gfr is
between 15 to 30, that is stage 4.
And the gfr below 15 is stage 5
kidney disease. So, most patients with GFR
below 15 will need dialysis,
unfortunately,
and the stage 5 and lower GFR is
definitely life threatening, unless you
go to dialysis.
At that stage, you basically are
left with dialysis as the only option. So,
what does your kidneys really do and
what happens when they fail? Well, the
main job of kidneys is to filter wastes
and extra water out of your blood,
and it makes urine. Your kidneys also
help control the blood pressure, and make
hormones such as aldosterone, adrenaline,
and renin, to help regulate the blood
pressure. When your kidneys are damaged,
they cannot filter blood like they should,
which can cause wastes to build up in
your body. These toxic substances that
accumulate in your body
can also cause other health problems
such as heart failure or even cardiovascular
disease, that includes the heart attacks
or strokes, god forbid. So, let's review
how the damage to kidneys happen with
diabetes. Well, first of all, high blood
sugars in your bloodstream causes your
blood cells to become sticky. They tend
to stick to one another, and along the
sides of the blood vessels. The blood
vessels then become inflamed, which
attracts even more inflammation and
inflammatory chemicals to the area. This
makes the inflammation even worse,
because it becomes a vicious cycle.
Remember how I said the insulin
resistance was also a major culprit in
causing the problem, it's because of
fatty acids. This means that you are
having these blood vessel changes even
before you have the real diabetes. So,
when fatty acids and glucose attach the
endothelial wall on your kidney
arterioles, which are the small arteries
within the kidneys,
they become larger, and the blood flow
increases to the kidney. The whole
filtering system is affected. This lasts
only a short while before the kidneys
begin to burn out. That is when you start
having chronic kidney disease, because
healthy cells in the kidney die of pre
early in the diabetic kidney disease. The
blood flow unfortunately starts to drop
and we measure the blood flow through
the kidneys, using what?
We just learned: GFR, the glomerular
filtration rate. You can find your GFR on
your lab test, where the kidney testing
is reported,
where the creatinine and BUN are,
you know, basically a CMP or BMP.
There will often be two values: one for
african-americans and one for all others.
Find the one that fits you, and look it
up on that stage. See where you are fitting,
as we discussed before.
Another important thing that happens in
the diabetic kidney disease is that the
glucose absorption increases. That means
that even if the glucose is filtered in
the urine, it gets reabsorbed easily back
into your bloodstream. Well, this causes
the blood sugar to remain high, and at
this point, kidneys' ability to excrete
the excess sugar is also gone. So, what
are the other names for diabetic kidney
disease, you're going to ask. Well you can
call it a diabetic kidney disease as DKD
in short, or CKD, or you can call this
"kidney disease of diabetes" or "diabetic
nephropathy". So, now, you all know all the
terms about that. Let's talk about
whether you are at risk for kidney
failure. Well, if your age is increasing,
which happens to everybody, that's a risk
factor. And if you're older than me,
that's definitely a risk factor. So, the
longer you have diabetes, and other risk factors,
the more chance is there to develop the
diabetic kidney disease.
Now, interestingly something that you cannot
control, which is race and ethnicity, can
be a risk factor. So, if you're an
african-american, latino, or american
indian, you are at higher risk
unfortunately.
Interestingly, chronic kidney disease due
to diabetes is more common in women than
men. Now, diabetic kidney disease is also
more common in people with a low
socioeconomic status.
Unfortunately, people with low
socioeconomic status, tend to see doctors
less often. Unfortunately, they also tend
to be less educated to prevent kidney
disease. Another one is obesity, is a risk
factor.
It's been listed as an independent risk
factor, even without diabetes. So, diabetic
patients, who are overweight, are
definitely adding more risk for diabetic
kidney disease, if they are morbidly
obese. Just like obesity, smoking can also
be a huge risk factor, independent of
diabetes. And when combined with diabetes,
smoking can be
super detrimental to your kidney
function. If you have diabetes and your
blood sugars remain high for years and
years, that will definitely put a huge
toll on your kidneys. Now, the high blood
pressure is also extremely important in
the progression of kidney disease, so,
do not, please, do not ignore your blood
pressure and keep it under control.
The best blood pressure for kidneys
is any blood pressure below 120 over 80.
As in many diseases, genetic factors also
contribute to the development of the
kidney disease, especially due to
diabetes. So, if your family members
developed kidney disease or kidney
failure due to diabetes, you have to be
extra careful. So, acute kidney injury
also is another thing that happens
sometimes on top of chronic kidney
disease, that also acutely lowers your
kidney function, and it may not come back.
So, those people are generally dehydrated,
and make sure that, understand that
dehydration definitely can trigger acute
over chronic kidney disease, so if you're
on drugs like Jardiance, Farxiga or
Trulicity, you have to be a little extra
careful for not to get dehydrated. So, how
can I tell if I have diabetic kidney
disease. What are the symptoms?
Most people with diabetic kidney disease
do not really have symptoms, unless, you
are in acute kidney failure, you will
have very little to no urination. But
with chronic kidney disease, it does not
really give symptom, until it's like
late stages. The only way that you know
if you have diabetic kidney disease is
to get your kidneys checked. In my clinic
I always monitor kidney function
regularly along with the A1C values and
the cholesterol, etc. How to manage,
prevent and treat diabetic disease, then?
Well, number one: control blood sugars,
right. So, when it comes to controlling
blood sugars, as an endocrinologist,
I always aim for
as low as reasonably achievable for
blood sugars. It means that, we strive to
keep the blood sugar as close to normal as possible,
without causing significantly low blood
sugar, which, in other words, is
hypoglycemia. Keeping A1C less than 7 and
if possible less than 6.5 is the
ultimate goal for most younger patients.
For patients over 80 years of age, then
for them, if they have too many problems,
it may make it more difficult to prevent
a low blood sugar. And in that case,
A1C goals, sometimes, is a little higher.
Remember, continuous glucose monitoring
systems, such as DexCom and Freestyle
Libre are extremely helpful to prevent
low blood sugars, especially if you are
already experiencing that. They also help
to control high blood sugars, because it
gives you the data that you have been
looking for. Number two: the blood
pressure control. Well, intensive blood
pressure control is extremely important,
in addition to your blood sugar control.
Remember, the magic number is
130 over 80. Keep it at that or lower.
Blood pressure control only reduces
kidney disease progression, I mean not
only it reduces kidney progression, but
also it reduces the death from
cardiovascular disease, such as stroke
and heart attacks. You should also know
that the chronic kidney disease itself
is a risk factor for heart attacks and
strokes, guys. Also, remember most patients
die from heart attacks and strokes even
before they end up with dialysis, due to
chronic kidney disease. So, preventing
heart disease and strokes are extremely
important. The most common agents we use
for blood pressure and blood pressure
control in patients with diabetes are
called ACE inhibitors or angiotensin
receptor blockers. So, talk to your doctor
about that. Number third is the obesity.
Obesity and diabetic disease is a
very important, the obesity alone is, a
huge risk factor as we discussed
previously. So, try to do your best,
try to keep your weight as low as possible.
Cholesterol. Now, reducing cholesterol
level, especially the LDL, is extremely
important. So, don't listen to those guys
saying that, "oh LDL is good for you".
That's total BS, okay? Most people resist
the idea of cholesterol medications
based on what they hear or see on the
internet or TV, please read from reliable
resources, and watch people with credible
credentials. I have not yet met a
credible endocrinologist or a
cardiologist who claim that the high LDL
is okay for you. Nor I read a credible
study showing that high LDL is okay
either. So I don't know where these
people are getting their information
from. Here is a diet question: Do I need
to reduce protein in my diet, especially
if i have chronic kidney disease? Well,
the role of protein restriction is
really unclear, unfortunately. But I would
still avoid excessive protein and try to
stick to around 50 to 60 grams of
protein daily, which is the commonly
recommended protein amount by most
nephrologists and the organizations for
kidney disease. So, how to prevent, how
often to monitor diabetic kidney disease?
Well, patients with chronic kidney
disease, especially due to diabetes,
should be seen by their doctors and have
a follow-up every 3 to 6 months.
I prefer 3 months. Now, the
endocrinologist or diabetes specialist
will review
not only the labs, but also blood
pressure control, and review the
medications that may need to be changed
if necessary.
In our diabetes center, we target the A1C,
the blood pressure, the blood cholesterol
control, all together in a holistic way.
This approach is the most effective
approach to reduce the chronic kidney
disease, not only to control the blood
sugar. So, here's another question: How
soon will I go to dialysis
when I have chronic kidney disease?
That's extremely common question.
Well, not all the individuals have
progressive loss of kidney function,
that's the good news.
So, some studies show
a high rate of progression, while the
others report a relatively stable
disease. And again most studies indicate
that the blood pressure cholesterol
control makes or breaks it. That also
depends on the degree of chronic disease
as well., and all the risk factors we just
discussed. Patients who have good glucose
control, the good blood pressure control,
and the cholesterol control are very
lucky, because they typically stay stable.
Especially if they are on the right
medications to prevent kidney disease,
the chances of progressing to dialysis
is way way lower. So, guys, thank you for
watching. And I hope you do not have
kidney disease, and if you do I hope it
just remains stable or even get better.
So, if you like this video, give a thumbs
up, share and like. And we'll see you in
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