kidney disease or damage. Diabetic nephropathy is damage to your kidneys caused
diabetes. In severe cases it can lead to kidney
failure. But not everyone with diabetes has kidney damage.
The kidneys have
many tiny blood vessels that filter waste from your blood. High blood sugar
from diabetes can destroy these blood vessels. Over time, the kidney isn't able
to do its job as well. Later it may stop working completely. This is called
For reasons doctors don't yet understand, only
some people who have diabetes get kidney damage.
Certain things make you more likely to get diabetic nephropathy. If you
high blood pressure or high cholesterol, or if you smoke, your risk is
higher. Also, Native Americans, African Americans, and Hispanics (especially
Mexican Americans) have a higher risk.
There are no symptoms in
the early stages. So it's important to have regular urine tests to find kidney
damage early. Sometimes early kidney damage can be reversed.
As your kidneys are less
able to do their job, you may notice swelling in your body, most often in your
feet and legs.
is diagnosed using simple tests that check for a protein called
albumin in the urine. Urine doesn't usually contain
protein. But in the early stages of kidney damage—before you have any
symptoms—some protein may be found in your urine, because your kidneys aren't
able to filter it out the way they should.
Finding kidney damage
early can keep it from getting worse. So it's important for people with
diabetes to have regular testing, usually every year.
The main treatment is medicine
to lower your blood pressure and prevent or slow the damage to your kidneys.
These medicines include:
As damage to the kidneys gets worse,
your blood pressure rises. Your
triglyceride levels rise too. You may need to take more than one medicine to treat these complications.
And there are other steps
you can take. For example:
best way to prevent kidney damage is to keep your blood sugar in your target range and your blood pressure under control. You do this by eating healthy foods, staying at a healthy weight, exercising regularly, and
taking your medicines as directed.
At the first sign of protein in
your urine, you can take high blood pressure medicines to keep kidney damage
from getting worse.
Learning about diabetic nephropathy:
Living with diabetic nephropathy:
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There are no symptoms in the early stages of
diabetic nephropathy. If you have kidney damage, you may have small amounts of protein leaking into your urine (microalbuminuria).
Normally, protein is not found in urine except during periods of high fever,
strenuous exercise, pregnancy, or infection.
Not everyone with diabetes will develop diabetic nephropathy. In people with
type 1 diabetes, diabetic nephropathy is more likely to develop
5 to 10 years or more after the onset of diabetes. People with
type 2 diabetes may find out that they already have a
small amount of protein in the urine (microalbuminuria) at the time diabetes is
diagnosed, because they may have had diabetes for several years.
As diabetic nephropathy progresses, your kidneys cannot do their job as well.
They cannot clear toxins or drugs from your body as well. And they cannot balance the chemicals in your blood very well. You may:
You may have symptoms if your nephropathy gets worse. These
If the kidneys are severely damaged, blood sugar levels may drop because
the kidneys cannot remove excess
insulin or filter oral medicines that increase insulin
Diabetic nephropathy is diagnosed using tests that check for a protein (albumin)
in the urine, which points to kidney damage. Your urine will be
checked for protein (urinalysis) when you are diagnosed with
Microalbumin urine tests can detect
very small amounts of protein in the urine that cannot be detected by a routine
urine test, allowing early detection of nephropathy. Early detection is
important, to prevent further damage to the kidneys. The results of two tests,
done within a 3- to 6-month period, are needed to diagnose nephropathy.
When to begin checking for protein in the urine depends on the type of
diabetes you have. After testing begins, it should be done every year.1
Type 1 diabetes
After you have had diabetes for
Type 2 diabetes
When you are diagnosed with
Diabetes present during
After age 10 and after the child has had diabetes for 5 years
A microalbuminuria dipstick test is a simple test that can
detect small amounts of protein in the urine (microalbuminuria, also called
proteinuria). The strip changes color if protein is present, providing an
estimate of the amount of protein. A spot urine test for microalbuminuria is a
more precise lab test that can measure the exact amount of protein in a
urine sample. Either of these tests may be used to test your urine for protein.
You will also have a
creatinine test done every year. The creatinine test
is a blood test that shows how well your kidneys are working.
your doctor suspects that the protein in your urine may be caused by a disease
other than diabetes, other blood and urine tests may be done. You may have a
small sample of kidney tissue removed and examined (kidney biopsy).
It is important to check your blood
pressure regularly, both at home and in your doctor's office, because blood
pressure rises as kidney damage progresses. For most people who have diabetes, the ideal blood pressure is below 120/80. High blood pressure is 140/80 or higher when you have diabetes. In between these two levels is called prehypertension.
Keeping your blood pressure at or
below your target can prevent or slow kidney damage.
triglycerides also should be checked regularly to see
nephrotic syndrome, or other factors are raising your
blood cholesterol level.
High cholesterol can increase the risk of hardening of
the arteries (atherosclerosis), possibly leading to heart disease,
peripheral arterial disease, and stroke.
Diabetic nephropathy is treated with medicines that lower blood pressure and
protect the kidneys. These medicines may slow down kidney damage and are started
as soon as any amount of protein is found in the urine (microalbuminuria). The
use of these medicines before nephropathy occurs may also help prevent
nephropathy in people who have normal blood pressure.
If you have
high blood pressure, two or more medicines may be
needed to lower your blood pressure enough to protect the kidneys. Medicines
are added one at a time as needed.
you take other medicines, avoid ones that damage or stress the kidneys,
nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include ibuprofen and naproxen.
It is also important to keep your blood sugar within your target range. Maintaining blood sugar levels within your target range prevents
damage to the small blood vessels in the kidneys.
amount of salt in your diet can help keep your high blood pressure from
getting worse. You may also want to restrict the amount of protein in your
diet. If diabetes has affected your kidneys, limiting how much protein you eat
may help you preserve kidney function. Talk to your doctor or
dietitian about how much protein is best for you.
Medicines that are used to treat
diabetic nephropathy are also used to control blood
pressure. If you have a very small amount of protein in your urine, these
medicines may reverse the kidney damage. Medicines used for initial treatment
of diabetic nephropathy include:
If you also have high blood pressure, two or more
medicines may be needed to lower your blood pressure enough to protect your
kidneys. Medicines are added one at a time as needed.
If you take other
medicines, avoid ones that damage or stress the kidneys, especially
nonsteroidal anti-inflammatory drugs (NSAIDs).
It is also important to keep your blood sugar within your target range to prevent damage to the small blood vessels in the kidneys.
diabetic nephropathy progresses, blood pressure
usually rises, making it necessary to add more medicine to control blood
may advise you to take the following medicines that lower blood pressure. You
may need to take different combinations of these medicines to best control your
blood pressure. By lowering your blood pressure, you may reduce your risk of
kidney damage. Medicines include:
Continue to avoid other medicines that may damage
or stress the kidneys, especially
nonsteroidal anti-inflammatory drugs (NSAIDs). And it is still important to keep your blood sugar within your target range, eat healthy foods, get regular exercise, and not smoke.
If damage to
the blood vessels in the kidneys continues,
kidney failure may eventually develop. When that occurs,
it is likely that you will need
dialysis treatment (renal replacement therapy)—an
artificial method of filtering the blood—or a kidney transplant to survive. To
learn more, see the topic
Chronic Kidney Disease.
Diabetic nephropathy can
get worse during pregnancy and can affect the growth
and development of the fetus. If your nephropathy is not severe, your kidney
function may return to its prepregnancy level after the baby is born. If you
have severe nephropathy, pregnancy may lead to permanent worsening of your
If you have
nephropathy and are pregnant or are planning to become pregnant, talk with your
doctor about which medicines you can take. You may not be able to take some
medicines (for example, angiotensin-converting enzyme [ACE] inhibitors or angiotensin II receptor blockers [ARBs]) during pregnancy, because they
may harm your developing baby.
Prevention is the best way to avoid
kidney damage from
If you already have diabetic nephropathy, you may be able
to slow the progression of kidney damage by:
The American Diabetes Association (ADA) is a national organization
for health professionals and consumers. Almost every state has a local office.
ADA sets the standards for the care of people with diabetes. Its focus is on
research for the prevention and treatment of all types of diabetes. ADA
provides patient and professional education mainly through its publications,
which include the monthly magazine Diabetes Forecast,
books, brochures, cookbooks and meal planning guides, and pamphlets. ADA also
provides information for parents about caring for a child with diabetes.
The National Diabetes Education Program (NDEP) is
sponsored by the U.S. National Institutes of Health (NIH) and the U.S. Centers
for Disease Control and Prevention (CDC). The program's goal is to improve the
treatment of people who have diabetes, to promote early diagnosis, and to
prevent the development of diabetes. Information about the program can be found
on two Web sites: one managed by NIH (http://ndep.nih.gov) and the other by CDC
This clearinghouse provides information about research
and clinical trials supported by the U.S. National Institutes of Health. This
service is provided by the National Institute of Diabetes and Digestive and
Kidney Disease (NIDDK), a part of the National Institutes of Health (NIH).
The National Kidney and Urologic Diseases Information
Clearinghouse (NKUDIC) provides information about diseases of the
kidneys and urologic system to people with these problems and to
their families, to health professionals, and to the public. NKUDIC answers
inquiries; develops, reviews, and distributes publications; and works closely
with professional and patient groups and government agencies to
coordinate resources about kidney and urologic diseases.
NKUDIC, a federal agency, is a service of the National
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIDDK is part
of the National Institutes of Health under the U.S. Department of Health and
The National Kidney Foundation works to prevent kidney
and urinary tract diseases and help people affected by these conditions. Its
website has a lot of information about adult and child conditions. The site
has interactive tools, donor information, recipes for kidney disease patients,
and message boards for many kidney topics. Free materials, such as brochures
and newsletters, are available.
American Diabetes Association (2013). Standards of medical care in diabetes—2013. Diabetes Care, 36(Suppl 1): S11–S66.
Other Works Consulted
American Diabetes Association (2013). Standards of medical care in diabetes—2013. Diabetes Care, 36(Suppl 1): S11–S66.
Brownlee M, et al. (2011). Complications of diabetes mellitus. In S Melmed et al., eds., Williams Textbook of Endocrinology, 12th ed., pp. 1462–1551. Philadelphia: Saunders.
Molitch ME, Genuth S (2006). Complications of diabetes mellitus. In DC Dale, DD Federman, eds., ACP Medicine, section 9, chap. 3. New York: WebMD.
Parving H, et al. (2008). Diabetic nephropathy. In BM Brenner, ed., Brenner and Rector's The Kidney, 8th ed., vol. 2, pp. 1265–1298. Philadelphia: Saunders Elsevier.
Shlipak M (2010). Diabetic nephropathy: Preventing progression, search date November 2009. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.
January 17, 2013
E. Gregory Thompson, MD - Internal Medicine
& Tushar J. Vachharajani, MD, FASN, FACP - Nephrology
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