Diabetic nephropathy

 

What is diabetic nephropathy?

Some people with diabetes develop problems with their kidneys. That’s because having diabetes can sometimes damage your kidneys over many years, causing diabetic kidney disease – otherwise known as diabetic nephropathy.


If you have type 1 diabetes, you’re slightly more likely to develop diabetic kidney disease than someone with type 2 diabetes. According to Patient UK, around one in seven people with type 1 diabetes develops the early stage of diabetic kidney disease five years after their diabetes diagnosis (i). Thirty years after a type 1 diabetes diagnosis, about four in 10 people will have developed early-stage diabetic kidney disease.
 
In comparison, around one in eight people with type 2 diabetes have early-stage diabetic kidney disease when they’re first diagnosed (this doesn’t mean kidney disease develops more quickly in people with type 2 diabetes, rather that many people with type 2 diabetes have the condition for years before it’s diagnosed). Of those who don’t have any problems when they’re first diagnosed, around one in seven develops early-stage kidney disease and one in 20 develops late-stage kidney disease within five years.

Having diabetes and kidney disease can also cause high blood pressure, which increases your risk of heart attacks and strokes. This may contribute to the fact that people who have diabetes have a higher-than-average risk of having a heart attack or a stroke. Having diabetic nephropathy also means you may be more susceptible to developing diabetic foot and eye problems. And while having diabetes and kidney disease increases your risk of having high blood pressure, on the flip side having diabetes and high blood pressure raises your risk of kidney disease too.
 

What is the relationship between diabetes and kidney disease?

Your kidneys have several important jobs to do, including maintaining your fluid balance, regulating your blood pressure, making certain hormones, keeping the levels of some blood chemicals balanced and filtering waste substances from your blood.
 
Blood is supplied to the many tiny capillaries found in each of your kidneys via the renal artery. In the outer part of your kidneys, these capillaries group together to form filtering structures called glomeruli that pass waste products, water and salt into little channels called tubules (there are around a million glomeruli and connected tubules in each kidney – each glomerulus/tubule combination is called a nephron (ii)).
 
However, the nephrons can become damaged if you have diabetes, since having high levels of sugar in your blood can increase levels of chemicals in the kidney that affect them, making them thicker and prone to leaking. When this happens, your kidneys start to leak a type of protein called albumin, which ends up in your urine. They also become increasingly unable to do a proper job of removing waste products from your blood and maintaining healthy fluid levels in your body.
 
If your kidneys are healthy, there should be no albumin or just a tiny amount in your urine. If your urine contains more albumin than it should, it’s usually the earliest sign that your kidneys have been damaged by high levels of sugar in your blood.
 
Meanwhile having high blood pressure can cause the same problems with your kidneys’ filtering elements, again causing high levels of albumin in your urine.
 

Who is most at risk of developing diabetic kidney disease?

Anyone who has diabetes can develop diabetic kidney disease, though men are more likely to be affected than women. Having poorly managed blood sugar levels and high blood pressure increases your risk even further. Meanwhile other factors that can make you more likely to develop diabetic kidney disease include:
 

• Your age (the older you are, the more likely you are to develop problems with your kidneys)

• How long you’ve had diabetes (if you’ve had diabetes for a long time your risk is higher than that of someone who was diagnosed more recently) 

• Being overweight (the heavier you are, the greater your risk) 

• Smoking 

• Being Black or of South Asian origin 

• Having a family history of kidney disease 

• Having other diabetes complications (including problems with your eyes or feet)  

• Having a family history of diabetes with complications 

 
Meanwhile if you’ve already developed early-stage diabetic kidney disease, it’s more likely your condition will progress to late-stage diabetic nephropathy if you have persistently high blood sugar levels, if you have high blood pressure, or if you smoke.
 

Stages and symptoms of diabetic nephropathy

The symptoms of diabetic kidney disease depend on which stage of the condition you’ve reached.
 

 Microalbuminuria

This is the name for the first stage of diabetic kidney disease, when small amounts of albumin leak into your urine. At this stage, your kidneys may have some damage but it’s likely they are still functioning well, or are functioning slightly below a normal level.
 
During this stage, it’s unlikely that you’ll notice any symptoms. Plus if treated, you may find the problem goes away in time. However, it can persist at the same level or advance to the next stage.
 

Proteinuria

Proteinuria is the later stage of diabetic kidney disease. Unlike microalbuminuria, however, proteinuria is irreversible, even with treatment, and is usually a sign that your kidney function is declining towards end-stage kidney failure at some point in the future. If you progress to this stage you may start to feel generally unwell, noticing symptoms such as:
 

• Tiredness and fatigue 

• Weight loss 

• Lack of appetite

• Headaches  

• Nausea 

• Insomnia  

• Breathing problems 

• Swollen ankles, feet or hands caused by fluid retention

• Muscle cramps  

• Itchy skin 

• Pale skin caused by anaemia 

• Puffy eyes 

• Nausea

• Blood in your urine

• Increased urination (especially at night) 

• Erectile dysfunction in men 

 

End-stage kidney failure

The final stage of diabetic kidney disease – is when your kidneys fail. When you get to this stage, you’ll usually need kidney dialysis or a kidney transplant (see below). Indeed according to Patient UK, diabetic kidney disease is the most common cause of kidney failure, with around one in five people needing dialysis having diabetic kidney disease (i).
 
The progression from early to end-stage kidney disease usually takes many years – according to the charity Kidney Care UK, it usually takes at least 10 years to progress to the stage where dialysis may be necessary (iii). However the earlier diabetic kidney disease is treated, the more likely you are to recover fully or stay at a level where your kidneys will continue to function.
 

Diabetic nephropathy treatment

 

How is diabetic nephropathy diagnosed?

Urine tests are among the tests most people with diabetes have every year as part of their annual review. Having these tests can help keep an eye on how well your condition is being controlled as well as checking for the development of complications, including diabetic kidney disease.
 
There are two tests that check how healthy your kidneys are:

• The ACR test checks for the amount of albumin compared with that of a substance called creatine in your urine (ACR is short for albumin:creatine ratio). You will be diagnosed with microalbuminuria if your ACR is greater than or equal to 2.5mg/mmol if you’re a man, or greater than or equal to 3.5mg/mmol if you’re a woman; or if you have an albumin concentration greater than or equal to 20mg/L. Proteinuria is detected when your ACR is greater than or equal to 30mg/mmol or albumin concentration greater than or equal to 200mg/L. 

• The eGFR test checks your glomerular filtration rate (eGFR is short for estimated glomerular filtration rate). It does this by checking how much creatinine – a breakdown product of muscle that’s normally filtered out of your blood by your kidneys – is in your blood. If your blood has higher-than-normal levels of creatine, it could be a sign that your kidneys aren’t working properly.

 

Diabetic kidney disease medicines

If your annual tests show you have problems with your kidneys, there are treatments available that may help prevent or delay early-stage diabetic kidney disease progressing to the later stages. The same treatments also help reduce your risk of developing problems with your cardiovascular system.
 

• ACE inhibitors – medicines often used to treat high blood pressure – have also been shown to have a protective effect on both the kidneys and the heart. They work by reducing the amount of a chemical in your bloodstream that makes your blood vessels narrow. Even if you don’t have high blood pressure you may be prescribed these medicines, as they are thought to help protect the kidneys from any further damage.

• ARBs – angiotensin II receptor blockers, also called angiotensin II receptor antagonists (AIIRAs) – work in a similar way to ACE inhibitors. These may be prescribed if you can’t take ACE inhibitors for any reason (if they cause side effects, for instance).

 
Whichever medicine you take, the aim is to get your blood pressure to 130/80g or lower. You may also be advised to take cholesterol-lowering medication to lower your risk of heart disease and stroke.
 
Other measures you may be advised about include keeping good control of your blood glucose levels – your GP or diabetes specialist will give you a target level to aim for. This will also help prevent or delay the progression of your kidney disease, as well as reduce your risk of developing cardiovascular problems.
 
Managing your blood sugar effectively includes taking your diabetes medicines regularly and as your GP or specialist has recommended, as well as making healthy lifestyle choices. Find out more about how your lifestyle can help in our guide to diabetes causes and treatments. 
 
However, if you‘ve progressed to end-stage kidney disease where your kidneys are no longer working, your main options are to have kidney dialysis or a kidney transplant (according to the National Institute for Health and Care Excellence – NICE – people with diabetes are five times more likely to need either kidney dialysis or a kidney transplant than people without diabetes (iv)).
 
Dialysis is a method of removing waste products and excess fluid from the blood – in other words, it does the work your kidneys should be doing themselves. This has to be carried out around three times a week or several times a day either at home or at a hospital, depending on which type of dialysis you’re having. A transplant is considered the better option, but according to The National Kidney Federation there is a severe shortage of kidneys available for transplantation (v). A kidney transplant is also a major operation, and afterwards you’ll have to take immunosuppressant medicines for the rest of your life. 
 

Is diabetic nephropathy reversible?

If you have early-stage diabetic nephropathy – or microalbuminuria – it’s possible that the condition can be reversed if you’re treated in time. If the problem has progressed to proteinuria, however, it is widely thought to be irreversible. This is a very good reason to make sure you have your annual urine and blood tests, as the earlier any problems with your kidneys are detected, the better.
 

Can diabetic nephropathy be prevented?

There’s no sure way to prevent diabetic kidney disease, but there are some steps you can take to reduce your risk of developing it. Keeping your blood sugar and blood pressure under control are perhaps the most important things you can do, so follow your GP’s or specialist’s advice on any medicines that have been prescribed for you and try to always go for any tests or other appointments they offer you.
 
Some of the other things you can do are related to your lifestyle:
 

• Avoid smoking, as this is associated with a higher risk of kidney disease as well as cardiovascular disease (vi). If you need help with managing your cravings for cigarettes, try a stop-smoking product such as nicotine patches, gum or lozenges. Find out more about quitting in our guide to stop smoking. 

• Eat a nutritious diet that includes at least five portions of fruit and vegetables a day with small amounts of sugar, salt and saturated fat. Your GP or specialist may also advise you to make specific changes to your diet that could help you manage your kidney disease, such as limiting foods that contain sodium, potassium and phosphorus as well as eating less protein. 

• Stay active as much as possible, as exercise can help keep your blood pressure at a normal level and keep your weight down. Aim to do at least 150 minutes of moderate exercise every week as well as exercise that strengthens all your major muscles twice a week.

• Drink alcohol in moderation, since too much can affect your blood pressure levels. Try to keep within the government’s current recommendations for drinking alcohol, which include having no more than 14 units of alcohol a week on a regular basis – find out more about cutting back on your drinking by reading our guide to alcohol misuse. 

 

Natural support for diabetes management

Certain nutritional supplements may also be worth considering if you’re aiming to prevent or delay the progression of diabetic kidney disease, especially those that have been shown to help with blood pressure control – though please be aware that supplements should never be used as an alternative to conventional diabetes medicines or medical care.

Meanwhile, if you have diabetes always check with your GP before taking these or any other supplements, as there’s a risk your blood sugar could dip too low and put you at risk of a serious complication called hypoglycaemia (hypo).

Find out more about hypos in our guide to diabetes. 

A good place to start may be to take a good-quality multivitamin and mineral product. This can help make sure you’re getting all the nutrients your body needs for your general health, which can be useful if you don’t always eat as healthily as you should.

Find out more about multivitamin supplements, including the variety of products on offer and which one may be suitable for you, by  reading our guide to multivitamins and daily requirements.

Other supplements you may want to consider include the following:
 

Cinnamon  

 
A natural remedy long used in traditional Chinese medicine, cinnamon is a spice that’s also often recommended by natural therapists for people with type 2 diabetes, as there is some evidence it may help support blood sugar levels (vii).
 

Alpha lipoic acid

 
There’s evidence to suggest this fatty acid and powerful antioxidant could help support blood sugar levels (viii) as well as improve insulin sensitivity in people with type 2 diabetes (ix). However, if you have diabetes always consult your GP before taking alpha lipoic acid as it may enhance insulin activity.
 

Magnesium

 
Researchers believe people who have diabetes may also have low magnesium levels (x), possibly because diabetes or the medicines used to treat it may cause magnesium deficiency. Some have also discovered magnesium may even help with blood sugar control (xi).
 

Turmeric

 
A compound found in the curry spice turmeric, curcumin is believed to have a number of potential health benefits, including the ability to reduce blood sugar levels (though to date most studies have been carried out in animals rather than humans, meaning the available evidence is weaker than it could be). Some researchers, however, have found that curcumin may help support blood sugar level control in a study that looked at its effects in people with diabetic foot ulcers (xii).
 

High-strength fish oils

 
Omega-3 fatty acids – particularly two found in oily fish such as salmon, trout, sardines and mackerel as well as fish oil supplements called EPA and DHA – are widely considered helpful for general health and wellbeing. One review of studies into omega 3 fatty acids and chronic kidney disease also suggests taking omega 3 supplements is associated with a reduced risk of end-stage kidney disease as well as a delay in the progression of chronic kidney disease (xiii).
 
Fish oil supplements are widely available, but vegetarians and vegans can get these beneficial omega-3 fats too by taking supplements that contain omega-3 oils derived from marine algae.
 

Fenugreek

 
Fenugreek seeds have a long tradition of use in some parts of the world, including in Ayurvedic medicine. These days, herbal practitioners recommend fenugreek seeds to people with diabetes, as they may help the body to produce insulin. There’s also some evidence fenugreek seeds may be helpful in controlling type 2 diabetes and reducing insulin resistance, though supporting studies to date are small in scale (xiv). However, don’t take fenugreek if you’re pregnant or breastfeeding.
 

Vitamin D

 
Best known for helping the body to absorb calcium, vitamin D is also thought to play an important part in regulating the immune system. However, some scientists believe people with chronic kidney disease may have severe vitamin D deficiency (xv). A review of studies also suggests that some chemical compounds that are similar to vitamin D may slow down the onset or progression of diabetic kidney disease (xvi).
 
Vitamin D deficiency is believed to be common in some countries including the UK, which explains why Public Health England advises adults and children over the age of one year old to consider taking a daily supplement containing 10mcg of vitamin D, particularly during autumn and winter (xvii).
 
However if your skin is rarely exposed to the sun – if you spend most of your time indoors, for instance, or if your skin is always covered when you’re out and about – you may need to take vitamin D throughout the year. People with dark skin from African, Afro-Caribbean and South Asian backgrounds should consider taking vitamin D all year round too, PHE advises.

The recommended form of vitamin D is vitamin D3 or cholecalciferol, as it’s the natural form of vitamin D that the body makes when it’s exposed to sunlight. Vitamin D3 supplements are available in tablet form, and now you can get them in veggie-friendly drops too. However most vitamin D3 supplements are made from the fat of lamb’s wool, which means they’re unsuitable for vegans. The good news is that vegan vitamin D3 supplements sourced from lichen are now more widely available.
 

High-strength anthocyanidins

 
Found in dark-skinned fruits such as blueberries, cranberries, raspberries, blackberries and red grapes – as well as vegetables such as red cabbage, red onions and aubergines –  anthocyanidins and their derivatives anthocyanins are potent antioxidant compounds. These substances are thought to help strengthen and repair the walls of blood vessels by protecting collagen in the body (collagen being the structural protein that gives blood vessels their strength).
 
Anthocyanidins are also available in supplement form (choose a product that combines anthocyanidins with vitamin C, as vitamin C supports the body’s ability to produce collagen).
 
 
It can be alarming to find out you have diabetic kidney disease. However if it’s at the early stage there’s lots you can do to prevent it getting worse – or even eliminating it altogether. If you’re living with diabetes this guide can help you discover ways of keeping your kidneys healthy, whether you’ve developed diabetic kidney disease or not. Meanwhile, to discover facts and other information relating to a wide range of general health conditions, take a tour around our pharmacy health library. 
 

References

(i) Available online: https://patient.info/diabetes/diabetes-mellitus-leaflet/diabetic-kidney-disease
 
(ii) Available online: https://patient.info/news-and-features/what-do-kidneys-do
 
(iii) Available online: https://www.kidneycareuk.org/about-kidney-health/conditions/diabetes/
 
(iv) Available online: https://cks.nice.org.uk/topics/diabetes-type-1/background-information/complications/
 
(v) Available online: https://www.kidney.org.uk/diabetes
 
(vi) Available online: https://www.nhs.uk/conditions/kidney-disease/prevention/
 
(vii) Mang. B, Wolters. M, Schmitt. B, et al. Effects of a cinnamon extract on plasma glucose, HbA, and serum lipids in diabetes mellitus type 2. Eur J Clin Invest. 2006;36:340-344. Available online: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2362.2006.01629.x

Akilen. R, Tsiami. A ,Devendra. D, Robinson. N, et al. Glycated haemoglobin and blood pressure-lowering effect of cinnamon in multi-ethnic Type 2 diabetic patients in the UK: a randomized, placebo-controlled, double-blind clinical trial. Diabet Med. 2010;27(10):1159-1167. Available online: https://onlinelibrary.wiley.com/doi/10.1111/j.1464-5491.2010.03079.x

Pham. AQ, Kourias. H, Pham. DQ. Cinnamon supplementation in patients with type 2 diabetes mellitus. Pharmacotherapy. 2007 Apr;27(4):595-9.Available online: https://accpjournals.onlinelibrary.wiley.com/doi/abs/10.1592/phco.27.4.595

Kirkham S, Akilen R, Sharma S, Tsiami A. The potential of cinnamon to reduce blood glucose levels in patients with type 2 diabetes and insulin resistance. Diabetes Obs Metab. 2009 Dec;11(12):1100-13. Available online: https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/j.1463-1326.2009.01094.x
 
(viii) Poh. ZX., Goh KP., A current update on the use of alpha lipoic acid in the management of type 2 diabetes mellitus. Endocr Metab Immune Disord Drug Targets. 2009 Dec;9(4):392-8. Available online: https://www.eurekaselect.com/article/30245
 
(ix) Evans JL, Goldfine ID. Alpha-lipoic acid: a multifunctional antioxidant that improves insulin sensitivity in patients with type 2 diabetes. Diabetes Technol ther. Autumn 2000;2(3):401-13. Available online: https://www.liebertpub.com/doi/10.1089/15209150050194279
 
(x) Elamin. A, Tuvemo. T. Magnesium and insulin-dependent diabetes mellitus. Diabetes Res Clin Pract. 1990;10:203-209. available online: https://www.diabetesresearchclinicalpractice.com/article/0168-8227(90)90062-X/pdf.

Barbagallow M, Dominguez LJ. Magnesium and type 2 diabetes. World J Diabetes 2015 Aug 25; 6(10):1152-57. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549665/
 
(xi) Song. Y, He. K, Levitan. EB. Effects of oral magnesium supplementation on glycaemic control in Type 2 diabetes: a meta-analysis of randomized double-blind controlled trials. Diabet Med. 2006;23:1050-1056. Available online: https://onlinelibrary.wiley.com/doi/10.1111/j.1464-5491.2006.01852.x
 
(xii) Mokhtari M., Razzaghi R, Momen-Heravi M. The effects of curcumin intake on wound healing and metabolic status in patients with diabetic foot ulcer: A randomized, double-blind, placebo-controlled trial. Phytother Research: PTR (2020) 35(4):2099–107. Available online: https://onlinelibrary.wiley.com/doi/10.1002/ptr.6957
 
(xiii) Jing Hu Zuoliang Liu, Hao Zhang. Omega-3 fatty acid supplementation as an adjunctive therapy in the treatment of chronic kidney disease: a meta-analysis. Clinics (Sao Paulo). 2017 Jan; 72(1): 58–64. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5251198/
 
(xiv) Yilmaz Z et al. Supplements for Diabetes Mellitus: A Review of the Literature. Pharm Pract 2017 Dec;30(6):631-638. Available online: https://journals.sagepub.com/doi/10.1177/0897190016663070.

Kassaian N et al. Effect of fenugreek seeds on blood glucose and lipid profiles in type 2 diabetic patients. Int J Vitam Nutr Res 2009 Jan;79(1):34-9. Available online: https://econtent.hogrefe.com/doi/10.1024/0300-9831.79.1.34 .

Gupta A, Gupta R, Lal B. Effect of Trigonella foenum-graecum (fenugreek) seeds on glycaemic control and insulin resistance in type 2 diabetes mellitus: a double blind placebo controlled study. Physicians India 2001 Nov;49:1057-61. Available online: https://pubmed.ncbi.nlm.nih.gov/11868855/
 
(xv) Williams S, Malatesta K, Norris K. Vitamin D and Chronic Kidney Disease. Ethn Dis. 2009 Autumn; 19(4 Suppl 5): S5-8-11. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2878736/
 
(xvi) Uwaezuoke SN. Vitamin D Analogs Can Retard the Onset or Progression of Diabetic Kidney Disease: A Systematic Review. Front. Clin. Diabetes Healthc, 15 October 2021. Available online: https://www.frontiersin.org/articles/10.3389/fcdhc.2021.763844/full
 
(xvii) Available online: https://www.gov.uk/government/news/phe-publishes-new-advice-on-vitamin-d
 

 

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Disclaimer: The information presented by Nature's Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor's care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.

 

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