Contributor: Hope Warshaw, MMSc, RD, CDCES, BC-ADM
In partnership with

As a person with diabetes, you may have worries about developing kidney disease. That is understandable, as diabetes continues to be the most common cause of chronic kidney disease and kidney failure that requires dialysis or a kidney transplant. That’s the bad news. But there is good news and actions you can take to prevent or delay the progression of kidney disease.

Evidence shows that it’s not having diabetes, per se, that causes kidneys to fail. According to the current American Diabetes Association (ADA) Standards of Care (Standards), getting and keeping your glucose levels and blood pressure in a healthy range over time is essential to keeping your kidneys healthy. Also critical is to get the recommended tests and checks regularly (at least annually, based on your situation) to ascertain your kidney status. And, if needed, take recommended actions to delay further disease progression. Let’s dig in…

BECOME AWARE
Knowledge is power! Learn about diabetes and kidney disease. Unfortunately, about 90 percent of people with diabetes are unaware they have kidney disease at any stage. This hampers early detection and aggressive treatment to slow progression. Learn the stages of chronic kidney disease (CKD).

GET REGULAR KIDNEY CHECKS
Current ADA Standards recommend two tests to check kidney function (see below). Everyone with type 2 diabetes, starting at the point of diagnosis, should have these tests annually. People who have type 1 diabetes should start to have these tests after about five years - but if you were diagnosed with type 1 as an adult, ask your provider about whether you should start having these tests beginning at diagnosis.

• Urinary Albumin-to-Creatinine Ratio (UACR) - This test checks the amount of protein (albumin) in your urine. The categories for UACR results and what they mean are:
• Normal to mildly increased: <30 milligrams/gram
• Moderately increased: <30-299 milligrams/gram
• Severely increased: > 300 milligrams/gram
• Estimated glomerular filtration rate (eGFR) - This measures the rate at which your kidneys filter waste products. eGFR is calculated from age, serum creatinine number (the amount of protein your body is breaking down), and gender. Normal eGFR is 60 or higher. As kidney function decreases, eGFR decreases.

Two changes in the 2023 ADA Standards regarding kidney disease are:

• People with kidney disease should get these tests done one to four times per year based on their level of kidney damage.
• People with continuously rising levels of UACR and eGFR should be referred to a nephrologist (kidney specialist).

Do not wait for your healthcare providers to order these kidney tests. Ask for them to be ordered according to the ADA Standards. Also, get and know your results. Discuss them and any additional steps that you should take with your provider.

And for the future, newer tests to check kidney function and predict kidney problems are just becoming available but are not yet integrated into ADA Standards or medical practice. These tests can identify people at risk of developing CKD before it’s present by measuring various biomarkers in the blood. The current diagnostic tests, UACR and eGFR, detects if kidney damage is present. One new test is NaviDKD^TM, developed by Journey Biosciences. This test uses a blood sample to observe the amount of advanced glycation end products (AGEs), which are linked to the aging of cells and some progressive diseases, like kidney disease. The other test is PromarkerD. It also uses a blood sample to measure a panel of three biomarkers that indicate and predict kidney disease.

PREVENT OR DELAY PROGRESSION
There are several daily actions you can take to prevent or delay kidney disease progression. These include glucose and blood pressure management as recommended by ADA or that you and your provider agree on. Also critical for kidney health are healthy eating, regular physical activity, and weight management.

About Glucose Management - If you have type 2 diabetes, you’ll likely need to take one or more glucose-lowering medications to achieve your glucose targets. Try to be open to taking glucose-lowering medications. A few newer glucose-lowering medications also keep your kidneys and heart healthier and assist with weight loss. The two main categories are SGLT-2 inhibitors and GLP-1 receptor agonists. These medications are not currently FDA-approved for people with type 1 diabetes.

If you have type 1 diabetes, you may want to discuss their use with your provider. If you have type 2 diabetes and CKD and cannot take an SGLT2- inhibitor, ask about a newer medication called Kerendia (generic name is finerenone). Kerendia slows the progression of CKD by blocking some steroids made in the body that have a role in heart and kidney damage.

About Blood Pressure Management - Get your blood pressure checked at every visit with your provider. If you have high blood pressure, the ADA recommends that you also check your blood pressure with a home monitor.

The use and choices of blood pressure medication depend on your results. If blood pressure is higher than 120/80 mmHg but lower than 130/80 mmHg, you may be able to manage your blood pressure through healthy eating (including reducing the amount of sodium you consume to no more than 2,300 mg/day) and regular physical aerobic activity

If your blood pressure is higher than 130/80 mmHg, you’ll likely need to take medication. There are several categories, but two recommended as a starting medication for people with diabetes are an ACE inhibitor or an ARB. They both aim to reduce heart and blood pressure problems and prevent or reduce kidney disease progression. The use of an ACE inhibitor or ARB is not recommended in people with diabetes with normal blood pressure and kidney function. To adequately manage blood pressure, you may also need to add another category of blood pressure medication, such as a calcium channel blocker or diuretic.

In a nutshell, take action to keep your glucose and blood pressure in your target range. Get the tests you need in the frequency you need them to detect any kidney disease as early as possible. Lastly, if kidney problems are detected, take recommended actions to slow the progression of kidney disease. It’s a lot, but you can do this!

** Elements of this article initially appeared in diaTribe Learn. That article contains a perspective from Anne Dalin, DiabetesSisters PODS Meetup co-leader, who had had a kidney transplant due to diabetes-related kidney disease detected when she was diagnosed with type 2 diabetes.

Hope Warshaw, MMSc, RD, CDCES, BC-ADM, owns Hope Warshaw Associates, LLC, a private practice and consultancy based in Asheville, NC. She has 40-plus years of expertise in diabetes care and management and is a tireless and passionate volunteer and leader in several professional organizations, including ACDCES, ADA, and the Academy of Nutrition and Dietetics. Hope is an advocate for the value of peer support and peer support communities such as DiabetesSisters. She’s thrilled to see these communities flourish.