KIDNEY DISEASE IN DIABETICS

 

I have been practicing Plastic & Reconstructive Surgery for 40 years now and over the years if ignorance has constantly plagued my patient population it is their understanding of Diabetes. I still see patients who are known diabetic for the last twenty years, walking in with two recent investigations, often totally unrelated to their disease. They know they are diabetic, but they have no idea how diabetes is harming them. They have no information about diabetic endarteritis, and how it affects their target organs – kidneys, heart, eyes and feet, and so naturally they are taking no notice of it. Their constant lament is that no doctor can control their blood sugar levels and the latter keeps on fluctuating constantly! I have in my previous blogs on Diabetes often mentioned about this problem. If you want to read them please click:

https://surajitbrainwaves.blogspot.com/2023/02/diabetes-myths-and-facts.html

https://surajitbrainwaves.blogspot.com/2025/05/are-you-diabetic-let-me-help.html

 

 

In this blog I would like to emphasize how kidneys are at risk in diabetics. For millions of people living with diabetes, the kidneys are quietly working overtime — and often, by the time something feels wrong, significant damage has already been done, because 75% of healthy kidney tissue is reserve, and not needed if the remaining 25% are fully functional. Diabetic nephropathy, or kidney disease caused by diabetes, is one of the most serious complications of diabetes. It can creep up on you almost silently and by the time the patient shows symptoms, the kidneys are significantly damaged.

 

What Is Diabetic Nephropathy?

When blood sugar levels stay high over time, they can gradually damage the tiny blood vessels inside our kidneys — the ones responsible for filtering waste from your blood. The result is diabetic nephropathy: a progressive form of kidney disease that affects a significant portion of people with both type 1 and type 2 diabetes. The condition is more common than many people realize. Roughly 1 in 3 adults with diabetes will develop some degree of kidney disease over the course of their lifetime. It's also one of the leading causes of kidney failure worldwide, making early awareness genuinely life-saving.

 

The condition unfolds in five stages, each measured by something called the Glomerular Filtration Rate (GFR) — essentially a score for how well our kidneys are doing their job.

• Stage 1: Mildly increased GFR, no clinical signs of disease.
• Stage 2: Elevated GFR, significant micro-albuminuria,  potential progression to end-stage renal disease. (Albumin in urine in microscopic amount)
• Stage 3: Overt diabetes, clinical albuminuria, and increasing proteinuria (Significant protein loss in urine)
• Stage 4: Severe loss of kidney function, GFR <15 mL/min/1.73m², requiring  renal replacement  therapy.
• Stage 5: End stage renal disease , GFR <10mL/min, requiring dialysis or kidney transplantation

 

In stage 1, the kidneys are damaged but still functioning well. By stage 5, the kidneys have failed entirely and dialysis or a transplant becomes necessary. What makes this progression so dangerous is that the kidneys are remarkably resilient organs — they can continue working even when significantly damaged, masking the problem until it becomes serious. This is why diabetic nephropathy is sometimes called a "silent disease."

 

The Earliest Warning Signs

Most people feel nothing in stage 1. It's only around stage 2 — when the GFR drops below 89 — that the first, often subtle, symptoms begin to surface. And subtle they are. Patients often dismiss them and attribute them to a bad week or a busy lifestyle. I usually try to look for:

·        Fatigue that doesn't match your activity level

·        Loss of appetite with no obvious reason

·        Persistent headaches

·        Dry or itchy skin unrelated to the weather

·        Nausea or vomiting with no clear cause

·        Mild swelling in the arms and legs

 

I always tell my patients that if any of these sound familiar — especially if they have diabetes they shouldn't brush them off. One particularly telling symptom worth mentioning is foamy or bubbly urine. This occurs when the kidneys begin leaking protein — something healthy kidneys are designed to retain. While it can be easy to overlook, it's one of the more distinctive early signals that something may be wrong.

 

Why should the patients visit their doctors?

A doctor – a physician, an endocrinologist, can detect diabetic nephropathy even before patients feel a thing. Routine blood and urine tests can reveal early red flags, including:

·        Elevated creatinine levels — creatinine is a waste product that healthy kidneys filter out efficiently. When it builds up in the blood, it suggests the kidneys are struggling.

·        Protein in the urine (proteinuria) — specifically a protein called albumin. Its presence in urine is one of the earliest and most reliable indicators of kidney damage.

·        Low albumin levels in the blood — as the kidneys leak protein, blood albumin levels drop, which can eventually affect everything from immune function to fluid balance in the body.

 

In some patients, a doctor may also order a renal biopsy — a minor procedure where a tiny sample of kidney tissue is examined under a microscope to assess the extent of damage. This is typically reserved for more complex or uncertain cases.

 

This is exactly why regular check-ups are so important for anyone living with diabetes. Current medical guidelines recommend that people with type 2 diabetes get screened for kidney disease annually from the time of diagnosis, and those with type 1 diabetes from around five years after diagnosis. My follow up schedule of investigations for my diabetic patients is:

1.      Physician’s consultation (MD Medicine / DM Endocrinology)          – monthly

2.      Blood Urea and Serum Creatnine                                                        - 2 monthly

3.      Blood Sugar – Fasting & PP                                                                - monthly

4.      HbA1C                                                                                                - 6 monthly

5.      Ultrasound of Kidneys, Ureters and Bladder                                       - 2 yearly

6.      Serum Lipid profile                                                                              - 6 monthly

7.      E.C.G                                                                                                  -6 monthly

8.      Fundus examination by Ophthalmologist                                            - 6 monthly

9.      X.Ray Chest                                                                                        - 2 yearly

 

Why is prompt diagnosis and treatment of Nephropathy important?

 If diabetic nephropathy is left undetected or untreated, the symptoms become harder to ignore. These include:

·        Constant fatigue

·        A persistent sense of feeling unwell

·        Shortness of breath

·        Difficulty concentrating

·        Foamy urine

·        Swelling in the hands, feet, and around the eyes

·        Blood pressure tends to climb and this accelerates the damage.

 

 In later stages other kidney functions too get affected:

1.      They struggle to regulate important minerals like potassium and phosphorus. This can lead to muscle cramps, bone weakening, and dangerous changes in heart rhythm.

2.       Anemia — a shortage of red blood cells — is also common, as the kidneys produce a hormone called erythropoietin that signals the body to make red blood cells. When kidney function declines, so does this signal, resulting in anaemia. This leaves many patients feeling persistently exhausted regardless of how much they rest.

 

Who is Most at Risk?

Beyond having diabetes itself, certain factors raise the odds of developing diabetic nephropathy:

·        A family history of kidney disease

·        High blood pressure

·        Obesity

·        Smoking

·        Type 1 diabetes diagnosed before age 20

·        Indians as a race are prone to diabetic nephropathy more than Caucacians

·        Existing eye or nerve damage from diabetes

 

A Vicious Cycle

High blood pressure and diabetic nephropathy form a particularly vicious cycle — kidney damage raises blood pressure, and high blood pressure in turn accelerates kidney damage. So, the real challenge is to break this cycle early, often with medication. This is one of the most important steps in managing the condition.

 

Prevention

While we can't undo damage that's already been done, there's a great deal we can do to slow it down — or prevent it from starting in the first place.

1.      Keep blood sugar in check. This is the single most important thing a diabetic patient can do for their kidneys. Consistently high glucose levels are the root cause of the damage, and studies show that tight blood sugar control can significantly reduce the risk of developing nephropathy.

2.      Manage your blood pressure. Target blood pressure for people with diabetes and kidney disease is generally below 130/80 mmHg. Medications called ACE inhibitors or ARBs are often prescribed specifically because they protect the kidneys beyond their blood pressure-lowering effects.

3.      Watch what you eat. A kidney-friendly diet typically means reducing sodium, limiting protein intake (which reduces the workload on the kidneys), and cutting back on potassium and phosphorus in later stages. Working with a dietitian can make this much more manageable.

4.      Quit smoking. Smoking narrows blood vessels and reduces blood flow to the kidneys, directly worsening their function. It also raises blood pressure and interferes with diabetes medications.

5.      Stay active. Regular moderate exercise helps control blood sugar, lower blood pressure, and maintain a healthy weight — all of which take pressure off the kidneys. A daily walk 4 Km in 40 minutes is ideal.

6.       Avoid NSAIDs. Common over-the-counter pain relievers like ibuprofen and Brufen can be hard on the kidneys. They are called nephro-toxic drugs. People with diabetic nephropathy are generally advised to use alternatives under medical guidance.

 

Kidney damage from diabetes cannot be reversed — but it absolutely can be slowed down, especially when caught early. Treatment options range from diabetes medications and dietary changes to dialysis and kidney transplants in advanced cases. Newer classes of diabetes medications, including SGLT2 inhibitors, have also shown promising results in protecting kidney function and are increasingly being prescribed for this purpose specifically. The most powerful thing you can do? Don't wait for symptoms. If you have diabetes, make kidney health part of your regular medical conversations. A simple blood or urine test and the habit of visiting the doctor every month, even when seemingly in good health could make all the difference — and in this case, catching something early isn't just good news, it's a genuine lifeline.